Obstetrics

DALLAS — Contrary to some previous findings, race played a role in the rates of recurrent spontaneous preterm birth in a retrospective study of 847 women receiving 17α-hydroxyprogesterone caproate.

Black women had a significant doubling in the rate of recurrent spontaneous preterm birth (SPTB) at less than 32 weeks' gestation, compared with white women (10% vs. 5%), Dr. Edwin Guzman reported in a poster at the annual meeting of the Society for Maternal-Fetal Medicine. The odds ratio (OR) was 2.1.

While the overall rate of SPTB at less than 37 weeks did not differ by maternal race (34% vs. 33%), rates of preterm birth at less than 34 weeks (15% vs. 9%, OR 1.8), less than 30 weeks (8% vs. 3%, OR 2.8), and less than 28 weeks (7% vs. 2%, OR 4.9) were also significantly higher in black women compared with white women.

Black race was the only maternal characteristic that was significantly different between the 86 women who delivered before 34 weeks and the 761 women who delivered at 34 weeks or more (27% vs. 17%, OR 1.8). Other variables analyzed included Medicaid status, 17α-hydroxyprogesterone caproate (17P) start between 21 and 26.9 weeks, more than one prior preterm delivery, less than 12 years of education, marital status, and current smoker.

At admission, the 151 black women were more likely than were the 696 white women to be younger (29 vs. 30 years), to be Medicaid beneficiaries (48% vs. 16.5%), to be unmarried (60% vs. 16%), to lack a high school education (14% vs. 7.5%), and to have had more than one prior preterm birth (43% vs. 24%). Clinical data were collected prospectively from high-risk women enrolled in an outpatient program from May 2004 through September 2006 who received weekly 250-mg injections of 17P.

Analyses of pregnancy outcomes by insurance type and maternal race showed that among 187 Medicaid recipients, black women had significantly higher rates of SPTB at less than 37 weeks (42% vs. 26%, OR 2.0), though the rates of SPTB at less than 34, 32, 30, and 28 weeks were similar for white and black women.

Among the 660 women with commercial insurance, while the overall rate of SPTB at less than 37 weeks was similar for white and black women, black women had significantly higher rates of recurrent SPTB at less than 34, 32, 30, and 28 weeks, reported Dr. Guzman of Saint Peter's University Hospital, New Brunswick, N.J.

There has been renewed interest in the use of 17P following publication of a randomized clinical trial of 17P versus placebo conducted by the Maternal-Fetal Medicine Units (MFMU) Network of the National Institute of Child Health and Human Development (N. Engl. J. Med. 2003;348:2379–85). In contrast with previous studies of women with prior preterm delivery, a subgroup analysis of the MFMU data revealed no differences in the rate of recurrent preterm birth between black and white women receiving 17P.

Final data on U.S. births in 2004 showed that approximately 11.5% of white newborns and 18% of black newborns were born prematurely (Natl. Vital Stat. Rep. 2006;55:1–101). Black women having a prior preterm infant also have been shown to be at a higher risk for recurrent preterm birth than white women with a similar history (Am. J. Obstet. Gynecol. 2007;196:131.e1–6).

The purpose of the current study was to determine if response to 17P treatment differed by maternal race when 17P administration occurred in a real-world clinical setting, reported Dr. Guzman, who disclosed no financial conflicts of interest and received no funding for the study.

In an interview, Dr. Guzman speculated that the difference in findings between the MFMU network study and his study may be related to differences in populations in terms of socioeconomic status and care received, and noted that further study is needed as progesterone is now the standard of care in women who have had a previous preterm birth.

DALLAS — Contrary to some previous findings, race played a role in the rates of recurrent spontaneous preterm birth in a retrospective study of 847 women receiving 17α-hydroxyprogesterone caproate.

Black women had a significant doubling in the rate of recurrent spontaneous preterm birth (SPTB) at less than 32 weeks' gestation, compared with white women (10% vs. 5%), Dr. Edwin Guzman reported in a poster at the annual meeting of the Society for Maternal-Fetal Medicine. The odds ratio (OR) was 2.1.

While the overall rate of SPTB at less than 37 weeks did not differ by maternal race (34% vs. 33%), rates of preterm birth at less than 34 weeks (15% vs. 9%, OR 1.8), less than 30 weeks (8% vs. 3%, OR 2.8), and less than 28 weeks (7% vs. 2%, OR 4.9) were also significantly higher in black women compared with white women.

Black race was the only maternal characteristic that was significantly different between the 86 women who delivered before 34 weeks and the 761 women who delivered at 34 weeks or more (27% vs. 17%, OR 1.8). Other variables analyzed included Medicaid status, 17α-hydroxyprogesterone caproate (17P) start between 21 and 26.9 weeks, more than one prior preterm delivery, less than 12 years of education, marital status, and current smoker.

At admission, the 151 black women were more likely than were the 696 white women to be younger (29 vs. 30 years), to be Medicaid beneficiaries (48% vs. 16.5%), to be unmarried (60% vs. 16%), to lack a high school education (14% vs. 7.5%), and to have had more than one prior preterm birth (43% vs. 24%). Clinical data were collected prospectively from high-risk women enrolled in an outpatient program from May 2004 through September 2006 who received weekly 250-mg injections of 17P.

Analyses of pregnancy outcomes by insurance type and maternal race showed that among 187 Medicaid recipients, black women had significantly higher rates of SPTB at less than 37 weeks (42% vs. 26%, OR 2.0), though the rates of SPTB at less than 34, 32, 30, and 28 weeks were similar for white and black women.

Among the 660 women with commercial insurance, while the overall rate of SPTB at less than 37 weeks was similar for white and black women, black women had significantly higher rates of recurrent SPTB at less than 34, 32, 30, and 28 weeks, reported Dr. Guzman of Saint Peter's University Hospital, New Brunswick, N.J.

There has been renewed interest in the use of 17P following publication of a randomized clinical trial of 17P versus placebo conducted by the Maternal-Fetal Medicine Units (MFMU) Network of the National Institute of Child Health and Human Development (N. Engl. J. Med. 2003;348:2379–85). In contrast with previous studies of women with prior preterm delivery, a subgroup analysis of the MFMU data revealed no differences in the rate of recurrent preterm birth between black and white women receiving 17P.

Final data on U.S. births in 2004 showed that approximately 11.5% of white newborns and 18% of black newborns were born prematurely (Natl. Vital Stat. Rep. 2006;55:1–101). Black women having a prior preterm infant also have been shown to be at a higher risk for recurrent preterm birth than white women with a similar history (Am. J. Obstet. Gynecol. 2007;196:131.e1–6).

The purpose of the current study was to determine if response to 17P treatment differed by maternal race when 17P administration occurred in a real-world clinical setting, reported Dr. Guzman, who disclosed no financial conflicts of interest and received no funding for the study.

In an interview, Dr. Guzman speculated that the difference in findings between the MFMU network study and his study may be related to differences in populations in terms of socioeconomic status and care received, and noted that further study is needed as progesterone is now the standard of care in women who have had a previous preterm birth.

DALLAS — Contrary to some previous findings, race played a role in the rates of recurrent spontaneous preterm birth in a retrospective study of 847 women receiving 17α-hydroxyprogesterone caproate.

Black women had a significant doubling in the rate of recurrent spontaneous preterm birth (SPTB) at less than 32 weeks' gestation, compared with white women (10% vs. 5%), Dr. Edwin Guzman reported in a poster at the annual meeting of the Society for Maternal-Fetal Medicine. The odds ratio (OR) was 2.1.

While the overall rate of SPTB at less than 37 weeks did not differ by maternal race (34% vs. 33%), rates of preterm birth at less than 34 weeks (15% vs. 9%, OR 1.8), less than 30 weeks (8% vs. 3%, OR 2.8), and less than 28 weeks (7% vs. 2%, OR 4.9) were also significantly higher in black women compared with white women.

Black race was the only maternal characteristic that was significantly different between the 86 women who delivered before 34 weeks and the 761 women who delivered at 34 weeks or more (27% vs. 17%, OR 1.8). Other variables analyzed included Medicaid status, 17α-hydroxyprogesterone caproate (17P) start between 21 and 26.9 weeks, more than one prior preterm delivery, less than 12 years of education, marital status, and current smoker.

At admission, the 151 black women were more likely than were the 696 white women to be younger (29 vs. 30 years), to be Medicaid beneficiaries (48% vs. 16.5%), to be unmarried (60% vs. 16%), to lack a high school education (14% vs. 7.5%), and to have had more than one prior preterm birth (43% vs. 24%). Clinical data were collected prospectively from high-risk women enrolled in an outpatient program from May 2004 through September 2006 who received weekly 250-mg injections of 17P.

Analyses of pregnancy outcomes by insurance type and maternal race showed that among 187 Medicaid recipients, black women had significantly higher rates of SPTB at less than 37 weeks (42% vs. 26%, OR 2.0), though the rates of SPTB at less than 34, 32, 30, and 28 weeks were similar for white and black women.

Among the 660 women with commercial insurance, while the overall rate of SPTB at less than 37 weeks was similar for white and black women, black women had significantly higher rates of recurrent SPTB at less than 34, 32, 30, and 28 weeks, reported Dr. Guzman of Saint Peter's University Hospital, New Brunswick, N.J.

There has been renewed interest in the use of 17P following publication of a randomized clinical trial of 17P versus placebo conducted by the Maternal-Fetal Medicine Units (MFMU) Network of the National Institute of Child Health and Human Development (N. Engl. J. Med. 2003;348:2379–85). In contrast with previous studies of women with prior preterm delivery, a subgroup analysis of the MFMU data revealed no differences in the rate of recurrent preterm birth between black and white women receiving 17P.

Final data on U.S. births in 2004 showed that approximately 11.5% of white newborns and 18% of black newborns were born prematurely (Natl. Vital Stat. Rep. 2006;55:1–101). Black women having a prior preterm infant also have been shown to be at a higher risk for recurrent preterm birth than white women with a similar history (Am. J. Obstet. Gynecol. 2007;196:131.e1–6).

The purpose of the current study was to determine if response to 17P treatment differed by maternal race when 17P administration occurred in a real-world clinical setting, reported Dr. Guzman, who disclosed no financial conflicts of interest and received no funding for the study.

In an interview, Dr. Guzman speculated that the difference in findings between the MFMU network study and his study may be related to differences in populations in terms of socioeconomic status and care received, and noted that further study is needed as progesterone is now the standard of care in women who have had a previous preterm birth.

DALLAS — Women with type 2 diabetes had a similar incidence of adverse obstetric outcomes as those with type 1 diabetes but fewer adverse neonatal outcomes in a retrospective cohort analysis of 384 pregnancies.

As expected, patients with both type 1 and type 2 diabetes had worse obstetric and neonatal outcomes, compared with nondiabetic controls, Dr. Kristin M. Knight and colleagues at the University of Rochester (N.Y.) reported in a poster at the annual meeting of the Society for Maternal-Fetal Medicine.

Using a preexisting database of pregestational diabetes patients, the researchers analyzed maternal and fetal outcomes of singleton pregnancies between July 2000 and August 2006 in 64 women with type 1 diabetes, 64 women with type 2 diabetes, and 256 matched controls with normal glucose screening during pregnancy.

Patients with type 2 diabetes were significantly older (mean 30.1 years) than patients with type 1 diabetes (26.8 years) or controls (27.4 years), and had a significantly higher prepregnancy body mass index (37 vs. 27 vs. 24 kg/m

Mean hemoglobin A_1c values did not differ significantly between women with type 1 and type 2 diabetes (7.1% vs. 6.9%). The majority of women with type 2 diabetes (91%) were on insulin during pregnancy.

