Obstetrics

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intraoperative and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep,” he said.

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make surgery and anesthesia a little more unpleasant, Dr. Allen said. The study's results have affected practice at his institution.

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intraoperative and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep,” he said.

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make surgery and anesthesia a little more unpleasant, Dr. Allen said. The study's results have affected practice at his institution.

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Administering the 5-HT₃ receptor antagonists ondansetron or granisetron to women undergoing cesarean delivery with neuraxial anesthesia significantly reduces intraoperative and postoperative nausea and vomiting, compared with placebo, according to a meta-analysis of nine randomized, double-blind trials.

Intraoperative nausea and vomiting are “emerging in obstetrical anesthesia practice as a major problem,” Dr. Terrence K. Allen, an anesthesiologist at Duke University, Durham, N.C., noted. “It's different from the general surgical population because, obviously, those patients are asleep,” he said.

Previous systematic reviews have shown the efficacy of these agents in reducing nausea and vomiting after surgery with general anesthesia. The nine individual studies of 5-HT₃ receptor antagonists in women who were administered neuraxial anesthesia for cesarean delivery produced inconsistent results, so the researchers grouped them in a meta-analysis, Dr. Allen said in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

The medication was administered intraoperatively following clamping of the umbilical cord or delivery of the baby in eight studies in the meta-analysis, and postoperatively in one study. Dr. Allen and his coinvestigator, Dr. Ashraf S. Habib, combined the data on ondansetron and granisetron and the dose ranges used in the studies because recent consensus guidelines report no evidence of differences in efficacy between these subgroups.

Results showed that the 5-HT₃ receptor antagonists significantly reduced the relative risks for nausea and vomiting, compared with placebo. They reduced the risk for intraoperative nausea by 38%, the risk for intraoperative vomiting by 46%, the risk for postoperative nausea by 49%, and the risk for postoperative vomiting by 49%, he reported.

Nausea and vomiting make surgery and anesthesia a little more unpleasant, Dr. Allen said. The study's results have affected practice at his institution.

Dr. Allen and Dr. Habib, also of Duke University, have no financial relationships with the companies that make the medications studied.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Signs of fetal well-being returned more rapidly after external cephalic version in 47 women given combined spinal-epidural analgesia, compared with 48 women given systemic opioids in a randomized study.

Neuraxial analgesia has been shown in previous studies to reduce pain from external cephalic version and to improve maternal satisfaction, compared with systemic opioids, but the fetal heart rate effects of the two types of analgesia have not been compared before the current study, Dr. John T. Sullivan and associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

As part of a larger study on the success of external cephalic version using different analgesia techniques, pregnant women with breech presentation were randomized to combined spinal-epidural analgesia using intrathecal bupivacaine 2.5 mg plus 15 mcg of fentanyl, or to intravenous systemic opioid analgesia using 50 mcg fentanyl. A perinatologist blinded to assignments evaluated fetal heart rate patterns for 30 minutes before and for 60 minutes after external cephalic version.

No significant differences were seen between groups in preprocedural and postprocedural baseline fetal heart rates, the degree of heart rate variability, the number of accelerations, or the number and type of decelerations, said Dr. Sullivan, associate professor of anesthesiology, Northwestern University, Chicago.

A reactive fetal heart rate after external cephalic version is a sign of fetal well-being, so investigators assessed the time to reactivity from initiation of analgesia to the development of two 15-beat accelerations (of 15 seconds duration) occurring within 20 minutes of each other.

The median time to reactivity in the combined spinal-epidural group was 13 minutes, significantly shorter than the median 39 minutes in the systemic opioid group.

One patient in each group underwent cesarean delivery immediately after external cephalic version for nonreassuring fetal heart rate patterns.

“Combined spinal-epidural analgesia for external cephalic version has no discernible deleterious impact on fetal heart rate pattern as compared with systemic opioid analgesia,” Dr. Sullivan and his associates concluded. “Furthermore, it results in a more rapid return of a reactive fetal heart rate tracing. Therefore, combined spinal epidural may provide more immediate reassurance of fetal well-being following external cephalic version.”

SAN FRANCISCO — Signs of fetal well-being returned more rapidly after external cephalic version in 47 women given combined spinal-epidural analgesia, compared with 48 women given systemic opioids in a randomized study.

Neuraxial analgesia has been shown in previous studies to reduce pain from external cephalic version and to improve maternal satisfaction, compared with systemic opioids, but the fetal heart rate effects of the two types of analgesia have not been compared before the current study, Dr. John T. Sullivan and associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

As part of a larger study on the success of external cephalic version using different analgesia techniques, pregnant women with breech presentation were randomized to combined spinal-epidural analgesia using intrathecal bupivacaine 2.5 mg plus 15 mcg of fentanyl, or to intravenous systemic opioid analgesia using 50 mcg fentanyl. A perinatologist blinded to assignments evaluated fetal heart rate patterns for 30 minutes before and for 60 minutes after external cephalic version.

No significant differences were seen between groups in preprocedural and postprocedural baseline fetal heart rates, the degree of heart rate variability, the number of accelerations, or the number and type of decelerations, said Dr. Sullivan, associate professor of anesthesiology, Northwestern University, Chicago.

A reactive fetal heart rate after external cephalic version is a sign of fetal well-being, so investigators assessed the time to reactivity from initiation of analgesia to the development of two 15-beat accelerations (of 15 seconds duration) occurring within 20 minutes of each other.

The median time to reactivity in the combined spinal-epidural group was 13 minutes, significantly shorter than the median 39 minutes in the systemic opioid group.

One patient in each group underwent cesarean delivery immediately after external cephalic version for nonreassuring fetal heart rate patterns.

“Combined spinal-epidural analgesia for external cephalic version has no discernible deleterious impact on fetal heart rate pattern as compared with systemic opioid analgesia,” Dr. Sullivan and his associates concluded. “Furthermore, it results in a more rapid return of a reactive fetal heart rate tracing. Therefore, combined spinal epidural may provide more immediate reassurance of fetal well-being following external cephalic version.”

SAN FRANCISCO — Signs of fetal well-being returned more rapidly after external cephalic version in 47 women given combined spinal-epidural analgesia, compared with 48 women given systemic opioids in a randomized study.

Neuraxial analgesia has been shown in previous studies to reduce pain from external cephalic version and to improve maternal satisfaction, compared with systemic opioids, but the fetal heart rate effects of the two types of analgesia have not been compared before the current study, Dr. John T. Sullivan and associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

As part of a larger study on the success of external cephalic version using different analgesia techniques, pregnant women with breech presentation were randomized to combined spinal-epidural analgesia using intrathecal bupivacaine 2.5 mg plus 15 mcg of fentanyl, or to intravenous systemic opioid analgesia using 50 mcg fentanyl. A perinatologist blinded to assignments evaluated fetal heart rate patterns for 30 minutes before and for 60 minutes after external cephalic version.

No significant differences were seen between groups in preprocedural and postprocedural baseline fetal heart rates, the degree of heart rate variability, the number of accelerations, or the number and type of decelerations, said Dr. Sullivan, associate professor of anesthesiology, Northwestern University, Chicago.

A reactive fetal heart rate after external cephalic version is a sign of fetal well-being, so investigators assessed the time to reactivity from initiation of analgesia to the development of two 15-beat accelerations (of 15 seconds duration) occurring within 20 minutes of each other.

