Obstetrics

TORONTO — There is much to be done to assist women with congenital heart disease in having healthy pregnancies and healthy babies, but this area is fraught with unknowns and requires expertise on the part of a multidisciplinary health care team.

At a session dedicated to the issue of pregnancy during the 18th International Symposium on Adult Congenital Heart Disease, several experts addressed the sticky issues of risk stratification and management before, during, and after pregnancy in women with congenital heart defects.

All speakers stressed the importance of extensive prepregnancy counseling. “Females with congenital heart disease (CHD) should have age-appropriate preconception counseling beginning in adolescence,” said Dr. Samuel Siu, the Gunton Professor of Medicine and chair of cardiology at the University of Western Ontario, London. This counseling should include careful discussion of the risk of pregnancy to both the mother and the fetus, the recurrent risk of CHD in offspring, and antepartum and peripartum management, he noted.

Several congenital conditions carry an excessively high mortality risk during pregnancy, and affected women should avoid pregnancy, said Dr. Siu. Marfan syndrome and aortopathy, Eisenmenger's syndrome (an advanced form of pulmonary artery hypertension), peripartum cardiomyopathy with residual left ventricular dysfunction, severe aortic stenosis, and mechanical valves are all associated with high maternal and fetal death rates, and pregnancy in women with these conditions should be avoided and possibly electively terminated when it does occur, urged the experts.

One particularly sensitive issue is the life expectancy of women with repaired heart defects, taking into account that motherhood is generally at least an 18-year job.

“What is difficult to discuss, and difficult to predict, is the likely longevity of the mother,” said Dr. Carole Warnes, director of adult congenital heart disease at the Mayo Clinic in Rochester, Minn. “Is she going to live another 10 years or 18 years to see this baby going off to college? This is a painful discussion for all of us but I think it's one we have to have as we gaze into our crystal balls.”

Dr. Matthew Sermer, an ob.gyn. from Mount Sinai Hospital in Toronto, stressed the importance of proactive rather than reactive management of this patient group. “Any institution opting to look after this often complex patient population must establish policies and practices that ensure optimal perinatal outcomes,” he said. This should include establishing a multidisciplinary team composed of not only cardiologists and perinatologists, but also a neonatologist, a hematologist, an anesthetist, and nursing staff.

“Nurses must be kept in the loop,” he added. “They are on the front lines and are often the ones seeing a patient crashing. They have to know what to look for and who to tell.”

Patient education is also important, Dr. Sermer noted. “There's no point in having your patient sitting at home in heart failure and waiting for it to go away,” he said.

Fontan Palliation Has Myriad Risks

Pregnant women who have undergone Fontan repair face myriad risks, to themselves and to their fetuses. Cardiac and obstetric complications are common, including New York Heart Association functional class deterioration, atrial fibrillation, gestational hypertension, premature rupture of the membranes, and fetal growth retardation.

Although data are scarce, fetal loss in patients with a Fontan is high, likely approaching 30%, Dr. Warnes said in a discussion of risk stratification and management of pregnant women post-Fontan palliation.

Prepregnancy counseling should include a discussion of the genetic risks to the fetus and a discussion of the patient's drug regimen. “Many of these patients, of course, are on ACE inhibitors and angiotensin receptor blockers that are contraindicated in pregnancy,” Dr. Warnes said.

TORONTO — There is much to be done to assist women with congenital heart disease in having healthy pregnancies and healthy babies, but this area is fraught with unknowns and requires expertise on the part of a multidisciplinary health care team.

At a session dedicated to the issue of pregnancy during the 18th International Symposium on Adult Congenital Heart Disease, several experts addressed the sticky issues of risk stratification and management before, during, and after pregnancy in women with congenital heart defects.

All speakers stressed the importance of extensive prepregnancy counseling. “Females with congenital heart disease (CHD) should have age-appropriate preconception counseling beginning in adolescence,” said Dr. Samuel Siu, the Gunton Professor of Medicine and chair of cardiology at the University of Western Ontario, London. This counseling should include careful discussion of the risk of pregnancy to both the mother and the fetus, the recurrent risk of CHD in offspring, and antepartum and peripartum management, he noted.

Several congenital conditions carry an excessively high mortality risk during pregnancy, and affected women should avoid pregnancy, said Dr. Siu. Marfan syndrome and aortopathy, Eisenmenger's syndrome (an advanced form of pulmonary artery hypertension), peripartum cardiomyopathy with residual left ventricular dysfunction, severe aortic stenosis, and mechanical valves are all associated with high maternal and fetal death rates, and pregnancy in women with these conditions should be avoided and possibly electively terminated when it does occur, urged the experts.

One particularly sensitive issue is the life expectancy of women with repaired heart defects, taking into account that motherhood is generally at least an 18-year job.

“What is difficult to discuss, and difficult to predict, is the likely longevity of the mother,” said Dr. Carole Warnes, director of adult congenital heart disease at the Mayo Clinic in Rochester, Minn. “Is she going to live another 10 years or 18 years to see this baby going off to college? This is a painful discussion for all of us but I think it's one we have to have as we gaze into our crystal balls.”

Dr. Matthew Sermer, an ob.gyn. from Mount Sinai Hospital in Toronto, stressed the importance of proactive rather than reactive management of this patient group. “Any institution opting to look after this often complex patient population must establish policies and practices that ensure optimal perinatal outcomes,” he said. This should include establishing a multidisciplinary team composed of not only cardiologists and perinatologists, but also a neonatologist, a hematologist, an anesthetist, and nursing staff.

“Nurses must be kept in the loop,” he added. “They are on the front lines and are often the ones seeing a patient crashing. They have to know what to look for and who to tell.”

Patient education is also important, Dr. Sermer noted. “There's no point in having your patient sitting at home in heart failure and waiting for it to go away,” he said.

Fontan Palliation Has Myriad Risks

Pregnant women who have undergone Fontan repair face myriad risks, to themselves and to their fetuses. Cardiac and obstetric complications are common, including New York Heart Association functional class deterioration, atrial fibrillation, gestational hypertension, premature rupture of the membranes, and fetal growth retardation.

Although data are scarce, fetal loss in patients with a Fontan is high, likely approaching 30%, Dr. Warnes said in a discussion of risk stratification and management of pregnant women post-Fontan palliation.

Prepregnancy counseling should include a discussion of the genetic risks to the fetus and a discussion of the patient's drug regimen. “Many of these patients, of course, are on ACE inhibitors and angiotensin receptor blockers that are contraindicated in pregnancy,” Dr. Warnes said.

TORONTO — There is much to be done to assist women with congenital heart disease in having healthy pregnancies and healthy babies, but this area is fraught with unknowns and requires expertise on the part of a multidisciplinary health care team.

At a session dedicated to the issue of pregnancy during the 18th International Symposium on Adult Congenital Heart Disease, several experts addressed the sticky issues of risk stratification and management before, during, and after pregnancy in women with congenital heart defects.

All speakers stressed the importance of extensive prepregnancy counseling. “Females with congenital heart disease (CHD) should have age-appropriate preconception counseling beginning in adolescence,” said Dr. Samuel Siu, the Gunton Professor of Medicine and chair of cardiology at the University of Western Ontario, London. This counseling should include careful discussion of the risk of pregnancy to both the mother and the fetus, the recurrent risk of CHD in offspring, and antepartum and peripartum management, he noted.

Several congenital conditions carry an excessively high mortality risk during pregnancy, and affected women should avoid pregnancy, said Dr. Siu. Marfan syndrome and aortopathy, Eisenmenger's syndrome (an advanced form of pulmonary artery hypertension), peripartum cardiomyopathy with residual left ventricular dysfunction, severe aortic stenosis, and mechanical valves are all associated with high maternal and fetal death rates, and pregnancy in women with these conditions should be avoided and possibly electively terminated when it does occur, urged the experts.

One particularly sensitive issue is the life expectancy of women with repaired heart defects, taking into account that motherhood is generally at least an 18-year job.

“What is difficult to discuss, and difficult to predict, is the likely longevity of the mother,” said Dr. Carole Warnes, director of adult congenital heart disease at the Mayo Clinic in Rochester, Minn. “Is she going to live another 10 years or 18 years to see this baby going off to college? This is a painful discussion for all of us but I think it's one we have to have as we gaze into our crystal balls.”

Dr. Matthew Sermer, an ob.gyn. from Mount Sinai Hospital in Toronto, stressed the importance of proactive rather than reactive management of this patient group. “Any institution opting to look after this often complex patient population must establish policies and practices that ensure optimal perinatal outcomes,” he said. This should include establishing a multidisciplinary team composed of not only cardiologists and perinatologists, but also a neonatologist, a hematologist, an anesthetist, and nursing staff.

“Nurses must be kept in the loop,” he added. “They are on the front lines and are often the ones seeing a patient crashing. They have to know what to look for and who to tell.”

Patient education is also important, Dr. Sermer noted. “There's no point in having your patient sitting at home in heart failure and waiting for it to go away,” he said.

Fontan Palliation Has Myriad Risks

Pregnant women who have undergone Fontan repair face myriad risks, to themselves and to their fetuses. Cardiac and obstetric complications are common, including New York Heart Association functional class deterioration, atrial fibrillation, gestational hypertension, premature rupture of the membranes, and fetal growth retardation.

Although data are scarce, fetal loss in patients with a Fontan is high, likely approaching 30%, Dr. Warnes said in a discussion of risk stratification and management of pregnant women post-Fontan palliation.

Prepregnancy counseling should include a discussion of the genetic risks to the fetus and a discussion of the patient's drug regimen. “Many of these patients, of course, are on ACE inhibitors and angiotensin receptor blockers that are contraindicated in pregnancy,” Dr. Warnes said.

CHICAGO — Proinflammatory cytokine levels escalate with normal labor but are not an underlying mechanism of epidural-related fever, according to the results of a study of 92 term parturients.

The researchers found no differences between febrile and afebrile patients in serum levels of the proinflammatory cytokine interleukin-6 during labor or post partum, Dr. Venkat Mantha reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Dr. Mantha of the University of Pittsburgh's Magee Women's Hospital and associates mapped changes in interleukin-6 levels at 4-hour intervals during labor and after delivery and measured neonatal interleukin-6 levels in umbilical cord blood samples in 92 healthy, nulliparous term parturients who went into spontaneous labor and who all received epidural analgesia.

Interleukin-6 levels rose significantly during labor in women who did not have fever as well as in those who did, he said.

The researchers drew peripheral blood and took tympanic temperatures at the time of labor epidural placement and every 4 hours until 4 hours following delivery.

Patients who, at any of the intervals, had a temperature equal to or greater than 38° C were considered febrile.

After delivery of the placenta, umbilical cord blood samples were taken, and neonatal rectal temperatures were taken within 30 minutes of birth.

The 66 afebrile patients and 26 febrile patients shared common characteristics with respect to height, weight, gestational age, and age.

In both groups, interleukin-6 was significantly higher at 8 hours and following delivery, compared with the baseline measurement, but no significant differences were found between the two groups in interleukin-6 levels at any of the measurement intervals.

