Obstetrics

WASHINGTON — The intensity of women's labor pain at the time of neuraxial anesthesia placement didn't influence the mode of delivery, based on data from a study of 555 nulliparous women.

No previous study has addressed whether timing of neuraxial anesthesia with regard to the degree of the patient's pain has an impact on the mode of delivery, Dr. Yaakov Beilin said in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

In this study, Dr. Beilin and Diana H. Mungall, both of Mount Sinai Hospital in New York, reviewed data from term, nulliparous women who presented to the labor floor of a single hospital between July 2005 and September 2008. Pain scores at the time of neuraxial analgesia placement were determined using a scale of 0-10 and divided into three groups: low (0-3), moderate (4-6), and high (7-10).

The cesarean section rate was 41%, 36%, and 34%, in the low-, moderate-, and high-pain groups, respectively; the differences were not significant.

Similarly, the operative delivery rate (which included cesarean plus instrumental assisted vaginal delivery) was 49%, 45%, and 45% in the low-, moderate-, and high-pain groups, respectively; these values were not significantly different. And the vaginal delivery rate of 51%, 55%, and 55% for the low-, moderate-, and high-pain groups, respectively, were not significantly different.

The results were limited by the retrospective nature of the study, but the data suggest that neuraxial analgesia can be safely placed in women with varying degrees of labor pain, Dr. Beilin said.

The researchers had no financial conflicts to disclose.

WASHINGTON — The intensity of women's labor pain at the time of neuraxial anesthesia placement didn't influence the mode of delivery, based on data from a study of 555 nulliparous women.

No previous study has addressed whether timing of neuraxial anesthesia with regard to the degree of the patient's pain has an impact on the mode of delivery, Dr. Yaakov Beilin said in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

In this study, Dr. Beilin and Diana H. Mungall, both of Mount Sinai Hospital in New York, reviewed data from term, nulliparous women who presented to the labor floor of a single hospital between July 2005 and September 2008. Pain scores at the time of neuraxial analgesia placement were determined using a scale of 0-10 and divided into three groups: low (0-3), moderate (4-6), and high (7-10).

The cesarean section rate was 41%, 36%, and 34%, in the low-, moderate-, and high-pain groups, respectively; the differences were not significant.

Similarly, the operative delivery rate (which included cesarean plus instrumental assisted vaginal delivery) was 49%, 45%, and 45% in the low-, moderate-, and high-pain groups, respectively; these values were not significantly different. And the vaginal delivery rate of 51%, 55%, and 55% for the low-, moderate-, and high-pain groups, respectively, were not significantly different.

The results were limited by the retrospective nature of the study, but the data suggest that neuraxial analgesia can be safely placed in women with varying degrees of labor pain, Dr. Beilin said.

The researchers had no financial conflicts to disclose.

WASHINGTON — The intensity of women's labor pain at the time of neuraxial anesthesia placement didn't influence the mode of delivery, based on data from a study of 555 nulliparous women.

No previous study has addressed whether timing of neuraxial anesthesia with regard to the degree of the patient's pain has an impact on the mode of delivery, Dr. Yaakov Beilin said in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

In this study, Dr. Beilin and Diana H. Mungall, both of Mount Sinai Hospital in New York, reviewed data from term, nulliparous women who presented to the labor floor of a single hospital between July 2005 and September 2008. Pain scores at the time of neuraxial analgesia placement were determined using a scale of 0-10 and divided into three groups: low (0-3), moderate (4-6), and high (7-10).

The cesarean section rate was 41%, 36%, and 34%, in the low-, moderate-, and high-pain groups, respectively; the differences were not significant.

Similarly, the operative delivery rate (which included cesarean plus instrumental assisted vaginal delivery) was 49%, 45%, and 45% in the low-, moderate-, and high-pain groups, respectively; these values were not significantly different. And the vaginal delivery rate of 51%, 55%, and 55% for the low-, moderate-, and high-pain groups, respectively, were not significantly different.

The results were limited by the retrospective nature of the study, but the data suggest that neuraxial analgesia can be safely placed in women with varying degrees of labor pain, Dr. Beilin said.

The researchers had no financial conflicts to disclose.

WASHINGTON — Given growing concerns about propylthiouracil-related liver toxicity, “it may be that we should be weighing the relative risks” of this drug and methimazole for the treatment of Graves' disease during pregnancy, Dr. Susan J. Mandel said.

Propylthiouracil (PTU) has been the preferred therapy for Graves' disease during pregnancy, especially during first-trimester organogenesis, because methimazole (MMI) and carbimazole have been associated with aplasia cutis and rare embryopathy including choanal atresia, esophageal atresia, tracheoesophageal fistula, and athelia.

None of these congenital anomalies has been reported with the use of PTU, Dr. Mandel said at an American Thyroid Association-sponsored meeting. Dr. Mandel is associate chief of the division of endocrinology, diabetes, and metabolism at the University of Pennsylvania, Philadelphia.

Last month, the Food and Drug Administration issued a warning about the risk of severe liver injury associated with the use of PTU with the treatment of Graves' disease. “After analyzing adverse event reports, the FDA has identified an increased risk of liver injury with propylthiouracil, compared with an alternative treatment for Graves' disease, methimazole,” Dr. Amy Egan, deputy director for safety, division of metabolism and endocrinology products, FDA Center for Drug Evaluation and Research, said in a statement.

“Health care professionals should carefully consider which drug to initiate in a patient recently diagnosed with Graves' disease. If PTU therapy is chosen, the patient should be closely monitored for symptoms and signs of liver injury, especially during the first 6 months after initiating therapy.”

The FDA is advising health care professionals to reserve PTU for patients in their first trimester of pregnancy or those who are intolerant of or allergic to methimazole.

The FDA statement, posted on the agency's MedWatch Web site, said that 32 cases of serious liver injury were reported to the FDA from 1969, when the agency's adverse event reporting program was established, through October 2008. Of these cases, 22 were in adults, and included 12 fatalities and 5 liver transplants. Among the 10 pediatric cases, there were 6 reports of liver transplants and 1 fatality, according to the statement.

On the basis of an analysis of these reports, the FDA has determined that the risk of hepatotoxicity is greater with PTU than with MMI. The FDA received only five reports of serious liver injury associated with MMI, which was approved in 1950.

The FDA announced plans to change the prescribing information for PTU to reflect the hepatotoxicity warning

Concerns about PTU's hepatotoxicity have come largely from the pediatric community. Last year, the National Institute of Child Health and Human Development (NICHD) held a conference on “hepatic toxicity following treatment for pediatric Graves' disease.” And most recently, Dr. Scott A. Rivkees of Yale University, New Haven, Conn., and Dr. Donald R. Mattison of NICHD called for an end to the use of PTU in children.

In a letter to the editor published in the April 9 issue of the New England Journal of Medicine (2009;360:1574-5), Dr. Rivkees and Dr. Mattison said that PTU-induced liver failure may occur in 1 in 2,000 to 1 in 4,000 treated children, with nearly 10 times that range developing reversible PTU-induced liver injury.

In the context of Graves' disease in pregnancy, Dr. Mandel said, “it may be that we should be rethinking, what are the relative risks of hepatotoxicity with PTU versus the very rare embryopathy reported with methimazole [and carbimazole].”

Because the changes apparently caused by MMI “all occur by 8-10 weeks' gestation, and some even earlier, there may be a rationale” to using PTU into early pregnancy and then switching to methimazole afterwards,” added Dr. Mandel, also professor of medicine and radiology at the University of Pennsylvania.

The original recommendations to use PTU in pregnancy—before the teratogenic effects of MMI were reported—came from studies suggesting that PTU was less likely to cross the placenta. More recent data acquired through the use of newer measurement techniques have challenged this, demonstrating a similar degree of transplacental passage with both drugs, she noted.

WASHINGTON — Given growing concerns about propylthiouracil-related liver toxicity, “it may be that we should be weighing the relative risks” of this drug and methimazole for the treatment of Graves' disease during pregnancy, Dr. Susan J. Mandel said.

Propylthiouracil (PTU) has been the preferred therapy for Graves' disease during pregnancy, especially during first-trimester organogenesis, because methimazole (MMI) and carbimazole have been associated with aplasia cutis and rare embryopathy including choanal atresia, esophageal atresia, tracheoesophageal fistula, and athelia.

None of these congenital anomalies has been reported with the use of PTU, Dr. Mandel said at an American Thyroid Association-sponsored meeting. Dr. Mandel is associate chief of the division of endocrinology, diabetes, and metabolism at the University of Pennsylvania, Philadelphia.

Last month, the Food and Drug Administration issued a warning about the risk of severe liver injury associated with the use of PTU with the treatment of Graves' disease. “After analyzing adverse event reports, the FDA has identified an increased risk of liver injury with propylthiouracil, compared with an alternative treatment for Graves' disease, methimazole,” Dr. Amy Egan, deputy director for safety, division of metabolism and endocrinology products, FDA Center for Drug Evaluation and Research, said in a statement.

“Health care professionals should carefully consider which drug to initiate in a patient recently diagnosed with Graves' disease. If PTU therapy is chosen, the patient should be closely monitored for symptoms and signs of liver injury, especially during the first 6 months after initiating therapy.”

The FDA is advising health care professionals to reserve PTU for patients in their first trimester of pregnancy or those who are intolerant of or allergic to methimazole.

The FDA statement, posted on the agency's MedWatch Web site, said that 32 cases of serious liver injury were reported to the FDA from 1969, when the agency's adverse event reporting program was established, through October 2008. Of these cases, 22 were in adults, and included 12 fatalities and 5 liver transplants. Among the 10 pediatric cases, there were 6 reports of liver transplants and 1 fatality, according to the statement.

On the basis of an analysis of these reports, the FDA has determined that the risk of hepatotoxicity is greater with PTU than with MMI. The FDA received only five reports of serious liver injury associated with MMI, which was approved in 1950.

The FDA announced plans to change the prescribing information for PTU to reflect the hepatotoxicity warning

Concerns about PTU's hepatotoxicity have come largely from the pediatric community. Last year, the National Institute of Child Health and Human Development (NICHD) held a conference on “hepatic toxicity following treatment for pediatric Graves' disease.” And most recently, Dr. Scott A. Rivkees of Yale University, New Haven, Conn., and Dr. Donald R. Mattison of NICHD called for an end to the use of PTU in children.

In a letter to the editor published in the April 9 issue of the New England Journal of Medicine (2009;360:1574-5), Dr. Rivkees and Dr. Mattison said that PTU-induced liver failure may occur in 1 in 2,000 to 1 in 4,000 treated children, with nearly 10 times that range developing reversible PTU-induced liver injury.

In the context of Graves' disease in pregnancy, Dr. Mandel said, “it may be that we should be rethinking, what are the relative risks of hepatotoxicity with PTU versus the very rare embryopathy reported with methimazole [and carbimazole].”

Because the changes apparently caused by MMI “all occur by 8-10 weeks' gestation, and some even earlier, there may be a rationale” to using PTU into early pregnancy and then switching to methimazole afterwards,” added Dr. Mandel, also professor of medicine and radiology at the University of Pennsylvania.

The original recommendations to use PTU in pregnancy—before the teratogenic effects of MMI were reported—came from studies suggesting that PTU was less likely to cross the placenta. More recent data acquired through the use of newer measurement techniques have challenged this, demonstrating a similar degree of transplacental passage with both drugs, she noted.

WASHINGTON — Given growing concerns about propylthiouracil-related liver toxicity, “it may be that we should be weighing the relative risks” of this drug and methimazole for the treatment of Graves' disease during pregnancy, Dr. Susan J. Mandel said.

Propylthiouracil (PTU) has been the preferred therapy for Graves' disease during pregnancy, especially during first-trimester organogenesis, because methimazole (MMI) and carbimazole have been associated with aplasia cutis and rare embryopathy including choanal atresia, esophageal atresia, tracheoesophageal fistula, and athelia.

None of these congenital anomalies has been reported with the use of PTU, Dr. Mandel said at an American Thyroid Association-sponsored meeting. Dr. Mandel is associate chief of the division of endocrinology, diabetes, and metabolism at the University of Pennsylvania, Philadelphia.

Last month, the Food and Drug Administration issued a warning about the risk of severe liver injury associated with the use of PTU with the treatment of Graves' disease. “After analyzing adverse event reports, the FDA has identified an increased risk of liver injury with propylthiouracil, compared with an alternative treatment for Graves' disease, methimazole,” Dr. Amy Egan, deputy director for safety, division of metabolism and endocrinology products, FDA Center for Drug Evaluation and Research, said in a statement.