The median time to reactivity in the combined spinal-epidural group was 13 minutes, significantly shorter than the median 39 minutes in the systemic opioid group.

One patient in each group underwent cesarean delivery immediately after external cephalic version for nonreassuring fetal heart rate patterns.

“Combined spinal-epidural analgesia for external cephalic version has no discernible deleterious impact on fetal heart rate pattern as compared with systemic opioid analgesia,” Dr. Sullivan and his associates concluded. “Furthermore, it results in a more rapid return of a reactive fetal heart rate tracing. Therefore, combined spinal epidural may provide more immediate reassurance of fetal well-being following external cephalic version.”

ORLANDO — Women with either gestational or established diabetes were much more likely to deliver an infant with an atrial septal defect than were those with normal glucose control, based on the results of a retrospective, case control study that included almost 5,000 women.

Women with established diabetes before they became pregnant were nearly 11-fold more likely to give birth to a child with an atrial septal defect (ASD), compared with women without diabetes, Dr. Creighton W. Don and his associates reported in a poster at the annual scientific sessions of the American Heart Association. Maternal diabetes was previously linked to other types of congenital defects in newborns, but the relationship of ASD with maternal diabetes had not been previously well studied, said Dr. Don, a cardiologist at the University of Washington, Seattle, and his coinvestigators.

They used January 1987-December 2005 birth certificate-hospital discharge data from all nonfederal hospitals in the Comprehensive Hospital Abstract Reporting System in Washington state. Cases were live-born singleton infants diagnosed with ASD. Controls were infants born without ASD in the same year.

The incidence of ASD reports in hospitals from eastern Washington seemed unusually high, so those hospitals were excluded and the analysis was limited to hospitals in western Washington. The analysis also excluded infants born at less than 32 weeks' gestation or less than 2,500 g. This left about 800 cases and 4,000 control infants who were included in a logistic regression analysis. The analysis controlled for several variables, including gestational age, birth weight, maternal age, maternal body mass index, race, and hospital location.

The analysis showed that women with established diabetes were 10.6-fold more likely to give birth to an infant with an ASD than were mothers without diabetes, and that mothers who developed gestational diabetes were 3-fold more likely to have a child with ASD. The differences between the case and control rates for both subgroups were statistically significant.

Other factors linked with significant increases in ASD were non-Hispanic black race, which raised the risk 3.9-fold, and maternal age of 35 years or older, which raised the risk 2.5-fold.

ORLANDO — Women with either gestational or established diabetes were much more likely to deliver an infant with an atrial septal defect than were those with normal glucose control, based on the results of a retrospective, case control study that included almost 5,000 women.

Women with established diabetes before they became pregnant were nearly 11-fold more likely to give birth to a child with an atrial septal defect (ASD), compared with women without diabetes, Dr. Creighton W. Don and his associates reported in a poster at the annual scientific sessions of the American Heart Association. Maternal diabetes was previously linked to other types of congenital defects in newborns, but the relationship of ASD with maternal diabetes had not been previously well studied, said Dr. Don, a cardiologist at the University of Washington, Seattle, and his coinvestigators.

They used January 1987-December 2005 birth certificate-hospital discharge data from all nonfederal hospitals in the Comprehensive Hospital Abstract Reporting System in Washington state. Cases were live-born singleton infants diagnosed with ASD. Controls were infants born without ASD in the same year.

The incidence of ASD reports in hospitals from eastern Washington seemed unusually high, so those hospitals were excluded and the analysis was limited to hospitals in western Washington. The analysis also excluded infants born at less than 32 weeks' gestation or less than 2,500 g. This left about 800 cases and 4,000 control infants who were included in a logistic regression analysis. The analysis controlled for several variables, including gestational age, birth weight, maternal age, maternal body mass index, race, and hospital location.

The analysis showed that women with established diabetes were 10.6-fold more likely to give birth to an infant with an ASD than were mothers without diabetes, and that mothers who developed gestational diabetes were 3-fold more likely to have a child with ASD. The differences between the case and control rates for both subgroups were statistically significant.

Other factors linked with significant increases in ASD were non-Hispanic black race, which raised the risk 3.9-fold, and maternal age of 35 years or older, which raised the risk 2.5-fold.

ORLANDO — Women with either gestational or established diabetes were much more likely to deliver an infant with an atrial septal defect than were those with normal glucose control, based on the results of a retrospective, case control study that included almost 5,000 women.

Women with established diabetes before they became pregnant were nearly 11-fold more likely to give birth to a child with an atrial septal defect (ASD), compared with women without diabetes, Dr. Creighton W. Don and his associates reported in a poster at the annual scientific sessions of the American Heart Association. Maternal diabetes was previously linked to other types of congenital defects in newborns, but the relationship of ASD with maternal diabetes had not been previously well studied, said Dr. Don, a cardiologist at the University of Washington, Seattle, and his coinvestigators.

They used January 1987-December 2005 birth certificate-hospital discharge data from all nonfederal hospitals in the Comprehensive Hospital Abstract Reporting System in Washington state. Cases were live-born singleton infants diagnosed with ASD. Controls were infants born without ASD in the same year.

The incidence of ASD reports in hospitals from eastern Washington seemed unusually high, so those hospitals were excluded and the analysis was limited to hospitals in western Washington. The analysis also excluded infants born at less than 32 weeks' gestation or less than 2,500 g. This left about 800 cases and 4,000 control infants who were included in a logistic regression analysis. The analysis controlled for several variables, including gestational age, birth weight, maternal age, maternal body mass index, race, and hospital location.

The analysis showed that women with established diabetes were 10.6-fold more likely to give birth to an infant with an ASD than were mothers without diabetes, and that mothers who developed gestational diabetes were 3-fold more likely to have a child with ASD. The differences between the case and control rates for both subgroups were statistically significant.

Other factors linked with significant increases in ASD were non-Hispanic black race, which raised the risk 3.9-fold, and maternal age of 35 years or older, which raised the risk 2.5-fold.

NEW ORLEANS — Women who put on more than the recommended weight during pregnancy increase the chances that their offspring will be overweight before they reach their 10th birthday, according to findings from a retrospective cohort study of 7,674 women.

The findings from this study, which is the largest to date on the subject, have important implications for counseling pregnant women, Brian Wrotniak, Ph.D., said at the annual meeting of NAASO, the Obesity Society.

Mothers-to-be who gained more than the weight recommended by the Institute of Medicine had a 44% greater likelihood of having offspring who were overweight at 7 years of age than did women who did not exceed the weight-gain recommendations during their pregnancy.

Study investigators reviewed data from the Collaborative Perinatal Project, a multicenter, multiethnic study that was initiated in 1959 to investigate risk factors for cerebral palsy in children, said Dr. Wrotniak of Children's Hospital of Philadelphia.

The association between excess weight gain during pregnancy and an overweight child by age 7 years was even stronger for women who were underweight at the time they became pregnant, he said.

The link between the mother's weight gain during pregnancy and her child's excess weight in later years remained significant after adjustment for the gender of the child, gestational age, infant birth weight, first-born status, mother's race, maternal age, maternal body mass index, smoking, and study site, the researchers reported.