In addition, while the neonates of febrile mothers had significantly higher temperatures than those of afebrile mothers (36.97° C and 36.68° C, respectively), their umbilical cord serum interleukin-6 levels were statistically the same as the afebrile group.

“We did not find any inflammatory basis for epidural-related fever,” said Dr. Mantha. “We agree with reports that suggest that maternal serum interleukin-6 levels rise in response to labor.”

The study reaffirms the generally accepted view regarding the nature of epidural-related fever, Dr. Mantha commented.

This thinking holds that epidural-related fever is the product of changes in thermoregulatory mechanisms, and that increases in proinflammatory cytokines such as interleukin-6 occur in normal pregnancy and labor.

“All of these years, it's been accepted that epidural-related fever has a physiological basis and that interleukin-6 plays a role in normal labor,” Dr. Mantha said in an interview, noting that interleukin-6's role in labor is not yet understood.

However, studies showing an increase in interleukin-6 during normal labor did not differentiate between patients who had received epidural analgesia and those who had not, he said.

“This [current study] was the first study where the primary aim was to try and find whether there is a relationship between epidural fever and increases in serum levels of interleukin-6,” Dr. Mantha said.

A catalyst for this investigation was the publication of two studies that challenged the thermoregulatory view of epidural-related fever by showing a strong relationship between epidural-related fever and increases in interleukin-6, suggesting the possibility that the fever has an inflammatory basis (Am. J. Obstet. Gynecol. 2002;187:834-8; Am. J. Obstet. Gynecol. 2003;188: 269-74).

Dr. Mantha noted that the study was limited by the fact that it did not include women who had not received labor epidural analgesia; however, performing a randomized study including these women is difficult because more than 90% of parturients at Magee request labor epidural analgesia.

CHICAGO — Proinflammatory cytokine levels escalate with normal labor but are not an underlying mechanism of epidural-related fever, according to the results of a study of 92 term parturients.

The researchers found no differences between febrile and afebrile patients in serum levels of the proinflammatory cytokine interleukin-6 during labor or post partum, Dr. Venkat Mantha reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Dr. Mantha of the University of Pittsburgh's Magee Women's Hospital and associates mapped changes in interleukin-6 levels at 4-hour intervals during labor and after delivery and measured neonatal interleukin-6 levels in umbilical cord blood samples in 92 healthy, nulliparous term parturients who went into spontaneous labor and who all received epidural analgesia.

Interleukin-6 levels rose significantly during labor in women who did not have fever as well as in those who did, he said.

The researchers drew peripheral blood and took tympanic temperatures at the time of labor epidural placement and every 4 hours until 4 hours following delivery.

Patients who, at any of the intervals, had a temperature equal to or greater than 38° C were considered febrile.

After delivery of the placenta, umbilical cord blood samples were taken, and neonatal rectal temperatures were taken within 30 minutes of birth.

The 66 afebrile patients and 26 febrile patients shared common characteristics with respect to height, weight, gestational age, and age.

In both groups, interleukin-6 was significantly higher at 8 hours and following delivery, compared with the baseline measurement, but no significant differences were found between the two groups in interleukin-6 levels at any of the measurement intervals.

In addition, while the neonates of febrile mothers had significantly higher temperatures than those of afebrile mothers (36.97° C and 36.68° C, respectively), their umbilical cord serum interleukin-6 levels were statistically the same as the afebrile group.

“We did not find any inflammatory basis for epidural-related fever,” said Dr. Mantha. “We agree with reports that suggest that maternal serum interleukin-6 levels rise in response to labor.”

The study reaffirms the generally accepted view regarding the nature of epidural-related fever, Dr. Mantha commented.

This thinking holds that epidural-related fever is the product of changes in thermoregulatory mechanisms, and that increases in proinflammatory cytokines such as interleukin-6 occur in normal pregnancy and labor.

“All of these years, it's been accepted that epidural-related fever has a physiological basis and that interleukin-6 plays a role in normal labor,” Dr. Mantha said in an interview, noting that interleukin-6's role in labor is not yet understood.

However, studies showing an increase in interleukin-6 during normal labor did not differentiate between patients who had received epidural analgesia and those who had not, he said.

“This [current study] was the first study where the primary aim was to try and find whether there is a relationship between epidural fever and increases in serum levels of interleukin-6,” Dr. Mantha said.

A catalyst for this investigation was the publication of two studies that challenged the thermoregulatory view of epidural-related fever by showing a strong relationship between epidural-related fever and increases in interleukin-6, suggesting the possibility that the fever has an inflammatory basis (Am. J. Obstet. Gynecol. 2002;187:834-8; Am. J. Obstet. Gynecol. 2003;188: 269-74).

Dr. Mantha noted that the study was limited by the fact that it did not include women who had not received labor epidural analgesia; however, performing a randomized study including these women is difficult because more than 90% of parturients at Magee request labor epidural analgesia.

CHICAGO — Proinflammatory cytokine levels escalate with normal labor but are not an underlying mechanism of epidural-related fever, according to the results of a study of 92 term parturients.

The researchers found no differences between febrile and afebrile patients in serum levels of the proinflammatory cytokine interleukin-6 during labor or post partum, Dr. Venkat Mantha reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Dr. Mantha of the University of Pittsburgh's Magee Women's Hospital and associates mapped changes in interleukin-6 levels at 4-hour intervals during labor and after delivery and measured neonatal interleukin-6 levels in umbilical cord blood samples in 92 healthy, nulliparous term parturients who went into spontaneous labor and who all received epidural analgesia.

Interleukin-6 levels rose significantly during labor in women who did not have fever as well as in those who did, he said.

The researchers drew peripheral blood and took tympanic temperatures at the time of labor epidural placement and every 4 hours until 4 hours following delivery.

Patients who, at any of the intervals, had a temperature equal to or greater than 38° C were considered febrile.

After delivery of the placenta, umbilical cord blood samples were taken, and neonatal rectal temperatures were taken within 30 minutes of birth.

The 66 afebrile patients and 26 febrile patients shared common characteristics with respect to height, weight, gestational age, and age.

In both groups, interleukin-6 was significantly higher at 8 hours and following delivery, compared with the baseline measurement, but no significant differences were found between the two groups in interleukin-6 levels at any of the measurement intervals.

In addition, while the neonates of febrile mothers had significantly higher temperatures than those of afebrile mothers (36.97° C and 36.68° C, respectively), their umbilical cord serum interleukin-6 levels were statistically the same as the afebrile group.

“We did not find any inflammatory basis for epidural-related fever,” said Dr. Mantha. “We agree with reports that suggest that maternal serum interleukin-6 levels rise in response to labor.”

The study reaffirms the generally accepted view regarding the nature of epidural-related fever, Dr. Mantha commented.

This thinking holds that epidural-related fever is the product of changes in thermoregulatory mechanisms, and that increases in proinflammatory cytokines such as interleukin-6 occur in normal pregnancy and labor.

“All of these years, it's been accepted that epidural-related fever has a physiological basis and that interleukin-6 plays a role in normal labor,” Dr. Mantha said in an interview, noting that interleukin-6's role in labor is not yet understood.

However, studies showing an increase in interleukin-6 during normal labor did not differentiate between patients who had received epidural analgesia and those who had not, he said.

“This [current study] was the first study where the primary aim was to try and find whether there is a relationship between epidural fever and increases in serum levels of interleukin-6,” Dr. Mantha said.

A catalyst for this investigation was the publication of two studies that challenged the thermoregulatory view of epidural-related fever by showing a strong relationship between epidural-related fever and increases in interleukin-6, suggesting the possibility that the fever has an inflammatory basis (Am. J. Obstet. Gynecol. 2002;187:834-8; Am. J. Obstet. Gynecol. 2003;188: 269-74).

Dr. Mantha noted that the study was limited by the fact that it did not include women who had not received labor epidural analgesia; however, performing a randomized study including these women is difficult because more than 90% of parturients at Magee request labor epidural analgesia.

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

Cesarean Delivery Too Late to Prevent Uterine Rupture
A pregnant woman with hypertension and associated medical concerns was admitted to the hospital for induction of labor. She had previously undergone a cesarean delivery.

Synthetic oxytocin was started. That evening, dinoprostone was administered, and synthetic oxytocin was substituted for it the following morning.

That afternoon, the patient complained of severe uterine pain. She was 3.0 cm dilated and 60% effaced; she was then given butorphanol tartrate.

Because labor was not progressing, the defendant obstetrician decided to perform a cesarean delivery, then left with the nurse to attend to another patient. When the nurse returned, she noted that the fetal heart rate tracing had become dangerously slow, and she paged the obstetrician.

By the time he arrived, the membranes had ruptured. A fetal scalp electrode was placed, revealing a fetal heart rate of 70 beats/min. A "stat" cesarean delivery was ordered.

Twenty-four minutes elapsed from the time the fetal heart rate anomaly was noted to the time the incision was made. The uterus was found to have ruptured; the infant, a boy, was floating in the woman's abdominal cavity under her diaphragm. He was resuscitated and transferred to a children's hospital, where he was diagnosed with hypoxic ischemic encephalopathy and choreoathetoid cerebral palsy.

The plaintiff charged the defendants with negligence in failing to perform the surgery earlier. The defendants denied any negligence and contended that the woman's complaints of pain were not extraordinary.

According to a published account, a defense verdict was returned.

Conflicting Accounts About ED Referral for Man With Back Pain
After being given prescriptions for carisoprodol and hydrocodone with acetaminophen for back pain, a 26-year-old man returned to Dr. S., the defendant primary care physician, complaining of unremitting pain. Dr. S., who had been treating the plaintiff for staph infections, suspected a spinal epidural abscess. He prescribed naproxen, referred the patient to a laboratory for blood testing, and directed him to go to the emergency department (ED) if the pain worsened or if he developed neurologic symptoms.

That evening, the man's pain worsened, and he was taken to the ED. The ED physician considered a differential diagnosis that included epidural abscess. After consulting with the on-call primary care physician, the ED physician wrote holding orders for admission to the hospital. Very early the next morning, the patient complained to a nurse that he could not move his legs. Morphine was administered, and he slept for seven hours.

When he awoke, a nurse checked his status and reported that the patient was flaccid and paralyzed from the umbilicus down. Dr. S. came to see the plaintiff at about 11:00 am and discovered that he was paralyzed. Dr. S. ordered CT, then changed the order to one for MRI. In the hospital history, Dr. S. dictated that he had directed the patient to report to the ED the previous afternoon, but that he had refused.

The MRI revealed a large epidural abscess. Laminectomy was performed, and the abscess was removed.

The plaintiff never regained function in his legs, bowel, or bladder. He continued to experience spasms that were strong enough to eject him from his wheelchair.

The plaintiff alleged negligence by Dr. S., the hospital, and the ED physicians. The hospital and ED physicians settled for $1.25 million prior to trial.

At trial, the plaintiff claimed that Dr. S. had failed to properly refer him to the ED.