Both groups with diabetes had higher incidences of cesarean delivery, preeclampsia, preterm delivery, polyhydramnios, large-for-gestational-age infants, and neonatal ICU admission than did the 256 nondiabetic controls. However, the incidences were not different for women with type 2 vs. type 1 diabetes, the researchers noted.

Women with type 1 diabetes had a higher incidence of composite poor neonatal outcome (perinatal death, respiratory distress syndrome, sepsis, meconium aspiration, hypoglycemia, seizures, necrotizing enterocolitis, or intubation) than did women with type 2 diabetes and controls.

Those with type 1 diabetes had significantly more fetal congenital anomalies than did controls (6.3% vs. 1.2%). While such anomalies were elevated in women with type 2 diabetes, they were not significantly different (3.2%).

This finding differs from some of the other literature that's available, Dr. Knight said in an interview. This might be because the study population included only women seeking prenatal care, which is not the norm in clinical practice, and thus might have underrepresented poorer outcomes in patients with type 2 diabetes, he noted.

Overall, few data are available regarding pregnancy outcomes in type 2 diabetes, even though this type of diabetes is becoming increasingly common in reproductive-age women, she said.

“Type 2 diabetic patients should receive the same degree of preconceptional counseling, diligent glucose control, and antenatal surveillance as type 1 diabetic patients, in order to minimize the occurrence of poor perinatal outcome,” the authors wrote.

In a second poster at the meeting, diabetic macrovascular and microvascular disease during pregnancy was associated with reduced intrauterine fetal growth among 358 women with type 1 diabetes enrolled in a “Diabetes in Pregnancy” program at the University of Cincinnati.

The women were enrolled before 14 weeks' gestation, prospectively followed through the postpartum period, and treated with intensive insulin therapy.

They were classified at entry based on vascular status, with no vasculopathy present in 192, hypertension or background retinopathy in 79, proliferative retinopathy in only 18, nephropathy in only 42, and proliferative retinopathy and nephropathy in 26. Their mean ages were 24, 27, 27, 26, and 29 years, respectively; and they had been diagnosed with diabetes mellitus for 10, 15, 18, 14, and 18 years, respectively.

After controlling for gestation at delivery and maternal age and race, the odds ratio for delivery of a low-birth-weight infant (less than 2,500 g), compared with women without vasculopathy, was highest in women with proliferative retinopathy and nephropathy, Dr. Sina Haeri of the department of obstetrics and gynecology, Washington Hospital Center, and associates reported.

Likewise, after controlling for maternal age and race, the odds ratio for delivery of a small-for-gestational-age infant, compared with women with no vasculopathy, was highest in those with proliferative retinopathy and nephropathy (see graph below).

“The implication is that in women with type 1 diabetes, you need to keep a close eye on the babies because growth restriction is, of course, associated with neonatal death, poor outcome, and respiratory distress,” Dr. Haeri said in an interview. The poorer neonatal outcomes were observed even though the population was tightly controlled, with a self-monitored fasting and preprandial blood glucose goal of less than 100 mg/dL and a 90-minute postprandial goal of less than 140 mg/dL.

Type 2 diabetic patients should receive the same counseling and treatments as type 1 patients. DR. KNIGHT

ELSEVIER GLOBAL MEDICAL NEWS

DALLAS — Women with type 2 diabetes had a similar incidence of adverse obstetric outcomes as those with type 1 diabetes but fewer adverse neonatal outcomes in a retrospective cohort analysis of 384 pregnancies.

As expected, patients with both type 1 and type 2 diabetes had worse obstetric and neonatal outcomes, compared with nondiabetic controls, Dr. Kristin M. Knight and colleagues at the University of Rochester (N.Y.) reported in a poster at the annual meeting of the Society for Maternal-Fetal Medicine.

Using a preexisting database of pregestational diabetes patients, the researchers analyzed maternal and fetal outcomes of singleton pregnancies between July 2000 and August 2006 in 64 women with type 1 diabetes, 64 women with type 2 diabetes, and 256 matched controls with normal glucose screening during pregnancy.

Patients with type 2 diabetes were significantly older (mean 30.1 years) than patients with type 1 diabetes (26.8 years) or controls (27.4 years), and had a significantly higher prepregnancy body mass index (37 vs. 27 vs. 24 kg/m

Mean hemoglobin A_1c values did not differ significantly between women with type 1 and type 2 diabetes (7.1% vs. 6.9%). The majority of women with type 2 diabetes (91%) were on insulin during pregnancy.

Both groups with diabetes had higher incidences of cesarean delivery, preeclampsia, preterm delivery, polyhydramnios, large-for-gestational-age infants, and neonatal ICU admission than did the 256 nondiabetic controls. However, the incidences were not different for women with type 2 vs. type 1 diabetes, the researchers noted.

Women with type 1 diabetes had a higher incidence of composite poor neonatal outcome (perinatal death, respiratory distress syndrome, sepsis, meconium aspiration, hypoglycemia, seizures, necrotizing enterocolitis, or intubation) than did women with type 2 diabetes and controls.

Those with type 1 diabetes had significantly more fetal congenital anomalies than did controls (6.3% vs. 1.2%). While such anomalies were elevated in women with type 2 diabetes, they were not significantly different (3.2%).

This finding differs from some of the other literature that's available, Dr. Knight said in an interview. This might be because the study population included only women seeking prenatal care, which is not the norm in clinical practice, and thus might have underrepresented poorer outcomes in patients with type 2 diabetes, he noted.

Overall, few data are available regarding pregnancy outcomes in type 2 diabetes, even though this type of diabetes is becoming increasingly common in reproductive-age women, she said.

“Type 2 diabetic patients should receive the same degree of preconceptional counseling, diligent glucose control, and antenatal surveillance as type 1 diabetic patients, in order to minimize the occurrence of poor perinatal outcome,” the authors wrote.

In a second poster at the meeting, diabetic macrovascular and microvascular disease during pregnancy was associated with reduced intrauterine fetal growth among 358 women with type 1 diabetes enrolled in a “Diabetes in Pregnancy” program at the University of Cincinnati.

The women were enrolled before 14 weeks' gestation, prospectively followed through the postpartum period, and treated with intensive insulin therapy.

They were classified at entry based on vascular status, with no vasculopathy present in 192, hypertension or background retinopathy in 79, proliferative retinopathy in only 18, nephropathy in only 42, and proliferative retinopathy and nephropathy in 26. Their mean ages were 24, 27, 27, 26, and 29 years, respectively; and they had been diagnosed with diabetes mellitus for 10, 15, 18, 14, and 18 years, respectively.

After controlling for gestation at delivery and maternal age and race, the odds ratio for delivery of a low-birth-weight infant (less than 2,500 g), compared with women without vasculopathy, was highest in women with proliferative retinopathy and nephropathy, Dr. Sina Haeri of the department of obstetrics and gynecology, Washington Hospital Center, and associates reported.

Likewise, after controlling for maternal age and race, the odds ratio for delivery of a small-for-gestational-age infant, compared with women with no vasculopathy, was highest in those with proliferative retinopathy and nephropathy (see graph below).

“The implication is that in women with type 1 diabetes, you need to keep a close eye on the babies because growth restriction is, of course, associated with neonatal death, poor outcome, and respiratory distress,” Dr. Haeri said in an interview. The poorer neonatal outcomes were observed even though the population was tightly controlled, with a self-monitored fasting and preprandial blood glucose goal of less than 100 mg/dL and a 90-minute postprandial goal of less than 140 mg/dL.

Type 2 diabetic patients should receive the same counseling and treatments as type 1 patients. DR. KNIGHT

ELSEVIER GLOBAL MEDICAL NEWS

DALLAS — Women with type 2 diabetes had a similar incidence of adverse obstetric outcomes as those with type 1 diabetes but fewer adverse neonatal outcomes in a retrospective cohort analysis of 384 pregnancies.

As expected, patients with both type 1 and type 2 diabetes had worse obstetric and neonatal outcomes, compared with nondiabetic controls, Dr. Kristin M. Knight and colleagues at the University of Rochester (N.Y.) reported in a poster at the annual meeting of the Society for Maternal-Fetal Medicine.

Using a preexisting database of pregestational diabetes patients, the researchers analyzed maternal and fetal outcomes of singleton pregnancies between July 2000 and August 2006 in 64 women with type 1 diabetes, 64 women with type 2 diabetes, and 256 matched controls with normal glucose screening during pregnancy.

Patients with type 2 diabetes were significantly older (mean 30.1 years) than patients with type 1 diabetes (26.8 years) or controls (27.4 years), and had a significantly higher prepregnancy body mass index (37 vs. 27 vs. 24 kg/m

Mean hemoglobin A_1c values did not differ significantly between women with type 1 and type 2 diabetes (7.1% vs. 6.9%). The majority of women with type 2 diabetes (91%) were on insulin during pregnancy.

Both groups with diabetes had higher incidences of cesarean delivery, preeclampsia, preterm delivery, polyhydramnios, large-for-gestational-age infants, and neonatal ICU admission than did the 256 nondiabetic controls. However, the incidences were not different for women with type 2 vs. type 1 diabetes, the researchers noted.

Women with type 1 diabetes had a higher incidence of composite poor neonatal outcome (perinatal death, respiratory distress syndrome, sepsis, meconium aspiration, hypoglycemia, seizures, necrotizing enterocolitis, or intubation) than did women with type 2 diabetes and controls.

Those with type 1 diabetes had significantly more fetal congenital anomalies than did controls (6.3% vs. 1.2%). While such anomalies were elevated in women with type 2 diabetes, they were not significantly different (3.2%).

This finding differs from some of the other literature that's available, Dr. Knight said in an interview. This might be because the study population included only women seeking prenatal care, which is not the norm in clinical practice, and thus might have underrepresented poorer outcomes in patients with type 2 diabetes, he noted.

Overall, few data are available regarding pregnancy outcomes in type 2 diabetes, even though this type of diabetes is becoming increasingly common in reproductive-age women, she said.

“Type 2 diabetic patients should receive the same degree of preconceptional counseling, diligent glucose control, and antenatal surveillance as type 1 diabetic patients, in order to minimize the occurrence of poor perinatal outcome,” the authors wrote.

In a second poster at the meeting, diabetic macrovascular and microvascular disease during pregnancy was associated with reduced intrauterine fetal growth among 358 women with type 1 diabetes enrolled in a “Diabetes in Pregnancy” program at the University of Cincinnati.

The women were enrolled before 14 weeks' gestation, prospectively followed through the postpartum period, and treated with intensive insulin therapy.

They were classified at entry based on vascular status, with no vasculopathy present in 192, hypertension or background retinopathy in 79, proliferative retinopathy in only 18, nephropathy in only 42, and proliferative retinopathy and nephropathy in 26. Their mean ages were 24, 27, 27, 26, and 29 years, respectively; and they had been diagnosed with diabetes mellitus for 10, 15, 18, 14, and 18 years, respectively.

After controlling for gestation at delivery and maternal age and race, the odds ratio for delivery of a low-birth-weight infant (less than 2,500 g), compared with women without vasculopathy, was highest in women with proliferative retinopathy and nephropathy, Dr. Sina Haeri of the department of obstetrics and gynecology, Washington Hospital Center, and associates reported.

Likewise, after controlling for maternal age and race, the odds ratio for delivery of a small-for-gestational-age infant, compared with women with no vasculopathy, was highest in those with proliferative retinopathy and nephropathy (see graph below).

“The implication is that in women with type 1 diabetes, you need to keep a close eye on the babies because growth restriction is, of course, associated with neonatal death, poor outcome, and respiratory distress,” Dr. Haeri said in an interview. The poorer neonatal outcomes were observed even though the population was tightly controlled, with a self-monitored fasting and preprandial blood glucose goal of less than 100 mg/dL and a 90-minute postprandial goal of less than 140 mg/dL.