“How much weight to gain depends on the mother's prepregnancy BMI. For women of normal weight, the recommendations for weight gain during [a singleton] pregnancy are 12.5–18 kg, but for women who are overweight, 7–11.5 kg is the recommended range,” Dr. Wrotniak said.

The Collaborative Perinatal Project data were collected in the 1960s. At that time, 11% of the cohort exceeded pregnancy weight-gain recommendations. Today, almost half—46% of expectant mothers—are gaining more weight than they should during their pregnancies, Dr. Wrotniak said.

“From a public health standpoint, helping women to develop healthy eating and physical activity habits and to achieve a healthier weight before becoming pregnant, and to adhere to weight gain recommendations during pregnancy, may be an effective way to help prevent childhood obesity.

“With almost half of women exceeding the recommendations, such counseling could have a sizeable impact on future obesity in children,” the study authors concluded.

NEW ORLEANS — Women who put on more than the recommended weight during pregnancy increase the chances that their offspring will be overweight before they reach their 10th birthday, according to findings from a retrospective cohort study of 7,674 women.

The findings from this study, which is the largest to date on the subject, have important implications for counseling pregnant women, Brian Wrotniak, Ph.D., said at the annual meeting of NAASO, the Obesity Society.

Mothers-to-be who gained more than the weight recommended by the Institute of Medicine had a 44% greater likelihood of having offspring who were overweight at 7 years of age than did women who did not exceed the weight-gain recommendations during their pregnancy.

Study investigators reviewed data from the Collaborative Perinatal Project, a multicenter, multiethnic study that was initiated in 1959 to investigate risk factors for cerebral palsy in children, said Dr. Wrotniak of Children's Hospital of Philadelphia.

The association between excess weight gain during pregnancy and an overweight child by age 7 years was even stronger for women who were underweight at the time they became pregnant, he said.

The link between the mother's weight gain during pregnancy and her child's excess weight in later years remained significant after adjustment for the gender of the child, gestational age, infant birth weight, first-born status, mother's race, maternal age, maternal body mass index, smoking, and study site, the researchers reported.

“How much weight to gain depends on the mother's prepregnancy BMI. For women of normal weight, the recommendations for weight gain during [a singleton] pregnancy are 12.5–18 kg, but for women who are overweight, 7–11.5 kg is the recommended range,” Dr. Wrotniak said.

The Collaborative Perinatal Project data were collected in the 1960s. At that time, 11% of the cohort exceeded pregnancy weight-gain recommendations. Today, almost half—46% of expectant mothers—are gaining more weight than they should during their pregnancies, Dr. Wrotniak said.

“From a public health standpoint, helping women to develop healthy eating and physical activity habits and to achieve a healthier weight before becoming pregnant, and to adhere to weight gain recommendations during pregnancy, may be an effective way to help prevent childhood obesity.

“With almost half of women exceeding the recommendations, such counseling could have a sizeable impact on future obesity in children,” the study authors concluded.

NEW ORLEANS — Women who put on more than the recommended weight during pregnancy increase the chances that their offspring will be overweight before they reach their 10th birthday, according to findings from a retrospective cohort study of 7,674 women.

The findings from this study, which is the largest to date on the subject, have important implications for counseling pregnant women, Brian Wrotniak, Ph.D., said at the annual meeting of NAASO, the Obesity Society.

Mothers-to-be who gained more than the weight recommended by the Institute of Medicine had a 44% greater likelihood of having offspring who were overweight at 7 years of age than did women who did not exceed the weight-gain recommendations during their pregnancy.

Study investigators reviewed data from the Collaborative Perinatal Project, a multicenter, multiethnic study that was initiated in 1959 to investigate risk factors for cerebral palsy in children, said Dr. Wrotniak of Children's Hospital of Philadelphia.

The association between excess weight gain during pregnancy and an overweight child by age 7 years was even stronger for women who were underweight at the time they became pregnant, he said.

The link between the mother's weight gain during pregnancy and her child's excess weight in later years remained significant after adjustment for the gender of the child, gestational age, infant birth weight, first-born status, mother's race, maternal age, maternal body mass index, smoking, and study site, the researchers reported.

“How much weight to gain depends on the mother's prepregnancy BMI. For women of normal weight, the recommendations for weight gain during [a singleton] pregnancy are 12.5–18 kg, but for women who are overweight, 7–11.5 kg is the recommended range,” Dr. Wrotniak said.

The Collaborative Perinatal Project data were collected in the 1960s. At that time, 11% of the cohort exceeded pregnancy weight-gain recommendations. Today, almost half—46% of expectant mothers—are gaining more weight than they should during their pregnancies, Dr. Wrotniak said.

“From a public health standpoint, helping women to develop healthy eating and physical activity habits and to achieve a healthier weight before becoming pregnant, and to adhere to weight gain recommendations during pregnancy, may be an effective way to help prevent childhood obesity.

“With almost half of women exceeding the recommendations, such counseling could have a sizeable impact on future obesity in children,” the study authors concluded.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea compared with nonpregnant women in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Among adult women in general, about 2% have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. The incidence of obstructive sleep apnea in pregnancy has been unknown.

“Obstructive sleep apnea is a condition that we see with a rising incidence because the population, in all honesty, is getting larger,” Dr. Higgins said in an interview, referring to the increasing prevalence of obesity. “That's one of the risk factors for obstructive sleep apnea.” In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, a validated means of identifying patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

Statistical analysis found that pregnancy doubled the chance for screening positive on the Berlin Questionnaire, and pregnant women who screened positive on the questionnaire were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those who screened positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

Previous studies have suggested that sleep-disordered breathing or obstructive sleep apnea may increase the risk for preeclampsia or preterm delivery.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

Dr. Higgins is working with colleagues in maternal-fetal medicine to use the Berlin Questionnaire to screen women in the first and third trimesters. Women who screen positive are referred for formal sleep studies, and those diagnosed with obstructive sleep apnea will be followed through pregnancy to assess outcomes, she said.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea compared with nonpregnant women in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Among adult women in general, about 2% have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. The incidence of obstructive sleep apnea in pregnancy has been unknown.

“Obstructive sleep apnea is a condition that we see with a rising incidence because the population, in all honesty, is getting larger,” Dr. Higgins said in an interview, referring to the increasing prevalence of obesity. “That's one of the risk factors for obstructive sleep apnea.” In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, a validated means of identifying patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

Statistical analysis found that pregnancy doubled the chance for screening positive on the Berlin Questionnaire, and pregnant women who screened positive on the questionnaire were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those who screened positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

Previous studies have suggested that sleep-disordered breathing or obstructive sleep apnea may increase the risk for preeclampsia or preterm delivery.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

Dr. Higgins is working with colleagues in maternal-fetal medicine to use the Berlin Questionnaire to screen women in the first and third trimesters. Women who screen positive are referred for formal sleep studies, and those diagnosed with obstructive sleep apnea will be followed through pregnancy to assess outcomes, she said.

SAN FRANCISCO — Pregnant women were more likely to have risk factors for obstructive sleep apnea compared with nonpregnant women in a study of 4,564 women.

In addition, pregnant women identified to be at risk for sleep apnea were more likely to develop preeclampsia compared with pregnant women who didn't have sleep apnea risk factors, Dr. Nicole Higgins, an anesthesiologist at Northwestern University, Chicago, and her associates reported in a poster presentation at the annual meeting of the American Society of Anesthesiologists.