The defendant claimed that even if the plaintiff had been sent to the ED, he might not have undergone MRI and received treatment before paralysis developed. Dr. S. claimed that the hospital physicians and staff had delayed the diagnosis and treatment of the epidural abscess. He also claimed that he had instructed the plaintiff to go to the ED immediately because he might be at risk for paralysis, but the plaintiff had refused. Dr. S. argued that he ordered the blood work and prescribed naproxen only after the plaintiff refused to go to the ED. The plaintiff denied that Dr. S. had told him to go to the ED or risk paralysis.

According to a published account, a verdict of $9,420,840 was returned. Calculation of credit for the settlements and application of the 1975 Medical Injury Compensation Reform Act were pending.

Did Acne Medication Cause IBD?
For four months, a 14-year-old boy was treated with isotretinoin for acne. During this time, he noticed that he had chapped lips and achy knees.

Within the following year, the patient began to experience severe gastrointestinal pain, which was ultimately diagnosed as inflammatory bowel disease (IBD). Eventually, he underwent partial removal of his rectum and almost his entire colon.

After years of using a colostomy bag, the patient underwent surgery to connect the remains of his colon and anus, but there was not enough left of his colon to draw out excess water, and he now has permanent diarrhea.

The plaintiff claimed that the labeling for isotretinoin provided insufficient warning regarding the risk of bowel disease. The defendant manufacturer claimed that isotretinoin labeling had warned about IBD as a possible adverse effect for more than 20 years. The company also maintained that there is no significant scientific evidence to prove that the medication causes IBD.

According to a published report, a $2,619,000 verdict was returned.

Symptoms Should Have Prompted Repeat Urinalysis
In September 2002, a 62-year-old man with a 30-year history of smoking went to the defendant, his primary care physician, with a complaint of urinary symptoms. He had not undergone a general physical examination in three years.

Laboratory work was ordered. Red and white blood cells, protein, and bacteria were found in the urinalysis. The blood chemistry panel revealed elevated total cholesterol, slightly elevated glucose, and findings indicating a hereditary red blood cell abnormality.

During a subsequent phone call, the primary care physician made a diagnosis of urinary tract infection and prescribed antibiotics. The patient told the physician that he was experiencing discomfort and pain during urination. Whether the patient was advised to return for repeat laboratory studies once he had completed the prescribed antibiotics was later disputed.

In March 2003, the man presented to a gastroenterologist for a screening colonoscopy, as recommended by the defendant in September 2002. The man mentioned to the gastroenterologist that he was experiencing urinary discomfort and frequency. The gastroenterologist ordered urinalysis, and red and white blood cells, bacteria, and protein were found once again. Ten days later, the patient visited a urologist, who performed a cystoscopy and made a diagnosis of bladder cancer. Surgery revealed that the cancer had metastasized into a lymph node.

The patient underwent chemotherapy, but in early 2006 the cancer recurred in his liver and hip joint. He died in March 2006.

The plaintiff, the decedent's widow, alleged negligence by the defendant primary care physician in failing to repeat the urinalysis (she claimed to have overheard the phone conversation in question and denied hearing any such instruction) and in failing to stress the importance of returning for repeat urinalysis. The plaintiff claimed that if the cancer had been diagnosed earlier, her husband would have had a high probability of survival.

The defendant maintained that the decedent had been treated properly and that the defendant's advice to repeat the urinalysis had been ignored. The defendant also claimed that he was not required to inform the decedent of any risk for bladder cancer. Additionally, the defendant claimed that the decedent had an extremely aggressive, high-grade bladder cancer that had most likely metastasized before September 2002.

According to a published account, a defense verdict was returned.

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

Cesarean Delivery Too Late to Prevent Uterine Rupture
A pregnant woman with hypertension and associated medical concerns was admitted to the hospital for induction of labor. She had previously undergone a cesarean delivery.

Synthetic oxytocin was started. That evening, dinoprostone was administered, and synthetic oxytocin was substituted for it the following morning.

That afternoon, the patient complained of severe uterine pain. She was 3.0 cm dilated and 60% effaced; she was then given butorphanol tartrate.

Because labor was not progressing, the defendant obstetrician decided to perform a cesarean delivery, then left with the nurse to attend to another patient. When the nurse returned, she noted that the fetal heart rate tracing had become dangerously slow, and she paged the obstetrician.

By the time he arrived, the membranes had ruptured. A fetal scalp electrode was placed, revealing a fetal heart rate of 70 beats/min. A "stat" cesarean delivery was ordered.

Twenty-four minutes elapsed from the time the fetal heart rate anomaly was noted to the time the incision was made. The uterus was found to have ruptured; the infant, a boy, was floating in the woman's abdominal cavity under her diaphragm. He was resuscitated and transferred to a children's hospital, where he was diagnosed with hypoxic ischemic encephalopathy and choreoathetoid cerebral palsy.

The plaintiff charged the defendants with negligence in failing to perform the surgery earlier. The defendants denied any negligence and contended that the woman's complaints of pain were not extraordinary.

According to a published account, a defense verdict was returned.

Conflicting Accounts About ED Referral for Man With Back Pain
After being given prescriptions for carisoprodol and hydrocodone with acetaminophen for back pain, a 26-year-old man returned to Dr. S., the defendant primary care physician, complaining of unremitting pain. Dr. S., who had been treating the plaintiff for staph infections, suspected a spinal epidural abscess. He prescribed naproxen, referred the patient to a laboratory for blood testing, and directed him to go to the emergency department (ED) if the pain worsened or if he developed neurologic symptoms.

That evening, the man's pain worsened, and he was taken to the ED. The ED physician considered a differential diagnosis that included epidural abscess. After consulting with the on-call primary care physician, the ED physician wrote holding orders for admission to the hospital. Very early the next morning, the patient complained to a nurse that he could not move his legs. Morphine was administered, and he slept for seven hours.

When he awoke, a nurse checked his status and reported that the patient was flaccid and paralyzed from the umbilicus down. Dr. S. came to see the plaintiff at about 11:00 am and discovered that he was paralyzed. Dr. S. ordered CT, then changed the order to one for MRI. In the hospital history, Dr. S. dictated that he had directed the patient to report to the ED the previous afternoon, but that he had refused.

The MRI revealed a large epidural abscess. Laminectomy was performed, and the abscess was removed.

The plaintiff never regained function in his legs, bowel, or bladder. He continued to experience spasms that were strong enough to eject him from his wheelchair.

The plaintiff alleged negligence by Dr. S., the hospital, and the ED physicians. The hospital and ED physicians settled for $1.25 million prior to trial.

At trial, the plaintiff claimed that Dr. S. had failed to properly refer him to the ED.

The defendant claimed that even if the plaintiff had been sent to the ED, he might not have undergone MRI and received treatment before paralysis developed. Dr. S. claimed that the hospital physicians and staff had delayed the diagnosis and treatment of the epidural abscess. He also claimed that he had instructed the plaintiff to go to the ED immediately because he might be at risk for paralysis, but the plaintiff had refused. Dr. S. argued that he ordered the blood work and prescribed naproxen only after the plaintiff refused to go to the ED. The plaintiff denied that Dr. S. had told him to go to the ED or risk paralysis.

According to a published account, a verdict of $9,420,840 was returned. Calculation of credit for the settlements and application of the 1975 Medical Injury Compensation Reform Act were pending.

Did Acne Medication Cause IBD?
For four months, a 14-year-old boy was treated with isotretinoin for acne. During this time, he noticed that he had chapped lips and achy knees.

Within the following year, the patient began to experience severe gastrointestinal pain, which was ultimately diagnosed as inflammatory bowel disease (IBD). Eventually, he underwent partial removal of his rectum and almost his entire colon.

After years of using a colostomy bag, the patient underwent surgery to connect the remains of his colon and anus, but there was not enough left of his colon to draw out excess water, and he now has permanent diarrhea.

The plaintiff claimed that the labeling for isotretinoin provided insufficient warning regarding the risk of bowel disease. The defendant manufacturer claimed that isotretinoin labeling had warned about IBD as a possible adverse effect for more than 20 years. The company also maintained that there is no significant scientific evidence to prove that the medication causes IBD.

According to a published report, a $2,619,000 verdict was returned.

Symptoms Should Have Prompted Repeat Urinalysis
In September 2002, a 62-year-old man with a 30-year history of smoking went to the defendant, his primary care physician, with a complaint of urinary symptoms. He had not undergone a general physical examination in three years.

Laboratory work was ordered. Red and white blood cells, protein, and bacteria were found in the urinalysis. The blood chemistry panel revealed elevated total cholesterol, slightly elevated glucose, and findings indicating a hereditary red blood cell abnormality.

During a subsequent phone call, the primary care physician made a diagnosis of urinary tract infection and prescribed antibiotics. The patient told the physician that he was experiencing discomfort and pain during urination. Whether the patient was advised to return for repeat laboratory studies once he had completed the prescribed antibiotics was later disputed.

In March 2003, the man presented to a gastroenterologist for a screening colonoscopy, as recommended by the defendant in September 2002. The man mentioned to the gastroenterologist that he was experiencing urinary discomfort and frequency. The gastroenterologist ordered urinalysis, and red and white blood cells, bacteria, and protein were found once again. Ten days later, the patient visited a urologist, who performed a cystoscopy and made a diagnosis of bladder cancer. Surgery revealed that the cancer had metastasized into a lymph node.

The patient underwent chemotherapy, but in early 2006 the cancer recurred in his liver and hip joint. He died in March 2006.

The plaintiff, the decedent's widow, alleged negligence by the defendant primary care physician in failing to repeat the urinalysis (she claimed to have overheard the phone conversation in question and denied hearing any such instruction) and in failing to stress the importance of returning for repeat urinalysis. The plaintiff claimed that if the cancer had been diagnosed earlier, her husband would have had a high probability of survival.

The defendant maintained that the decedent had been treated properly and that the defendant's advice to repeat the urinalysis had been ignored. The defendant also claimed that he was not required to inform the decedent of any risk for bladder cancer. Additionally, the defendant claimed that the decedent had an extremely aggressive, high-grade bladder cancer that had most likely metastasized before September 2002.

According to a published account, a defense verdict was returned.

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

Cesarean Delivery Too Late to Prevent Uterine Rupture
A pregnant woman with hypertension and associated medical concerns was admitted to the hospital for induction of labor. She had previously undergone a cesarean delivery.

Synthetic oxytocin was started. That evening, dinoprostone was administered, and synthetic oxytocin was substituted for it the following morning.

That afternoon, the patient complained of severe uterine pain. She was 3.0 cm dilated and 60% effaced; she was then given butorphanol tartrate.

Because labor was not progressing, the defendant obstetrician decided to perform a cesarean delivery, then left with the nurse to attend to another patient. When the nurse returned, she noted that the fetal heart rate tracing had become dangerously slow, and she paged the obstetrician.

By the time he arrived, the membranes had ruptured. A fetal scalp electrode was placed, revealing a fetal heart rate of 70 beats/min. A "stat" cesarean delivery was ordered.