“Health care professionals should carefully consider which drug to initiate in a patient recently diagnosed with Graves' disease. If PTU therapy is chosen, the patient should be closely monitored for symptoms and signs of liver injury, especially during the first 6 months after initiating therapy.”

The FDA is advising health care professionals to reserve PTU for patients in their first trimester of pregnancy or those who are intolerant of or allergic to methimazole.

The FDA statement, posted on the agency's MedWatch Web site, said that 32 cases of serious liver injury were reported to the FDA from 1969, when the agency's adverse event reporting program was established, through October 2008. Of these cases, 22 were in adults, and included 12 fatalities and 5 liver transplants. Among the 10 pediatric cases, there were 6 reports of liver transplants and 1 fatality, according to the statement.

On the basis of an analysis of these reports, the FDA has determined that the risk of hepatotoxicity is greater with PTU than with MMI. The FDA received only five reports of serious liver injury associated with MMI, which was approved in 1950.

The FDA announced plans to change the prescribing information for PTU to reflect the hepatotoxicity warning

Concerns about PTU's hepatotoxicity have come largely from the pediatric community. Last year, the National Institute of Child Health and Human Development (NICHD) held a conference on “hepatic toxicity following treatment for pediatric Graves' disease.” And most recently, Dr. Scott A. Rivkees of Yale University, New Haven, Conn., and Dr. Donald R. Mattison of NICHD called for an end to the use of PTU in children.

In a letter to the editor published in the April 9 issue of the New England Journal of Medicine (2009;360:1574-5), Dr. Rivkees and Dr. Mattison said that PTU-induced liver failure may occur in 1 in 2,000 to 1 in 4,000 treated children, with nearly 10 times that range developing reversible PTU-induced liver injury.

In the context of Graves' disease in pregnancy, Dr. Mandel said, “it may be that we should be rethinking, what are the relative risks of hepatotoxicity with PTU versus the very rare embryopathy reported with methimazole [and carbimazole].”

Because the changes apparently caused by MMI “all occur by 8-10 weeks' gestation, and some even earlier, there may be a rationale” to using PTU into early pregnancy and then switching to methimazole afterwards,” added Dr. Mandel, also professor of medicine and radiology at the University of Pennsylvania.

The original recommendations to use PTU in pregnancy—before the teratogenic effects of MMI were reported—came from studies suggesting that PTU was less likely to cross the placenta. More recent data acquired through the use of newer measurement techniques have challenged this, demonstrating a similar degree of transplacental passage with both drugs, she noted.

Pregnant women consumed just as much alcohol in 2005 as they did in 1991, with 12% drinking at least once during pregnancy and 2% reporting binge drinking.

The findings illustrate the small effect of national educational programs aimed at decreasing this dangerous behavior, according to primary author Clark Denny, Ph.D. (MMWR 2009;58:529-32).

In Healthy People 2010, the national health agenda published in 2000, Dr. David Satcher, the U.S. surgeon general at that time, set abstinence targets of 95% for alcohol and 100% for binge drinking among pregnant women.

“The prevalence of both types of drinking behavior among pregnant women remains higher than the Healthy People 2010 targets and greater progress will be needed to reach them,” Dr. Denny wrote.

The 15-year study found that women aged 35-44 years had the highest incidence of drinking during pregnancy (18%), wrote Dr. Denny, an epidemiologist from the Centers for Disease Control and Prevention. Rates were also higher in college-educated women, employed women, and unmarried women.

The study was based on data collected from 1991 to 2005 through the Behavioral Risk Factor Surveillance System surveys. These annual surveys randomly poll community-dwelling U.S. adults about behavioral health issues. The CDC study included data collected from women aged 18-44 years, who were asked about alcohol use (at least one drink in the last 30 days) and binge drinking (at least five drinks on any one occasion in the last 30 days).

During the 15-year period, 533,500 women were surveyed; 22,000 (4%) reported being pregnant at the time of the survey. The average annual percentage of any alcohol use among the pregnant women was 12%, and did not change from 1991 to 2005. The average annual percentage of pregnant women who said they binged was 2%; again, that percentage was stable over the survey period.

From 2001 to 2005, the study also examined the relationship between drinking during pregnancy and demographic factors. Age was associated with both any drinking and binge drinking. The oldest women (35-44 years) had the highest drinking rate (18%), while the youngest women (18-24 years) had the lowest rate (9%). Age was not highly associated with binge drinking.

Education, employment, and marital status were also associated with drinking during pregnancy. Any drinking was higher among employed women than unemployed (14% vs. 8%), and among unmarried women than married women (13% vs. 10%). Binge drinking was also more common among employed than unemployed women (2% vs. 1%), and unmarried women than married women (4% vs. 1%).

The reasons for these associations are unclear, wrote Dr. Denny. “Some possible reasons include that older women might be more likely to be alcohol dependent and have more difficulty abstaining while pregnant, more educated and employed women might have more discretionary money for the purchase of alcohol, and unmarried women might attend more social occasions where alcohol is served.”

Rates of drinking and binge drinking were higher among nonpregnant women (54% and 12%). Prepregnancy alcohol use is a strong predictor of use during pregnancy, and many women who drink continue to do so before realizing that they are pregnant, Dr. Denny noted. “Approximately 40% of women realize they are pregnant at 4 weeks of gestation, a critical period for fetal organ development.”

The findings confirm the need for alcohol use screening and counseling among all women, he wrote in a press statement. “By screening and advising women about the risks of drinking while pregnant, health care providers can play a key role in reducing rates of fetal alcohol syndrome. This study revealed that there is still a great need for health care professionals to routinely ask all women who are pregnant or at risk of being pregnant about their alcohol consumption.”

Pregnant women consumed just as much alcohol in 2005 as they did in 1991, with 12% drinking at least once during pregnancy and 2% reporting binge drinking.

The findings illustrate the small effect of national educational programs aimed at decreasing this dangerous behavior, according to primary author Clark Denny, Ph.D. (MMWR 2009;58:529-32).

In Healthy People 2010, the national health agenda published in 2000, Dr. David Satcher, the U.S. surgeon general at that time, set abstinence targets of 95% for alcohol and 100% for binge drinking among pregnant women.

“The prevalence of both types of drinking behavior among pregnant women remains higher than the Healthy People 2010 targets and greater progress will be needed to reach them,” Dr. Denny wrote.

The 15-year study found that women aged 35-44 years had the highest incidence of drinking during pregnancy (18%), wrote Dr. Denny, an epidemiologist from the Centers for Disease Control and Prevention. Rates were also higher in college-educated women, employed women, and unmarried women.

The study was based on data collected from 1991 to 2005 through the Behavioral Risk Factor Surveillance System surveys. These annual surveys randomly poll community-dwelling U.S. adults about behavioral health issues. The CDC study included data collected from women aged 18-44 years, who were asked about alcohol use (at least one drink in the last 30 days) and binge drinking (at least five drinks on any one occasion in the last 30 days).

During the 15-year period, 533,500 women were surveyed; 22,000 (4%) reported being pregnant at the time of the survey. The average annual percentage of any alcohol use among the pregnant women was 12%, and did not change from 1991 to 2005. The average annual percentage of pregnant women who said they binged was 2%; again, that percentage was stable over the survey period.

From 2001 to 2005, the study also examined the relationship between drinking during pregnancy and demographic factors. Age was associated with both any drinking and binge drinking. The oldest women (35-44 years) had the highest drinking rate (18%), while the youngest women (18-24 years) had the lowest rate (9%). Age was not highly associated with binge drinking.

Education, employment, and marital status were also associated with drinking during pregnancy. Any drinking was higher among employed women than unemployed (14% vs. 8%), and among unmarried women than married women (13% vs. 10%). Binge drinking was also more common among employed than unemployed women (2% vs. 1%), and unmarried women than married women (4% vs. 1%).

The reasons for these associations are unclear, wrote Dr. Denny. “Some possible reasons include that older women might be more likely to be alcohol dependent and have more difficulty abstaining while pregnant, more educated and employed women might have more discretionary money for the purchase of alcohol, and unmarried women might attend more social occasions where alcohol is served.”

Rates of drinking and binge drinking were higher among nonpregnant women (54% and 12%). Prepregnancy alcohol use is a strong predictor of use during pregnancy, and many women who drink continue to do so before realizing that they are pregnant, Dr. Denny noted. “Approximately 40% of women realize they are pregnant at 4 weeks of gestation, a critical period for fetal organ development.”

The findings confirm the need for alcohol use screening and counseling among all women, he wrote in a press statement. “By screening and advising women about the risks of drinking while pregnant, health care providers can play a key role in reducing rates of fetal alcohol syndrome. This study revealed that there is still a great need for health care professionals to routinely ask all women who are pregnant or at risk of being pregnant about their alcohol consumption.”

Pregnant women consumed just as much alcohol in 2005 as they did in 1991, with 12% drinking at least once during pregnancy and 2% reporting binge drinking.

The findings illustrate the small effect of national educational programs aimed at decreasing this dangerous behavior, according to primary author Clark Denny, Ph.D. (MMWR 2009;58:529-32).

In Healthy People 2010, the national health agenda published in 2000, Dr. David Satcher, the U.S. surgeon general at that time, set abstinence targets of 95% for alcohol and 100% for binge drinking among pregnant women.

“The prevalence of both types of drinking behavior among pregnant women remains higher than the Healthy People 2010 targets and greater progress will be needed to reach them,” Dr. Denny wrote.

The 15-year study found that women aged 35-44 years had the highest incidence of drinking during pregnancy (18%), wrote Dr. Denny, an epidemiologist from the Centers for Disease Control and Prevention. Rates were also higher in college-educated women, employed women, and unmarried women.

The study was based on data collected from 1991 to 2005 through the Behavioral Risk Factor Surveillance System surveys. These annual surveys randomly poll community-dwelling U.S. adults about behavioral health issues. The CDC study included data collected from women aged 18-44 years, who were asked about alcohol use (at least one drink in the last 30 days) and binge drinking (at least five drinks on any one occasion in the last 30 days).

During the 15-year period, 533,500 women were surveyed; 22,000 (4%) reported being pregnant at the time of the survey. The average annual percentage of any alcohol use among the pregnant women was 12%, and did not change from 1991 to 2005. The average annual percentage of pregnant women who said they binged was 2%; again, that percentage was stable over the survey period.

From 2001 to 2005, the study also examined the relationship between drinking during pregnancy and demographic factors. Age was associated with both any drinking and binge drinking. The oldest women (35-44 years) had the highest drinking rate (18%), while the youngest women (18-24 years) had the lowest rate (9%). Age was not highly associated with binge drinking.

Education, employment, and marital status were also associated with drinking during pregnancy. Any drinking was higher among employed women than unemployed (14% vs. 8%), and among unmarried women than married women (13% vs. 10%). Binge drinking was also more common among employed than unemployed women (2% vs. 1%), and unmarried women than married women (4% vs. 1%).

The reasons for these associations are unclear, wrote Dr. Denny. “Some possible reasons include that older women might be more likely to be alcohol dependent and have more difficulty abstaining while pregnant, more educated and employed women might have more discretionary money for the purchase of alcohol, and unmarried women might attend more social occasions where alcohol is served.”

Rates of drinking and binge drinking were higher among nonpregnant women (54% and 12%). Prepregnancy alcohol use is a strong predictor of use during pregnancy, and many women who drink continue to do so before realizing that they are pregnant, Dr. Denny noted. “Approximately 40% of women realize they are pregnant at 4 weeks of gestation, a critical period for fetal organ development.”

The findings confirm the need for alcohol use screening and counseling among all women, he wrote in a press statement. “By screening and advising women about the risks of drinking while pregnant, health care providers can play a key role in reducing rates of fetal alcohol syndrome. This study revealed that there is still a great need for health care professionals to routinely ask all women who are pregnant or at risk of being pregnant about their alcohol consumption.”

SAN ANTONIO — Routine repeat screening for sexually transmitted infections is worthwhile for pregnant adolescents during the third trimester, a Canadian study showed.

“We screen all adolescent pregnancies at baseline and again during the third trimester. This is different from adults, who we only screen at baseline,” said Dr. Anjali Aggarwal of the Hospital for Sick Children in Toronto.