Among adult women in general, about 2% have obstructive sleep apnea, a condition characterized by obstruction of the upper airway and episodes of apnea and hypopnea during sleep. The incidence of obstructive sleep apnea in pregnancy has been unknown.

“Obstructive sleep apnea is a condition that we see with a rising incidence because the population, in all honesty, is getting larger,” Dr. Higgins said in an interview, referring to the increasing prevalence of obesity. “That's one of the risk factors for obstructive sleep apnea.” In the prospective study, 33% of 4,074 pregnant women presenting for delivery and 20% of 490 control women presenting for outpatient surgery screened positive on the Berlin Questionnaire, a validated means of identifying patients at increased risk for sleep apnea through questions about snoring and daytime sleepiness.

Statistical analysis found that pregnancy doubled the chance for screening positive on the Berlin Questionnaire, and pregnant women who screened positive on the questionnaire were four times more likely to develop preeclampsia, compared with pregnant women who screened negative. Those who screened positive were significantly shorter, heavier before pregnancy, and heavier during pregnancy than were those with a negative screen.

Previous studies have suggested that sleep-disordered breathing or obstructive sleep apnea may increase the risk for preeclampsia or preterm delivery.

In the current study, there was a significant correlation between a positive Berlin screen and heavier infant weight (3,475 g vs. 3,374 g if the mother screened negative). A positive Berlin screen also correlated significantly with risk for low 1-minute Apgar scores. About 7% of infants born to mothers who screened positive had 1-minute Apgar scores below 7, compared with 6% of infants if the mother screened negative for sleep apnea.

Dr. Higgins is working with colleagues in maternal-fetal medicine to use the Berlin Questionnaire to screen women in the first and third trimesters. Women who screen positive are referred for formal sleep studies, and those diagnosed with obstructive sleep apnea will be followed through pregnancy to assess outcomes, she said.

CHICAGO — You are caring for a gravid woman with very low platelets and hemolytic anemia. You diagnose her with HELLP syndrome and order a platelet transfusion. Is this the best management of a pregnant patient with thrombocytopenia at risk of bleeding?

Not always, according to Dr. James J. Martin Jr. of the University of Mississippi Medical Center in Jackson.

Thrombotic thrombocytopenic purpura (TTP) can masquerade as HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome. Administering platelets to any patient with this rare but often fatal hematologic disorder can paradoxically worsen the patient's condition, leading to severe disability and death.

Physicians must always consider TTP when caring for pregnant women who present with low platelets.

“Obstetricians-gynecologists are really in a quandary,” Dr. Martin said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“The main problem is differentiating between TTP and HELLP,” he said. “You need to do it right away,” he added.

While TTP is an extremely rare disease that affects only 4–11 patients per million population, the combination of low platelets, hemolytic anemia, renal failure, and mental status changes can be deadly if undiagnosed.

If physicians mistake TTP for HELLP syndrome and administer one or more platelet transfusions, they may aggravate the hemolytic state caused by absent or severely low levels of a von Willebrand factor-cleaving protease, a potentially fatal error.

Plasma therapy can help replete this protease—known as ADAMTS-13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—and stop the destructive hemolysis that TTP causes. Maternal mortality caused by TTP can drop to less than 10% in women properly treated with plasma therapy.

Obstetricians lack a straightforward method to differentiate between TTP and HELLP syndrome. “We need a definite test for TTP,” said Dr. Martin.

To obtain more information about lab findings in pregnant women that could shed light on possible tests to ease diagnosis of these confounding disorders, Dr. Martin and his colleagues performed an extensive English-language literature search of pregnant patients with TTP, and uncovered 166 reported cases from 1955 to 2006. They excluded patients with hemolytic-uremic syndrome, postpartum renal failure, or severe preeclampsia/eclampsia/HELLP syndrome who lacked reasonable information that could diagnose TTP.

The researchers uncovered only seven papers published between 2002 and 2006 looking at ADAMTS-13 activity levels in suspected TTP patients. Additional analysis revealed that several common lab tests could help differentiate women who have TTP only from women who have TTP together with preeclampsia/HELLP syndrome. The researchers found that the ratio of lactate dehydrogenase (LDH) to serum glutamic oxaloacetic transaminase (SGOT) levels was considerably higher in patients with TTP only, compared to women with combined TTP/preeclampsia/HELLP syndrome.

Dr. Martin recommends testing for ADAMTS-13 levels in pregnant patients who have a LDH/SGOT ratio that exceeds 15. He also recommends this test early in pregnancy in women who have a history of TTP.

A rapid, reliable lab test could help physicians distinguish more easily between the common preeclampsia/HELLP syndromes and TTP, the deadly masquerader. Until then, physicians must keep in mind that pregnant patients who present with low platelets and hemolytic anemia could have TTP and act accordingly, Dr. Martin said.

CHICAGO — You are caring for a gravid woman with very low platelets and hemolytic anemia. You diagnose her with HELLP syndrome and order a platelet transfusion. Is this the best management of a pregnant patient with thrombocytopenia at risk of bleeding?

Not always, according to Dr. James J. Martin Jr. of the University of Mississippi Medical Center in Jackson.

Thrombotic thrombocytopenic purpura (TTP) can masquerade as HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome. Administering platelets to any patient with this rare but often fatal hematologic disorder can paradoxically worsen the patient's condition, leading to severe disability and death.

Physicians must always consider TTP when caring for pregnant women who present with low platelets.

“Obstetricians-gynecologists are really in a quandary,” Dr. Martin said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“The main problem is differentiating between TTP and HELLP,” he said. “You need to do it right away,” he added.

While TTP is an extremely rare disease that affects only 4–11 patients per million population, the combination of low platelets, hemolytic anemia, renal failure, and mental status changes can be deadly if undiagnosed.

If physicians mistake TTP for HELLP syndrome and administer one or more platelet transfusions, they may aggravate the hemolytic state caused by absent or severely low levels of a von Willebrand factor-cleaving protease, a potentially fatal error.

Plasma therapy can help replete this protease—known as ADAMTS-13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—and stop the destructive hemolysis that TTP causes. Maternal mortality caused by TTP can drop to less than 10% in women properly treated with plasma therapy.

Obstetricians lack a straightforward method to differentiate between TTP and HELLP syndrome. “We need a definite test for TTP,” said Dr. Martin.

To obtain more information about lab findings in pregnant women that could shed light on possible tests to ease diagnosis of these confounding disorders, Dr. Martin and his colleagues performed an extensive English-language literature search of pregnant patients with TTP, and uncovered 166 reported cases from 1955 to 2006. They excluded patients with hemolytic-uremic syndrome, postpartum renal failure, or severe preeclampsia/eclampsia/HELLP syndrome who lacked reasonable information that could diagnose TTP.

The researchers uncovered only seven papers published between 2002 and 2006 looking at ADAMTS-13 activity levels in suspected TTP patients. Additional analysis revealed that several common lab tests could help differentiate women who have TTP only from women who have TTP together with preeclampsia/HELLP syndrome. The researchers found that the ratio of lactate dehydrogenase (LDH) to serum glutamic oxaloacetic transaminase (SGOT) levels was considerably higher in patients with TTP only, compared to women with combined TTP/preeclampsia/HELLP syndrome.