Twenty-four minutes elapsed from the time the fetal heart rate anomaly was noted to the time the incision was made. The uterus was found to have ruptured; the infant, a boy, was floating in the woman's abdominal cavity under her diaphragm. He was resuscitated and transferred to a children's hospital, where he was diagnosed with hypoxic ischemic encephalopathy and choreoathetoid cerebral palsy.

The plaintiff charged the defendants with negligence in failing to perform the surgery earlier. The defendants denied any negligence and contended that the woman's complaints of pain were not extraordinary.

According to a published account, a defense verdict was returned.

Conflicting Accounts About ED Referral for Man With Back Pain
After being given prescriptions for carisoprodol and hydrocodone with acetaminophen for back pain, a 26-year-old man returned to Dr. S., the defendant primary care physician, complaining of unremitting pain. Dr. S., who had been treating the plaintiff for staph infections, suspected a spinal epidural abscess. He prescribed naproxen, referred the patient to a laboratory for blood testing, and directed him to go to the emergency department (ED) if the pain worsened or if he developed neurologic symptoms.

That evening, the man's pain worsened, and he was taken to the ED. The ED physician considered a differential diagnosis that included epidural abscess. After consulting with the on-call primary care physician, the ED physician wrote holding orders for admission to the hospital. Very early the next morning, the patient complained to a nurse that he could not move his legs. Morphine was administered, and he slept for seven hours.

When he awoke, a nurse checked his status and reported that the patient was flaccid and paralyzed from the umbilicus down. Dr. S. came to see the plaintiff at about 11:00 am and discovered that he was paralyzed. Dr. S. ordered CT, then changed the order to one for MRI. In the hospital history, Dr. S. dictated that he had directed the patient to report to the ED the previous afternoon, but that he had refused.

The MRI revealed a large epidural abscess. Laminectomy was performed, and the abscess was removed.

The plaintiff never regained function in his legs, bowel, or bladder. He continued to experience spasms that were strong enough to eject him from his wheelchair.

The plaintiff alleged negligence by Dr. S., the hospital, and the ED physicians. The hospital and ED physicians settled for $1.25 million prior to trial.

At trial, the plaintiff claimed that Dr. S. had failed to properly refer him to the ED.

The defendant claimed that even if the plaintiff had been sent to the ED, he might not have undergone MRI and received treatment before paralysis developed. Dr. S. claimed that the hospital physicians and staff had delayed the diagnosis and treatment of the epidural abscess. He also claimed that he had instructed the plaintiff to go to the ED immediately because he might be at risk for paralysis, but the plaintiff had refused. Dr. S. argued that he ordered the blood work and prescribed naproxen only after the plaintiff refused to go to the ED. The plaintiff denied that Dr. S. had told him to go to the ED or risk paralysis.

According to a published account, a verdict of $9,420,840 was returned. Calculation of credit for the settlements and application of the 1975 Medical Injury Compensation Reform Act were pending.

Did Acne Medication Cause IBD?
For four months, a 14-year-old boy was treated with isotretinoin for acne. During this time, he noticed that he had chapped lips and achy knees.

Within the following year, the patient began to experience severe gastrointestinal pain, which was ultimately diagnosed as inflammatory bowel disease (IBD). Eventually, he underwent partial removal of his rectum and almost his entire colon.

After years of using a colostomy bag, the patient underwent surgery to connect the remains of his colon and anus, but there was not enough left of his colon to draw out excess water, and he now has permanent diarrhea.

The plaintiff claimed that the labeling for isotretinoin provided insufficient warning regarding the risk of bowel disease. The defendant manufacturer claimed that isotretinoin labeling had warned about IBD as a possible adverse effect for more than 20 years. The company also maintained that there is no significant scientific evidence to prove that the medication causes IBD.

According to a published report, a $2,619,000 verdict was returned.

Symptoms Should Have Prompted Repeat Urinalysis
In September 2002, a 62-year-old man with a 30-year history of smoking went to the defendant, his primary care physician, with a complaint of urinary symptoms. He had not undergone a general physical examination in three years.

Laboratory work was ordered. Red and white blood cells, protein, and bacteria were found in the urinalysis. The blood chemistry panel revealed elevated total cholesterol, slightly elevated glucose, and findings indicating a hereditary red blood cell abnormality.

During a subsequent phone call, the primary care physician made a diagnosis of urinary tract infection and prescribed antibiotics. The patient told the physician that he was experiencing discomfort and pain during urination. Whether the patient was advised to return for repeat laboratory studies once he had completed the prescribed antibiotics was later disputed.

In March 2003, the man presented to a gastroenterologist for a screening colonoscopy, as recommended by the defendant in September 2002. The man mentioned to the gastroenterologist that he was experiencing urinary discomfort and frequency. The gastroenterologist ordered urinalysis, and red and white blood cells, bacteria, and protein were found once again. Ten days later, the patient visited a urologist, who performed a cystoscopy and made a diagnosis of bladder cancer. Surgery revealed that the cancer had metastasized into a lymph node.

The patient underwent chemotherapy, but in early 2006 the cancer recurred in his liver and hip joint. He died in March 2006.

The plaintiff, the decedent's widow, alleged negligence by the defendant primary care physician in failing to repeat the urinalysis (she claimed to have overheard the phone conversation in question and denied hearing any such instruction) and in failing to stress the importance of returning for repeat urinalysis. The plaintiff claimed that if the cancer had been diagnosed earlier, her husband would have had a high probability of survival.

The defendant maintained that the decedent had been treated properly and that the defendant's advice to repeat the urinalysis had been ignored. The defendant also claimed that he was not required to inform the decedent of any risk for bladder cancer. Additionally, the defendant claimed that the decedent had an extremely aggressive, high-grade bladder cancer that had most likely metastasized before September 2002.

According to a published account, a defense verdict was returned.

HONOLULU — Depressed Hispanic mothers are more likely than are nondepressed Hispanic mothers to supplement breast-feeding with water and flavored teas as early as 4–6 weeks and to be giving their babies soda, chips, and syrup-flavored cow's milk by 6–12 months, according to a study of 201 women.

Interestingly, the primary hypothesis for the prospective study—that depressed Hispanic mothers would be more likely to have overweight babies—was not confirmed in the cohort of women recruited during pregnancy and followed for 24 months, Dr. Janet M. Wojcicki reported at the annual meeting of the Pediatric Academic Societies.

Nondepressed mothers were actually more likely to have overweight 6-month-old infants than were those who were depressed, 22% versus 9%, respectively, said Dr. Wojcicki, a fellow in pediatric gastroenterology at the University of California, San Francisco.

However, the feeding patterns established early by depressed mothers could have a later impact on their children's development, health, and body size, she said.

Dr. Wojcicki and associates found a high rate of depression among Hispanic mothers prenatally, when 29% reported depressive symptoms on instruments validated for Spanish-speaking subjects.

At 4–6 weeks post partum, 15% of mothers were depressed. By 6 months and 12 months post partum, rates of depression were 18% and 14%, respectively. A prior history of depression was reported by 11% of the cohort.

Of the total, 92% received assistance from the Women, Infants, and Children nutrition program.

Nearly all of the women (93%) spoke Spanish as a primary language. One-third were married and 40% were living with a partner. Three-quarters were employed and had a high school education or less.

Initially, rates of breast-feeding were very high: 91% at 4–6 weeks with 51% reporting exclusive breast-feeding. However, by that time, 24% were supplementing their infants with liquids other than formula, including water and Yerba Buena, chamomile, and manzanita teas.

Twice as many depressed mothers as their nondepressed peers were supplementing their infants with water and tea at 4–6 weeks, reported Dr. Wojcicki. Other factors associated with the practice were Central and South American ethnicity and mixed feeding practices.

In an interview at the meeting, Dr. Wojcicki said the reasons for early tea supplementation by depressed mothers remain unclear and merit further study. One possibility is that these mothers have a lower tolerance for crying or fussiness in their babies and offer them a bottle as well as the breast to quiet them.

“They may be more desperate,” she said. “We may be measuring some level of anxiety or uncertainty in these mothers.”

A second finding, not fully analyzed, was that mothers who remain depressed demonstrate “important feeding differences” in the latter half of their infants' first year. By the time their babies were 6 months old, 10% of mothers with depressive symptoms were giving them soda, compared with 2% of nondepressed mothers in the study.

That difference remained significant at 12 months, by which time the depressed mothers also were likely to be introducing chips and supplementing cow's milk with sugary flavored syrups.

Dr. Wojcicki said feeding practices among depressed mothers failed to correlate with rapid weight gain or obesity at the 6-month mark, when their infants were far less likely to be overweight than were nondepressed mothers.

She noted that previous research has linked maternal depression to failure to thrive and poor weight gain, suggesting that slow to average weight gain may be the rule in these babies.

Weight trends in the group as a whole were rather alarming, with 26% of infants overweight at 6 months.

HONOLULU — Depressed Hispanic mothers are more likely than are nondepressed Hispanic mothers to supplement breast-feeding with water and flavored teas as early as 4–6 weeks and to be giving their babies soda, chips, and syrup-flavored cow's milk by 6–12 months, according to a study of 201 women.

Interestingly, the primary hypothesis for the prospective study—that depressed Hispanic mothers would be more likely to have overweight babies—was not confirmed in the cohort of women recruited during pregnancy and followed for 24 months, Dr. Janet M. Wojcicki reported at the annual meeting of the Pediatric Academic Societies.

Nondepressed mothers were actually more likely to have overweight 6-month-old infants than were those who were depressed, 22% versus 9%, respectively, said Dr. Wojcicki, a fellow in pediatric gastroenterology at the University of California, San Francisco.

However, the feeding patterns established early by depressed mothers could have a later impact on their children's development, health, and body size, she said.

Dr. Wojcicki and associates found a high rate of depression among Hispanic mothers prenatally, when 29% reported depressive symptoms on instruments validated for Spanish-speaking subjects.

At 4–6 weeks post partum, 15% of mothers were depressed. By 6 months and 12 months post partum, rates of depression were 18% and 14%, respectively. A prior history of depression was reported by 11% of the cohort.

Of the total, 92% received assistance from the Women, Infants, and Children nutrition program.

Nearly all of the women (93%) spoke Spanish as a primary language. One-third were married and 40% were living with a partner. Three-quarters were employed and had a high school education or less.

Initially, rates of breast-feeding were very high: 91% at 4–6 weeks with 51% reporting exclusive breast-feeding. However, by that time, 24% were supplementing their infants with liquids other than formula, including water and Yerba Buena, chamomile, and manzanita teas.

Twice as many depressed mothers as their nondepressed peers were supplementing their infants with water and tea at 4–6 weeks, reported Dr. Wojcicki. Other factors associated with the practice were Central and South American ethnicity and mixed feeding practices.

In an interview at the meeting, Dr. Wojcicki said the reasons for early tea supplementation by depressed mothers remain unclear and merit further study. One possibility is that these mothers have a lower tolerance for crying or fussiness in their babies and offer them a bottle as well as the breast to quiet them.

“They may be more desperate,” she said. “We may be measuring some level of anxiety or uncertainty in these mothers.”