Part of the concern is that teenage women tend to use condoms less often once they become pregnant (Am. J. Public Health 2009 April 16 [doi:10.2105/AJPH.2007.131870

She and her associates at the University of Toronto hospital assessed 89 pregnant adolescents with a median age of 16 years (range, 13-17 years) who were screened both at baseline and during the third trimester. They also screened 77 of the same participants again during the postpartum period.

Overall, 26 patients (29%) were diagnosed with an STI during or after pregnancy. “I was surprised it was that high,” Dr. Aggarwal said in an interview. Specifically, STIs were detected in 17 patients during the first trimester, 7 in the third trimester, and 1 in the postpartum period. An additional patient was diagnosed in the first trimester, treated, and then treated again during the third trimester, based on symptoms later in her pregnancy.

The finding that more than 25% of the patients identified as having an STI were diagnosed in the third trimester justifies routine rescreening, said Dr. Aggarwal.

Only one statistically significant risk factor was associated with an STI in pregnancy: a history of not using contraception, other than a condom. There was no significant association with patient age, previous pregnancy, or previous STI. Women who lived with a partner, lived with the baby's father, or reported only one previous sexual partner versus more than one were at lower risk of an STI during pregnancy. These factors only trended toward statistical significance.

Dr. Aggarwal said she plans to compare computer-based patient interviews with those done by clinicians. The goal would be to determine if pregnant teenagers are more forthright when interfacing with a computer, she said.

SAN ANTONIO — Routine repeat screening for sexually transmitted infections is worthwhile for pregnant adolescents during the third trimester, a Canadian study showed.

“We screen all adolescent pregnancies at baseline and again during the third trimester. This is different from adults, who we only screen at baseline,” said Dr. Anjali Aggarwal of the Hospital for Sick Children in Toronto.

Part of the concern is that teenage women tend to use condoms less often once they become pregnant (Am. J. Public Health 2009 April 16 [doi:10.2105/AJPH.2007.131870

She and her associates at the University of Toronto hospital assessed 89 pregnant adolescents with a median age of 16 years (range, 13-17 years) who were screened both at baseline and during the third trimester. They also screened 77 of the same participants again during the postpartum period.

Overall, 26 patients (29%) were diagnosed with an STI during or after pregnancy. “I was surprised it was that high,” Dr. Aggarwal said in an interview. Specifically, STIs were detected in 17 patients during the first trimester, 7 in the third trimester, and 1 in the postpartum period. An additional patient was diagnosed in the first trimester, treated, and then treated again during the third trimester, based on symptoms later in her pregnancy.

The finding that more than 25% of the patients identified as having an STI were diagnosed in the third trimester justifies routine rescreening, said Dr. Aggarwal.

Only one statistically significant risk factor was associated with an STI in pregnancy: a history of not using contraception, other than a condom. There was no significant association with patient age, previous pregnancy, or previous STI. Women who lived with a partner, lived with the baby's father, or reported only one previous sexual partner versus more than one were at lower risk of an STI during pregnancy. These factors only trended toward statistical significance.

Dr. Aggarwal said she plans to compare computer-based patient interviews with those done by clinicians. The goal would be to determine if pregnant teenagers are more forthright when interfacing with a computer, she said.

SAN ANTONIO — Routine repeat screening for sexually transmitted infections is worthwhile for pregnant adolescents during the third trimester, a Canadian study showed.

“We screen all adolescent pregnancies at baseline and again during the third trimester. This is different from adults, who we only screen at baseline,” said Dr. Anjali Aggarwal of the Hospital for Sick Children in Toronto.

Part of the concern is that teenage women tend to use condoms less often once they become pregnant (Am. J. Public Health 2009 April 16 [doi:10.2105/AJPH.2007.131870

She and her associates at the University of Toronto hospital assessed 89 pregnant adolescents with a median age of 16 years (range, 13-17 years) who were screened both at baseline and during the third trimester. They also screened 77 of the same participants again during the postpartum period.

Overall, 26 patients (29%) were diagnosed with an STI during or after pregnancy. “I was surprised it was that high,” Dr. Aggarwal said in an interview. Specifically, STIs were detected in 17 patients during the first trimester, 7 in the third trimester, and 1 in the postpartum period. An additional patient was diagnosed in the first trimester, treated, and then treated again during the third trimester, based on symptoms later in her pregnancy.

The finding that more than 25% of the patients identified as having an STI were diagnosed in the third trimester justifies routine rescreening, said Dr. Aggarwal.

Only one statistically significant risk factor was associated with an STI in pregnancy: a history of not using contraception, other than a condom. There was no significant association with patient age, previous pregnancy, or previous STI. Women who lived with a partner, lived with the baby's father, or reported only one previous sexual partner versus more than one were at lower risk of an STI during pregnancy. These factors only trended toward statistical significance.

Dr. Aggarwal said she plans to compare computer-based patient interviews with those done by clinicians. The goal would be to determine if pregnant teenagers are more forthright when interfacing with a computer, she said.

SAN FRANCISCO — Complications from a prolactinoma during pregnancy are best avoided by treating the adenoma before conception.

But with many women delaying pregnancy, it's not uncommon to see a woman in her late 30s with a macro-adenoma who says she wants to get pregnant soon and doesn't have the luxury of suppressing the tumor for a year or two on medical therapy before conception, Dr. J. Blake Tyrrell said at a conference on diabetes and advances in endocrinology and metabolism sponsored by the University of California, San Francisco.

The sparse data available to help guide the management of these patients suggest that suppressing prolactin-secreting adenomas with dopamine agonists reduces the effects of the tumor and allows the patient to get pregnant without increasing the risk of fetal loss or fetal abnormalities.

There is less experience with cabergoline, today's treatment of choice, than with the former first-line agent bromocriptine.

Whether the patient has a microadenoma or macroadenoma, Dr. Tyrrell prefers to treat with cabergoline to allow menstrual cycles to normalize. If the patient misses a period, test for pregnancy, and if she is pregnant discontinue cabergoline, advised Dr. Tyrrell, director of the endocrinology clinic at the university. With this method, fetal exposure to the drug should be no more than a couple of weeks, he said.

Once off of therapy, fewer than 2% of microadenomas will enlarge during pregnancy. Given this low risk, many providers choose to leave them alone during pregnancy. Dr. Tyrrell suggested following prolactin levels every 6 weeks, and if they get as high as 500 ng/mL, “I might get a bit concerned and ask the patient how she's doing,” he said.

Macroadenomas that are left untreated during pregnancy will enlarge in about 23% of cases and cause headache and visual field defects. “That's not a situation you want to get into,” he said. Only 3% of macroadenomas that were surgically debulked prior to conception enlarged during pregnancy, but medical therapy has largely replaced surgical treatment for prolactinomas.

In the management of macroadenomas during pregnancy, “we're on very thin ice” due to very limited data on the risks from taking dopamine agonists before or during pregnancy, he said.

One study reported on 86 women with macroadenomas who conceived after bromocriptine treatment, which was then stopped. Twenty women (23%) developed visual field defects during pregnancy. Four patients then underwent surgical treatment and 15 received bromocriptine therapy, and all 20 had successful pregnancy outcomes (Endocrinol. Metab. Clin. North Am. 2006;35:99–116).

Data from the early 1980s described 29 women with macroadenomas who were managed with continuous bromocriptine throughout pregnancy. Two developed visual field defects. All had successful pregnancy outcomes. Dr. Tyrrell noted that 7 of these 29 women probably had nonfunctional tumors because their serum prolactin levels were less than 200 ng/mL, which suggests that continuous drug therapy was associated with an even higher rate of visual field defects in women with functioning tumors (in 2 of 22) patients.

That's about the extent of the world literature on managing macroadenomas during pregnancy, which is “not very good considering that these drugs have been around for 30-plus years,” he said. There are no data on continuous cabergoline therapy during pregnancy.

In the worst-case scenario, a macro-adenoma may enlarge, usually during the second or third trimester, causing headache and visual field defects. A noncontrast MRI can be done safely during pregnancy to define the size.

If the tumor is enlarging, try medical therapy, and deliver the fetus early if it's viable. Surgery is a last resort, Dr. Tyrrell said. “Think about this if you can ahead of time to deal with the tumor before conception, before getting into trouble during pregnancy,” he concluded.

SAN FRANCISCO — Complications from a prolactinoma during pregnancy are best avoided by treating the adenoma before conception.

But with many women delaying pregnancy, it's not uncommon to see a woman in her late 30s with a macro-adenoma who says she wants to get pregnant soon and doesn't have the luxury of suppressing the tumor for a year or two on medical therapy before conception, Dr. J. Blake Tyrrell said at a conference on diabetes and advances in endocrinology and metabolism sponsored by the University of California, San Francisco.

The sparse data available to help guide the management of these patients suggest that suppressing prolactin-secreting adenomas with dopamine agonists reduces the effects of the tumor and allows the patient to get pregnant without increasing the risk of fetal loss or fetal abnormalities.

There is less experience with cabergoline, today's treatment of choice, than with the former first-line agent bromocriptine.

Whether the patient has a microadenoma or macroadenoma, Dr. Tyrrell prefers to treat with cabergoline to allow menstrual cycles to normalize. If the patient misses a period, test for pregnancy, and if she is pregnant discontinue cabergoline, advised Dr. Tyrrell, director of the endocrinology clinic at the university. With this method, fetal exposure to the drug should be no more than a couple of weeks, he said.

Once off of therapy, fewer than 2% of microadenomas will enlarge during pregnancy. Given this low risk, many providers choose to leave them alone during pregnancy. Dr. Tyrrell suggested following prolactin levels every 6 weeks, and if they get as high as 500 ng/mL, “I might get a bit concerned and ask the patient how she's doing,” he said.

Macroadenomas that are left untreated during pregnancy will enlarge in about 23% of cases and cause headache and visual field defects. “That's not a situation you want to get into,” he said. Only 3% of macroadenomas that were surgically debulked prior to conception enlarged during pregnancy, but medical therapy has largely replaced surgical treatment for prolactinomas.

In the management of macroadenomas during pregnancy, “we're on very thin ice” due to very limited data on the risks from taking dopamine agonists before or during pregnancy, he said.

One study reported on 86 women with macroadenomas who conceived after bromocriptine treatment, which was then stopped. Twenty women (23%) developed visual field defects during pregnancy. Four patients then underwent surgical treatment and 15 received bromocriptine therapy, and all 20 had successful pregnancy outcomes (Endocrinol. Metab. Clin. North Am. 2006;35:99–116).

Data from the early 1980s described 29 women with macroadenomas who were managed with continuous bromocriptine throughout pregnancy. Two developed visual field defects. All had successful pregnancy outcomes. Dr. Tyrrell noted that 7 of these 29 women probably had nonfunctional tumors because their serum prolactin levels were less than 200 ng/mL, which suggests that continuous drug therapy was associated with an even higher rate of visual field defects in women with functioning tumors (in 2 of 22) patients.

That's about the extent of the world literature on managing macroadenomas during pregnancy, which is “not very good considering that these drugs have been around for 30-plus years,” he said. There are no data on continuous cabergoline therapy during pregnancy.

In the worst-case scenario, a macro-adenoma may enlarge, usually during the second or third trimester, causing headache and visual field defects. A noncontrast MRI can be done safely during pregnancy to define the size.

If the tumor is enlarging, try medical therapy, and deliver the fetus early if it's viable. Surgery is a last resort, Dr. Tyrrell said. “Think about this if you can ahead of time to deal with the tumor before conception, before getting into trouble during pregnancy,” he concluded.

SAN FRANCISCO — Complications from a prolactinoma during pregnancy are best avoided by treating the adenoma before conception.

But with many women delaying pregnancy, it's not uncommon to see a woman in her late 30s with a macro-adenoma who says she wants to get pregnant soon and doesn't have the luxury of suppressing the tumor for a year or two on medical therapy before conception, Dr. J. Blake Tyrrell said at a conference on diabetes and advances in endocrinology and metabolism sponsored by the University of California, San Francisco.

The sparse data available to help guide the management of these patients suggest that suppressing prolactin-secreting adenomas with dopamine agonists reduces the effects of the tumor and allows the patient to get pregnant without increasing the risk of fetal loss or fetal abnormalities.

There is less experience with cabergoline, today's treatment of choice, than with the former first-line agent bromocriptine.