Dr. Martin recommends testing for ADAMTS-13 levels in pregnant patients who have a LDH/SGOT ratio that exceeds 15. He also recommends this test early in pregnancy in women who have a history of TTP.

A rapid, reliable lab test could help physicians distinguish more easily between the common preeclampsia/HELLP syndromes and TTP, the deadly masquerader. Until then, physicians must keep in mind that pregnant patients who present with low platelets and hemolytic anemia could have TTP and act accordingly, Dr. Martin said.

CHICAGO — You are caring for a gravid woman with very low platelets and hemolytic anemia. You diagnose her with HELLP syndrome and order a platelet transfusion. Is this the best management of a pregnant patient with thrombocytopenia at risk of bleeding?

Not always, according to Dr. James J. Martin Jr. of the University of Mississippi Medical Center in Jackson.

Thrombotic thrombocytopenic purpura (TTP) can masquerade as HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome. Administering platelets to any patient with this rare but often fatal hematologic disorder can paradoxically worsen the patient's condition, leading to severe disability and death.

Physicians must always consider TTP when caring for pregnant women who present with low platelets.

“Obstetricians-gynecologists are really in a quandary,” Dr. Martin said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“The main problem is differentiating between TTP and HELLP,” he said. “You need to do it right away,” he added.

While TTP is an extremely rare disease that affects only 4–11 patients per million population, the combination of low platelets, hemolytic anemia, renal failure, and mental status changes can be deadly if undiagnosed.

If physicians mistake TTP for HELLP syndrome and administer one or more platelet transfusions, they may aggravate the hemolytic state caused by absent or severely low levels of a von Willebrand factor-cleaving protease, a potentially fatal error.

Plasma therapy can help replete this protease—known as ADAMTS-13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13—and stop the destructive hemolysis that TTP causes. Maternal mortality caused by TTP can drop to less than 10% in women properly treated with plasma therapy.

Obstetricians lack a straightforward method to differentiate between TTP and HELLP syndrome. “We need a definite test for TTP,” said Dr. Martin.

To obtain more information about lab findings in pregnant women that could shed light on possible tests to ease diagnosis of these confounding disorders, Dr. Martin and his colleagues performed an extensive English-language literature search of pregnant patients with TTP, and uncovered 166 reported cases from 1955 to 2006. They excluded patients with hemolytic-uremic syndrome, postpartum renal failure, or severe preeclampsia/eclampsia/HELLP syndrome who lacked reasonable information that could diagnose TTP.

The researchers uncovered only seven papers published between 2002 and 2006 looking at ADAMTS-13 activity levels in suspected TTP patients. Additional analysis revealed that several common lab tests could help differentiate women who have TTP only from women who have TTP together with preeclampsia/HELLP syndrome. The researchers found that the ratio of lactate dehydrogenase (LDH) to serum glutamic oxaloacetic transaminase (SGOT) levels was considerably higher in patients with TTP only, compared to women with combined TTP/preeclampsia/HELLP syndrome.

Dr. Martin recommends testing for ADAMTS-13 levels in pregnant patients who have a LDH/SGOT ratio that exceeds 15. He also recommends this test early in pregnancy in women who have a history of TTP.

A rapid, reliable lab test could help physicians distinguish more easily between the common preeclampsia/HELLP syndromes and TTP, the deadly masquerader. Until then, physicians must keep in mind that pregnant patients who present with low platelets and hemolytic anemia could have TTP and act accordingly, Dr. Martin said.

A mother who smokes and breast-feeds appears to be giving her infant a dose of nicotine that significantly interferes with the baby's sleep, according to the results of a study.

Infants spent an average of about a third less time sleeping after their mothers smoked just prior to breast-feeding, compared with when the mothers refrained, wrote Julie A. Mennella, Ph.D., and her associates at the Monell Chemical Senses Center in Philadelphia.

Nicotine is not listed as a drug that is contraindicated during breast-feeding because the benefits of breast-feeding are considered to be so great, Dr. Mennella and her associates noted.

But the presence of nicotine in breast milk could have many adverse consequences.

Mothers who smoke are known to wean their children earlier than are mothers who do not. It might be that sleep-deprived infants tend to be fussier and, if the sleep deprivation occurs because of smoking, the fussiness may stop when the mother stops breast-feeding. That in turn may reinforce a smoking mother's decision to wean, they suggested.

Sleep also is known to be important for learning and development, and therefore disruption of sleep caused by smoking could have lasting consequences, they said.

Lastly, adolescents whose mothers smoked during their early life are more likely to smoke, and this may sometimes be because they recognize the tobacco-related flavors from breast milk, and come to appreciate them.

The study was conducted with 15 volunteer mother-infant pairs. The average age of the infants was 4 months.

The mothers were brought into a testing center twice, and told to refrain from smoking for 12 hours before each testing session, with the last breast-feeding done about 2.5 hours before the session.

During one testing session, they were allowed to smoke at least one cigarette, in a separate room from the infant, and during one session they were not (Pediatrics 2007;120:497-502).

Nicotine levels in breast milk were measured at baseline and after smoking. The infants' sleep and awake times were monitored using an ambulatory monitor for 3.5 hours.

During the session when the mothers smoked, the estimated dose of nicotine delivered to the infants was a mean of 549 ng/kg. That compared with a mean dose of 127 ng/kg during the nonsmoking sessions.

During the nonsmoking sessions, the infants slept a mean of 84.5 minutes. That compared with a mean of 53.4 minutes during the smoking sessions. All but two of the infants slept less during the smoking session.

Both active sleep and quiet sleep were reduced with smoking, and the duration of the longest bout of sleep declined from a mean of 60 minutes during the nonsmoking session to a mean of 37 minutes during the smoking session.

With greater doses of nicotine, the reduction in active sleep was greater, Dr. Mennella and her associates said.

Mothers often cut back on their smoking during pregnancy. But then they tend to relapse to more smoking once their infants are born, the investigators said. And, this information may give them an added incentive to continue to curb their smoking while breast-feeding.

Nicotine that is stored in breast milk reaches peak levels about 30-60 minutes after the mother's smoking and then declines fairly rapidly.

A mother who smokes and breast-feeds appears to be giving her infant a dose of nicotine that significantly interferes with the baby's sleep, according to the results of a study.

Infants spent an average of about a third less time sleeping after their mothers smoked just prior to breast-feeding, compared with when the mothers refrained, wrote Julie A. Mennella, Ph.D., and her associates at the Monell Chemical Senses Center in Philadelphia.

Nicotine is not listed as a drug that is contraindicated during breast-feeding because the benefits of breast-feeding are considered to be so great, Dr. Mennella and her associates noted.

But the presence of nicotine in breast milk could have many adverse consequences.

Mothers who smoke are known to wean their children earlier than are mothers who do not. It might be that sleep-deprived infants tend to be fussier and, if the sleep deprivation occurs because of smoking, the fussiness may stop when the mother stops breast-feeding. That in turn may reinforce a smoking mother's decision to wean, they suggested.

Sleep also is known to be important for learning and development, and therefore disruption of sleep caused by smoking could have lasting consequences, they said.

Lastly, adolescents whose mothers smoked during their early life are more likely to smoke, and this may sometimes be because they recognize the tobacco-related flavors from breast milk, and come to appreciate them.

The study was conducted with 15 volunteer mother-infant pairs. The average age of the infants was 4 months.