Type 2 diabetic patients should receive the same counseling and treatments as type 1 patients. DR. KNIGHT

ELSEVIER GLOBAL MEDICAL NEWS

DALLAS — Several years after a pregnancy complicated by eclampsia, significantly more women demonstrate subcortical cerebral white matter lesions on MRI, compared with women with a normotensive pregnancy.

In a study of 103 women, white matter lesions were observed in 16 of 39 (41%) formerly eclamptic women, in 10 of 35 (29%) formerly preeclamptic women, and 5 of 29 (17%) women who had a normotensive pregnancy, lead investigator Annet Aukes and associates reported at the annual meeting of the Society for Maternal-Fetal Medicine.

The average time from index pregnancy was not significantly different between the formerly eclamptic and normotensive groups (7 years vs. 5 years), who were the focus of the analysis. Their mean age was 38 years.

The findings are remarkable because the predominant opinion holds that eclampsia is a one-time event from which women can expect a full clinical recovery.

“We conclude that the paradigm that eclampsia is reversible should be revised,” said Ms. Aukes, an MD/PhD student at the University of Groningen (the Netherlands).

The researchers also observed that the number of eclamptic seizures appeared to be related to the presence and severity of the brain matter lesions. In all, 19 eclamptic women had one grand mal seizure, 10 had two, and 10 had three or more. Women who reported three or more eclamptic seizures were three times more likely to have white matter lesions than were women with no seizures, she said.

The total volume of the lesions was significantly greater among formerly eclamptic women than controls (0.04 mL vs. 0.004 mL).

The neurologic disturbances in eclampsia and preeclampsia are thought to represent a form of posterior reversible encephalopathy syndrome (PRES), which is recognized as a complication in various non-pregnancy-related disorders, including several of iatrogenic or neurotoxic origin, connective tissue disease, and acute glomerulonephritis. It can be reversed by lowering blood pressure and/or discontinuing the offending drug.

In PRES, it is thought that an acute elevation of systemic blood pressure exceeds the upper limit of cerebral autoregulation. This causes forced dilation of cerebral arteries, disruption of the blood-brain barrier, and formation of vasogenic cerebral edema, Ms. Aukes explained.

More recently, it has been hypothesized that when vasogenic edema becomes severe enough, it can result in reduced tissue perfusion and cytotoxic edema because of irreversible ischemic changes that lead to white matter lesions.

The theory is supported by studies, she said, including one in which persistent brain white matter lesions, consistent with the appearance of cerebral tissue loss, were demonstrated in nearly one-fourth of 27 eclamptic women when imaged 6 weeks after delivery (Am. J. Obstet. Gyn. 2004;190:714–20).

A study by Ms. Aukes and associates presented at last year's Society for Maternal-Fetal Medicine meeting demonstrated that formerly eclamptic women reported significantly more disruptions in cognitive function 7.6 years after the index pregnancy than did healthy parous controls (Am. J. Obstet. Gynecol. 2007;197; 365.e1–6).

An audience member asked if baseline imaging data were available on the women who seized to determine if the lesions were predisposing to eclampsia or if they were a result of eclampsia. Ms. Aukes responded that very few women had imaging at the time of their seizures, and thus they had not linked the data. “We're not sure if these lesions were preexisting or occurred during or after the seizures,” she said.

The investigators did not report any conflicts of interest and did not receive funding for the study.

A fluid-attenuated inversion-recovery MRI of a formerly eclamptic patient reveals white matter lesions (arrows). Neuro-Imaging Center of the School of Behavioural and Cognitive Neurosciences in Groningen

DALLAS — Several years after a pregnancy complicated by eclampsia, significantly more women demonstrate subcortical cerebral white matter lesions on MRI, compared with women with a normotensive pregnancy.

In a study of 103 women, white matter lesions were observed in 16 of 39 (41%) formerly eclamptic women, in 10 of 35 (29%) formerly preeclamptic women, and 5 of 29 (17%) women who had a normotensive pregnancy, lead investigator Annet Aukes and associates reported at the annual meeting of the Society for Maternal-Fetal Medicine.

The average time from index pregnancy was not significantly different between the formerly eclamptic and normotensive groups (7 years vs. 5 years), who were the focus of the analysis. Their mean age was 38 years.

The findings are remarkable because the predominant opinion holds that eclampsia is a one-time event from which women can expect a full clinical recovery.

“We conclude that the paradigm that eclampsia is reversible should be revised,” said Ms. Aukes, an MD/PhD student at the University of Groningen (the Netherlands).

The researchers also observed that the number of eclamptic seizures appeared to be related to the presence and severity of the brain matter lesions. In all, 19 eclamptic women had one grand mal seizure, 10 had two, and 10 had three or more. Women who reported three or more eclamptic seizures were three times more likely to have white matter lesions than were women with no seizures, she said.

The total volume of the lesions was significantly greater among formerly eclamptic women than controls (0.04 mL vs. 0.004 mL).

The neurologic disturbances in eclampsia and preeclampsia are thought to represent a form of posterior reversible encephalopathy syndrome (PRES), which is recognized as a complication in various non-pregnancy-related disorders, including several of iatrogenic or neurotoxic origin, connective tissue disease, and acute glomerulonephritis. It can be reversed by lowering blood pressure and/or discontinuing the offending drug.

In PRES, it is thought that an acute elevation of systemic blood pressure exceeds the upper limit of cerebral autoregulation. This causes forced dilation of cerebral arteries, disruption of the blood-brain barrier, and formation of vasogenic cerebral edema, Ms. Aukes explained.

More recently, it has been hypothesized that when vasogenic edema becomes severe enough, it can result in reduced tissue perfusion and cytotoxic edema because of irreversible ischemic changes that lead to white matter lesions.

The theory is supported by studies, she said, including one in which persistent brain white matter lesions, consistent with the appearance of cerebral tissue loss, were demonstrated in nearly one-fourth of 27 eclamptic women when imaged 6 weeks after delivery (Am. J. Obstet. Gyn. 2004;190:714–20).

A study by Ms. Aukes and associates presented at last year's Society for Maternal-Fetal Medicine meeting demonstrated that formerly eclamptic women reported significantly more disruptions in cognitive function 7.6 years after the index pregnancy than did healthy parous controls (Am. J. Obstet. Gynecol. 2007;197; 365.e1–6).

An audience member asked if baseline imaging data were available on the women who seized to determine if the lesions were predisposing to eclampsia or if they were a result of eclampsia. Ms. Aukes responded that very few women had imaging at the time of their seizures, and thus they had not linked the data. “We're not sure if these lesions were preexisting or occurred during or after the seizures,” she said.

The investigators did not report any conflicts of interest and did not receive funding for the study.

A fluid-attenuated inversion-recovery MRI of a formerly eclamptic patient reveals white matter lesions (arrows). Neuro-Imaging Center of the School of Behavioural and Cognitive Neurosciences in Groningen

DALLAS — Several years after a pregnancy complicated by eclampsia, significantly more women demonstrate subcortical cerebral white matter lesions on MRI, compared with women with a normotensive pregnancy.

In a study of 103 women, white matter lesions were observed in 16 of 39 (41%) formerly eclamptic women, in 10 of 35 (29%) formerly preeclamptic women, and 5 of 29 (17%) women who had a normotensive pregnancy, lead investigator Annet Aukes and associates reported at the annual meeting of the Society for Maternal-Fetal Medicine.

The average time from index pregnancy was not significantly different between the formerly eclamptic and normotensive groups (7 years vs. 5 years), who were the focus of the analysis. Their mean age was 38 years.

The findings are remarkable because the predominant opinion holds that eclampsia is a one-time event from which women can expect a full clinical recovery.

“We conclude that the paradigm that eclampsia is reversible should be revised,” said Ms. Aukes, an MD/PhD student at the University of Groningen (the Netherlands).

The researchers also observed that the number of eclamptic seizures appeared to be related to the presence and severity of the brain matter lesions. In all, 19 eclamptic women had one grand mal seizure, 10 had two, and 10 had three or more. Women who reported three or more eclamptic seizures were three times more likely to have white matter lesions than were women with no seizures, she said.

The total volume of the lesions was significantly greater among formerly eclamptic women than controls (0.04 mL vs. 0.004 mL).

The neurologic disturbances in eclampsia and preeclampsia are thought to represent a form of posterior reversible encephalopathy syndrome (PRES), which is recognized as a complication in various non-pregnancy-related disorders, including several of iatrogenic or neurotoxic origin, connective tissue disease, and acute glomerulonephritis. It can be reversed by lowering blood pressure and/or discontinuing the offending drug.

In PRES, it is thought that an acute elevation of systemic blood pressure exceeds the upper limit of cerebral autoregulation. This causes forced dilation of cerebral arteries, disruption of the blood-brain barrier, and formation of vasogenic cerebral edema, Ms. Aukes explained.

More recently, it has been hypothesized that when vasogenic edema becomes severe enough, it can result in reduced tissue perfusion and cytotoxic edema because of irreversible ischemic changes that lead to white matter lesions.

The theory is supported by studies, she said, including one in which persistent brain white matter lesions, consistent with the appearance of cerebral tissue loss, were demonstrated in nearly one-fourth of 27 eclamptic women when imaged 6 weeks after delivery (Am. J. Obstet. Gyn. 2004;190:714–20).

A study by Ms. Aukes and associates presented at last year's Society for Maternal-Fetal Medicine meeting demonstrated that formerly eclamptic women reported significantly more disruptions in cognitive function 7.6 years after the index pregnancy than did healthy parous controls (Am. J. Obstet. Gynecol. 2007;197; 365.e1–6).

An audience member asked if baseline imaging data were available on the women who seized to determine if the lesions were predisposing to eclampsia or if they were a result of eclampsia. Ms. Aukes responded that very few women had imaging at the time of their seizures, and thus they had not linked the data. “We're not sure if these lesions were preexisting or occurred during or after the seizures,” she said.

The investigators did not report any conflicts of interest and did not receive funding for the study.

A fluid-attenuated inversion-recovery MRI of a formerly eclamptic patient reveals white matter lesions (arrows). Neuro-Imaging Center of the School of Behavioural and Cognitive Neurosciences in Groningen

DALLAS — Multiple courses of antenatal corticosteroids did not offer additional benefits to infants born to mothers at high risk of preterm delivery, and were associated with significantly smaller birth weight, birth length, and head circumference in a phase IV study of 1,858 women.

In 2000, the National Institutes of Health reaffirmed that a single course of antenatal corticosteroids should be considered for pregnant women between 24 and 34 weeks of gestation who are at risk for preterm delivery within 7 days, but concluded that the data available at that time were inadequate to argue for or against repeat or rescue courses of antenatal corticosteroids (ACS) for fetal maturation.

Treatment consists of two doses of 12 mg betamethasone given intramuscularly 24 hours apart or four doses of 6 mg betamethasone given intramuscularly 12 hours apart.

In their latest October 2007 Guidelines for Perinatal Care, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics advise that “repeated corticosteroid courses should not be used routinely because clinical trials show decreased brain size, decreased birth weight, and adrenal insufficiency in neonates exposed to repeated doses.”

In the current study, the primary composite outcome of mortality, severe respiratory distress syndrome, grade 3–4 intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, or necrotizing enterocolitis was similar between infants born to women who received multiple courses of corticosteroids (12.9%) and those born to women receiving placebo (12.5%) after an initial course of corticosteroids. The odds ratio was 1.04.

The rate of still births also was not significantly different between groups (43 vs. 40, OR 1.08), principal investigator Dr. Kellie Murphy reported on behalf of the Women in the Multiple Courses of Antenatal Corticosteroids or Preterm Birth Study (MACS) group at the annual meeting of the Society for Maternal-Fetal Medicine.