Whether the patient has a microadenoma or macroadenoma, Dr. Tyrrell prefers to treat with cabergoline to allow menstrual cycles to normalize. If the patient misses a period, test for pregnancy, and if she is pregnant discontinue cabergoline, advised Dr. Tyrrell, director of the endocrinology clinic at the university. With this method, fetal exposure to the drug should be no more than a couple of weeks, he said.

Once off of therapy, fewer than 2% of microadenomas will enlarge during pregnancy. Given this low risk, many providers choose to leave them alone during pregnancy. Dr. Tyrrell suggested following prolactin levels every 6 weeks, and if they get as high as 500 ng/mL, “I might get a bit concerned and ask the patient how she's doing,” he said.

Macroadenomas that are left untreated during pregnancy will enlarge in about 23% of cases and cause headache and visual field defects. “That's not a situation you want to get into,” he said. Only 3% of macroadenomas that were surgically debulked prior to conception enlarged during pregnancy, but medical therapy has largely replaced surgical treatment for prolactinomas.

In the management of macroadenomas during pregnancy, “we're on very thin ice” due to very limited data on the risks from taking dopamine agonists before or during pregnancy, he said.

One study reported on 86 women with macroadenomas who conceived after bromocriptine treatment, which was then stopped. Twenty women (23%) developed visual field defects during pregnancy. Four patients then underwent surgical treatment and 15 received bromocriptine therapy, and all 20 had successful pregnancy outcomes (Endocrinol. Metab. Clin. North Am. 2006;35:99–116).

Data from the early 1980s described 29 women with macroadenomas who were managed with continuous bromocriptine throughout pregnancy. Two developed visual field defects. All had successful pregnancy outcomes. Dr. Tyrrell noted that 7 of these 29 women probably had nonfunctional tumors because their serum prolactin levels were less than 200 ng/mL, which suggests that continuous drug therapy was associated with an even higher rate of visual field defects in women with functioning tumors (in 2 of 22) patients.

That's about the extent of the world literature on managing macroadenomas during pregnancy, which is “not very good considering that these drugs have been around for 30-plus years,” he said. There are no data on continuous cabergoline therapy during pregnancy.

In the worst-case scenario, a macro-adenoma may enlarge, usually during the second or third trimester, causing headache and visual field defects. A noncontrast MRI can be done safely during pregnancy to define the size.

If the tumor is enlarging, try medical therapy, and deliver the fetus early if it's viable. Surgery is a last resort, Dr. Tyrrell said. “Think about this if you can ahead of time to deal with the tumor before conception, before getting into trouble during pregnancy,” he concluded.

Obese women should gain no more than 20 pounds during pregnancy, according to new guidelines released by the Institute of Medicine and the National Research Council.

The IOM hasn't updated its guidelines on weight gain during pregnancy since 1990. The revised recommendations are designed to reflect the increasing number of overweight and obese Americans, women having children at an older age, and multiple births, and the increase in weight gain during pregnancy, as well as other changing demographic factors.

The new guidelines set an upper and lower threshold for weight gain among obese women, advising women with a body mass index of greater than 30 kg/m

The new guidelines also include charts on the recommended rate of weight gain at various stages throughout pregnancy. For example, normal-weight women are advised to gain a mean of 1 pound per week during the second and third trimesters.

“The committee intends that the new guidelines will be used in concert with good clinical judgment and include a discussion between the woman and her health care provider about diet and exercise,” Kathleen M. Rasmussen, Sc.D., professor in the division of nutritional sciences at Cornell University, Ithaca, N.Y., and chair of the committee, said during a press briefing to release the report.

Currently, the average weight gain in pregnancy is about 30.5 pounds, but it varies considerably based on the woman's prepregnancy BMI category, Dr. Rasmussen said. For underweight and normal-weight women, the average weight gain is about 32 pounds, compared with 30 pounds among overweight women and 25 pounds among obese women. Between 40% and 73% of women are outside of the new recommended ranges, with some gaining more and some less than recommended.

A woman's weight at the time of conception, and weight gain that is outside the recommended ranges during pregnancy, can have health consequences, especially for obese and overweight women. If a woman is overweight or obese before she gets pregnant, she has a higher risk for complications such as preeclampsia and gestational diabetes. Add to that excessive weight gain during pregnancy and there is an increased risk of needing a cesarean delivery and an increased risk of retaining the weight in the postpartum period. Obese women also are at risk for having babies who are either small for gestational age or large for gestational age, committee members said.

Although the committee's recommendations are not dramatically different from those issued in 1990, fully implementing them would represent a shift in prenatal care in the United States, Dr. Rasmussen said. This shift begins with ob.gyns. and other providers of prenatal care offering overweight and obese women counseling on diet and exercise before they conceive. And all pregnant women should be offered counseling on diet and physical activity to help them stay within the recommended weight limits during pregnancy, she said.

Counseling on diet and exercise should also continue into the postpartum period, the committee recommended, so that women can return to a healthy weight before a future pregnancy.

But not all of this counseling needs to be on the shoulders of the ob.gyn. community, said committee member David A. Savitz, Ph.D., professor of community and preventive medicine at Mount Sinai School of Medicine in New York. “It's clear that we don't look at this issue as something that will be solely and fully managed within the confines of the obstetrician's office. This is a community issue.”

Tailoring diet and exercise advice to the individual woman also is critical, said Anna Maria Siega-Riz, Ph.D., of the department of maternal and child health at the University of North Carolina at Chapel Hill and a member of the committee. Many women are simply handed the guidelines, but aren't given a chance to talk through how the weight gain recommendations could fit into their individual lifestyles.

The report does offer “provisional” guidelines for women carrying twins to term. The committee advised that normal-weight women gain between 37 and 54 pounds; overweight women, between 31 and 50 pounds; and obese women, between 25 and 42 pounds. There was not enough information to develop recommendations on underweight women who are carrying twins.

This study was supported by funds from the Department of Health and Human Services Health Resources and Services Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, the Office on Women's Health, the Office of Disease Prevention and Health Promotion, the Office of Minority Health, and the March of Dimes.

The full report is available online at www.iom.edu/pregnancyweightgain

ELSEVIER GLOBAL MEDICAL NEWS

Obese women should gain no more than 20 pounds during pregnancy, according to new guidelines released by the Institute of Medicine and the National Research Council.

The IOM hasn't updated its guidelines on weight gain during pregnancy since 1990. The revised recommendations are designed to reflect the increasing number of overweight and obese Americans, women having children at an older age, and multiple births, and the increase in weight gain during pregnancy, as well as other changing demographic factors.

The new guidelines set an upper and lower threshold for weight gain among obese women, advising women with a body mass index of greater than 30 kg/m

The new guidelines also include charts on the recommended rate of weight gain at various stages throughout pregnancy. For example, normal-weight women are advised to gain a mean of 1 pound per week during the second and third trimesters.

“The committee intends that the new guidelines will be used in concert with good clinical judgment and include a discussion between the woman and her health care provider about diet and exercise,” Kathleen M. Rasmussen, Sc.D., professor in the division of nutritional sciences at Cornell University, Ithaca, N.Y., and chair of the committee, said during a press briefing to release the report.

Currently, the average weight gain in pregnancy is about 30.5 pounds, but it varies considerably based on the woman's prepregnancy BMI category, Dr. Rasmussen said. For underweight and normal-weight women, the average weight gain is about 32 pounds, compared with 30 pounds among overweight women and 25 pounds among obese women. Between 40% and 73% of women are outside of the new recommended ranges, with some gaining more and some less than recommended.

A woman's weight at the time of conception, and weight gain that is outside the recommended ranges during pregnancy, can have health consequences, especially for obese and overweight women. If a woman is overweight or obese before she gets pregnant, she has a higher risk for complications such as preeclampsia and gestational diabetes. Add to that excessive weight gain during pregnancy and there is an increased risk of needing a cesarean delivery and an increased risk of retaining the weight in the postpartum period. Obese women also are at risk for having babies who are either small for gestational age or large for gestational age, committee members said.

Although the committee's recommendations are not dramatically different from those issued in 1990, fully implementing them would represent a shift in prenatal care in the United States, Dr. Rasmussen said. This shift begins with ob.gyns. and other providers of prenatal care offering overweight and obese women counseling on diet and exercise before they conceive. And all pregnant women should be offered counseling on diet and physical activity to help them stay within the recommended weight limits during pregnancy, she said.

Counseling on diet and exercise should also continue into the postpartum period, the committee recommended, so that women can return to a healthy weight before a future pregnancy.

But not all of this counseling needs to be on the shoulders of the ob.gyn. community, said committee member David A. Savitz, Ph.D., professor of community and preventive medicine at Mount Sinai School of Medicine in New York. “It's clear that we don't look at this issue as something that will be solely and fully managed within the confines of the obstetrician's office. This is a community issue.”

Tailoring diet and exercise advice to the individual woman also is critical, said Anna Maria Siega-Riz, Ph.D., of the department of maternal and child health at the University of North Carolina at Chapel Hill and a member of the committee. Many women are simply handed the guidelines, but aren't given a chance to talk through how the weight gain recommendations could fit into their individual lifestyles.

The report does offer “provisional” guidelines for women carrying twins to term. The committee advised that normal-weight women gain between 37 and 54 pounds; overweight women, between 31 and 50 pounds; and obese women, between 25 and 42 pounds. There was not enough information to develop recommendations on underweight women who are carrying twins.

This study was supported by funds from the Department of Health and Human Services Health Resources and Services Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, the Office on Women's Health, the Office of Disease Prevention and Health Promotion, the Office of Minority Health, and the March of Dimes.

The full report is available online at www.iom.edu/pregnancyweightgain

ELSEVIER GLOBAL MEDICAL NEWS

Obese women should gain no more than 20 pounds during pregnancy, according to new guidelines released by the Institute of Medicine and the National Research Council.

The IOM hasn't updated its guidelines on weight gain during pregnancy since 1990. The revised recommendations are designed to reflect the increasing number of overweight and obese Americans, women having children at an older age, and multiple births, and the increase in weight gain during pregnancy, as well as other changing demographic factors.

The new guidelines set an upper and lower threshold for weight gain among obese women, advising women with a body mass index of greater than 30 kg/m

The new guidelines also include charts on the recommended rate of weight gain at various stages throughout pregnancy. For example, normal-weight women are advised to gain a mean of 1 pound per week during the second and third trimesters.

“The committee intends that the new guidelines will be used in concert with good clinical judgment and include a discussion between the woman and her health care provider about diet and exercise,” Kathleen M. Rasmussen, Sc.D., professor in the division of nutritional sciences at Cornell University, Ithaca, N.Y., and chair of the committee, said during a press briefing to release the report.

Currently, the average weight gain in pregnancy is about 30.5 pounds, but it varies considerably based on the woman's prepregnancy BMI category, Dr. Rasmussen said. For underweight and normal-weight women, the average weight gain is about 32 pounds, compared with 30 pounds among overweight women and 25 pounds among obese women. Between 40% and 73% of women are outside of the new recommended ranges, with some gaining more and some less than recommended.

A woman's weight at the time of conception, and weight gain that is outside the recommended ranges during pregnancy, can have health consequences, especially for obese and overweight women. If a woman is overweight or obese before she gets pregnant, she has a higher risk for complications such as preeclampsia and gestational diabetes. Add to that excessive weight gain during pregnancy and there is an increased risk of needing a cesarean delivery and an increased risk of retaining the weight in the postpartum period. Obese women also are at risk for having babies who are either small for gestational age or large for gestational age, committee members said.

Although the committee's recommendations are not dramatically different from those issued in 1990, fully implementing them would represent a shift in prenatal care in the United States, Dr. Rasmussen said. This shift begins with ob.gyns. and other providers of prenatal care offering overweight and obese women counseling on diet and exercise before they conceive. And all pregnant women should be offered counseling on diet and physical activity to help them stay within the recommended weight limits during pregnancy, she said.

Counseling on diet and exercise should also continue into the postpartum period, the committee recommended, so that women can return to a healthy weight before a future pregnancy.

But not all of this counseling needs to be on the shoulders of the ob.gyn. community, said committee member David A. Savitz, Ph.D., professor of community and preventive medicine at Mount Sinai School of Medicine in New York. “It's clear that we don't look at this issue as something that will be solely and fully managed within the confines of the obstetrician's office. This is a community issue.”

Tailoring diet and exercise advice to the individual woman also is critical, said Anna Maria Siega-Riz, Ph.D., of the department of maternal and child health at the University of North Carolina at Chapel Hill and a member of the committee. Many women are simply handed the guidelines, but aren't given a chance to talk through how the weight gain recommendations could fit into their individual lifestyles.