The mothers were brought into a testing center twice, and told to refrain from smoking for 12 hours before each testing session, with the last breast-feeding done about 2.5 hours before the session.

During one testing session, they were allowed to smoke at least one cigarette, in a separate room from the infant, and during one session they were not (Pediatrics 2007;120:497-502).

Nicotine levels in breast milk were measured at baseline and after smoking. The infants' sleep and awake times were monitored using an ambulatory monitor for 3.5 hours.

During the session when the mothers smoked, the estimated dose of nicotine delivered to the infants was a mean of 549 ng/kg. That compared with a mean dose of 127 ng/kg during the nonsmoking sessions.

During the nonsmoking sessions, the infants slept a mean of 84.5 minutes. That compared with a mean of 53.4 minutes during the smoking sessions. All but two of the infants slept less during the smoking session.

Both active sleep and quiet sleep were reduced with smoking, and the duration of the longest bout of sleep declined from a mean of 60 minutes during the nonsmoking session to a mean of 37 minutes during the smoking session.

With greater doses of nicotine, the reduction in active sleep was greater, Dr. Mennella and her associates said.

Mothers often cut back on their smoking during pregnancy. But then they tend to relapse to more smoking once their infants are born, the investigators said. And, this information may give them an added incentive to continue to curb their smoking while breast-feeding.

Nicotine that is stored in breast milk reaches peak levels about 30-60 minutes after the mother's smoking and then declines fairly rapidly.

A mother who smokes and breast-feeds appears to be giving her infant a dose of nicotine that significantly interferes with the baby's sleep, according to the results of a study.

Infants spent an average of about a third less time sleeping after their mothers smoked just prior to breast-feeding, compared with when the mothers refrained, wrote Julie A. Mennella, Ph.D., and her associates at the Monell Chemical Senses Center in Philadelphia.

Nicotine is not listed as a drug that is contraindicated during breast-feeding because the benefits of breast-feeding are considered to be so great, Dr. Mennella and her associates noted.

But the presence of nicotine in breast milk could have many adverse consequences.

Mothers who smoke are known to wean their children earlier than are mothers who do not. It might be that sleep-deprived infants tend to be fussier and, if the sleep deprivation occurs because of smoking, the fussiness may stop when the mother stops breast-feeding. That in turn may reinforce a smoking mother's decision to wean, they suggested.

Sleep also is known to be important for learning and development, and therefore disruption of sleep caused by smoking could have lasting consequences, they said.

Lastly, adolescents whose mothers smoked during their early life are more likely to smoke, and this may sometimes be because they recognize the tobacco-related flavors from breast milk, and come to appreciate them.

The study was conducted with 15 volunteer mother-infant pairs. The average age of the infants was 4 months.

The mothers were brought into a testing center twice, and told to refrain from smoking for 12 hours before each testing session, with the last breast-feeding done about 2.5 hours before the session.

During one testing session, they were allowed to smoke at least one cigarette, in a separate room from the infant, and during one session they were not (Pediatrics 2007;120:497-502).

Nicotine levels in breast milk were measured at baseline and after smoking. The infants' sleep and awake times were monitored using an ambulatory monitor for 3.5 hours.

During the session when the mothers smoked, the estimated dose of nicotine delivered to the infants was a mean of 549 ng/kg. That compared with a mean dose of 127 ng/kg during the nonsmoking sessions.

During the nonsmoking sessions, the infants slept a mean of 84.5 minutes. That compared with a mean of 53.4 minutes during the smoking sessions. All but two of the infants slept less during the smoking session.

Both active sleep and quiet sleep were reduced with smoking, and the duration of the longest bout of sleep declined from a mean of 60 minutes during the nonsmoking session to a mean of 37 minutes during the smoking session.

With greater doses of nicotine, the reduction in active sleep was greater, Dr. Mennella and her associates said.

Mothers often cut back on their smoking during pregnancy. But then they tend to relapse to more smoking once their infants are born, the investigators said. And, this information may give them an added incentive to continue to curb their smoking while breast-feeding.

Nicotine that is stored in breast milk reaches peak levels about 30-60 minutes after the mother's smoking and then declines fairly rapidly.

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Multiple clinical trials have shown that both ginger and vitamin B6 can safely help reduce the nausea and vomiting of “morning sickness” in pregnancy.

Cathi Dennehy, Pharm.D., reviewed the evidence for the efficacy and safety of the two supplements at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

PIGinger. Six randomized, controlled trials found significant reductions in nausea and vomiting during pregnancy in women who took powdered ginger, ginger syrup, or ginger extract products for 4-21 days. Four trials found greater reductions in nausea and vomiting, compared with placebo, and two trials found effects that were equivalent to treatment with 30 mg or 75 mg per day of vitamin B6 (with no placebo arm in those studies).

The most common dose was 1 g per day of powdered ginger, which comes in capsules containing 250-500 mg each. Patients took divided doses b.i.d. or q.i.d. depending on the capsule size.

The studies included 26-291 women each. Four trials that included a total of 265 women found no increased risk of negative birth outcomes in the ginger groups. Most of the women in these studies used ginger during the first trimester of pregnancy, but some studies included women up to the 20th week of gestation and after the critical developmental stages, which might have diluted the findings regarding safety. A separate observational study that focused strictly on ginger use during the first trimester also found no increase in adverse events.

Side effects are rare but may include GI upset, heartburn, flatulence, or bloating. Much higher doses of ginger (2.5 g/day or higher) can produce antiplatelet effects.

Two previous studies–one in rats and the other an in vitro study–had raised some concerns about possible mutagenic properties or some increase in early embryonic loss. However, “there is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, said Dr. Dennehy of the university's School of Pharmacy.

PIVitamin B6. Two randomized, controlled trials (with 59 and 342 patients, respectively) found that vitamin B6 supplements worked significantly better than placebo to decrease severe nausea and vomiting in pregnancy or to decrease overall nausea scores and vomiting in the first 3 days of use.

Bendectin, a product that combined vitamin B6, an antihistamine, and an anticholinergic, was pulled off the U.S. market in the early 1980s after lawsuits alleged that it caused limb deformities in children. Plaintiff victories on those charges were overturned on appeal. Moreover, late last year, the FDA took the unusual step of publishing a notice in the Federal Register stating that Bendectin had not been withdrawn from the market for safety or health reasons. The move was widely seen as an invitation for a pharmaceutical manufacturer to begin selling the drug again.

Today, a similar product called Diclectin is sold in Canada and combines vitamin B6 with doxylamine. A meta-analysis of 170,000 exposures to Diclectin found no adverse effects on fetuses. “Overall, it looks like vitamin B6 is a safe product to use” in pregnancy, Dr. Dennehy said.

Dr. Dennehy also reviewed the prospect of peppermint tea as a morning-sickness palliative. There are no trials of peppermint tea either in general use or during pregnancy, she said, but a small randomized controlled study of peppermint oil for postoperative pain found it to be more effective than placebo. Peppermint oil relaxes GI smooth muscle, and commonly is used for irritable bowel syndrome.

Peppermint oil also decreases lower esophageal sphincter tone, increases bile flow, and can worsen gastroesophageal reflux disease, “which can get problematic during pregnancy,” she said. “You wouldn't want to give this to someone who already was complaining of those types of symptoms.”