The interventional study was conducted at 80 centers and included women at 26–30 weeks of gestation who remained at high risk for early delivery 14 or more days after being given a single course of ACS. At randomization, 937 received two doses of 12 mg betamethasone intramuscularly 24 hours apart every 14 days until 33 6/7 weeks or delivery and 921 received placebo. The mean age in both groups was 29 years.

The 1,164 babies born to women in the repeat-corticosteroid group weighed less (2,216 g vs. 2,330 g), were shorter (44.5 cm vs. 45.4 cm), and had a smaller head circumference (31.1 cm vs. 31.7 cm), compared with the 1,140 babies born to mothers in the placebo group. All the differences were statistically significant.

“What was surprising to us is that even though the majority of patients, 70%, received only one or two [additional] doses, which one wouldn't think was a large amount, there was still a significant decrease in all those parameters,” said Dr. Murphy, a perinatologist at Mount Sinai Hospital, Toronto.

In all, 385 women received one additional course, 305 received two additional courses, and 247 received three to five courses.

An unplanned ad hoc analysis of infants born less than 7 days after study drug exposure and those born less at than 32 weeks' gestational age showed no significant difference in the primary composite outcome between groups.

Dr. Murphy acknowledged during the question-and-answer session that the MACS findings are quite different from those of the recent Australian ACTORDS study in which repeat doses of antenatal steroids reduced neonatal morbidity without changes in body size or survival free of neurosensory disability at 2 years (N. Engl. J. Med. 2007;357:1179–89).

That study used a single intramuscular injection of betamethasone 11.4 mg repeated weekly, not times two; the definition of respiratory distress syndrome was slightly different; and z-scores were used to determine outcomes—all of which may account for the different findings, she said.

The MACS group concluded that multiple courses of ACS should not be given every 14 days to women at increased risk of preterm birth after receiving an initial course. When asked by an audience member about the efficacy of a single course of ACS, Dr. Murphy replied, “I still believe that it is efficacious and beneficial.”

The study was funded by the Canadian Institutes of Health Research. Dr. Murphy disclosed no relevant financial conflicts of interest.

DALLAS — Multiple courses of antenatal corticosteroids did not offer additional benefits to infants born to mothers at high risk of preterm delivery, and were associated with significantly smaller birth weight, birth length, and head circumference in a phase IV study of 1,858 women.

In 2000, the National Institutes of Health reaffirmed that a single course of antenatal corticosteroids should be considered for pregnant women between 24 and 34 weeks of gestation who are at risk for preterm delivery within 7 days, but concluded that the data available at that time were inadequate to argue for or against repeat or rescue courses of antenatal corticosteroids (ACS) for fetal maturation.

Treatment consists of two doses of 12 mg betamethasone given intramuscularly 24 hours apart or four doses of 6 mg betamethasone given intramuscularly 12 hours apart.

In their latest October 2007 Guidelines for Perinatal Care, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics advise that “repeated corticosteroid courses should not be used routinely because clinical trials show decreased brain size, decreased birth weight, and adrenal insufficiency in neonates exposed to repeated doses.”

In the current study, the primary composite outcome of mortality, severe respiratory distress syndrome, grade 3–4 intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, or necrotizing enterocolitis was similar between infants born to women who received multiple courses of corticosteroids (12.9%) and those born to women receiving placebo (12.5%) after an initial course of corticosteroids. The odds ratio was 1.04.

The rate of still births also was not significantly different between groups (43 vs. 40, OR 1.08), principal investigator Dr. Kellie Murphy reported on behalf of the Women in the Multiple Courses of Antenatal Corticosteroids or Preterm Birth Study (MACS) group at the annual meeting of the Society for Maternal-Fetal Medicine.

The interventional study was conducted at 80 centers and included women at 26–30 weeks of gestation who remained at high risk for early delivery 14 or more days after being given a single course of ACS. At randomization, 937 received two doses of 12 mg betamethasone intramuscularly 24 hours apart every 14 days until 33 6/7 weeks or delivery and 921 received placebo. The mean age in both groups was 29 years.

The 1,164 babies born to women in the repeat-corticosteroid group weighed less (2,216 g vs. 2,330 g), were shorter (44.5 cm vs. 45.4 cm), and had a smaller head circumference (31.1 cm vs. 31.7 cm), compared with the 1,140 babies born to mothers in the placebo group. All the differences were statistically significant.

“What was surprising to us is that even though the majority of patients, 70%, received only one or two [additional] doses, which one wouldn't think was a large amount, there was still a significant decrease in all those parameters,” said Dr. Murphy, a perinatologist at Mount Sinai Hospital, Toronto.

In all, 385 women received one additional course, 305 received two additional courses, and 247 received three to five courses.

An unplanned ad hoc analysis of infants born less than 7 days after study drug exposure and those born less at than 32 weeks' gestational age showed no significant difference in the primary composite outcome between groups.

Dr. Murphy acknowledged during the question-and-answer session that the MACS findings are quite different from those of the recent Australian ACTORDS study in which repeat doses of antenatal steroids reduced neonatal morbidity without changes in body size or survival free of neurosensory disability at 2 years (N. Engl. J. Med. 2007;357:1179–89).

That study used a single intramuscular injection of betamethasone 11.4 mg repeated weekly, not times two; the definition of respiratory distress syndrome was slightly different; and z-scores were used to determine outcomes—all of which may account for the different findings, she said.

The MACS group concluded that multiple courses of ACS should not be given every 14 days to women at increased risk of preterm birth after receiving an initial course. When asked by an audience member about the efficacy of a single course of ACS, Dr. Murphy replied, “I still believe that it is efficacious and beneficial.”

The study was funded by the Canadian Institutes of Health Research. Dr. Murphy disclosed no relevant financial conflicts of interest.

DALLAS — Multiple courses of antenatal corticosteroids did not offer additional benefits to infants born to mothers at high risk of preterm delivery, and were associated with significantly smaller birth weight, birth length, and head circumference in a phase IV study of 1,858 women.

In 2000, the National Institutes of Health reaffirmed that a single course of antenatal corticosteroids should be considered for pregnant women between 24 and 34 weeks of gestation who are at risk for preterm delivery within 7 days, but concluded that the data available at that time were inadequate to argue for or against repeat or rescue courses of antenatal corticosteroids (ACS) for fetal maturation.

Treatment consists of two doses of 12 mg betamethasone given intramuscularly 24 hours apart or four doses of 6 mg betamethasone given intramuscularly 12 hours apart.

In their latest October 2007 Guidelines for Perinatal Care, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics advise that “repeated corticosteroid courses should not be used routinely because clinical trials show decreased brain size, decreased birth weight, and adrenal insufficiency in neonates exposed to repeated doses.”

In the current study, the primary composite outcome of mortality, severe respiratory distress syndrome, grade 3–4 intraventricular hemorrhage, periventricular leukomalacia, bronchopulmonary dysplasia, or necrotizing enterocolitis was similar between infants born to women who received multiple courses of corticosteroids (12.9%) and those born to women receiving placebo (12.5%) after an initial course of corticosteroids. The odds ratio was 1.04.

The rate of still births also was not significantly different between groups (43 vs. 40, OR 1.08), principal investigator Dr. Kellie Murphy reported on behalf of the Women in the Multiple Courses of Antenatal Corticosteroids or Preterm Birth Study (MACS) group at the annual meeting of the Society for Maternal-Fetal Medicine.

The interventional study was conducted at 80 centers and included women at 26–30 weeks of gestation who remained at high risk for early delivery 14 or more days after being given a single course of ACS. At randomization, 937 received two doses of 12 mg betamethasone intramuscularly 24 hours apart every 14 days until 33 6/7 weeks or delivery and 921 received placebo. The mean age in both groups was 29 years.

The 1,164 babies born to women in the repeat-corticosteroid group weighed less (2,216 g vs. 2,330 g), were shorter (44.5 cm vs. 45.4 cm), and had a smaller head circumference (31.1 cm vs. 31.7 cm), compared with the 1,140 babies born to mothers in the placebo group. All the differences were statistically significant.

“What was surprising to us is that even though the majority of patients, 70%, received only one or two [additional] doses, which one wouldn't think was a large amount, there was still a significant decrease in all those parameters,” said Dr. Murphy, a perinatologist at Mount Sinai Hospital, Toronto.

In all, 385 women received one additional course, 305 received two additional courses, and 247 received three to five courses.

An unplanned ad hoc analysis of infants born less than 7 days after study drug exposure and those born less at than 32 weeks' gestational age showed no significant difference in the primary composite outcome between groups.

Dr. Murphy acknowledged during the question-and-answer session that the MACS findings are quite different from those of the recent Australian ACTORDS study in which repeat doses of antenatal steroids reduced neonatal morbidity without changes in body size or survival free of neurosensory disability at 2 years (N. Engl. J. Med. 2007;357:1179–89).

That study used a single intramuscular injection of betamethasone 11.4 mg repeated weekly, not times two; the definition of respiratory distress syndrome was slightly different; and z-scores were used to determine outcomes—all of which may account for the different findings, she said.

The MACS group concluded that multiple courses of ACS should not be given every 14 days to women at increased risk of preterm birth after receiving an initial course. When asked by an audience member about the efficacy of a single course of ACS, Dr. Murphy replied, “I still believe that it is efficacious and beneficial.”

The study was funded by the Canadian Institutes of Health Research. Dr. Murphy disclosed no relevant financial conflicts of interest.

DALLAS — Buccal misoprostol was as effective as vaginal for cervical ripening, but was associated with a significantly higher incidence of tachysystole in a prospective randomized trial of 738 women.

Although tachysystole was increased, maternal and neonatal complications were comparable between groups, Dr. Zoi Russell said at the annual meeting of the Society for Maternal-Fetal Medicine.

The efficacy of misoprostol (Cytotec) for cervical ripening or labor induction has been confirmed in more than 100 randomized trials, but physicians are seeking the optimal route and dose of administration for the synthetic prostaglandin E1 analogue.

Vaginal routes have the advantage of more sustained activity and greater bioavailability, while oral and sublingual routes have more rapid onset and a lower rate of gastrointestinal side effects, said Dr. Russell of the University of South Florida, Tampa.

In the current study, women at a gestational age of more than 26 weeks with a medical indication for labor induction and an unripe cervix were randomized to initial doses of 100 mcg buccal misoprostol administered between the cheek and gum or 25 mcg misoprostol administered intravaginally, and increased to 200 mcg and 50 mcg after two doses. Doses were given every 3–6 hours in both groups, until a Bishop score of at least 7, labor, intervention, or a total of six misoprostol doses.

In both groups, the median age was 25 years, the initial Bishop score was 2, and the Bishop score at induction was 8.

In all, 364 women were randomized to the vaginal group and 374 to the buccal group. However, 44 in each group were excluded for protocol violations, leaving 320 vaginal patients and 330 buccal patients available for analysis.

The buccal group appeared to deliver faster than the vaginal group when all routes of delivery were included (19.8 vs. 22.5 hours), but the difference did not persist when cesarean deliveries were excluded, Dr. Russell said.

The study's primary outcome of median interval from first dose to vaginal delivery was not significantly different between the buccal (19 hours) and vaginal (21 hours) groups.

There were no significant differences between groups in cesarean rates (111 vs. 103) or cesarean deliveries performed for reasons of nonreassuring fetal surveillance (61 vs. 54).

Buccal misoprostol was significantly associated with higher rates of intervention for nonreassuring fetal surveillance (36 vs. 20) and tachysystole (46 vs. 26), defined as three to six contractions of 1–2 minutes for two consecutive 10-minute periods. However, buccal administration was also significantly associated with less need for oxytocin augmentation (237 vs. 259), said Dr. Russell, who reported receiving no financial support for the study and disclosed no relevant conflicts of interest.