The report does offer “provisional” guidelines for women carrying twins to term. The committee advised that normal-weight women gain between 37 and 54 pounds; overweight women, between 31 and 50 pounds; and obese women, between 25 and 42 pounds. There was not enough information to develop recommendations on underweight women who are carrying twins.

This study was supported by funds from the Department of Health and Human Services Health Resources and Services Administration, the Centers for Disease Control and Prevention, the National Institutes of Health, the Office on Women's Health, the Office of Disease Prevention and Health Promotion, the Office of Minority Health, and the March of Dimes.

The full report is available online at www.iom.edu/pregnancyweightgain

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO — Virtually any weight gain during pregnancy by obese women with gestational diabetes resulted in high rates of large-for-gestational-age infants, according to a study released at the annual meeting of the American College of Obstetricians and Gynecologists.

Obese women in the study who either lost weight or maintained their prepregnancy weight during pregnancy while on a medically supervised low-carbohydrate diet gave birth to babies with “close to normal” birth weights. They also had the lowest cesarean delivery rates (10.5%) in the study.

In contrast, more than one in five obese women who gained a modest amount of weight during pregnancy—1-14 pounds—had large-for-gestational-age (LGA) infants.

The LGA rate increased with more weight gain, accounting for 36% of infants born to women who gained 26–35 pounds, and nearly 40% of those born to women who gained more than 35 pounds, said Dr. Deborah L. Conway of the University of Texas Health Science Center at San Antonio.

Dr. Conway explained that her institution carefully monitors women with gestational diabetes and places them on a calorie-controlled, low-carbohydrate diet that includes nutritional counseling. They also receive glyburide or insulin as necessary to achieve euglycemia.

“Although it wasn't the intention, we noticed that some of these women didn't gain weight as you might expect during pregnancy. We weren't sure that was such a bad thing,” said Dr. Conway during an interview at the meeting, where her study was presented in poster form.

The Institute of Medicine is still recommending an 11- to 20 -lb weight gain for obese women during pregnancy in its recently released new guidelines. “What we saw in our study was that under nutritional supervision, it did not appear necessary for obese women with gestational diabetes to gain weight to have normal obstetrical rates of outcome and normal fetal size,” she said in a later interview.

To better understand gestational weight changes in this group, Dr. Poornima Kaul, a fourth-year resident, analyzed birth weights and pregnancy complications among 302 women with gestational diabetes who had a mean prepregnancy body mass index of 35.6 kg/m

The LGA rate among those who lost weight or maintained their prepregnancy weight was 11.8%.

The macrosomia rate (weight greater than 4,000 g) among their infants was 8.8%, and the rate of small-for-gestational-age infants was 8.8%.

These rates are “pretty close to normal,” Dr. Conway said.

Infants born to women who gained a small amount of weight (1–14 pounds) had a 27.3% LGA rate and a 13.6% rate of macrosomia. These women had a 15.1% cesarean delivery rate.

Women who gained 15–25 pounds had rates of LGA, macrosomia, and cesarean delivery of 27.6%, 13.2%, and 23.4%, respectively.

Those who gained 26–35 pounds had rates of LGA, macrosomia, and cesarean delivery of 36.4%, 21.8%, and 26.7%, while rates in women who gained more than 35 pounds were 39.6%, 25%, and 17.2%.

Dr. Kaul and Dr. Conway reported no disclosures.

Dr. Deborah L. Conway (right) and Dr. Poornima Kaul found that more than one in five obese women who gained a modest amount of weight during pregnancy—1–14 pounds—had LGA infants. The LGA rate increased with more weight gain. COURTESY LESTER ROSEBROCK/UT HEALTH SCIENCE CENTER SAN ANTONIO

CHICAGO — Virtually any weight gain during pregnancy by obese women with gestational diabetes resulted in high rates of large-for-gestational-age infants, according to a study released at the annual meeting of the American College of Obstetricians and Gynecologists.

Obese women in the study who either lost weight or maintained their prepregnancy weight during pregnancy while on a medically supervised low-carbohydrate diet gave birth to babies with “close to normal” birth weights. They also had the lowest cesarean delivery rates (10.5%) in the study.

In contrast, more than one in five obese women who gained a modest amount of weight during pregnancy—1-14 pounds—had large-for-gestational-age (LGA) infants.

The LGA rate increased with more weight gain, accounting for 36% of infants born to women who gained 26–35 pounds, and nearly 40% of those born to women who gained more than 35 pounds, said Dr. Deborah L. Conway of the University of Texas Health Science Center at San Antonio.

Dr. Conway explained that her institution carefully monitors women with gestational diabetes and places them on a calorie-controlled, low-carbohydrate diet that includes nutritional counseling. They also receive glyburide or insulin as necessary to achieve euglycemia.

“Although it wasn't the intention, we noticed that some of these women didn't gain weight as you might expect during pregnancy. We weren't sure that was such a bad thing,” said Dr. Conway during an interview at the meeting, where her study was presented in poster form.

The Institute of Medicine is still recommending an 11- to 20 -lb weight gain for obese women during pregnancy in its recently released new guidelines. “What we saw in our study was that under nutritional supervision, it did not appear necessary for obese women with gestational diabetes to gain weight to have normal obstetrical rates of outcome and normal fetal size,” she said in a later interview.

To better understand gestational weight changes in this group, Dr. Poornima Kaul, a fourth-year resident, analyzed birth weights and pregnancy complications among 302 women with gestational diabetes who had a mean prepregnancy body mass index of 35.6 kg/m

The LGA rate among those who lost weight or maintained their prepregnancy weight was 11.8%.

The macrosomia rate (weight greater than 4,000 g) among their infants was 8.8%, and the rate of small-for-gestational-age infants was 8.8%.

These rates are “pretty close to normal,” Dr. Conway said.

Infants born to women who gained a small amount of weight (1–14 pounds) had a 27.3% LGA rate and a 13.6% rate of macrosomia. These women had a 15.1% cesarean delivery rate.

Women who gained 15–25 pounds had rates of LGA, macrosomia, and cesarean delivery of 27.6%, 13.2%, and 23.4%, respectively.

Those who gained 26–35 pounds had rates of LGA, macrosomia, and cesarean delivery of 36.4%, 21.8%, and 26.7%, while rates in women who gained more than 35 pounds were 39.6%, 25%, and 17.2%.

Dr. Kaul and Dr. Conway reported no disclosures.

Dr. Deborah L. Conway (right) and Dr. Poornima Kaul found that more than one in five obese women who gained a modest amount of weight during pregnancy—1–14 pounds—had LGA infants. The LGA rate increased with more weight gain. COURTESY LESTER ROSEBROCK/UT HEALTH SCIENCE CENTER SAN ANTONIO

CHICAGO — Virtually any weight gain during pregnancy by obese women with gestational diabetes resulted in high rates of large-for-gestational-age infants, according to a study released at the annual meeting of the American College of Obstetricians and Gynecologists.

Obese women in the study who either lost weight or maintained their prepregnancy weight during pregnancy while on a medically supervised low-carbohydrate diet gave birth to babies with “close to normal” birth weights. They also had the lowest cesarean delivery rates (10.5%) in the study.

In contrast, more than one in five obese women who gained a modest amount of weight during pregnancy—1-14 pounds—had large-for-gestational-age (LGA) infants.

The LGA rate increased with more weight gain, accounting for 36% of infants born to women who gained 26–35 pounds, and nearly 40% of those born to women who gained more than 35 pounds, said Dr. Deborah L. Conway of the University of Texas Health Science Center at San Antonio.

Dr. Conway explained that her institution carefully monitors women with gestational diabetes and places them on a calorie-controlled, low-carbohydrate diet that includes nutritional counseling. They also receive glyburide or insulin as necessary to achieve euglycemia.

“Although it wasn't the intention, we noticed that some of these women didn't gain weight as you might expect during pregnancy. We weren't sure that was such a bad thing,” said Dr. Conway during an interview at the meeting, where her study was presented in poster form.

The Institute of Medicine is still recommending an 11- to 20 -lb weight gain for obese women during pregnancy in its recently released new guidelines. “What we saw in our study was that under nutritional supervision, it did not appear necessary for obese women with gestational diabetes to gain weight to have normal obstetrical rates of outcome and normal fetal size,” she said in a later interview.

To better understand gestational weight changes in this group, Dr. Poornima Kaul, a fourth-year resident, analyzed birth weights and pregnancy complications among 302 women with gestational diabetes who had a mean prepregnancy body mass index of 35.6 kg/m

The LGA rate among those who lost weight or maintained their prepregnancy weight was 11.8%.

The macrosomia rate (weight greater than 4,000 g) among their infants was 8.8%, and the rate of small-for-gestational-age infants was 8.8%.

These rates are “pretty close to normal,” Dr. Conway said.

Infants born to women who gained a small amount of weight (1–14 pounds) had a 27.3% LGA rate and a 13.6% rate of macrosomia. These women had a 15.1% cesarean delivery rate.

Women who gained 15–25 pounds had rates of LGA, macrosomia, and cesarean delivery of 27.6%, 13.2%, and 23.4%, respectively.

Those who gained 26–35 pounds had rates of LGA, macrosomia, and cesarean delivery of 36.4%, 21.8%, and 26.7%, while rates in women who gained more than 35 pounds were 39.6%, 25%, and 17.2%.

Dr. Kaul and Dr. Conway reported no disclosures.

Dr. Deborah L. Conway (right) and Dr. Poornima Kaul found that more than one in five obese women who gained a modest amount of weight during pregnancy—1–14 pounds—had LGA infants. The LGA rate increased with more weight gain. COURTESY LESTER ROSEBROCK/UT HEALTH SCIENCE CENTER SAN ANTONIO

Children exposed to valproate in utero have significantly lower IQs at age 3 than do children exposed to other antiepileptics during gestation, according to findings from the interim analysis of a large international study.

The drug previously had been associated with a higher rate of birth defects in children exposed prenatally. The combination of findings strengthens a recommendation to avoid valproate as a first-line antiepileptic in women who may bear children, Dr. Kimford J. Meador said in an interview.

“Valproate poses a special risk for both congenital malformations and for cognitive impairment,” said Dr. Meador, principal investigator in the Neurodevelopmental Effects of Antiepileptics Drugs (NEAD) study. “Since there are other therapeutic options, it would seem prudent to try those first. At a minimum, it is critical that physicians inform women of this risk when prescribing valproate so that they may make an informed choice.”

NEAD is an ongoing study of 309 children, including three sets of twins, born in either the United States or the United Kingdom from 1999 to 2004, whose mothers were taking a single antiepileptic drug (AED): carbamazepine, lamotrigine, phenytoin, or valproate. The children are being followed to age 6. Dr. Meador, professor of neurology at Emory University, Atlanta, and his associates reported the results of a planned 3-year interim analysis in the New England Journal of Medicine (2009;360:1597–605).

All of the 303 women in the study were taking the drugs for a seizure disorder. Their mean age at delivery was 30 years. Most women were well controlled on their AED, with about 80% having no seizures during their pregnancy.

Most of the children in the study (258) underwent cognitive assessment at either 2 or 3 years of age, or at both ages. Of these, 73 (28%) had been exposed to carbamazepine, 84 (32%) to lamotrigine, 48 (19%) to phenytoin, and 53 (21%) to valproate. Cognitive testing consisted of the Bayley Scales of Infant Development and the Differential Ability Scales.

IQ scores were adjusted for factors that could significantly affect cognitive development, some of which were maternal IQ; age at delivery; education; type of epilepsy; seizure frequency; socioeconomic status; the use of folate, alcohol, tobacco, and drugs; obstetrical complications; gestational age; birth weight; and breastfeeding.

Children exposed to valproate had the lowest mean IQs of any of the exposure groups (92)—significantly lower than those of any other treatment group. The mean IQ in those exposed to carbamazepine was 98; to lamotrigine, 101; and to phenytoin, 99. These did not vary significantly from one another.

The association of valproate with reduced IQ held after adjustment for the confounders in both a linear regression and subgroup analysis, the investigators said. They also examined whether the IQ scores were related to AED dosage. In this analysis, only valproate maintained a significant dose-response relationship.

Additionally, higher maternal IQs were associated with higher child IQs in all of the treatment groups except valproate.

The results are consistent with several European studies that have found poor cognitive outcomes in children exposed to the drug prenatally, the investigators said. The drug also has been found to increase the rate of congenital malformations, compared with other AEDs. A recent meta-analysis found the rate to be as many as 11% of births.