A second finding, not fully analyzed, was that mothers who remain depressed demonstrate “important feeding differences” in the latter half of their infants' first year. By the time their babies were 6 months old, 10% of mothers with depressive symptoms were giving them soda, compared with 2% of nondepressed mothers in the study.

That difference remained significant at 12 months, by which time the depressed mothers also were likely to be introducing chips and supplementing cow's milk with sugary flavored syrups.

Dr. Wojcicki said feeding practices among depressed mothers failed to correlate with rapid weight gain or obesity at the 6-month mark, when their infants were far less likely to be overweight than were nondepressed mothers.

She noted that previous research has linked maternal depression to failure to thrive and poor weight gain, suggesting that slow to average weight gain may be the rule in these babies.

Weight trends in the group as a whole were rather alarming, with 26% of infants overweight at 6 months.

HONOLULU — Depressed Hispanic mothers are more likely than are nondepressed Hispanic mothers to supplement breast-feeding with water and flavored teas as early as 4–6 weeks and to be giving their babies soda, chips, and syrup-flavored cow's milk by 6–12 months, according to a study of 201 women.

Interestingly, the primary hypothesis for the prospective study—that depressed Hispanic mothers would be more likely to have overweight babies—was not confirmed in the cohort of women recruited during pregnancy and followed for 24 months, Dr. Janet M. Wojcicki reported at the annual meeting of the Pediatric Academic Societies.

Nondepressed mothers were actually more likely to have overweight 6-month-old infants than were those who were depressed, 22% versus 9%, respectively, said Dr. Wojcicki, a fellow in pediatric gastroenterology at the University of California, San Francisco.

However, the feeding patterns established early by depressed mothers could have a later impact on their children's development, health, and body size, she said.

Dr. Wojcicki and associates found a high rate of depression among Hispanic mothers prenatally, when 29% reported depressive symptoms on instruments validated for Spanish-speaking subjects.

At 4–6 weeks post partum, 15% of mothers were depressed. By 6 months and 12 months post partum, rates of depression were 18% and 14%, respectively. A prior history of depression was reported by 11% of the cohort.

Of the total, 92% received assistance from the Women, Infants, and Children nutrition program.

Nearly all of the women (93%) spoke Spanish as a primary language. One-third were married and 40% were living with a partner. Three-quarters were employed and had a high school education or less.

Initially, rates of breast-feeding were very high: 91% at 4–6 weeks with 51% reporting exclusive breast-feeding. However, by that time, 24% were supplementing their infants with liquids other than formula, including water and Yerba Buena, chamomile, and manzanita teas.

Twice as many depressed mothers as their nondepressed peers were supplementing their infants with water and tea at 4–6 weeks, reported Dr. Wojcicki. Other factors associated with the practice were Central and South American ethnicity and mixed feeding practices.

In an interview at the meeting, Dr. Wojcicki said the reasons for early tea supplementation by depressed mothers remain unclear and merit further study. One possibility is that these mothers have a lower tolerance for crying or fussiness in their babies and offer them a bottle as well as the breast to quiet them.

“They may be more desperate,” she said. “We may be measuring some level of anxiety or uncertainty in these mothers.”

A second finding, not fully analyzed, was that mothers who remain depressed demonstrate “important feeding differences” in the latter half of their infants' first year. By the time their babies were 6 months old, 10% of mothers with depressive symptoms were giving them soda, compared with 2% of nondepressed mothers in the study.

That difference remained significant at 12 months, by which time the depressed mothers also were likely to be introducing chips and supplementing cow's milk with sugary flavored syrups.

Dr. Wojcicki said feeding practices among depressed mothers failed to correlate with rapid weight gain or obesity at the 6-month mark, when their infants were far less likely to be overweight than were nondepressed mothers.

She noted that previous research has linked maternal depression to failure to thrive and poor weight gain, suggesting that slow to average weight gain may be the rule in these babies.

Weight trends in the group as a whole were rather alarming, with 26% of infants overweight at 6 months.

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.”

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.”

ELSEVIER GLOBAL MEDICAL NEWS

TORONTO — Pregnant women with congenital heart defects are not able to ramp up their cardiac output to handle the stresses of pregnancy, according to a small study out of the Netherlands. Dr. Jolien Roos-Hesselink reported the study results in a poster presentation at the 18th International Symposium on Adult Congenital Heart Disease.

“We know that cardiac output generally rises during pregnancy and we felt it important to see what happens in women with congenital heart disease as a means of perhaps explaining the increased risk of complications seen in these women and their offspring,” Dr. Roos-Hesselink, a cardiologist, said in an interview. “We suspected that maybe cardiac output wasn't increasing enough in these patients.”

Pregnancy is a major issue in the management of women with congenital heart disease, complicated by a greater risk of fetal growth retardation, premature birth, and perinatal mortality. Normally, cardiac output increases by 40%–50% during pregnancy.

Dr. Roos-Hesselink's team at the Thoraxcenter of Erasmus Medical Center in Rotterdam, the Netherlands, studied eight patients before, during, and after pregnancy. Subjects had a variety of congenital heart defects, including aortic valve replacement, tetralogy of Fallot, Ebstein anomaly, ventricular septal defect, atrioventricular septal defect, and pulmonary stenosis. Subjects underwent cardiac magnetic resonance imaging (cMRI) at 20 weeks' gestation and again at 32 weeks. Measurements were compared with measurements taken 6–12 months preconception and post partum.

“In the first eight patients we studied, we saw that in seven of the patients, cardiac output did not rise as the pregnancy progressed, but rather fell,” reported Dr. Roos-Hesselink.

Although the data presented are limited, Dr. Roos-Hesselink notes that they have now tested 25 patients and will be presenting further data soon.

Previous echocardiography studies have hinted at the issue of cardiac output in pregnancy complicated by coronary heart disease, but until cMRI was determined to be safe for women in pregnancy, there was no means of accurately measuring cardiac output during gestation, said Dr. Roos-Hesselink.

“It seems to be that the ventricular function in these women is not capable of handling the stress of pregnancy, although it does increase from baseline during the first trimester.”

After increasing appropriately from pre-and postpregnancy baseline values up to 20 weeks' gestation, cardiac output decreased significantly, from 6.9 L/min at 20 weeks to 5.4 L/min at 32 weeks of gestation. In addition, a significant reduction in end-diastolic volume and stroke volume between 20 and 32 weeks of gestation was observed, along with a decline in left ventricular ejection fraction from 53% to 49%. Left ventricular mass increased from 87.5 grams at 20 weeks to 94.4 grams at 32 weeks.

Said Dr. Roos-Hesselink, “These findings could add to our ability to risk-stratify these patients and could explain many of the complications we see in this patient subgroup. We haven't yet tested cardiac output with MRI during exercise prepregnancy, but if women at risk are tested before or during pregnancy and cardiac output is found to be lacking, this might be an indication to treat them more intensively, maybe with diuretics or other medications.”

ELSEVIER GLOBAL MEDICAL NEWS

Postpartum depression affected 12%–20% of mothers surveyed in the most recent report from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System (PRAMS).

These proportions are somewhat higher than the 10%–15% of mothers generally thought to be affected by postpartum depression within 1 year of giving birth, Kate Brett, Ph.D., and associates in the Office of Analysis and Epidemiology, National Center for Health Statistics.

PRAMS is an ongoing population-based surveillance project that collects data on mothers' attitudes and experiences before, during, and after delivery of a live infant. It targets subjects who are representative of women who have recently delivered in 17 participating states.

In an analysis of the data collected in 2004–2005—the most recent period for which data were available—Dr. Brett and her colleagues found that four characteristics were significantly associated with postpartum depression in all 17 states: young maternal age, low levels of maternal education, single marital status, and Medicaid coverage for delivery.

Five potential risk factors also were associated with postpartum depression: maternal tobacco use during the last trimester, physical abuse before or during the pregnancy, partner-related stress during the pregnancy, traumatic stress during the pregnancy, and financial stress during the pregnancy.

In addition, delivering a low-birth-weight infant was significantly associated with postpartum depression in 14 states.

In the current survey, 11.8% of new mothers in Maine and 11.8% in Vermont reported postpartum depression, compared with about 20.4% of mothers in New Mexico. Oregon and Minneapolis were also clustered in the lower ranges, with 12.2%, and 12.7%, respectively, of new mothers reporting symptoms, whereas in South Carolina and North Carolina, 19.5% and 19.0%, respectively, reported symptoms.

The associations with young maternal age and partner-related stress or physical abuse have been reported in previous research. In contrast, the associations with low-birth-weight infants, tobacco use during pregnancy, and traumatic or financial stress have not been identified before, the investigators said (MMWR 2008;57:361-6).

These findings can be used to tailor screening and interventions so that they target mothers at highest risk for postpartum depression. For example, “adolescent mothers or women who received Medicaid for their delivery are examples of subsets of the population” who can be easily identified at delivery and referred for treatment, the CDC said.

Postpartum depression affected 12%–20% of mothers surveyed in the most recent report from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System (PRAMS).

These proportions are somewhat higher than the 10%–15% of mothers generally thought to be affected by postpartum depression within 1 year of giving birth, Kate Brett, Ph.D., and associates in the Office of Analysis and Epidemiology, National Center for Health Statistics.

PRAMS is an ongoing population-based surveillance project that collects data on mothers' attitudes and experiences before, during, and after delivery of a live infant. It targets subjects who are representative of women who have recently delivered in 17 participating states.

In an analysis of the data collected in 2004–2005—the most recent period for which data were available—Dr. Brett and her colleagues found that four characteristics were significantly associated with postpartum depression in all 17 states: young maternal age, low levels of maternal education, single marital status, and Medicaid coverage for delivery.

Five potential risk factors also were associated with postpartum depression: maternal tobacco use during the last trimester, physical abuse before or during the pregnancy, partner-related stress during the pregnancy, traumatic stress during the pregnancy, and financial stress during the pregnancy.

In addition, delivering a low-birth-weight infant was significantly associated with postpartum depression in 14 states.

In the current survey, 11.8% of new mothers in Maine and 11.8% in Vermont reported postpartum depression, compared with about 20.4% of mothers in New Mexico. Oregon and Minneapolis were also clustered in the lower ranges, with 12.2%, and 12.7%, respectively, of new mothers reporting symptoms, whereas in South Carolina and North Carolina, 19.5% and 19.0%, respectively, reported symptoms.

The associations with young maternal age and partner-related stress or physical abuse have been reported in previous research. In contrast, the associations with low-birth-weight infants, tobacco use during pregnancy, and traumatic or financial stress have not been identified before, the investigators said (MMWR 2008;57:361-6).

These findings can be used to tailor screening and interventions so that they target mothers at highest risk for postpartum depression. For example, “adolescent mothers or women who received Medicaid for their delivery are examples of subsets of the population” who can be easily identified at delivery and referred for treatment, the CDC said.

Postpartum depression affected 12%–20% of mothers surveyed in the most recent report from the Centers for Disease Control and Prevention's Pregnancy Risk Assessment Monitoring System (PRAMS).

These proportions are somewhat higher than the 10%–15% of mothers generally thought to be affected by postpartum depression within 1 year of giving birth, Kate Brett, Ph.D., and associates in the Office of Analysis and Epidemiology, National Center for Health Statistics.