An earlier Cochrane meta-analysis of three small trials with a total of 502 women reported that the buccal route was associated with a trend to fewer cesarean sections than the vaginal route, but concluded that sublingual or buccal misoprostol should not enter clinical use until its safety and optimal dosage have been established by larger trials (Cochrane Database Syst. Rev. 2004;CD004221 [doi: 10.1002/14651858.CD004221.pub2]).

When asked if the current data are enough to support clinical use of buccal misoprostol, Dr. Russell said in an interview that the study was designed as an efficacy study, and as such, showed that “buccal can be at least as effective as vaginal misoprostol in ripening the cervix and induction of labor in the third trimester.

“Although the maternal and neonatal outcomes were similar between the two groups, our study would be underpowered to detect any significant differences in rare but serious adverse outcomes,” she said. “That is a question that can only be answered by a much larger study—a safety study.”

DALLAS — Buccal misoprostol was as effective as vaginal for cervical ripening, but was associated with a significantly higher incidence of tachysystole in a prospective randomized trial of 738 women.

Although tachysystole was increased, maternal and neonatal complications were comparable between groups, Dr. Zoi Russell said at the annual meeting of the Society for Maternal-Fetal Medicine.

The efficacy of misoprostol (Cytotec) for cervical ripening or labor induction has been confirmed in more than 100 randomized trials, but physicians are seeking the optimal route and dose of administration for the synthetic prostaglandin E1 analogue.

Vaginal routes have the advantage of more sustained activity and greater bioavailability, while oral and sublingual routes have more rapid onset and a lower rate of gastrointestinal side effects, said Dr. Russell of the University of South Florida, Tampa.

In the current study, women at a gestational age of more than 26 weeks with a medical indication for labor induction and an unripe cervix were randomized to initial doses of 100 mcg buccal misoprostol administered between the cheek and gum or 25 mcg misoprostol administered intravaginally, and increased to 200 mcg and 50 mcg after two doses. Doses were given every 3–6 hours in both groups, until a Bishop score of at least 7, labor, intervention, or a total of six misoprostol doses.

In both groups, the median age was 25 years, the initial Bishop score was 2, and the Bishop score at induction was 8.

In all, 364 women were randomized to the vaginal group and 374 to the buccal group. However, 44 in each group were excluded for protocol violations, leaving 320 vaginal patients and 330 buccal patients available for analysis.

The buccal group appeared to deliver faster than the vaginal group when all routes of delivery were included (19.8 vs. 22.5 hours), but the difference did not persist when cesarean deliveries were excluded, Dr. Russell said.

The study's primary outcome of median interval from first dose to vaginal delivery was not significantly different between the buccal (19 hours) and vaginal (21 hours) groups.

There were no significant differences between groups in cesarean rates (111 vs. 103) or cesarean deliveries performed for reasons of nonreassuring fetal surveillance (61 vs. 54).

Buccal misoprostol was significantly associated with higher rates of intervention for nonreassuring fetal surveillance (36 vs. 20) and tachysystole (46 vs. 26), defined as three to six contractions of 1–2 minutes for two consecutive 10-minute periods. However, buccal administration was also significantly associated with less need for oxytocin augmentation (237 vs. 259), said Dr. Russell, who reported receiving no financial support for the study and disclosed no relevant conflicts of interest.

An earlier Cochrane meta-analysis of three small trials with a total of 502 women reported that the buccal route was associated with a trend to fewer cesarean sections than the vaginal route, but concluded that sublingual or buccal misoprostol should not enter clinical use until its safety and optimal dosage have been established by larger trials (Cochrane Database Syst. Rev. 2004;CD004221 [doi: 10.1002/14651858.CD004221.pub2]).

When asked if the current data are enough to support clinical use of buccal misoprostol, Dr. Russell said in an interview that the study was designed as an efficacy study, and as such, showed that “buccal can be at least as effective as vaginal misoprostol in ripening the cervix and induction of labor in the third trimester.

“Although the maternal and neonatal outcomes were similar between the two groups, our study would be underpowered to detect any significant differences in rare but serious adverse outcomes,” she said. “That is a question that can only be answered by a much larger study—a safety study.”

DALLAS — Buccal misoprostol was as effective as vaginal for cervical ripening, but was associated with a significantly higher incidence of tachysystole in a prospective randomized trial of 738 women.

Although tachysystole was increased, maternal and neonatal complications were comparable between groups, Dr. Zoi Russell said at the annual meeting of the Society for Maternal-Fetal Medicine.

The efficacy of misoprostol (Cytotec) for cervical ripening or labor induction has been confirmed in more than 100 randomized trials, but physicians are seeking the optimal route and dose of administration for the synthetic prostaglandin E1 analogue.

Vaginal routes have the advantage of more sustained activity and greater bioavailability, while oral and sublingual routes have more rapid onset and a lower rate of gastrointestinal side effects, said Dr. Russell of the University of South Florida, Tampa.

In the current study, women at a gestational age of more than 26 weeks with a medical indication for labor induction and an unripe cervix were randomized to initial doses of 100 mcg buccal misoprostol administered between the cheek and gum or 25 mcg misoprostol administered intravaginally, and increased to 200 mcg and 50 mcg after two doses. Doses were given every 3–6 hours in both groups, until a Bishop score of at least 7, labor, intervention, or a total of six misoprostol doses.

In both groups, the median age was 25 years, the initial Bishop score was 2, and the Bishop score at induction was 8.

In all, 364 women were randomized to the vaginal group and 374 to the buccal group. However, 44 in each group were excluded for protocol violations, leaving 320 vaginal patients and 330 buccal patients available for analysis.

The buccal group appeared to deliver faster than the vaginal group when all routes of delivery were included (19.8 vs. 22.5 hours), but the difference did not persist when cesarean deliveries were excluded, Dr. Russell said.

The study's primary outcome of median interval from first dose to vaginal delivery was not significantly different between the buccal (19 hours) and vaginal (21 hours) groups.

There were no significant differences between groups in cesarean rates (111 vs. 103) or cesarean deliveries performed for reasons of nonreassuring fetal surveillance (61 vs. 54).

Buccal misoprostol was significantly associated with higher rates of intervention for nonreassuring fetal surveillance (36 vs. 20) and tachysystole (46 vs. 26), defined as three to six contractions of 1–2 minutes for two consecutive 10-minute periods. However, buccal administration was also significantly associated with less need for oxytocin augmentation (237 vs. 259), said Dr. Russell, who reported receiving no financial support for the study and disclosed no relevant conflicts of interest.

An earlier Cochrane meta-analysis of three small trials with a total of 502 women reported that the buccal route was associated with a trend to fewer cesarean sections than the vaginal route, but concluded that sublingual or buccal misoprostol should not enter clinical use until its safety and optimal dosage have been established by larger trials (Cochrane Database Syst. Rev. 2004;CD004221 [doi: 10.1002/14651858.CD004221.pub2]).

When asked if the current data are enough to support clinical use of buccal misoprostol, Dr. Russell said in an interview that the study was designed as an efficacy study, and as such, showed that “buccal can be at least as effective as vaginal misoprostol in ripening the cervix and induction of labor in the third trimester.

“Although the maternal and neonatal outcomes were similar between the two groups, our study would be underpowered to detect any significant differences in rare but serious adverse outcomes,” she said. “That is a question that can only be answered by a much larger study—a safety study.”

SNOWMASS, COLO. — Don't hesitate to continue β-blocker therapy throughout pregnancy when the situation calls for it, Dr. Carole A. Warnes urged at a conference sponsored by the Society for Cardiovascular Angiography and Interventions.

“In practice I have been using β-blockers in pregnancy for 30 years. I've never had a significant problem with a baby after the mother has had a β-blocker,” declared Dr. Warnes, professor of medicine at the Mayo Clinic, Rochester, Minn.

“Do we worry about the growth of the fetus? Yes, and it needs to be monitored. At the time of delivery the baby may be bradycardic or may have hypoglycemia, but we can deal with that very easily. So for the woman who needs a β-blocker—for example, a patient with hypertrophic cardiomyopathy, or perhaps hypertension with a dilated aorta—we can use them and use them safely, and if it's better for the mother to continue then we do so,” she added at the conference, which was cosponsored by the American College of Cardiology.

There are four key principles to keep in mind when prescribing cardiovascular drugs in pregnancy: Stick to the ones with a long safety record, use the lowest effective dose and shortest duration, avoid multidrug regimens, and steer clear of agents labeled category D or X by the Food and Drug Administration, the cardiologist said.

In addition to many of the β-blockers, other cardiovascular drugs she listed as relatively safe in pregnancy include digoxin, calcium channel blockers, procainamide, hydralazine, methyldopa, and furosemide.

Agents that are not safe to use during pregnancy include statins, ACE inhibitors, angiotensin receptor blockers, phenytoin, and folic acid antagonists, including some antibiotics, Dr. Warnes said.

SNOWMASS, COLO. — Don't hesitate to continue β-blocker therapy throughout pregnancy when the situation calls for it, Dr. Carole A. Warnes urged at a conference sponsored by the Society for Cardiovascular Angiography and Interventions.

“In practice I have been using β-blockers in pregnancy for 30 years. I've never had a significant problem with a baby after the mother has had a β-blocker,” declared Dr. Warnes, professor of medicine at the Mayo Clinic, Rochester, Minn.

“Do we worry about the growth of the fetus? Yes, and it needs to be monitored. At the time of delivery the baby may be bradycardic or may have hypoglycemia, but we can deal with that very easily. So for the woman who needs a β-blocker—for example, a patient with hypertrophic cardiomyopathy, or perhaps hypertension with a dilated aorta—we can use them and use them safely, and if it's better for the mother to continue then we do so,” she added at the conference, which was cosponsored by the American College of Cardiology.

There are four key principles to keep in mind when prescribing cardiovascular drugs in pregnancy: Stick to the ones with a long safety record, use the lowest effective dose and shortest duration, avoid multidrug regimens, and steer clear of agents labeled category D or X by the Food and Drug Administration, the cardiologist said.

In addition to many of the β-blockers, other cardiovascular drugs she listed as relatively safe in pregnancy include digoxin, calcium channel blockers, procainamide, hydralazine, methyldopa, and furosemide.

Agents that are not safe to use during pregnancy include statins, ACE inhibitors, angiotensin receptor blockers, phenytoin, and folic acid antagonists, including some antibiotics, Dr. Warnes said.

SNOWMASS, COLO. — Don't hesitate to continue β-blocker therapy throughout pregnancy when the situation calls for it, Dr. Carole A. Warnes urged at a conference sponsored by the Society for Cardiovascular Angiography and Interventions.

“In practice I have been using β-blockers in pregnancy for 30 years. I've never had a significant problem with a baby after the mother has had a β-blocker,” declared Dr. Warnes, professor of medicine at the Mayo Clinic, Rochester, Minn.

“Do we worry about the growth of the fetus? Yes, and it needs to be monitored. At the time of delivery the baby may be bradycardic or may have hypoglycemia, but we can deal with that very easily. So for the woman who needs a β-blocker—for example, a patient with hypertrophic cardiomyopathy, or perhaps hypertension with a dilated aorta—we can use them and use them safely, and if it's better for the mother to continue then we do so,” she added at the conference, which was cosponsored by the American College of Cardiology.

There are four key principles to keep in mind when prescribing cardiovascular drugs in pregnancy: Stick to the ones with a long safety record, use the lowest effective dose and shortest duration, avoid multidrug regimens, and steer clear of agents labeled category D or X by the Food and Drug Administration, the cardiologist said.

In addition to many of the β-blockers, other cardiovascular drugs she listed as relatively safe in pregnancy include digoxin, calcium channel blockers, procainamide, hydralazine, methyldopa, and furosemide.

Agents that are not safe to use during pregnancy include statins, ACE inhibitors, angiotensin receptor blockers, phenytoin, and folic acid antagonists, including some antibiotics, Dr. Warnes said.