Unfortunately, Dr. Meador and his colleagues wrote, women whose seizures are well controlled on valproate may be placed on the horns of a dilemma when trying to balance gestational safety with seizure control.

“For some patients, valproate is the only medication that adequately controls seizures. Such women should be informed of the potential risks associated with the use of this medication in pregnancy. If a woman taking valproate is already pregnant, it's critical that she not stop valproate without consultation with her physician, since stopping an antiepileptic drug could lead to seizures and serious consequences for both the woman and her fetus.”

“One other important point is that less than half of the prescriptions for valproate are for seizures or epilepsy. The majority are for pain or psychiatric indications. I believe that the women taking valproate for other indications are at the same risk as our women with epilepsy,” he said in the interview.

The study was supported by grants from the United Kingdom Epilepsy Research Foundation and the National Institute of Neurological Disorders and Stroke. Dr. Meador reported receiving research support from GlaxoSmithKline, Myriad Pharmaceuticals, Marinus Pharmaceuticals, UCB Pharmaceuticals, and several other companies and foundations.

Children exposed to valproate in utero have significantly lower IQs at age 3 than do children exposed to other antiepileptics during gestation, according to findings from the interim analysis of a large international study.

The drug previously had been associated with a higher rate of birth defects in children exposed prenatally. The combination of findings strengthens a recommendation to avoid valproate as a first-line antiepileptic in women who may bear children, Dr. Kimford J. Meador said in an interview.

“Valproate poses a special risk for both congenital malformations and for cognitive impairment,” said Dr. Meador, principal investigator in the Neurodevelopmental Effects of Antiepileptics Drugs (NEAD) study. “Since there are other therapeutic options, it would seem prudent to try those first. At a minimum, it is critical that physicians inform women of this risk when prescribing valproate so that they may make an informed choice.”

NEAD is an ongoing study of 309 children, including three sets of twins, born in either the United States or the United Kingdom from 1999 to 2004, whose mothers were taking a single antiepileptic drug (AED): carbamazepine, lamotrigine, phenytoin, or valproate. The children are being followed to age 6. Dr. Meador, professor of neurology at Emory University, Atlanta, and his associates reported the results of a planned 3-year interim analysis in the New England Journal of Medicine (2009;360:1597–605).

All of the 303 women in the study were taking the drugs for a seizure disorder. Their mean age at delivery was 30 years. Most women were well controlled on their AED, with about 80% having no seizures during their pregnancy.

Most of the children in the study (258) underwent cognitive assessment at either 2 or 3 years of age, or at both ages. Of these, 73 (28%) had been exposed to carbamazepine, 84 (32%) to lamotrigine, 48 (19%) to phenytoin, and 53 (21%) to valproate. Cognitive testing consisted of the Bayley Scales of Infant Development and the Differential Ability Scales.

IQ scores were adjusted for factors that could significantly affect cognitive development, some of which were maternal IQ; age at delivery; education; type of epilepsy; seizure frequency; socioeconomic status; the use of folate, alcohol, tobacco, and drugs; obstetrical complications; gestational age; birth weight; and breastfeeding.

Children exposed to valproate had the lowest mean IQs of any of the exposure groups (92)—significantly lower than those of any other treatment group. The mean IQ in those exposed to carbamazepine was 98; to lamotrigine, 101; and to phenytoin, 99. These did not vary significantly from one another.

The association of valproate with reduced IQ held after adjustment for the confounders in both a linear regression and subgroup analysis, the investigators said. They also examined whether the IQ scores were related to AED dosage. In this analysis, only valproate maintained a significant dose-response relationship.

Additionally, higher maternal IQs were associated with higher child IQs in all of the treatment groups except valproate.

The results are consistent with several European studies that have found poor cognitive outcomes in children exposed to the drug prenatally, the investigators said. The drug also has been found to increase the rate of congenital malformations, compared with other AEDs. A recent meta-analysis found the rate to be as many as 11% of births.

Unfortunately, Dr. Meador and his colleagues wrote, women whose seizures are well controlled on valproate may be placed on the horns of a dilemma when trying to balance gestational safety with seizure control.

“For some patients, valproate is the only medication that adequately controls seizures. Such women should be informed of the potential risks associated with the use of this medication in pregnancy. If a woman taking valproate is already pregnant, it's critical that she not stop valproate without consultation with her physician, since stopping an antiepileptic drug could lead to seizures and serious consequences for both the woman and her fetus.”

“One other important point is that less than half of the prescriptions for valproate are for seizures or epilepsy. The majority are for pain or psychiatric indications. I believe that the women taking valproate for other indications are at the same risk as our women with epilepsy,” he said in the interview.

The study was supported by grants from the United Kingdom Epilepsy Research Foundation and the National Institute of Neurological Disorders and Stroke. Dr. Meador reported receiving research support from GlaxoSmithKline, Myriad Pharmaceuticals, Marinus Pharmaceuticals, UCB Pharmaceuticals, and several other companies and foundations.

Children exposed to valproate in utero have significantly lower IQs at age 3 than do children exposed to other antiepileptics during gestation, according to findings from the interim analysis of a large international study.

The drug previously had been associated with a higher rate of birth defects in children exposed prenatally. The combination of findings strengthens a recommendation to avoid valproate as a first-line antiepileptic in women who may bear children, Dr. Kimford J. Meador said in an interview.

“Valproate poses a special risk for both congenital malformations and for cognitive impairment,” said Dr. Meador, principal investigator in the Neurodevelopmental Effects of Antiepileptics Drugs (NEAD) study. “Since there are other therapeutic options, it would seem prudent to try those first. At a minimum, it is critical that physicians inform women of this risk when prescribing valproate so that they may make an informed choice.”

NEAD is an ongoing study of 309 children, including three sets of twins, born in either the United States or the United Kingdom from 1999 to 2004, whose mothers were taking a single antiepileptic drug (AED): carbamazepine, lamotrigine, phenytoin, or valproate. The children are being followed to age 6. Dr. Meador, professor of neurology at Emory University, Atlanta, and his associates reported the results of a planned 3-year interim analysis in the New England Journal of Medicine (2009;360:1597–605).

All of the 303 women in the study were taking the drugs for a seizure disorder. Their mean age at delivery was 30 years. Most women were well controlled on their AED, with about 80% having no seizures during their pregnancy.

Most of the children in the study (258) underwent cognitive assessment at either 2 or 3 years of age, or at both ages. Of these, 73 (28%) had been exposed to carbamazepine, 84 (32%) to lamotrigine, 48 (19%) to phenytoin, and 53 (21%) to valproate. Cognitive testing consisted of the Bayley Scales of Infant Development and the Differential Ability Scales.

IQ scores were adjusted for factors that could significantly affect cognitive development, some of which were maternal IQ; age at delivery; education; type of epilepsy; seizure frequency; socioeconomic status; the use of folate, alcohol, tobacco, and drugs; obstetrical complications; gestational age; birth weight; and breastfeeding.

Children exposed to valproate had the lowest mean IQs of any of the exposure groups (92)—significantly lower than those of any other treatment group. The mean IQ in those exposed to carbamazepine was 98; to lamotrigine, 101; and to phenytoin, 99. These did not vary significantly from one another.

The association of valproate with reduced IQ held after adjustment for the confounders in both a linear regression and subgroup analysis, the investigators said. They also examined whether the IQ scores were related to AED dosage. In this analysis, only valproate maintained a significant dose-response relationship.

Additionally, higher maternal IQs were associated with higher child IQs in all of the treatment groups except valproate.

The results are consistent with several European studies that have found poor cognitive outcomes in children exposed to the drug prenatally, the investigators said. The drug also has been found to increase the rate of congenital malformations, compared with other AEDs. A recent meta-analysis found the rate to be as many as 11% of births.

Unfortunately, Dr. Meador and his colleagues wrote, women whose seizures are well controlled on valproate may be placed on the horns of a dilemma when trying to balance gestational safety with seizure control.

“For some patients, valproate is the only medication that adequately controls seizures. Such women should be informed of the potential risks associated with the use of this medication in pregnancy. If a woman taking valproate is already pregnant, it's critical that she not stop valproate without consultation with her physician, since stopping an antiepileptic drug could lead to seizures and serious consequences for both the woman and her fetus.”

“One other important point is that less than half of the prescriptions for valproate are for seizures or epilepsy. The majority are for pain or psychiatric indications. I believe that the women taking valproate for other indications are at the same risk as our women with epilepsy,” he said in the interview.

The study was supported by grants from the United Kingdom Epilepsy Research Foundation and the National Institute of Neurological Disorders and Stroke. Dr. Meador reported receiving research support from GlaxoSmithKline, Myriad Pharmaceuticals, Marinus Pharmaceuticals, UCB Pharmaceuticals, and several other companies and foundations.

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

Atrial Fibrillation and Syncope After Leg Fracture
A 53-year-old man with a history of atrial fibrillation broke his leg in a fall. He was transported to the defendant hospital, where he received a cast. He was released with instructions to remain immobile.

Two days later, the man experienced an episode of syncope, atrial fibrillation, shortness of breath, seizure-like activity, and profuse sweating. He was taken by ambulance to the defendant hospital. By the time he arrived there, his atrial fibrillation had converted spontaneously to normal sinus rhythm, and his other symptoms had also resolved. The differential diagnosis included syncope, seizure, acute coronary syndrome, and pulmonary embolism.

An ECG performed at the hospital was negative for ischemia. Shortly after the test, however, the patient’s oxygen saturation fell to between 91% and 94% on room air, and supplemental oxygen was started. A chest x-ray was initially read as normal, but a radiologist who reviewed it noted that it was suggestive of pulmonary embolism. There was no indication that this was communicated to the emergency department (ED) staff.

CT was ordered but not performed until about three hours later. It revealed a large pulmonary embolism in the right and left pulmonary arteries. The scan was not read until an hour after it was performed—at about the same time that the man experienced fatal cardiac arrest as a result of the pulmonary embolism. The decedent had not been given anticoagulants at any time while in the hospital.

The plaintiff claimed that more aggressive testing should have been performed to rule out pulmonary embolism and that CT should have been performed earlier, with heparin administered until a diagnosis of pulmonary embolism was confirmed.

The defendants argued that the actions they took were proper and that the size of the pulmonary embolism made the decedent’s survival impossible.

According to a published account, a $1 million settlement was reached.

Defense Claims Placental Abruption Was Sudden, Unpredictable
A 38-year-old woman had received uneventful prenatal care from the defendant obstetricians since March. In October, she presented to the defendants’ office with persistent vaginal bleeding and abdominal and back pain. She was hospitalized for evaluation and electronic fetal heart monitoring.

After about one hour of monitoring, it was determined that the patient was not in labor. Reassuring signs of fetal well-being were also reported. The woman was discharged to home despite continued bleeding and abdominal pain.

She returned to the defendants’ office early that afternoon with complaints of increasing bleeding and pain. She was advised to go to the hospital for delivery. Shortly before arriving there, the patient experienced massive hemorrhaging in the car due to placental abruption. The infant was stillborn before an emergency cesarean delivery could be performed. The mother required transfusions for disseminated intravascular coagulation and blood loss.

The plaintiff claimed that she had been discharged from the hospital without a proper workup for persistent bleeding and abdominal pain and that ultrasonography should have been ordered.

The defendant claimed that the discharge was appropriate because the woman’s condition had improved and delivery did not appear imminent. The defendant also claimed that the sudden massive placental abruption was unpredictable.

A verdict of $1,651,166 was returned.

Surgery Delayed Due to Patient’s Body Habitus
In May 2003, a 48-year-old woman presented to the defendant hospital’s ED with complaints of left lower quadrant pain with possible gynecologic etiology. She was examined by the defendant general surgeon, Dr. B., who ordered CT. The test revealed a left pelvic inflammation and a possible cystic mass in the left ovary.

During the patient’s hospitalization, Dr. B. consulted with specialists in gastroenterology, pulmonary disease, family practice, infectious disease, and gynecology. The infectious disease specialist administered IV antibiotics as a precaution against an infectious process. The patient was discharged after 12 days’ hospitalization with a prescription for oral antibiotics from the infectious disease consultant.

The woman returned to the ED the following day, complaining of pain, shortness of breath, and diaphoresis. Her white blood cell count was 17,000/mL, which was consistent with findings from the previous week. Results of other laboratory tests were normal. Apart from revealing a resolving left lower lung infiltrate, abdominal x-ray yielded unremarkable results.