Peppermint “likely is safe as a tea formulation in pregnancy,” Dr. Dennehy concluded.

Three separate studies in the past decade suggest that 7%-13% of women use herbal preparations during pregnancy for a variety of indications, a practice that is more common in Australia and some European countries than in the United States. However, a year 2000 survey of certified nurse-midwives in North Carolina found that 73% recommended herbal products in pregnancy, most commonly for nausea and vomiting, Dr. Dennehy noted.

“There is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, says Dr. Cathi Dennehy. ©Tasha/Fotolia.com

SAN FRANCISCO – Multiple clinical trials have shown that both ginger and vitamin B6 can safely help reduce the nausea and vomiting of “morning sickness” in pregnancy.

Cathi Dennehy, Pharm.D., reviewed the evidence for the efficacy and safety of the two supplements at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

PIGinger. Six randomized, controlled trials found significant reductions in nausea and vomiting during pregnancy in women who took powdered ginger, ginger syrup, or ginger extract products for 4-21 days. Four trials found greater reductions in nausea and vomiting, compared with placebo, and two trials found effects that were equivalent to treatment with 30 mg or 75 mg per day of vitamin B6 (with no placebo arm in those studies).

The most common dose was 1 g per day of powdered ginger, which comes in capsules containing 250-500 mg each. Patients took divided doses b.i.d. or q.i.d. depending on the capsule size.

The studies included 26-291 women each. Four trials that included a total of 265 women found no increased risk of negative birth outcomes in the ginger groups. Most of the women in these studies used ginger during the first trimester of pregnancy, but some studies included women up to the 20th week of gestation and after the critical developmental stages, which might have diluted the findings regarding safety. A separate observational study that focused strictly on ginger use during the first trimester also found no increase in adverse events.

Side effects are rare but may include GI upset, heartburn, flatulence, or bloating. Much higher doses of ginger (2.5 g/day or higher) can produce antiplatelet effects.

Two previous studies–one in rats and the other an in vitro study–had raised some concerns about possible mutagenic properties or some increase in early embryonic loss. However, “there is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, said Dr. Dennehy of the university's School of Pharmacy.

PIVitamin B6. Two randomized, controlled trials (with 59 and 342 patients, respectively) found that vitamin B6 supplements worked significantly better than placebo to decrease severe nausea and vomiting in pregnancy or to decrease overall nausea scores and vomiting in the first 3 days of use.

Bendectin, a product that combined vitamin B6, an antihistamine, and an anticholinergic, was pulled off the U.S. market in the early 1980s after lawsuits alleged that it caused limb deformities in children. Plaintiff victories on those charges were overturned on appeal. Moreover, late last year, the FDA took the unusual step of publishing a notice in the Federal Register stating that Bendectin had not been withdrawn from the market for safety or health reasons. The move was widely seen as an invitation for a pharmaceutical manufacturer to begin selling the drug again.

Today, a similar product called Diclectin is sold in Canada and combines vitamin B6 with doxylamine. A meta-analysis of 170,000 exposures to Diclectin found no adverse effects on fetuses. “Overall, it looks like vitamin B6 is a safe product to use” in pregnancy, Dr. Dennehy said.

Dr. Dennehy also reviewed the prospect of peppermint tea as a morning-sickness palliative. There are no trials of peppermint tea either in general use or during pregnancy, she said, but a small randomized controlled study of peppermint oil for postoperative pain found it to be more effective than placebo. Peppermint oil relaxes GI smooth muscle, and commonly is used for irritable bowel syndrome.

Peppermint oil also decreases lower esophageal sphincter tone, increases bile flow, and can worsen gastroesophageal reflux disease, “which can get problematic during pregnancy,” she said. “You wouldn't want to give this to someone who already was complaining of those types of symptoms.”

Peppermint “likely is safe as a tea formulation in pregnancy,” Dr. Dennehy concluded.

Three separate studies in the past decade suggest that 7%-13% of women use herbal preparations during pregnancy for a variety of indications, a practice that is more common in Australia and some European countries than in the United States. However, a year 2000 survey of certified nurse-midwives in North Carolina found that 73% recommended herbal products in pregnancy, most commonly for nausea and vomiting, Dr. Dennehy noted.

“There is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, says Dr. Cathi Dennehy. ©Tasha/Fotolia.com

SAN FRANCISCO – Multiple clinical trials have shown that both ginger and vitamin B6 can safely help reduce the nausea and vomiting of “morning sickness” in pregnancy.

Cathi Dennehy, Pharm.D., reviewed the evidence for the efficacy and safety of the two supplements at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

PIGinger. Six randomized, controlled trials found significant reductions in nausea and vomiting during pregnancy in women who took powdered ginger, ginger syrup, or ginger extract products for 4-21 days. Four trials found greater reductions in nausea and vomiting, compared with placebo, and two trials found effects that were equivalent to treatment with 30 mg or 75 mg per day of vitamin B6 (with no placebo arm in those studies).

The most common dose was 1 g per day of powdered ginger, which comes in capsules containing 250-500 mg each. Patients took divided doses b.i.d. or q.i.d. depending on the capsule size.

The studies included 26-291 women each. Four trials that included a total of 265 women found no increased risk of negative birth outcomes in the ginger groups. Most of the women in these studies used ginger during the first trimester of pregnancy, but some studies included women up to the 20th week of gestation and after the critical developmental stages, which might have diluted the findings regarding safety. A separate observational study that focused strictly on ginger use during the first trimester also found no increase in adverse events.

Side effects are rare but may include GI upset, heartburn, flatulence, or bloating. Much higher doses of ginger (2.5 g/day or higher) can produce antiplatelet effects.

Two previous studies–one in rats and the other an in vitro study–had raised some concerns about possible mutagenic properties or some increase in early embryonic loss. However, “there is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, said Dr. Dennehy of the university's School of Pharmacy.

PIVitamin B6. Two randomized, controlled trials (with 59 and 342 patients, respectively) found that vitamin B6 supplements worked significantly better than placebo to decrease severe nausea and vomiting in pregnancy or to decrease overall nausea scores and vomiting in the first 3 days of use.

Bendectin, a product that combined vitamin B6, an antihistamine, and an anticholinergic, was pulled off the U.S. market in the early 1980s after lawsuits alleged that it caused limb deformities in children. Plaintiff victories on those charges were overturned on appeal. Moreover, late last year, the FDA took the unusual step of publishing a notice in the Federal Register stating that Bendectin had not been withdrawn from the market for safety or health reasons. The move was widely seen as an invitation for a pharmaceutical manufacturer to begin selling the drug again.

Today, a similar product called Diclectin is sold in Canada and combines vitamin B6 with doxylamine. A meta-analysis of 170,000 exposures to Diclectin found no adverse effects on fetuses. “Overall, it looks like vitamin B6 is a safe product to use” in pregnancy, Dr. Dennehy said.

Dr. Dennehy also reviewed the prospect of peppermint tea as a morning-sickness palliative. There are no trials of peppermint tea either in general use or during pregnancy, she said, but a small randomized controlled study of peppermint oil for postoperative pain found it to be more effective than placebo. Peppermint oil relaxes GI smooth muscle, and commonly is used for irritable bowel syndrome.