PRAMS is an ongoing population-based surveillance project that collects data on mothers' attitudes and experiences before, during, and after delivery of a live infant. It targets subjects who are representative of women who have recently delivered in 17 participating states.

In an analysis of the data collected in 2004–2005—the most recent period for which data were available—Dr. Brett and her colleagues found that four characteristics were significantly associated with postpartum depression in all 17 states: young maternal age, low levels of maternal education, single marital status, and Medicaid coverage for delivery.

Five potential risk factors also were associated with postpartum depression: maternal tobacco use during the last trimester, physical abuse before or during the pregnancy, partner-related stress during the pregnancy, traumatic stress during the pregnancy, and financial stress during the pregnancy.

In addition, delivering a low-birth-weight infant was significantly associated with postpartum depression in 14 states.

In the current survey, 11.8% of new mothers in Maine and 11.8% in Vermont reported postpartum depression, compared with about 20.4% of mothers in New Mexico. Oregon and Minneapolis were also clustered in the lower ranges, with 12.2%, and 12.7%, respectively, of new mothers reporting symptoms, whereas in South Carolina and North Carolina, 19.5% and 19.0%, respectively, reported symptoms.

The associations with young maternal age and partner-related stress or physical abuse have been reported in previous research. In contrast, the associations with low-birth-weight infants, tobacco use during pregnancy, and traumatic or financial stress have not been identified before, the investigators said (MMWR 2008;57:361-6).

These findings can be used to tailor screening and interventions so that they target mothers at highest risk for postpartum depression. For example, “adolescent mothers or women who received Medicaid for their delivery are examples of subsets of the population” who can be easily identified at delivery and referred for treatment, the CDC said.

CHICAGO — Laboring women can rely on sports drinks for hydration and sustenance without increasing their risk for cesarean section or instrumental vaginal delivery and without affecting the metabolic profiles of their newborns, according to a study of 198 women.

Sports drink consumption alleviated maternal ketosis without affecting neonatal Apgar score, glycemia, or umbilical cord gas, Dr. Marie-Eve Perron reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The findings contradict previous research (BJOG 2002;109:178-81), which indicated a threefold increase in C-sections among women who drank isotonic fluids during labor.

“The dissimilar results may be explained by the difference in the population studied and by the use of a lower carbohydrate concentration sports drink [in this study],” Dr. Perron said.

The isotonic drink in the earlier study contained a 12.6% carbohydrate concentration, more than twice that in the present study. Most of the patients in the previous research had high-risk pregnancies, and some had also received opioids during the course of labor.

Dr. Perron and her associates at Laval University, Quebec City, reported on 198 consecutive women who requested epidural analgesia at cervical dilation of 5 cm or less and in whom labor had begun spontaneously.

All patients had a single fetus in cephalic presentation. Women with known obstetric or medical conditions such as diabetes or previous C-section were not included.

There were no significant differences in the incidence of C-sections or instrumental vaginal deliveries among the intervention patients, who were encouraged to drink 200 mL/hr of a clear isotonic liquid containing a 6% carbohydrate concentration, and the control patients, who were limited to 30 mL/hr of water (standard practice at the hospital). The two groups were similar demographically.

Patients' maternal ketone bodies and glycemia were measured immediately after randomization into the intervention or control group and at the end of the first stage of labor using the Precision Xtra system. Apgar scores, neonatal glycemias, and umbilical cord gases were measured as well.

C-section rates for the intervention and control groups were 12.2% and 15%, respectively. Instrumental vaginal delivery rates for the intervention and control groups were 14.3% and 13%, respectively.

Maternal ketone bodies (beta-oxybutyrate) were 0.23 and 0.22 in the intervention and control groups at baseline, but nearly four times greater in the control group (0.19) than in the intervention group (0.5) at the end of the first stage of labor.

Apgar scores were 8.9 and 8.7 in the intervention and control groups at 1 minute, and 9.9 and 9.8 at 5 minutes. Neonatal arterial pH, venous pH, and glucose in the two groups were almost identical.

“The possible risk of pulmonary aspiration led many hospitals to restrict oral intake during labor,” said Dr. Perron. “However, the metabolic demand of labor is high. As clear fluids are rapidly evacuated from the stomach, they could represent a suitable source of energy.”

CHICAGO — Laboring women can rely on sports drinks for hydration and sustenance without increasing their risk for cesarean section or instrumental vaginal delivery and without affecting the metabolic profiles of their newborns, according to a study of 198 women.

Sports drink consumption alleviated maternal ketosis without affecting neonatal Apgar score, glycemia, or umbilical cord gas, Dr. Marie-Eve Perron reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The findings contradict previous research (BJOG 2002;109:178-81), which indicated a threefold increase in C-sections among women who drank isotonic fluids during labor.

“The dissimilar results may be explained by the difference in the population studied and by the use of a lower carbohydrate concentration sports drink [in this study],” Dr. Perron said.

The isotonic drink in the earlier study contained a 12.6% carbohydrate concentration, more than twice that in the present study. Most of the patients in the previous research had high-risk pregnancies, and some had also received opioids during the course of labor.

Dr. Perron and her associates at Laval University, Quebec City, reported on 198 consecutive women who requested epidural analgesia at cervical dilation of 5 cm or less and in whom labor had begun spontaneously.

All patients had a single fetus in cephalic presentation. Women with known obstetric or medical conditions such as diabetes or previous C-section were not included.

There were no significant differences in the incidence of C-sections or instrumental vaginal deliveries among the intervention patients, who were encouraged to drink 200 mL/hr of a clear isotonic liquid containing a 6% carbohydrate concentration, and the control patients, who were limited to 30 mL/hr of water (standard practice at the hospital). The two groups were similar demographically.

Patients' maternal ketone bodies and glycemia were measured immediately after randomization into the intervention or control group and at the end of the first stage of labor using the Precision Xtra system. Apgar scores, neonatal glycemias, and umbilical cord gases were measured as well.

C-section rates for the intervention and control groups were 12.2% and 15%, respectively. Instrumental vaginal delivery rates for the intervention and control groups were 14.3% and 13%, respectively.

Maternal ketone bodies (beta-oxybutyrate) were 0.23 and 0.22 in the intervention and control groups at baseline, but nearly four times greater in the control group (0.19) than in the intervention group (0.5) at the end of the first stage of labor.

Apgar scores were 8.9 and 8.7 in the intervention and control groups at 1 minute, and 9.9 and 9.8 at 5 minutes. Neonatal arterial pH, venous pH, and glucose in the two groups were almost identical.

“The possible risk of pulmonary aspiration led many hospitals to restrict oral intake during labor,” said Dr. Perron. “However, the metabolic demand of labor is high. As clear fluids are rapidly evacuated from the stomach, they could represent a suitable source of energy.”

CHICAGO — Laboring women can rely on sports drinks for hydration and sustenance without increasing their risk for cesarean section or instrumental vaginal delivery and without affecting the metabolic profiles of their newborns, according to a study of 198 women.

Sports drink consumption alleviated maternal ketosis without affecting neonatal Apgar score, glycemia, or umbilical cord gas, Dr. Marie-Eve Perron reported in a poster presentation at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The findings contradict previous research (BJOG 2002;109:178-81), which indicated a threefold increase in C-sections among women who drank isotonic fluids during labor.

“The dissimilar results may be explained by the difference in the population studied and by the use of a lower carbohydrate concentration sports drink [in this study],” Dr. Perron said.

The isotonic drink in the earlier study contained a 12.6% carbohydrate concentration, more than twice that in the present study. Most of the patients in the previous research had high-risk pregnancies, and some had also received opioids during the course of labor.

Dr. Perron and her associates at Laval University, Quebec City, reported on 198 consecutive women who requested epidural analgesia at cervical dilation of 5 cm or less and in whom labor had begun spontaneously.

All patients had a single fetus in cephalic presentation. Women with known obstetric or medical conditions such as diabetes or previous C-section were not included.

There were no significant differences in the incidence of C-sections or instrumental vaginal deliveries among the intervention patients, who were encouraged to drink 200 mL/hr of a clear isotonic liquid containing a 6% carbohydrate concentration, and the control patients, who were limited to 30 mL/hr of water (standard practice at the hospital). The two groups were similar demographically.

Patients' maternal ketone bodies and glycemia were measured immediately after randomization into the intervention or control group and at the end of the first stage of labor using the Precision Xtra system. Apgar scores, neonatal glycemias, and umbilical cord gases were measured as well.

C-section rates for the intervention and control groups were 12.2% and 15%, respectively. Instrumental vaginal delivery rates for the intervention and control groups were 14.3% and 13%, respectively.

Maternal ketone bodies (beta-oxybutyrate) were 0.23 and 0.22 in the intervention and control groups at baseline, but nearly four times greater in the control group (0.19) than in the intervention group (0.5) at the end of the first stage of labor.

Apgar scores were 8.9 and 8.7 in the intervention and control groups at 1 minute, and 9.9 and 9.8 at 5 minutes. Neonatal arterial pH, venous pH, and glucose in the two groups were almost identical.

“The possible risk of pulmonary aspiration led many hospitals to restrict oral intake during labor,” said Dr. Perron. “However, the metabolic demand of labor is high. As clear fluids are rapidly evacuated from the stomach, they could represent a suitable source of energy.”

NEW ORLEANS — A rapid polymerase chain reaction-based diagnostic to detect group B streptococcus infection during pregnancy is as specific and sensitive as are standard cultures and delivers results in a matter of a few hours, according to a small comparative study.

Dr. Lori Goranson, a resident at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., presented data from 99 women who came to the center's outpatient clinic.

The Centers for Disease Control and Prevention has issued a call for a rapid assay for group B strep that is available 24 hours a day, 7 days a week, and that can be easily performed without a sophisticated lab or highly trained personnel, Dr. Goranson said at the annual meeting of the American College of Obstetricians and Gynecologists.

The agency recommends that all women be tested for GBS by 35–37 weeks' gestational age, she said. Laboring women who present with unknown GBS status, however, are empirically given antibiotics as a precaution. As a result, thousands of women are likely being treated unnecessarily, Dr. Goranson said.

There are a little more than 4 million live births a year in the United States, she said.

Given that 10%–30% of women are colonized with GBS, that 13% of women present preterm, and that 8% are without prenatal care, as many as 600,000 may inappropriately receive antibiotics, according to Dr. Goranson.

She and her colleagues at Dartmouth aimed to determine whether the Xpert GBS test could fulfill the CDC's parameters. The Xpert was approved by the Food and Drug Administration in 2006. Two vaginal/rectal swabs were taken from 99 women; one swab was tested using standard culture and the other with the Xpert device.

The swab is placed into a cartridge with reagents. It takes 2 minutes from sampling to the start of analysis, said Dr. Goranson. Results generally are available within 75 minutes, although the average in the Dartmouth study was 83 minutes. That compares with an average of 2.3 days to receive a culture result, she said.

The average maternal age was 29.7 years and the average gestational age at collection was 36 weeks.