When the ED physician consulted with Dr. B., it was determined that the patient had been taking an insufficient amount of acetaminophen/hydrocodone for her body habitus (BMI, 53.2). The plaintiff was discharged with instructions to take the pain medication as prescribed and to follow up with her family clinician in two days.

At this appointment, the family clinician was concerned about the woman’s respiratory status and instructed her to return to the ED. She was readmitted and underwent an exploratory laparotomy, appendectomy, lysis of adhesions, drainage of a pelvic abscess, and a right oophorectomy. It was extremely difficult to wean the patient from the ventilator after surgery, which necessitated treatment at an extended-stay facility until early July. She was then referred to a rehabilitation center for more than one month. As of the date of trial, she remained dependent on supplemental oxygen.

The plaintiff claimed that Dr. B. was negligent for failing to order additional abdominal scans before the patient’s initial discharge as well as for not continuing IV antibiotics, not performing a needle aspiration of a suspected tubo-ovarian abscess, and not removing the diseased ovary surgically. Further, the patient claimed that she had been discharged improperly.

The defendant argued that the plaintiff’s obesity, her pulmonary problems, and her cigarette smoking convinced the physicians that surgery should not be performed without giving medical treatment a chance to work.

A defense verdict was returned.

Colon Perforated During Surgery for Endometriosis
After a miscarriage attributed to endometriosis, a 35-year-old woman was treated by the defendant Ob-Gyn, Dr. V., at the defendant women’s health center. Dr. V. performed an exploratory laparoscopy to remove the endometriotic lesions. The patient was discharged but returned later that day with symptoms of peritonitis.

During an open exploratory emergency surgery, a perforation was discovered and the bowel was repaired. The surgery included placement of a colostomy bag, which was reversed five months later. The patient required an extended recovery, which included an ICU stay for treatment of peritonitis, development of intestinal problems due to scar tissue, recurrence and worsening of preexisting irritable bowel syndrome, and development of a hernia at the surgical site, which required additional surgery and scar revision one year later. She continued to have intestinal problems.

It was during the initial laparoscopic surgery, the plaintiff claimed, that her large bowel was perforated, and the perforation went unnoticed—both due to negligence.

The defendant contended that the endometrial nodule was some distance from the bowel and that a small portion of the bowel was bound up in the scarring but was not visible in the operative field. The defendant also claimed that the plaintiff’s intestinal complications following the colostomy reversal were due to preexisting irritable bowel syndrome and were not related to the bowel perforation. Finally, the defendant argued that perforation was a known risk of the surgery.

A verdict of $717,871 was returned.

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

Atrial Fibrillation and Syncope After Leg Fracture
A 53-year-old man with a history of atrial fibrillation broke his leg in a fall. He was transported to the defendant hospital, where he received a cast. He was released with instructions to remain immobile.

Two days later, the man experienced an episode of syncope, atrial fibrillation, shortness of breath, seizure-like activity, and profuse sweating. He was taken by ambulance to the defendant hospital. By the time he arrived there, his atrial fibrillation had converted spontaneously to normal sinus rhythm, and his other symptoms had also resolved. The differential diagnosis included syncope, seizure, acute coronary syndrome, and pulmonary embolism.

An ECG performed at the hospital was negative for ischemia. Shortly after the test, however, the patient’s oxygen saturation fell to between 91% and 94% on room air, and supplemental oxygen was started. A chest x-ray was initially read as normal, but a radiologist who reviewed it noted that it was suggestive of pulmonary embolism. There was no indication that this was communicated to the emergency department (ED) staff.

CT was ordered but not performed until about three hours later. It revealed a large pulmonary embolism in the right and left pulmonary arteries. The scan was not read until an hour after it was performed—at about the same time that the man experienced fatal cardiac arrest as a result of the pulmonary embolism. The decedent had not been given anticoagulants at any time while in the hospital.

The plaintiff claimed that more aggressive testing should have been performed to rule out pulmonary embolism and that CT should have been performed earlier, with heparin administered until a diagnosis of pulmonary embolism was confirmed.

The defendants argued that the actions they took were proper and that the size of the pulmonary embolism made the decedent’s survival impossible.

According to a published account, a $1 million settlement was reached.

Defense Claims Placental Abruption Was Sudden, Unpredictable
A 38-year-old woman had received uneventful prenatal care from the defendant obstetricians since March. In October, she presented to the defendants’ office with persistent vaginal bleeding and abdominal and back pain. She was hospitalized for evaluation and electronic fetal heart monitoring.

After about one hour of monitoring, it was determined that the patient was not in labor. Reassuring signs of fetal well-being were also reported. The woman was discharged to home despite continued bleeding and abdominal pain.

She returned to the defendants’ office early that afternoon with complaints of increasing bleeding and pain. She was advised to go to the hospital for delivery. Shortly before arriving there, the patient experienced massive hemorrhaging in the car due to placental abruption. The infant was stillborn before an emergency cesarean delivery could be performed. The mother required transfusions for disseminated intravascular coagulation and blood loss.

The plaintiff claimed that she had been discharged from the hospital without a proper workup for persistent bleeding and abdominal pain and that ultrasonography should have been ordered.

The defendant claimed that the discharge was appropriate because the woman’s condition had improved and delivery did not appear imminent. The defendant also claimed that the sudden massive placental abruption was unpredictable.

A verdict of $1,651,166 was returned.

Surgery Delayed Due to Patient’s Body Habitus
In May 2003, a 48-year-old woman presented to the defendant hospital’s ED with complaints of left lower quadrant pain with possible gynecologic etiology. She was examined by the defendant general surgeon, Dr. B., who ordered CT. The test revealed a left pelvic inflammation and a possible cystic mass in the left ovary.

During the patient’s hospitalization, Dr. B. consulted with specialists in gastroenterology, pulmonary disease, family practice, infectious disease, and gynecology. The infectious disease specialist administered IV antibiotics as a precaution against an infectious process. The patient was discharged after 12 days’ hospitalization with a prescription for oral antibiotics from the infectious disease consultant.

The woman returned to the ED the following day, complaining of pain, shortness of breath, and diaphoresis. Her white blood cell count was 17,000/mL, which was consistent with findings from the previous week. Results of other laboratory tests were normal. Apart from revealing a resolving left lower lung infiltrate, abdominal x-ray yielded unremarkable results.

When the ED physician consulted with Dr. B., it was determined that the patient had been taking an insufficient amount of acetaminophen/hydrocodone for her body habitus (BMI, 53.2). The plaintiff was discharged with instructions to take the pain medication as prescribed and to follow up with her family clinician in two days.

At this appointment, the family clinician was concerned about the woman’s respiratory status and instructed her to return to the ED. She was readmitted and underwent an exploratory laparotomy, appendectomy, lysis of adhesions, drainage of a pelvic abscess, and a right oophorectomy. It was extremely difficult to wean the patient from the ventilator after surgery, which necessitated treatment at an extended-stay facility until early July. She was then referred to a rehabilitation center for more than one month. As of the date of trial, she remained dependent on supplemental oxygen.

The plaintiff claimed that Dr. B. was negligent for failing to order additional abdominal scans before the patient’s initial discharge as well as for not continuing IV antibiotics, not performing a needle aspiration of a suspected tubo-ovarian abscess, and not removing the diseased ovary surgically. Further, the patient claimed that she had been discharged improperly.

The defendant argued that the plaintiff’s obesity, her pulmonary problems, and her cigarette smoking convinced the physicians that surgery should not be performed without giving medical treatment a chance to work.

A defense verdict was returned.

Colon Perforated During Surgery for Endometriosis
After a miscarriage attributed to endometriosis, a 35-year-old woman was treated by the defendant Ob-Gyn, Dr. V., at the defendant women’s health center. Dr. V. performed an exploratory laparoscopy to remove the endometriotic lesions. The patient was discharged but returned later that day with symptoms of peritonitis.

During an open exploratory emergency surgery, a perforation was discovered and the bowel was repaired. The surgery included placement of a colostomy bag, which was reversed five months later. The patient required an extended recovery, which included an ICU stay for treatment of peritonitis, development of intestinal problems due to scar tissue, recurrence and worsening of preexisting irritable bowel syndrome, and development of a hernia at the surgical site, which required additional surgery and scar revision one year later. She continued to have intestinal problems.

It was during the initial laparoscopic surgery, the plaintiff claimed, that her large bowel was perforated, and the perforation went unnoticed—both due to negligence.

The defendant contended that the endometrial nodule was some distance from the bowel and that a small portion of the bowel was bound up in the scarring but was not visible in the operative field. The defendant also claimed that the plaintiff’s intestinal complications following the colostomy reversal were due to preexisting irritable bowel syndrome and were not related to the bowel perforation. Finally, the defendant argued that perforation was a known risk of the surgery.

A verdict of $717,871 was returned.

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

Atrial Fibrillation and Syncope After Leg Fracture
A 53-year-old man with a history of atrial fibrillation broke his leg in a fall. He was transported to the defendant hospital, where he received a cast. He was released with instructions to remain immobile.

Two days later, the man experienced an episode of syncope, atrial fibrillation, shortness of breath, seizure-like activity, and profuse sweating. He was taken by ambulance to the defendant hospital. By the time he arrived there, his atrial fibrillation had converted spontaneously to normal sinus rhythm, and his other symptoms had also resolved. The differential diagnosis included syncope, seizure, acute coronary syndrome, and pulmonary embolism.

An ECG performed at the hospital was negative for ischemia. Shortly after the test, however, the patient’s oxygen saturation fell to between 91% and 94% on room air, and supplemental oxygen was started. A chest x-ray was initially read as normal, but a radiologist who reviewed it noted that it was suggestive of pulmonary embolism. There was no indication that this was communicated to the emergency department (ED) staff.

CT was ordered but not performed until about three hours later. It revealed a large pulmonary embolism in the right and left pulmonary arteries. The scan was not read until an hour after it was performed—at about the same time that the man experienced fatal cardiac arrest as a result of the pulmonary embolism. The decedent had not been given anticoagulants at any time while in the hospital.

The plaintiff claimed that more aggressive testing should have been performed to rule out pulmonary embolism and that CT should have been performed earlier, with heparin administered until a diagnosis of pulmonary embolism was confirmed.

The defendants argued that the actions they took were proper and that the size of the pulmonary embolism made the decedent’s survival impossible.

According to a published account, a $1 million settlement was reached.

Defense Claims Placental Abruption Was Sudden, Unpredictable
A 38-year-old woman had received uneventful prenatal care from the defendant obstetricians since March. In October, she presented to the defendants’ office with persistent vaginal bleeding and abdominal and back pain. She was hospitalized for evaluation and electronic fetal heart monitoring.

After about one hour of monitoring, it was determined that the patient was not in labor. Reassuring signs of fetal well-being were also reported. The woman was discharged to home despite continued bleeding and abdominal pain.

She returned to the defendants’ office early that afternoon with complaints of increasing bleeding and pain. She was advised to go to the hospital for delivery. Shortly before arriving there, the patient experienced massive hemorrhaging in the car due to placental abruption. The infant was stillborn before an emergency cesarean delivery could be performed. The mother required transfusions for disseminated intravascular coagulation and blood loss.

The plaintiff claimed that she had been discharged from the hospital without a proper workup for persistent bleeding and abdominal pain and that ultrasonography should have been ordered.

The defendant claimed that the discharge was appropriate because the woman’s condition had improved and delivery did not appear imminent. The defendant also claimed that the sudden massive placental abruption was unpredictable.

A verdict of $1,651,166 was returned.

Surgery Delayed Due to Patient’s Body Habitus
In May 2003, a 48-year-old woman presented to the defendant hospital’s ED with complaints of left lower quadrant pain with possible gynecologic etiology. She was examined by the defendant general surgeon, Dr. B., who ordered CT. The test revealed a left pelvic inflammation and a possible cystic mass in the left ovary.

During the patient’s hospitalization, Dr. B. consulted with specialists in gastroenterology, pulmonary disease, family practice, infectious disease, and gynecology. The infectious disease specialist administered IV antibiotics as a precaution against an infectious process. The patient was discharged after 12 days’ hospitalization with a prescription for oral antibiotics from the infectious disease consultant.