SNOWMASS, COLO. — When it comes to managing anticoagulation in the pregnant patient with a mechanical heart valve, there is simply no ideal solution, Dr. Carole A. Warnes stressed at a conference sponsored by the Society for Cardiovascular Angiography and Interventions.

“This is not the same as getting your patient through noncardiac surgery. It's very different. The blood is stickier than at any other time you'll have to manage a mechanical valve,” cautioned Dr. Warnes, professor of medicine at the Mayo Clinic, Rochester, Minn.

Other normal physiologic changes in pregnancy that increase the risk of thromboembolic events in patients with mitral or aortic valve prostheses include a nearly 50% increase in circulating blood volume, accompanied by a 30% rise in cardiac output and a 10–20 beat-per-minute increase in resting heart rate. Also, uterine contractions can trigger sudden jumps in systolic and diastolic blood pressure.

What makes managing thromboembolic risk in pregnant patients with a mechanical heart valve so challenging is the need to trade off maternal versus fetal risk.

Unfractionated heparin doesn't cross the placenta. It is often considered safer for the fetus than warfarin in pregnancy. But unfractionated heparin is a poor anticoagulant in pregnancy. The response to the standard dosage varies widely because of the background increases in factor VIII and fibrinogen. As a result, the risk of a thrombosed valve or other thromboembolic event with prolonged heparin is about 10%. The maternal hemorrhage risk is increased as well.

Warfarin is far more effective than unfractionated heparin at preventing valve thrombosis in pregnancy. However, it crosses the placenta, and fetal exposure during gestational weeks 6–9 can result in warfarin embryopathy. The risk is approximately 6% but might be dose dependent. In one older Italian study involving 58 pregnancies, no cases of embryopathy occurred at warfarin doses of 5 mg/day or less, compared with a 9% rate at doses above 5 mg/day (J. Am. Coll. Cardiol. 1999;33:1637–41).

“The fetal risk is probably not as high with warfarin as you might think, but for medicolegal reasons you probably want to avoid it in most circumstances,” Dr. Warnes observed at the conference, which was cosponsored by the American College of Cardiology.

Some advocate low-molecular-weight heparin throughout pregnancy as the best approach, but Dr. Warnes is leery. The supporting data are extremely limited. Moreover, she has seen thromboembolic complications occur even when LMWH dosing was guided by monitoring of factor Xa levels rather than relying on fixed-dose therapy.

The most popular management strategy in the United States entails a switch from warfarin to unfractionated heparin as soon as pregnancy is diagnosed, with a switch back to warfarin at 13 weeks' gestation, after the risk of embryopathy is over.

This is followed by yet another switch back to heparin at about 35 weeks in anticipation of delivery, because the fetus can't safely pass through the birth canal while anticoagulated.

The heparin is stopped for as short a time as possible around delivery. Heparin is resumed 6–12 hours post partum, because that's still a high-risk period for valve thrombosis.

If this strategy is employed, it's important to give heparin at an adequate intensity. This means maintaining the activated partial thromboplastin time at greater than twice control. If factor Xa monitoring is used, aim for 0.35–0.7 U/mL of anti-factor Xa, Dr. Warnes urged.

The highest-risk situation in pregnancy in terms of thromboembolism involves a tilting disc prosthesis in the mitral position. This is a situation in which continued use of warfarin throughout pregnancy is a reasonable strategy up until the switch to intravenous heparin at week 35, even though the Physicians Desk Reference lists warfarin as contraindicated in pregnancy, the cardiologist said.

Warfarin throughout pregnancy is a particularly attractive strategy in a high-risk woman who was well controlled on the anticoagulant at 5 mg/day or less prior to pregnancy, which might lessen the risk of warfarin embryopathy, she continued.

Whatever anticoagulation strategy is used in pregnancy, a daily baby aspirin during the second and third trimesters is safe and probably beneficial. It should be used routinely, according to Dr. Warnes.

'This is not the same as getting your patient through noncardiac surgery.' DR. WARNES

SNOWMASS, COLO. — When it comes to managing anticoagulation in the pregnant patient with a mechanical heart valve, there is simply no ideal solution, Dr. Carole A. Warnes stressed at a conference sponsored by the Society for Cardiovascular Angiography and Interventions.

“This is not the same as getting your patient through noncardiac surgery. It's very different. The blood is stickier than at any other time you'll have to manage a mechanical valve,” cautioned Dr. Warnes, professor of medicine at the Mayo Clinic, Rochester, Minn.

Other normal physiologic changes in pregnancy that increase the risk of thromboembolic events in patients with mitral or aortic valve prostheses include a nearly 50% increase in circulating blood volume, accompanied by a 30% rise in cardiac output and a 10–20 beat-per-minute increase in resting heart rate. Also, uterine contractions can trigger sudden jumps in systolic and diastolic blood pressure.

What makes managing thromboembolic risk in pregnant patients with a mechanical heart valve so challenging is the need to trade off maternal versus fetal risk.

Unfractionated heparin doesn't cross the placenta. It is often considered safer for the fetus than warfarin in pregnancy. But unfractionated heparin is a poor anticoagulant in pregnancy. The response to the standard dosage varies widely because of the background increases in factor VIII and fibrinogen. As a result, the risk of a thrombosed valve or other thromboembolic event with prolonged heparin is about 10%. The maternal hemorrhage risk is increased as well.

Warfarin is far more effective than unfractionated heparin at preventing valve thrombosis in pregnancy. However, it crosses the placenta, and fetal exposure during gestational weeks 6–9 can result in warfarin embryopathy. The risk is approximately 6% but might be dose dependent. In one older Italian study involving 58 pregnancies, no cases of embryopathy occurred at warfarin doses of 5 mg/day or less, compared with a 9% rate at doses above 5 mg/day (J. Am. Coll. Cardiol. 1999;33:1637–41).

“The fetal risk is probably not as high with warfarin as you might think, but for medicolegal reasons you probably want to avoid it in most circumstances,” Dr. Warnes observed at the conference, which was cosponsored by the American College of Cardiology.

Some advocate low-molecular-weight heparin throughout pregnancy as the best approach, but Dr. Warnes is leery. The supporting data are extremely limited. Moreover, she has seen thromboembolic complications occur even when LMWH dosing was guided by monitoring of factor Xa levels rather than relying on fixed-dose therapy.

The most popular management strategy in the United States entails a switch from warfarin to unfractionated heparin as soon as pregnancy is diagnosed, with a switch back to warfarin at 13 weeks' gestation, after the risk of embryopathy is over.

This is followed by yet another switch back to heparin at about 35 weeks in anticipation of delivery, because the fetus can't safely pass through the birth canal while anticoagulated.

The heparin is stopped for as short a time as possible around delivery. Heparin is resumed 6–12 hours post partum, because that's still a high-risk period for valve thrombosis.

If this strategy is employed, it's important to give heparin at an adequate intensity. This means maintaining the activated partial thromboplastin time at greater than twice control. If factor Xa monitoring is used, aim for 0.35–0.7 U/mL of anti-factor Xa, Dr. Warnes urged.

The highest-risk situation in pregnancy in terms of thromboembolism involves a tilting disc prosthesis in the mitral position. This is a situation in which continued use of warfarin throughout pregnancy is a reasonable strategy up until the switch to intravenous heparin at week 35, even though the Physicians Desk Reference lists warfarin as contraindicated in pregnancy, the cardiologist said.

Warfarin throughout pregnancy is a particularly attractive strategy in a high-risk woman who was well controlled on the anticoagulant at 5 mg/day or less prior to pregnancy, which might lessen the risk of warfarin embryopathy, she continued.

Whatever anticoagulation strategy is used in pregnancy, a daily baby aspirin during the second and third trimesters is safe and probably beneficial. It should be used routinely, according to Dr. Warnes.

'This is not the same as getting your patient through noncardiac surgery.' DR. WARNES

SNOWMASS, COLO. — When it comes to managing anticoagulation in the pregnant patient with a mechanical heart valve, there is simply no ideal solution, Dr. Carole A. Warnes stressed at a conference sponsored by the Society for Cardiovascular Angiography and Interventions.

“This is not the same as getting your patient through noncardiac surgery. It's very different. The blood is stickier than at any other time you'll have to manage a mechanical valve,” cautioned Dr. Warnes, professor of medicine at the Mayo Clinic, Rochester, Minn.

Other normal physiologic changes in pregnancy that increase the risk of thromboembolic events in patients with mitral or aortic valve prostheses include a nearly 50% increase in circulating blood volume, accompanied by a 30% rise in cardiac output and a 10–20 beat-per-minute increase in resting heart rate. Also, uterine contractions can trigger sudden jumps in systolic and diastolic blood pressure.

What makes managing thromboembolic risk in pregnant patients with a mechanical heart valve so challenging is the need to trade off maternal versus fetal risk.

Unfractionated heparin doesn't cross the placenta. It is often considered safer for the fetus than warfarin in pregnancy. But unfractionated heparin is a poor anticoagulant in pregnancy. The response to the standard dosage varies widely because of the background increases in factor VIII and fibrinogen. As a result, the risk of a thrombosed valve or other thromboembolic event with prolonged heparin is about 10%. The maternal hemorrhage risk is increased as well.

Warfarin is far more effective than unfractionated heparin at preventing valve thrombosis in pregnancy. However, it crosses the placenta, and fetal exposure during gestational weeks 6–9 can result in warfarin embryopathy. The risk is approximately 6% but might be dose dependent. In one older Italian study involving 58 pregnancies, no cases of embryopathy occurred at warfarin doses of 5 mg/day or less, compared with a 9% rate at doses above 5 mg/day (J. Am. Coll. Cardiol. 1999;33:1637–41).

“The fetal risk is probably not as high with warfarin as you might think, but for medicolegal reasons you probably want to avoid it in most circumstances,” Dr. Warnes observed at the conference, which was cosponsored by the American College of Cardiology.

Some advocate low-molecular-weight heparin throughout pregnancy as the best approach, but Dr. Warnes is leery. The supporting data are extremely limited. Moreover, she has seen thromboembolic complications occur even when LMWH dosing was guided by monitoring of factor Xa levels rather than relying on fixed-dose therapy.

The most popular management strategy in the United States entails a switch from warfarin to unfractionated heparin as soon as pregnancy is diagnosed, with a switch back to warfarin at 13 weeks' gestation, after the risk of embryopathy is over.

This is followed by yet another switch back to heparin at about 35 weeks in anticipation of delivery, because the fetus can't safely pass through the birth canal while anticoagulated.

The heparin is stopped for as short a time as possible around delivery. Heparin is resumed 6–12 hours post partum, because that's still a high-risk period for valve thrombosis.

If this strategy is employed, it's important to give heparin at an adequate intensity. This means maintaining the activated partial thromboplastin time at greater than twice control. If factor Xa monitoring is used, aim for 0.35–0.7 U/mL of anti-factor Xa, Dr. Warnes urged.

The highest-risk situation in pregnancy in terms of thromboembolism involves a tilting disc prosthesis in the mitral position. This is a situation in which continued use of warfarin throughout pregnancy is a reasonable strategy up until the switch to intravenous heparin at week 35, even though the Physicians Desk Reference lists warfarin as contraindicated in pregnancy, the cardiologist said.

Warfarin throughout pregnancy is a particularly attractive strategy in a high-risk woman who was well controlled on the anticoagulant at 5 mg/day or less prior to pregnancy, which might lessen the risk of warfarin embryopathy, she continued.

Whatever anticoagulation strategy is used in pregnancy, a daily baby aspirin during the second and third trimesters is safe and probably beneficial. It should be used routinely, according to Dr. Warnes.

'This is not the same as getting your patient through noncardiac surgery.' DR. WARNES

DALLAS — Early cardiovascular risk-factor screening is warranted in women with a history of early-onset preeclampsia, according to results of a study in 617 women.