Twenty-five of 99 specimens cultured positive, for a prevalence rate of 25%, which was consistent with the literature, noted Dr. Goranson.

Seventy-four of 99 (75%) cultured negative. With the PCR-based Xpert system, 27 of 99 specimens were positive, and 72 of 99 were negative. The overall agreement rate between the two tests was 96%. There were discordant results. Three of the four PCR-positive results cultured negative. One PCR-negative swab cultured positive.

The Xpert test had 96% sensitivity and 96% specificity, with a negative predictive value of 99%, and a positive predictive value of 88%.

The test is highly sensitive and specific, easy to use, and produces rapid results, concluded Dr. Goranson. Though they are not yet using the Xpert system clinically at Dartmouth, it could eventually be used to support standard culture or as a substitute for women presenting preterm with an unknown GBS status, she said.

It is more expensive than standard culture—probably about 1.5 times as much, said Dr. Goranson. The device costs about $65,000 and cartridges cost about $45 each, she said. But the Xpert system can also be used to conduct rapid enterovirus, methicillin-resistant Streptococcus aureus, and other diagnostics, she said.

Dr. Goranson stated that she had no financial conflicts of interest to report.

NEW ORLEANS — A rapid polymerase chain reaction-based diagnostic to detect group B streptococcus infection during pregnancy is as specific and sensitive as are standard cultures and delivers results in a matter of a few hours, according to a small comparative study.

Dr. Lori Goranson, a resident at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., presented data from 99 women who came to the center's outpatient clinic.

The Centers for Disease Control and Prevention has issued a call for a rapid assay for group B strep that is available 24 hours a day, 7 days a week, and that can be easily performed without a sophisticated lab or highly trained personnel, Dr. Goranson said at the annual meeting of the American College of Obstetricians and Gynecologists.

The agency recommends that all women be tested for GBS by 35–37 weeks' gestational age, she said. Laboring women who present with unknown GBS status, however, are empirically given antibiotics as a precaution. As a result, thousands of women are likely being treated unnecessarily, Dr. Goranson said.

There are a little more than 4 million live births a year in the United States, she said.

Given that 10%–30% of women are colonized with GBS, that 13% of women present preterm, and that 8% are without prenatal care, as many as 600,000 may inappropriately receive antibiotics, according to Dr. Goranson.

She and her colleagues at Dartmouth aimed to determine whether the Xpert GBS test could fulfill the CDC's parameters. The Xpert was approved by the Food and Drug Administration in 2006. Two vaginal/rectal swabs were taken from 99 women; one swab was tested using standard culture and the other with the Xpert device.

The swab is placed into a cartridge with reagents. It takes 2 minutes from sampling to the start of analysis, said Dr. Goranson. Results generally are available within 75 minutes, although the average in the Dartmouth study was 83 minutes. That compares with an average of 2.3 days to receive a culture result, she said.

The average maternal age was 29.7 years and the average gestational age at collection was 36 weeks.

Twenty-five of 99 specimens cultured positive, for a prevalence rate of 25%, which was consistent with the literature, noted Dr. Goranson.

Seventy-four of 99 (75%) cultured negative. With the PCR-based Xpert system, 27 of 99 specimens were positive, and 72 of 99 were negative. The overall agreement rate between the two tests was 96%. There were discordant results. Three of the four PCR-positive results cultured negative. One PCR-negative swab cultured positive.

The Xpert test had 96% sensitivity and 96% specificity, with a negative predictive value of 99%, and a positive predictive value of 88%.

The test is highly sensitive and specific, easy to use, and produces rapid results, concluded Dr. Goranson. Though they are not yet using the Xpert system clinically at Dartmouth, it could eventually be used to support standard culture or as a substitute for women presenting preterm with an unknown GBS status, she said.

It is more expensive than standard culture—probably about 1.5 times as much, said Dr. Goranson. The device costs about $65,000 and cartridges cost about $45 each, she said. But the Xpert system can also be used to conduct rapid enterovirus, methicillin-resistant Streptococcus aureus, and other diagnostics, she said.

Dr. Goranson stated that she had no financial conflicts of interest to report.

NEW ORLEANS — A rapid polymerase chain reaction-based diagnostic to detect group B streptococcus infection during pregnancy is as specific and sensitive as are standard cultures and delivers results in a matter of a few hours, according to a small comparative study.

Dr. Lori Goranson, a resident at Dartmouth-Hitchcock Medical Center in Lebanon, N.H., presented data from 99 women who came to the center's outpatient clinic.

The Centers for Disease Control and Prevention has issued a call for a rapid assay for group B strep that is available 24 hours a day, 7 days a week, and that can be easily performed without a sophisticated lab or highly trained personnel, Dr. Goranson said at the annual meeting of the American College of Obstetricians and Gynecologists.

The agency recommends that all women be tested for GBS by 35–37 weeks' gestational age, she said. Laboring women who present with unknown GBS status, however, are empirically given antibiotics as a precaution. As a result, thousands of women are likely being treated unnecessarily, Dr. Goranson said.

There are a little more than 4 million live births a year in the United States, she said.

Given that 10%–30% of women are colonized with GBS, that 13% of women present preterm, and that 8% are without prenatal care, as many as 600,000 may inappropriately receive antibiotics, according to Dr. Goranson.

She and her colleagues at Dartmouth aimed to determine whether the Xpert GBS test could fulfill the CDC's parameters. The Xpert was approved by the Food and Drug Administration in 2006. Two vaginal/rectal swabs were taken from 99 women; one swab was tested using standard culture and the other with the Xpert device.

The swab is placed into a cartridge with reagents. It takes 2 minutes from sampling to the start of analysis, said Dr. Goranson. Results generally are available within 75 minutes, although the average in the Dartmouth study was 83 minutes. That compares with an average of 2.3 days to receive a culture result, she said.

The average maternal age was 29.7 years and the average gestational age at collection was 36 weeks.

Twenty-five of 99 specimens cultured positive, for a prevalence rate of 25%, which was consistent with the literature, noted Dr. Goranson.

Seventy-four of 99 (75%) cultured negative. With the PCR-based Xpert system, 27 of 99 specimens were positive, and 72 of 99 were negative. The overall agreement rate between the two tests was 96%. There were discordant results. Three of the four PCR-positive results cultured negative. One PCR-negative swab cultured positive.

The Xpert test had 96% sensitivity and 96% specificity, with a negative predictive value of 99%, and a positive predictive value of 88%.

The test is highly sensitive and specific, easy to use, and produces rapid results, concluded Dr. Goranson. Though they are not yet using the Xpert system clinically at Dartmouth, it could eventually be used to support standard culture or as a substitute for women presenting preterm with an unknown GBS status, she said.

It is more expensive than standard culture—probably about 1.5 times as much, said Dr. Goranson. The device costs about $65,000 and cartridges cost about $45 each, she said. But the Xpert system can also be used to conduct rapid enterovirus, methicillin-resistant Streptococcus aureus, and other diagnostics, she said.

Dr. Goranson stated that she had no financial conflicts of interest to report.

NEWPORT BEACH, CALIF. — Compared with pregnant adults, pregnant adolescents are significantly more likely to be anemic, to smoke during pregnancy, and to deliver before 32 weeks' gestation, a retrospective study of nearly 26,000 pregnancies found.

These factors, plus a significantly lower rate of breast-feeding in the 996 pregnant adolescents in the study, put these young mothers and their offspring at higher risk compared with the pregnant adults in the rest of the cohort, Dr. Andrew Stewart of Dalhousie University, Halifax, N.S., said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dr. Stewart and his associates analyzed data on all nulliparous, singleton gestations resulting in live births from 2000 to 2006 in Nova Scotia; these data are from the H.B. Atlee Perinatal Database. The investigators compared the characteristics and outcomes for adolescent mothers aged 18 years and younger with those of older mothers.

Their findings stress the importance of regularly checking hemoglobin levels in pregnant adolescents, of treating anemia, and of making sure they have access to prenatal vitamins and to nutritionists or social workers when needed. Extra effort should be put into encouraging the cessation of smoking, and clinicians should consider educating pregnant adolescents about the signs and symptoms of preterm labor, said Dr. Stewart.

“We must ask ourselves if we should be screening these patients with a transvaginal ultrasound to monitor cervical length,” he added. The results also point to a need for increased promotion of breast-feeding through education and support before and after delivery.

Although it's well accepted that adolescents are a high-risk obstetric population, the medical literature is contradictory about the specific risk factors and outcomes of adolescent pregnancies, he noted. The literature does not reveal whether young maternal age itself enhances the risk for poor obstetric outcomes, or if they are the result of a constellation of biological, psychological, and sociological factors.

In the current study, 39% of adolescents smoked during pregnancy, compared with 18% of adults. In all, 10% percent of adolescents and 8% of adults were anemic.

The adolescents weighed less than the adults before pregnancy (59 kg vs. 69 kg) and gained more weight during pregnancy (17 kg vs. 16 kg); these differences between age groups were statistically significant. The lower an adolescent's weight before pregnancy, the more she gained during pregnancy, he said.

Spontaneous vaginal delivery was significantly more common for adolescent mothers (72%) than for adult mothers (54%). Adolescents had lower rates of assisted vaginal delivery (14%) or C-section (15%), compared with adults (17% and 29%).

Although the mean gestational age at birth was 39 weeks in both groups, 2% of adolescents delivered before 32 weeks' gestation, compared with 1% of adults, which was a significant difference. Adolescents were less likely, however, to deliver a baby needing neonatal intensive care (9%), compared with adults (13%).

After controlling for the effects of smoking and anemia, the investigators found that being age 18 years or younger increased the likelihood of delivery before 32 weeks by 65%, Dr. Stewart reported. After controlling for the effects of young age, investigators found that smoking and anemia remained significant risk factors for preterm birth.

The mean weight of 3,311 g for babies born to adolescents was significantly lower than the mean weight of 3,404 g for babies born to adults. Babies with low birth weight (defined as less than 2,500 g) constituted 8% of births to adolescents and 6% of births to adults, a significant difference.

Adolescents were less likely than adults to develop gestational diabetes (1% vs. 2%) or mild pregnancy-induced hypertension (5% vs. 9%), or to give birth to a macrosomic baby (10% vs. 13%).

At discharge from the hospital, 40% of adolescent mothers were breast-feeding, compared with 72% of adult mothers.

The investigators hope to conduct future research on the potential influence of diet, socioeconomic status, small stature, and sexually transmitted infections on the increased risk for preterm delivery in pregnant adolescents.

NEWPORT BEACH, CALIF. — Compared with pregnant adults, pregnant adolescents are significantly more likely to be anemic, to smoke during pregnancy, and to deliver before 32 weeks' gestation, a retrospective study of nearly 26,000 pregnancies found.

These factors, plus a significantly lower rate of breast-feeding in the 996 pregnant adolescents in the study, put these young mothers and their offspring at higher risk compared with the pregnant adults in the rest of the cohort, Dr. Andrew Stewart of Dalhousie University, Halifax, N.S., said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dr. Stewart and his associates analyzed data on all nulliparous, singleton gestations resulting in live births from 2000 to 2006 in Nova Scotia; these data are from the H.B. Atlee Perinatal Database. The investigators compared the characteristics and outcomes for adolescent mothers aged 18 years and younger with those of older mothers.