The woman returned to the ED the following day, complaining of pain, shortness of breath, and diaphoresis. Her white blood cell count was 17,000/mL, which was consistent with findings from the previous week. Results of other laboratory tests were normal. Apart from revealing a resolving left lower lung infiltrate, abdominal x-ray yielded unremarkable results.

When the ED physician consulted with Dr. B., it was determined that the patient had been taking an insufficient amount of acetaminophen/hydrocodone for her body habitus (BMI, 53.2). The plaintiff was discharged with instructions to take the pain medication as prescribed and to follow up with her family clinician in two days.

At this appointment, the family clinician was concerned about the woman’s respiratory status and instructed her to return to the ED. She was readmitted and underwent an exploratory laparotomy, appendectomy, lysis of adhesions, drainage of a pelvic abscess, and a right oophorectomy. It was extremely difficult to wean the patient from the ventilator after surgery, which necessitated treatment at an extended-stay facility until early July. She was then referred to a rehabilitation center for more than one month. As of the date of trial, she remained dependent on supplemental oxygen.

The plaintiff claimed that Dr. B. was negligent for failing to order additional abdominal scans before the patient’s initial discharge as well as for not continuing IV antibiotics, not performing a needle aspiration of a suspected tubo-ovarian abscess, and not removing the diseased ovary surgically. Further, the patient claimed that she had been discharged improperly.

The defendant argued that the plaintiff’s obesity, her pulmonary problems, and her cigarette smoking convinced the physicians that surgery should not be performed without giving medical treatment a chance to work.

A defense verdict was returned.

Colon Perforated During Surgery for Endometriosis
After a miscarriage attributed to endometriosis, a 35-year-old woman was treated by the defendant Ob-Gyn, Dr. V., at the defendant women’s health center. Dr. V. performed an exploratory laparoscopy to remove the endometriotic lesions. The patient was discharged but returned later that day with symptoms of peritonitis.

During an open exploratory emergency surgery, a perforation was discovered and the bowel was repaired. The surgery included placement of a colostomy bag, which was reversed five months later. The patient required an extended recovery, which included an ICU stay for treatment of peritonitis, development of intestinal problems due to scar tissue, recurrence and worsening of preexisting irritable bowel syndrome, and development of a hernia at the surgical site, which required additional surgery and scar revision one year later. She continued to have intestinal problems.

It was during the initial laparoscopic surgery, the plaintiff claimed, that her large bowel was perforated, and the perforation went unnoticed—both due to negligence.

The defendant contended that the endometrial nodule was some distance from the bowel and that a small portion of the bowel was bound up in the scarring but was not visible in the operative field. The defendant also claimed that the plaintiff’s intestinal complications following the colostomy reversal were due to preexisting irritable bowel syndrome and were not related to the bowel perforation. Finally, the defendant argued that perforation was a known risk of the surgery.

A verdict of $717,871 was returned.

Women diagnosed with gestational diabetes who gained more than 10 pounds after the pregnancy significantly increased their risk for a cesarean delivery at the next pregnancy, a study of 2,581 women found.

In the study, 5% of women who returned to their prepregnancy weight after being delivered vaginally of a live singleton, or whose prepregnancy weight decreased by more than 10 pounds by the time of their next pregnancy, were delivered by cesarean section in that subsequent pregnancy. Of women whose prepregnancy weights increased by more than 10 pounds, however, 10% had cesarean deliveries in the subsequent pregnancy, Dr. Pathmaja Paramsothy and associates reported (Obstet. Gynecol. 2009;113:817–23).

The risk for cesarean delivery was 70% higher in the weight-gain group after adjustment for the effects of confounding factors including maternal age, race/ethnicity, education, duration of birth interval, weight gain during each pregnancy, smoking, and year of birth, wrote Dr. Paramsothy and colleagues at the University of Washington, Seattle. The results were obtained in a retrospective analysis of linked birth-certificate data for women with at least two singleton births in Washington state from 1992 to 2005.

Of the 2,581 women studied, 35% were in the weight-gain group, 11% were in the weight-loss group, and 54% were in the weight-stable group.

Prepregnancy weight typically is measured at the first prenatal visit. The interpregnancy weight change was calculated by subtracting the prepregnancy weight for the subsequent pregnancy from the prepregnancy weight for the first pregnancy.

Previous studies have identified gestational diabetes, obesity, and excessive weight gain as independent risk factors for cesarean delivery and analyzed the effects of each separately. This may be the first study to look at the association between interpregnancy weight gain and subsequent cesarean delivery in women with gestational diabetes, a population that the investigators hypothesized would be at particularly high risk.

Women who gained more weight between pregnancies were more likely to deliver by cesarean at the subsequent pregnancy, with the risk increasing by 48%–136% depending on the number of pounds gained. Interpregnancy weight gain was more likely in women who were younger, African American or Hispanic, less educated, and more than 3 years from the initial pregnancy.

The rate of cesarean deliveries in the United States climbed from 6% in 1970 to 30% in 2005, potentially increasing the health risks for mothers and newborns and adding at least $15 billion in costs to the health care system, the authors noted. Delivering physicians should counsel women with gestational diabetes about weight management between pregnancies, Dr. Paramsothy and associates said.

Dr. Catherine Spong of the National Institute of Child Health and Human Development commented, “The take-home message from this is that interpregnancy weight gain is an important thing to keep in mind as you are managing patients with gestational diabetes.

“Not only do you want to test them for subsequent development of diabetes, but also monitor their weight gain to try to optimize subsequent pregnancy outcomes.”

New attention is being paid to questions about how much weight a woman can safely gain during or between pregnancies. Guidelines from the Institute of Medicine focus mainly on preventing low birth weight, and aim for at least a 10-pound maternal weight gain during pregnancy but don't address the upper limits of weight gain during or between pregnancies, Dr. Spong said in an interview.

“Now, really, low birth weight isn't particularly the issue. It's the obesity epidemic,” she said.

The Institute of Medicine is reviewing the guidelines and should produce new recommendations in the next few months that Dr. Spong hopes will also target obese and morbidly obese weight levels.

The investigators and Dr. Spong reported no conflicts of interest related to the study.

Women diagnosed with gestational diabetes who gained more than 10 pounds after the pregnancy significantly increased their risk for a cesarean delivery at the next pregnancy, a study of 2,581 women found.

In the study, 5% of women who returned to their prepregnancy weight after being delivered vaginally of a live singleton, or whose prepregnancy weight decreased by more than 10 pounds by the time of their next pregnancy, were delivered by cesarean section in that subsequent pregnancy. Of women whose prepregnancy weights increased by more than 10 pounds, however, 10% had cesarean deliveries in the subsequent pregnancy, Dr. Pathmaja Paramsothy and associates reported (Obstet. Gynecol. 2009;113:817–23).

The risk for cesarean delivery was 70% higher in the weight-gain group after adjustment for the effects of confounding factors including maternal age, race/ethnicity, education, duration of birth interval, weight gain during each pregnancy, smoking, and year of birth, wrote Dr. Paramsothy and colleagues at the University of Washington, Seattle. The results were obtained in a retrospective analysis of linked birth-certificate data for women with at least two singleton births in Washington state from 1992 to 2005.

Of the 2,581 women studied, 35% were in the weight-gain group, 11% were in the weight-loss group, and 54% were in the weight-stable group.

Prepregnancy weight typically is measured at the first prenatal visit. The interpregnancy weight change was calculated by subtracting the prepregnancy weight for the subsequent pregnancy from the prepregnancy weight for the first pregnancy.

Previous studies have identified gestational diabetes, obesity, and excessive weight gain as independent risk factors for cesarean delivery and analyzed the effects of each separately. This may be the first study to look at the association between interpregnancy weight gain and subsequent cesarean delivery in women with gestational diabetes, a population that the investigators hypothesized would be at particularly high risk.

Women who gained more weight between pregnancies were more likely to deliver by cesarean at the subsequent pregnancy, with the risk increasing by 48%–136% depending on the number of pounds gained. Interpregnancy weight gain was more likely in women who were younger, African American or Hispanic, less educated, and more than 3 years from the initial pregnancy.

The rate of cesarean deliveries in the United States climbed from 6% in 1970 to 30% in 2005, potentially increasing the health risks for mothers and newborns and adding at least $15 billion in costs to the health care system, the authors noted. Delivering physicians should counsel women with gestational diabetes about weight management between pregnancies, Dr. Paramsothy and associates said.

Dr. Catherine Spong of the National Institute of Child Health and Human Development commented, “The take-home message from this is that interpregnancy weight gain is an important thing to keep in mind as you are managing patients with gestational diabetes.

“Not only do you want to test them for subsequent development of diabetes, but also monitor their weight gain to try to optimize subsequent pregnancy outcomes.”

New attention is being paid to questions about how much weight a woman can safely gain during or between pregnancies. Guidelines from the Institute of Medicine focus mainly on preventing low birth weight, and aim for at least a 10-pound maternal weight gain during pregnancy but don't address the upper limits of weight gain during or between pregnancies, Dr. Spong said in an interview.

“Now, really, low birth weight isn't particularly the issue. It's the obesity epidemic,” she said.

The Institute of Medicine is reviewing the guidelines and should produce new recommendations in the next few months that Dr. Spong hopes will also target obese and morbidly obese weight levels.

The investigators and Dr. Spong reported no conflicts of interest related to the study.

Women diagnosed with gestational diabetes who gained more than 10 pounds after the pregnancy significantly increased their risk for a cesarean delivery at the next pregnancy, a study of 2,581 women found.

In the study, 5% of women who returned to their prepregnancy weight after being delivered vaginally of a live singleton, or whose prepregnancy weight decreased by more than 10 pounds by the time of their next pregnancy, were delivered by cesarean section in that subsequent pregnancy. Of women whose prepregnancy weights increased by more than 10 pounds, however, 10% had cesarean deliveries in the subsequent pregnancy, Dr. Pathmaja Paramsothy and associates reported (Obstet. Gynecol. 2009;113:817–23).

The risk for cesarean delivery was 70% higher in the weight-gain group after adjustment for the effects of confounding factors including maternal age, race/ethnicity, education, duration of birth interval, weight gain during each pregnancy, smoking, and year of birth, wrote Dr. Paramsothy and colleagues at the University of Washington, Seattle. The results were obtained in a retrospective analysis of linked birth-certificate data for women with at least two singleton births in Washington state from 1992 to 2005.

Of the 2,581 women studied, 35% were in the weight-gain group, 11% were in the weight-loss group, and 54% were in the weight-stable group.

Prepregnancy weight typically is measured at the first prenatal visit. The interpregnancy weight change was calculated by subtracting the prepregnancy weight for the subsequent pregnancy from the prepregnancy weight for the first pregnancy.

Previous studies have identified gestational diabetes, obesity, and excessive weight gain as independent risk factors for cesarean delivery and analyzed the effects of each separately. This may be the first study to look at the association between interpregnancy weight gain and subsequent cesarean delivery in women with gestational diabetes, a population that the investigators hypothesized would be at particularly high risk.

Women who gained more weight between pregnancies were more likely to deliver by cesarean at the subsequent pregnancy, with the risk increasing by 48%–136% depending on the number of pounds gained. Interpregnancy weight gain was more likely in women who were younger, African American or Hispanic, less educated, and more than 3 years from the initial pregnancy.

The rate of cesarean deliveries in the United States climbed from 6% in 1970 to 30% in 2005, potentially increasing the health risks for mothers and newborns and adding at least $15 billion in costs to the health care system, the authors noted. Delivering physicians should counsel women with gestational diabetes about weight management between pregnancies, Dr. Paramsothy and associates said.

Dr. Catherine Spong of the National Institute of Child Health and Human Development commented, “The take-home message from this is that interpregnancy weight gain is an important thing to keep in mind as you are managing patients with gestational diabetes.

“Not only do you want to test them for subsequent development of diabetes, but also monitor their weight gain to try to optimize subsequent pregnancy outcomes.”

New attention is being paid to questions about how much weight a woman can safely gain during or between pregnancies. Guidelines from the Institute of Medicine focus mainly on preventing low birth weight, and aim for at least a 10-pound maternal weight gain during pregnancy but don't address the upper limits of weight gain during or between pregnancies, Dr. Spong said in an interview.

“Now, really, low birth weight isn't particularly the issue. It's the obesity epidemic,” she said.

The Institute of Medicine is reviewing the guidelines and should produce new recommendations in the next few months that Dr. Spong hopes will also target obese and morbidly obese weight levels.

The investigators and Dr. Spong reported no conflicts of interest related to the study.