Significantly more women with a history of early-onset preeclampsia exhibited at least one major cardiovascular risk factor, as defined by the American Heart Association, when screened 6 months after delivery, and compared with healthy controls (89% vs. 71%).

The percentages of women exhibiting at least two and at least three cardiovascular risk factors were also significantly higher in the preeclampsia group, Dr. Bas Van Rijn said at the annual meeting of the Society for Maternal-Fetal Medicine.

Among women in the preeclampsia group 51% had two or more cardiovascular risk factors vs. 26% in the control group, and 19% had three or more risk factors vs. 6% in the control group.

“We advise using global risk estimations, such as the Framingham chart, to identify women that require lifestyle intervention programs aimed at primary prevention of cardiovascular disease,” said Dr. Van Rijn of the division of perinatology and gynecology, University Medical Center Utrecht (the Netherlands).

The study included 243 women (mean age 30.5 years) admitted from 1995 to 2005 for early-onset preeclampsia and delivery before 34 weeks and a population-based control group of 374 healthy, nonpregnant women (mean 28.3 years). Women with chronic hypertension (greater than 140/90 mm Hg) were excluded. Outcomes were adjusted for age.

When compared with matched controls, women in the preeclampsia group had significantly higher rates of obesity (body mass index 26.1 vs. 24.3 kg/m

HDL-cholesterol levels were significantly lower among cases versus controls (55 vs. 61 mg/dL).

No significant differences were found for rates of diabetes mellitus and smoking.

In all, 15.2% of women with a history of preeclampsia met the criteria for metabolic syndrome, as formulated by the AHA and World Health Organization versus only 4.3% of controls (odds ratio 3.6).

The estimated 10-year risk of first cardiovascular disease events, as calculated by the Framingham CHD risk prediction scores, remained less than 10% for all of the women. This places the women in the AHA low-risk range, which is a 1%–3% absolute risk of developing a major cardiovascular event in the coming years, he said.

However, this is a bit deceptive, mainly because of the young age of the women, Dr. Van Rijn added.

For example, if one adds 10 years to the Framingham risk score (mean age 40 years), the risk category for the preeclampsia group would be 5%–10%, which is comparable to a woman who has experienced a myocardial infarction.

“Women with a history of early-onset preeclampsia exhibit many risk factors, but their relatively young age is masking their absolute cardiovascular risk,” said Dr. Van Rijn, who disclosed no financial conflicts of interest.

The study was sponsored by the Netherlands Organization for Scientific Research.

DALLAS — Early cardiovascular risk-factor screening is warranted in women with a history of early-onset preeclampsia, according to results of a study in 617 women.

Significantly more women with a history of early-onset preeclampsia exhibited at least one major cardiovascular risk factor, as defined by the American Heart Association, when screened 6 months after delivery, and compared with healthy controls (89% vs. 71%).

The percentages of women exhibiting at least two and at least three cardiovascular risk factors were also significantly higher in the preeclampsia group, Dr. Bas Van Rijn said at the annual meeting of the Society for Maternal-Fetal Medicine.

Among women in the preeclampsia group 51% had two or more cardiovascular risk factors vs. 26% in the control group, and 19% had three or more risk factors vs. 6% in the control group.

“We advise using global risk estimations, such as the Framingham chart, to identify women that require lifestyle intervention programs aimed at primary prevention of cardiovascular disease,” said Dr. Van Rijn of the division of perinatology and gynecology, University Medical Center Utrecht (the Netherlands).

The study included 243 women (mean age 30.5 years) admitted from 1995 to 2005 for early-onset preeclampsia and delivery before 34 weeks and a population-based control group of 374 healthy, nonpregnant women (mean 28.3 years). Women with chronic hypertension (greater than 140/90 mm Hg) were excluded. Outcomes were adjusted for age.

When compared with matched controls, women in the preeclampsia group had significantly higher rates of obesity (body mass index 26.1 vs. 24.3 kg/m

HDL-cholesterol levels were significantly lower among cases versus controls (55 vs. 61 mg/dL).

No significant differences were found for rates of diabetes mellitus and smoking.

In all, 15.2% of women with a history of preeclampsia met the criteria for metabolic syndrome, as formulated by the AHA and World Health Organization versus only 4.3% of controls (odds ratio 3.6).

The estimated 10-year risk of first cardiovascular disease events, as calculated by the Framingham CHD risk prediction scores, remained less than 10% for all of the women. This places the women in the AHA low-risk range, which is a 1%–3% absolute risk of developing a major cardiovascular event in the coming years, he said.

However, this is a bit deceptive, mainly because of the young age of the women, Dr. Van Rijn added.

For example, if one adds 10 years to the Framingham risk score (mean age 40 years), the risk category for the preeclampsia group would be 5%–10%, which is comparable to a woman who has experienced a myocardial infarction.

“Women with a history of early-onset preeclampsia exhibit many risk factors, but their relatively young age is masking their absolute cardiovascular risk,” said Dr. Van Rijn, who disclosed no financial conflicts of interest.

The study was sponsored by the Netherlands Organization for Scientific Research.

DALLAS — Early cardiovascular risk-factor screening is warranted in women with a history of early-onset preeclampsia, according to results of a study in 617 women.

Significantly more women with a history of early-onset preeclampsia exhibited at least one major cardiovascular risk factor, as defined by the American Heart Association, when screened 6 months after delivery, and compared with healthy controls (89% vs. 71%).

The percentages of women exhibiting at least two and at least three cardiovascular risk factors were also significantly higher in the preeclampsia group, Dr. Bas Van Rijn said at the annual meeting of the Society for Maternal-Fetal Medicine.

Among women in the preeclampsia group 51% had two or more cardiovascular risk factors vs. 26% in the control group, and 19% had three or more risk factors vs. 6% in the control group.

“We advise using global risk estimations, such as the Framingham chart, to identify women that require lifestyle intervention programs aimed at primary prevention of cardiovascular disease,” said Dr. Van Rijn of the division of perinatology and gynecology, University Medical Center Utrecht (the Netherlands).

The study included 243 women (mean age 30.5 years) admitted from 1995 to 2005 for early-onset preeclampsia and delivery before 34 weeks and a population-based control group of 374 healthy, nonpregnant women (mean 28.3 years). Women with chronic hypertension (greater than 140/90 mm Hg) were excluded. Outcomes were adjusted for age.

When compared with matched controls, women in the preeclampsia group had significantly higher rates of obesity (body mass index 26.1 vs. 24.3 kg/m

HDL-cholesterol levels were significantly lower among cases versus controls (55 vs. 61 mg/dL).

No significant differences were found for rates of diabetes mellitus and smoking.

In all, 15.2% of women with a history of preeclampsia met the criteria for metabolic syndrome, as formulated by the AHA and World Health Organization versus only 4.3% of controls (odds ratio 3.6).

The estimated 10-year risk of first cardiovascular disease events, as calculated by the Framingham CHD risk prediction scores, remained less than 10% for all of the women. This places the women in the AHA low-risk range, which is a 1%–3% absolute risk of developing a major cardiovascular event in the coming years, he said.

However, this is a bit deceptive, mainly because of the young age of the women, Dr. Van Rijn added.

For example, if one adds 10 years to the Framingham risk score (mean age 40 years), the risk category for the preeclampsia group would be 5%–10%, which is comparable to a woman who has experienced a myocardial infarction.

“Women with a history of early-onset preeclampsia exhibit many risk factors, but their relatively young age is masking their absolute cardiovascular risk,” said Dr. Van Rijn, who disclosed no financial conflicts of interest.

The study was sponsored by the Netherlands Organization for Scientific Research.

Physicians advising women on nutritional options related to allergies during pregnancy, lactation, and the first year of life can be less restrictive than they have been up to now, according to a revised policy statement of the American Academy of Pediatrics.

“Pediatricians and obstetricians need to reconsider the entire issue of how they feed babies with the intention of preventing allergies,” said Dr. Frank R. Greer.

“We've been too strict and too dogmatic,” said Dr. Greer, chairman of the American Academy of Pediatrics (AAP) Committee on Nutrition, which developed the statement in cooperation with the academy's Section on Allergy and Immunology.

The new document replaces a 2000 policy statement from the AAP that addressed the use of hypoallergenic infant formulas and included provisional recommendations for dietary management for the prevention of atopic disease (Pediatrics 2008;?21:183–91).

According to this new report, the documented benefits of nutritional intervention that might prevent or delay the onset of atopic disease are largely limited to infants at high risk of developing allergy because a parent or sibling has allergic disease.

“Current evidence does not support a major role for maternal dietary restrictions during pregnancy or lactation,” according to the report.

“The idea that egg, fish, and foods containing peanut protein should not be introduced before 1 year of age is not based on good science,” Dr. Greer said in an interview. “I suppose that if I had a baby with severe eczema, I would not recommend those foods, but the problem is these restrictions have been applied to all babies.”

There is evidence that breast-feeding for at least 4 months, compared with feeding formula made with intact cow milk protein, prevents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood, according to the reviewers.

In studies of infants at high risk of atopy and who are not exclusively breast-fed for 4–6 months or are formula fed, there is modest evidence that the onset of atopic dermatitis might be delayed or prevented in early childhood by the use of extensively or partially hydrolyzed formulas, compared with cow milk formula, they said.

However, not all hydrolyzed formula might have the same effect, and more research is needed to determine if the benefits extend to later childhood and adolescence.

Dr. Greer and his colleagues also concluded that there is scant evidence that delaying the introduction of complementary foods beyond 4–6 months of age prevents atopic disease.

Other major statements summarizing the current evidence included the following:

▸ Maternal dietary restrictions during pregnancy do not appear to play a significant role in the prevention of atopic disease in infants.

▸ There is no convincing evidence for the use of soy-based infant formula for the purpose of allergy prevention.

▸ For infants beyond 4–6 months of age, there is insufficient data to support a protective effect of any dietary intervention for the development of atopic disease.

▸ In infants at risk of developing atopic disease, the current evidence does not support the hypothesis that exclusive breast-feeding protects against allergic asthma occurring beyond 6 years of age.

▸ For a child who has developed an atopic disease that might be precipitated or exacerbated by ingested proteins (via human milk, infant formula, or specific complementary foods), treatment could require specific identification and restriction of causal food proteins. This topic was not reviewed in this document.

“If the child is not at risk, the lactating mother can eat what she wants, and it really doesn't matter when you introduce a child to fish or eggs,” said Dr. Greer.

Physicians advising women on nutritional options related to allergies during pregnancy, lactation, and the first year of life can be less restrictive than they have been up to now, according to a revised policy statement of the American Academy of Pediatrics.

“Pediatricians and obstetricians need to reconsider the entire issue of how they feed babies with the intention of preventing allergies,” said Dr. Frank R. Greer.

“We've been too strict and too dogmatic,” said Dr. Greer, chairman of the American Academy of Pediatrics (AAP) Committee on Nutrition, which developed the statement in cooperation with the academy's Section on Allergy and Immunology.

The new document replaces a 2000 policy statement from the AAP that addressed the use of hypoallergenic infant formulas and included provisional recommendations for dietary management for the prevention of atopic disease (Pediatrics 2008;?21:183–91).

According to this new report, the documented benefits of nutritional intervention that might prevent or delay the onset of atopic disease are largely limited to infants at high risk of developing allergy because a parent or sibling has allergic disease.

“Current evidence does not support a major role for maternal dietary restrictions during pregnancy or lactation,” according to the report.

“The idea that egg, fish, and foods containing peanut protein should not be introduced before 1 year of age is not based on good science,” Dr. Greer said in an interview. “I suppose that if I had a baby with severe eczema, I would not recommend those foods, but the problem is these restrictions have been applied to all babies.”