Their findings stress the importance of regularly checking hemoglobin levels in pregnant adolescents, of treating anemia, and of making sure they have access to prenatal vitamins and to nutritionists or social workers when needed. Extra effort should be put into encouraging the cessation of smoking, and clinicians should consider educating pregnant adolescents about the signs and symptoms of preterm labor, said Dr. Stewart.

“We must ask ourselves if we should be screening these patients with a transvaginal ultrasound to monitor cervical length,” he added. The results also point to a need for increased promotion of breast-feeding through education and support before and after delivery.

Although it's well accepted that adolescents are a high-risk obstetric population, the medical literature is contradictory about the specific risk factors and outcomes of adolescent pregnancies, he noted. The literature does not reveal whether young maternal age itself enhances the risk for poor obstetric outcomes, or if they are the result of a constellation of biological, psychological, and sociological factors.

In the current study, 39% of adolescents smoked during pregnancy, compared with 18% of adults. In all, 10% percent of adolescents and 8% of adults were anemic.

The adolescents weighed less than the adults before pregnancy (59 kg vs. 69 kg) and gained more weight during pregnancy (17 kg vs. 16 kg); these differences between age groups were statistically significant. The lower an adolescent's weight before pregnancy, the more she gained during pregnancy, he said.

Spontaneous vaginal delivery was significantly more common for adolescent mothers (72%) than for adult mothers (54%). Adolescents had lower rates of assisted vaginal delivery (14%) or C-section (15%), compared with adults (17% and 29%).

Although the mean gestational age at birth was 39 weeks in both groups, 2% of adolescents delivered before 32 weeks' gestation, compared with 1% of adults, which was a significant difference. Adolescents were less likely, however, to deliver a baby needing neonatal intensive care (9%), compared with adults (13%).

After controlling for the effects of smoking and anemia, the investigators found that being age 18 years or younger increased the likelihood of delivery before 32 weeks by 65%, Dr. Stewart reported. After controlling for the effects of young age, investigators found that smoking and anemia remained significant risk factors for preterm birth.

The mean weight of 3,311 g for babies born to adolescents was significantly lower than the mean weight of 3,404 g for babies born to adults. Babies with low birth weight (defined as less than 2,500 g) constituted 8% of births to adolescents and 6% of births to adults, a significant difference.

Adolescents were less likely than adults to develop gestational diabetes (1% vs. 2%) or mild pregnancy-induced hypertension (5% vs. 9%), or to give birth to a macrosomic baby (10% vs. 13%).

At discharge from the hospital, 40% of adolescent mothers were breast-feeding, compared with 72% of adult mothers.

The investigators hope to conduct future research on the potential influence of diet, socioeconomic status, small stature, and sexually transmitted infections on the increased risk for preterm delivery in pregnant adolescents.

NEWPORT BEACH, CALIF. — Compared with pregnant adults, pregnant adolescents are significantly more likely to be anemic, to smoke during pregnancy, and to deliver before 32 weeks' gestation, a retrospective study of nearly 26,000 pregnancies found.

These factors, plus a significantly lower rate of breast-feeding in the 996 pregnant adolescents in the study, put these young mothers and their offspring at higher risk compared with the pregnant adults in the rest of the cohort, Dr. Andrew Stewart of Dalhousie University, Halifax, N.S., said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dr. Stewart and his associates analyzed data on all nulliparous, singleton gestations resulting in live births from 2000 to 2006 in Nova Scotia; these data are from the H.B. Atlee Perinatal Database. The investigators compared the characteristics and outcomes for adolescent mothers aged 18 years and younger with those of older mothers.

Their findings stress the importance of regularly checking hemoglobin levels in pregnant adolescents, of treating anemia, and of making sure they have access to prenatal vitamins and to nutritionists or social workers when needed. Extra effort should be put into encouraging the cessation of smoking, and clinicians should consider educating pregnant adolescents about the signs and symptoms of preterm labor, said Dr. Stewart.

“We must ask ourselves if we should be screening these patients with a transvaginal ultrasound to monitor cervical length,” he added. The results also point to a need for increased promotion of breast-feeding through education and support before and after delivery.

Although it's well accepted that adolescents are a high-risk obstetric population, the medical literature is contradictory about the specific risk factors and outcomes of adolescent pregnancies, he noted. The literature does not reveal whether young maternal age itself enhances the risk for poor obstetric outcomes, or if they are the result of a constellation of biological, psychological, and sociological factors.

In the current study, 39% of adolescents smoked during pregnancy, compared with 18% of adults. In all, 10% percent of adolescents and 8% of adults were anemic.

The adolescents weighed less than the adults before pregnancy (59 kg vs. 69 kg) and gained more weight during pregnancy (17 kg vs. 16 kg); these differences between age groups were statistically significant. The lower an adolescent's weight before pregnancy, the more she gained during pregnancy, he said.

Spontaneous vaginal delivery was significantly more common for adolescent mothers (72%) than for adult mothers (54%). Adolescents had lower rates of assisted vaginal delivery (14%) or C-section (15%), compared with adults (17% and 29%).

Although the mean gestational age at birth was 39 weeks in both groups, 2% of adolescents delivered before 32 weeks' gestation, compared with 1% of adults, which was a significant difference. Adolescents were less likely, however, to deliver a baby needing neonatal intensive care (9%), compared with adults (13%).

After controlling for the effects of smoking and anemia, the investigators found that being age 18 years or younger increased the likelihood of delivery before 32 weeks by 65%, Dr. Stewart reported. After controlling for the effects of young age, investigators found that smoking and anemia remained significant risk factors for preterm birth.

The mean weight of 3,311 g for babies born to adolescents was significantly lower than the mean weight of 3,404 g for babies born to adults. Babies with low birth weight (defined as less than 2,500 g) constituted 8% of births to adolescents and 6% of births to adults, a significant difference.

Adolescents were less likely than adults to develop gestational diabetes (1% vs. 2%) or mild pregnancy-induced hypertension (5% vs. 9%), or to give birth to a macrosomic baby (10% vs. 13%).

At discharge from the hospital, 40% of adolescent mothers were breast-feeding, compared with 72% of adult mothers.

The investigators hope to conduct future research on the potential influence of diet, socioeconomic status, small stature, and sexually transmitted infections on the increased risk for preterm delivery in pregnant adolescents.

SAVANNAH, GA. — Women who have received lacerations requiring sutures as a result of childbirth might have poorer sexual function post partum than women who did not, according to data from questionnaires completed by 326 postpartum women.

Dr. Rebecca Rogers of the University of New Mexico, Albuquerque, presented study results in a poster session at the annual meeting of the Society of Gynecologic Surgeons. She and her colleagues followed 576 low-risk pregnant women who were cared for by midwives between 2005 and 2007. The women's cases were classified as minor or major trauma. Minor trauma was defined as no trauma or first-degree perineal, labial, periurethral, or clitoral lacerations. Major trauma was defined as second-, third-, or fourth-degree lacerations or any trauma requiring suturing. Women who had an episiotomy or who required operative delivery were excluded.

At follow-up, the women were asked if they had been sexually active since the birth. The 326 women who answered yes were asked to complete the Intimate Relationship Scale, a 12-item questionnaire designed to measure postpartum sexual function.

Of these women, 273 reported being sexually active at 3 months post partum. The majority of the women sustained some type of trauma, with only 16% delivering intact. Of those with trauma, most had minor trauma (70%). Women in the two groups differed by parity, length of active pushing, and education. Intimate Relationship Scale scores were not significantly different between women with major and minor trauma—36 vs. 33. However, women requiring sutures had significantly lower scores (mean 31) than did women who did not (mean 35.5) after adjusting for parity, length of pushing, and education.

Dr. Rogers disclosed that she is a speaker and investigator for Pfizer Inc. The meeting was jointly sponsored by the American College of Surgeons.

SAVANNAH, GA. — Women who have received lacerations requiring sutures as a result of childbirth might have poorer sexual function post partum than women who did not, according to data from questionnaires completed by 326 postpartum women.

Dr. Rebecca Rogers of the University of New Mexico, Albuquerque, presented study results in a poster session at the annual meeting of the Society of Gynecologic Surgeons. She and her colleagues followed 576 low-risk pregnant women who were cared for by midwives between 2005 and 2007. The women's cases were classified as minor or major trauma. Minor trauma was defined as no trauma or first-degree perineal, labial, periurethral, or clitoral lacerations. Major trauma was defined as second-, third-, or fourth-degree lacerations or any trauma requiring suturing. Women who had an episiotomy or who required operative delivery were excluded.

At follow-up, the women were asked if they had been sexually active since the birth. The 326 women who answered yes were asked to complete the Intimate Relationship Scale, a 12-item questionnaire designed to measure postpartum sexual function.

Of these women, 273 reported being sexually active at 3 months post partum. The majority of the women sustained some type of trauma, with only 16% delivering intact. Of those with trauma, most had minor trauma (70%). Women in the two groups differed by parity, length of active pushing, and education. Intimate Relationship Scale scores were not significantly different between women with major and minor trauma—36 vs. 33. However, women requiring sutures had significantly lower scores (mean 31) than did women who did not (mean 35.5) after adjusting for parity, length of pushing, and education.

Dr. Rogers disclosed that she is a speaker and investigator for Pfizer Inc. The meeting was jointly sponsored by the American College of Surgeons.

SAVANNAH, GA. — Women who have received lacerations requiring sutures as a result of childbirth might have poorer sexual function post partum than women who did not, according to data from questionnaires completed by 326 postpartum women.

Dr. Rebecca Rogers of the University of New Mexico, Albuquerque, presented study results in a poster session at the annual meeting of the Society of Gynecologic Surgeons. She and her colleagues followed 576 low-risk pregnant women who were cared for by midwives between 2005 and 2007. The women's cases were classified as minor or major trauma. Minor trauma was defined as no trauma or first-degree perineal, labial, periurethral, or clitoral lacerations. Major trauma was defined as second-, third-, or fourth-degree lacerations or any trauma requiring suturing. Women who had an episiotomy or who required operative delivery were excluded.

At follow-up, the women were asked if they had been sexually active since the birth. The 326 women who answered yes were asked to complete the Intimate Relationship Scale, a 12-item questionnaire designed to measure postpartum sexual function.

Of these women, 273 reported being sexually active at 3 months post partum. The majority of the women sustained some type of trauma, with only 16% delivering intact. Of those with trauma, most had minor trauma (70%). Women in the two groups differed by parity, length of active pushing, and education. Intimate Relationship Scale scores were not significantly different between women with major and minor trauma—36 vs. 33. However, women requiring sutures had significantly lower scores (mean 31) than did women who did not (mean 35.5) after adjusting for parity, length of pushing, and education.

Dr. Rogers disclosed that she is a speaker and investigator for Pfizer Inc. The meeting was jointly sponsored by the American College of Surgeons.