There is evidence that breast-feeding for at least 4 months, compared with feeding formula made with intact cow milk protein, prevents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood, according to the reviewers.

In studies of infants at high risk of atopy and who are not exclusively breast-fed for 4–6 months or are formula fed, there is modest evidence that the onset of atopic dermatitis might be delayed or prevented in early childhood by the use of extensively or partially hydrolyzed formulas, compared with cow milk formula, they said.

However, not all hydrolyzed formula might have the same effect, and more research is needed to determine if the benefits extend to later childhood and adolescence.

Dr. Greer and his colleagues also concluded that there is scant evidence that delaying the introduction of complementary foods beyond 4–6 months of age prevents atopic disease.

Other major statements summarizing the current evidence included the following:

▸ Maternal dietary restrictions during pregnancy do not appear to play a significant role in the prevention of atopic disease in infants.

▸ There is no convincing evidence for the use of soy-based infant formula for the purpose of allergy prevention.

▸ For infants beyond 4–6 months of age, there is insufficient data to support a protective effect of any dietary intervention for the development of atopic disease.

▸ In infants at risk of developing atopic disease, the current evidence does not support the hypothesis that exclusive breast-feeding protects against allergic asthma occurring beyond 6 years of age.

▸ For a child who has developed an atopic disease that might be precipitated or exacerbated by ingested proteins (via human milk, infant formula, or specific complementary foods), treatment could require specific identification and restriction of causal food proteins. This topic was not reviewed in this document.

“If the child is not at risk, the lactating mother can eat what she wants, and it really doesn't matter when you introduce a child to fish or eggs,” said Dr. Greer.

Physicians advising women on nutritional options related to allergies during pregnancy, lactation, and the first year of life can be less restrictive than they have been up to now, according to a revised policy statement of the American Academy of Pediatrics.

“Pediatricians and obstetricians need to reconsider the entire issue of how they feed babies with the intention of preventing allergies,” said Dr. Frank R. Greer.

“We've been too strict and too dogmatic,” said Dr. Greer, chairman of the American Academy of Pediatrics (AAP) Committee on Nutrition, which developed the statement in cooperation with the academy's Section on Allergy and Immunology.

The new document replaces a 2000 policy statement from the AAP that addressed the use of hypoallergenic infant formulas and included provisional recommendations for dietary management for the prevention of atopic disease (Pediatrics 2008;?21:183–91).

According to this new report, the documented benefits of nutritional intervention that might prevent or delay the onset of atopic disease are largely limited to infants at high risk of developing allergy because a parent or sibling has allergic disease.

“Current evidence does not support a major role for maternal dietary restrictions during pregnancy or lactation,” according to the report.

“The idea that egg, fish, and foods containing peanut protein should not be introduced before 1 year of age is not based on good science,” Dr. Greer said in an interview. “I suppose that if I had a baby with severe eczema, I would not recommend those foods, but the problem is these restrictions have been applied to all babies.”

There is evidence that breast-feeding for at least 4 months, compared with feeding formula made with intact cow milk protein, prevents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood, according to the reviewers.

In studies of infants at high risk of atopy and who are not exclusively breast-fed for 4–6 months or are formula fed, there is modest evidence that the onset of atopic dermatitis might be delayed or prevented in early childhood by the use of extensively or partially hydrolyzed formulas, compared with cow milk formula, they said.

However, not all hydrolyzed formula might have the same effect, and more research is needed to determine if the benefits extend to later childhood and adolescence.

Dr. Greer and his colleagues also concluded that there is scant evidence that delaying the introduction of complementary foods beyond 4–6 months of age prevents atopic disease.

Other major statements summarizing the current evidence included the following:

▸ Maternal dietary restrictions during pregnancy do not appear to play a significant role in the prevention of atopic disease in infants.

▸ There is no convincing evidence for the use of soy-based infant formula for the purpose of allergy prevention.

▸ For infants beyond 4–6 months of age, there is insufficient data to support a protective effect of any dietary intervention for the development of atopic disease.

▸ In infants at risk of developing atopic disease, the current evidence does not support the hypothesis that exclusive breast-feeding protects against allergic asthma occurring beyond 6 years of age.

▸ For a child who has developed an atopic disease that might be precipitated or exacerbated by ingested proteins (via human milk, infant formula, or specific complementary foods), treatment could require specific identification and restriction of causal food proteins. This topic was not reviewed in this document.

“If the child is not at risk, the lactating mother can eat what she wants, and it really doesn't matter when you introduce a child to fish or eggs,” said Dr. Greer.

Women who follow a Mediterranean diet during pregnancy may avert asthmalike symptoms and atopy in their children, results of a population study in the journal Thorax suggest.

Researchers studying a birth cohort of 412 children in Menorca, Spain, found that offspring of mothers who closely followed a Mediterranean diet in pregnancy were less likely to experience persistent wheeze (adjusted odds ratio 0.22), atopic wheeze (OR 0.30), or atopy (OR 0.55) at a 6.5-year follow-up, compared with children of mothers who were less adherent to the diet.

Micronutrients such as antioxidants or polyphenols contained in the fruits, vegetables, legumes, and oils that are key ingredients of the Mediterranean diet may have protective effects against asthma, may protect the airways against oxidative damage, or may have anti-inflammatory effects, wrote Dr. Leda Chatzi of the University of Crete, Heraklion, Greece, and associates (Thorax 2008 Jan. 15 [Epub doi:10.1136/thx.2007.081745]).

Over a 12-month period beginning in mid-1997, the researchers enrolled 507 women seeking antenatal care at general practices in Menorca.

A total of 412 children of the women who were enrolled underwent skin-prick tests for allergies at a 6.5-year follow-up.

In addition, 468 parents completed questionnaires on children's respiratory and allergic symptoms, and supplied information on the mother's diet during pregnancy and the children's diet at 6.5 years using a food frequency questionnaire.

The questionnaires were then scored according to how much of the food intake matched a traditional Mediterranean diet.

A total of 36% of mothers had a low-quality Mediterranean diet in pregnancy; the remainder had a high-quality diet.

Approximately 13% of the children at follow-up had persistent wheeze, 6% had atopic wheeze, and 17% had atopy.

Maternal intake of vegetables more than eight times a week in pregnancy was significantly associated with a reduced risk of persistent wheeze (odds ratio 0.36) and atopy (OR 0.4) in their children, compared with children of mothers who ate fewer servings.

Eating fish two to three times a week and legumes at least once a week during pregnancy each was also significantly associated with a reduced risk of persistent wheeze (OR 0.34 and OR 0.36, respectively).

Although there was a trend toward a high-quality Mediterranean diet in pregnancy having a protective effect against atopic wheeze, the association was not significant, possibly because of the small number of children affected (n = 20), the investigators wrote.

At 6.5 years, 9% of the children had a diet that scored low, 54% scored intermediate and 37% scored high on Mediterranean diet measures.

A high score was protective against persistent wheeze, but the effect was only marginally significant, the researchers said.

Women who follow a Mediterranean diet during pregnancy may avert asthmalike symptoms and atopy in their children, results of a population study in the journal Thorax suggest.

Researchers studying a birth cohort of 412 children in Menorca, Spain, found that offspring of mothers who closely followed a Mediterranean diet in pregnancy were less likely to experience persistent wheeze (adjusted odds ratio 0.22), atopic wheeze (OR 0.30), or atopy (OR 0.55) at a 6.5-year follow-up, compared with children of mothers who were less adherent to the diet.

Micronutrients such as antioxidants or polyphenols contained in the fruits, vegetables, legumes, and oils that are key ingredients of the Mediterranean diet may have protective effects against asthma, may protect the airways against oxidative damage, or may have anti-inflammatory effects, wrote Dr. Leda Chatzi of the University of Crete, Heraklion, Greece, and associates (Thorax 2008 Jan. 15 [Epub doi:10.1136/thx.2007.081745]).

Over a 12-month period beginning in mid-1997, the researchers enrolled 507 women seeking antenatal care at general practices in Menorca.

A total of 412 children of the women who were enrolled underwent skin-prick tests for allergies at a 6.5-year follow-up.

In addition, 468 parents completed questionnaires on children's respiratory and allergic symptoms, and supplied information on the mother's diet during pregnancy and the children's diet at 6.5 years using a food frequency questionnaire.

The questionnaires were then scored according to how much of the food intake matched a traditional Mediterranean diet.

A total of 36% of mothers had a low-quality Mediterranean diet in pregnancy; the remainder had a high-quality diet.

Approximately 13% of the children at follow-up had persistent wheeze, 6% had atopic wheeze, and 17% had atopy.

Maternal intake of vegetables more than eight times a week in pregnancy was significantly associated with a reduced risk of persistent wheeze (odds ratio 0.36) and atopy (OR 0.4) in their children, compared with children of mothers who ate fewer servings.

Eating fish two to three times a week and legumes at least once a week during pregnancy each was also significantly associated with a reduced risk of persistent wheeze (OR 0.34 and OR 0.36, respectively).

Although there was a trend toward a high-quality Mediterranean diet in pregnancy having a protective effect against atopic wheeze, the association was not significant, possibly because of the small number of children affected (n = 20), the investigators wrote.

At 6.5 years, 9% of the children had a diet that scored low, 54% scored intermediate and 37% scored high on Mediterranean diet measures.

A high score was protective against persistent wheeze, but the effect was only marginally significant, the researchers said.

Women who follow a Mediterranean diet during pregnancy may avert asthmalike symptoms and atopy in their children, results of a population study in the journal Thorax suggest.

Researchers studying a birth cohort of 412 children in Menorca, Spain, found that offspring of mothers who closely followed a Mediterranean diet in pregnancy were less likely to experience persistent wheeze (adjusted odds ratio 0.22), atopic wheeze (OR 0.30), or atopy (OR 0.55) at a 6.5-year follow-up, compared with children of mothers who were less adherent to the diet.

Micronutrients such as antioxidants or polyphenols contained in the fruits, vegetables, legumes, and oils that are key ingredients of the Mediterranean diet may have protective effects against asthma, may protect the airways against oxidative damage, or may have anti-inflammatory effects, wrote Dr. Leda Chatzi of the University of Crete, Heraklion, Greece, and associates (Thorax 2008 Jan. 15 [Epub doi:10.1136/thx.2007.081745]).

Over a 12-month period beginning in mid-1997, the researchers enrolled 507 women seeking antenatal care at general practices in Menorca.

A total of 412 children of the women who were enrolled underwent skin-prick tests for allergies at a 6.5-year follow-up.

In addition, 468 parents completed questionnaires on children's respiratory and allergic symptoms, and supplied information on the mother's diet during pregnancy and the children's diet at 6.5 years using a food frequency questionnaire.

The questionnaires were then scored according to how much of the food intake matched a traditional Mediterranean diet.

A total of 36% of mothers had a low-quality Mediterranean diet in pregnancy; the remainder had a high-quality diet.

Approximately 13% of the children at follow-up had persistent wheeze, 6% had atopic wheeze, and 17% had atopy.

Maternal intake of vegetables more than eight times a week in pregnancy was significantly associated with a reduced risk of persistent wheeze (odds ratio 0.36) and atopy (OR 0.4) in their children, compared with children of mothers who ate fewer servings.

Eating fish two to three times a week and legumes at least once a week during pregnancy each was also significantly associated with a reduced risk of persistent wheeze (OR 0.34 and OR 0.36, respectively).

Although there was a trend toward a high-quality Mediterranean diet in pregnancy having a protective effect against atopic wheeze, the association was not significant, possibly because of the small number of children affected (n = 20), the investigators wrote.

At 6.5 years, 9% of the children had a diet that scored low, 54% scored intermediate and 37% scored high on Mediterranean diet measures.

A high score was protective against persistent wheeze, but the effect was only marginally significant, the researchers said.