Peppermint oil also decreases lower esophageal sphincter tone, increases bile flow, and can worsen gastroesophageal reflux disease, “which can get problematic during pregnancy,” she said. “You wouldn't want to give this to someone who already was complaining of those types of symptoms.”

Peppermint “likely is safe as a tea formulation in pregnancy,” Dr. Dennehy concluded.

Three separate studies in the past decade suggest that 7%-13% of women use herbal preparations during pregnancy for a variety of indications, a practice that is more common in Australia and some European countries than in the United States. However, a year 2000 survey of certified nurse-midwives in North Carolina found that 73% recommended herbal products in pregnancy, most commonly for nausea and vomiting, Dr. Dennehy noted.

“There is quite a bit of evidence in clinical trials” to support the safety of ginger in pregnancy, says Dr. Cathi Dennehy. ©Tasha/Fotolia.com

MINNEAPOLIS – Data from a surveillance system in Maryland show that the burden of unintended pregnancy remains large, with multiple potential risks for both mothers and infants, according to Dr. Diana Cheng of the Maryland Department of Health and Mental Hygiene, Baltimore.

The Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) was established by the Centers for Disease Control and Prevention with the goal of obtaining information about maternal behaviors and experiences that may be associated with adverse pregnancy outcomes.

Between 2001 and 2005, a random sample of 7,381 mothers completed the PRAMS survey from 2 to 6 months after delivery.

The survey included the following question: Thinking back to just before you got pregnant, how did you feel about becoming pregnant?

Available answers were “I wanted to be pregnant sooner,” “I wanted to be pregnant later,” “I wanted to be pregnant then,” or “I didn't want to be pregnant then or at any time in the future.”

Pregnancies were classified as intended if the mothers had wanted them then or sooner and as unintended if they said they wanted them later or not at all.

Analysis of the survey responses determined that 58% of the pregnancies were intended, while 42% were unintended, Dr. Cheng reported at the annual meeting of the Association of Reproductive Health Professionals.

Among women with intended pregnancies, 16% said they wanted their pregnancy sooner and 42% said they wanted their pregnancy then.

Among women with unintended pregnancies, 31% said they wanted their pregnancies later and 11% said they didn't want to be pregnant then or ever.

“We also looked at maternal behaviors and risk factors, and the group whose pregnancies were unwanted really fared much worse,” Dr. Cheng said. A total of 86% of the mothers whose pregnancies were unwanted did not take folic acid daily, 44% initiated prenatal care after the first trimester, and about 24% smoked during pregnancy.

Post partum, 37% did not breast-feed, 30% smoked, 27% reported depression, and 50% did not place their babies on their backs to sleep.

Moreover, 11% of women in this group reported a history of physical abuse.

In contrast, significantly lower percentages of women with intended pregnancies reported unhealthy behaviors. For example, among mothers in this group, 87% initiated prenatal care during the first trimester, 81% breast-fed, and 69% placed their babies on their backs for sleep.

A total of 10% of babies born to mothers whose pregnancies were unwanted were low birth weight, as were 7% of babies born to mothers whose pregnancies were intended.

The survey also found that 43% of the women were using birth control at the time they became pregnant.

“Discouragingly, the fact that this many women were using birth control and became pregnant anyway suggests inconsistent or improper use of contraceptives,” Dr. Cheng noted.

Among the women who did not use birth control, most said they did not think they could get pregnant at that time. Other reasons for failure to use contraceptives included cost and difficulties in obtaining birth control supplies, she noted.

Improving women's access to education about contraception will help couples better plan pregnancies and increase the rates of intended pregnancies, and counseling, particularly with the inclusion of the partner, can help clarify common misconceptions about birth control, she said.

Unwanted and mistimed births remain a huge educational challenge and opportunity for family planning organizations and specialists, Dr. Cheng concluded.

MINNEAPOLIS – Data from a surveillance system in Maryland show that the burden of unintended pregnancy remains large, with multiple potential risks for both mothers and infants, according to Dr. Diana Cheng of the Maryland Department of Health and Mental Hygiene, Baltimore.

The Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) was established by the Centers for Disease Control and Prevention with the goal of obtaining information about maternal behaviors and experiences that may be associated with adverse pregnancy outcomes.

Between 2001 and 2005, a random sample of 7,381 mothers completed the PRAMS survey from 2 to 6 months after delivery.

The survey included the following question: Thinking back to just before you got pregnant, how did you feel about becoming pregnant?

Available answers were “I wanted to be pregnant sooner,” “I wanted to be pregnant later,” “I wanted to be pregnant then,” or “I didn't want to be pregnant then or at any time in the future.”

Pregnancies were classified as intended if the mothers had wanted them then or sooner and as unintended if they said they wanted them later or not at all.

Analysis of the survey responses determined that 58% of the pregnancies were intended, while 42% were unintended, Dr. Cheng reported at the annual meeting of the Association of Reproductive Health Professionals.

Among women with intended pregnancies, 16% said they wanted their pregnancy sooner and 42% said they wanted their pregnancy then.

Among women with unintended pregnancies, 31% said they wanted their pregnancies later and 11% said they didn't want to be pregnant then or ever.

“We also looked at maternal behaviors and risk factors, and the group whose pregnancies were unwanted really fared much worse,” Dr. Cheng said. A total of 86% of the mothers whose pregnancies were unwanted did not take folic acid daily, 44% initiated prenatal care after the first trimester, and about 24% smoked during pregnancy.

Post partum, 37% did not breast-feed, 30% smoked, 27% reported depression, and 50% did not place their babies on their backs to sleep.

Moreover, 11% of women in this group reported a history of physical abuse.

In contrast, significantly lower percentages of women with intended pregnancies reported unhealthy behaviors. For example, among mothers in this group, 87% initiated prenatal care during the first trimester, 81% breast-fed, and 69% placed their babies on their backs for sleep.

A total of 10% of babies born to mothers whose pregnancies were unwanted were low birth weight, as were 7% of babies born to mothers whose pregnancies were intended.

The survey also found that 43% of the women were using birth control at the time they became pregnant.

“Discouragingly, the fact that this many women were using birth control and became pregnant anyway suggests inconsistent or improper use of contraceptives,” Dr. Cheng noted.

Among the women who did not use birth control, most said they did not think they could get pregnant at that time. Other reasons for failure to use contraceptives included cost and difficulties in obtaining birth control supplies, she noted.

Improving women's access to education about contraception will help couples better plan pregnancies and increase the rates of intended pregnancies, and counseling, particularly with the inclusion of the partner, can help clarify common misconceptions about birth control, she said.

Unwanted and mistimed births remain a huge educational challenge and opportunity for family planning organizations and specialists, Dr. Cheng concluded.

MINNEAPOLIS – Data from a surveillance system in Maryland show that the burden of unintended pregnancy remains large, with multiple potential risks for both mothers and infants, according to Dr. Diana Cheng of the Maryland Department of Health and Mental Hygiene, Baltimore.

The Maryland Pregnancy Risk Assessment Monitoring System (PRAMS) was established by the Centers for Disease Control and Prevention with the goal of obtaining information about maternal behaviors and experiences that may be associated with adverse pregnancy outcomes.

Between 2001 and 2005, a random sample of 7,381 mothers completed the PRAMS survey from 2 to 6 months after delivery.

The survey included the following question: Thinking back to just before you got pregnant, how did you feel about becoming pregnant?

Available answers were “I wanted to be pregnant sooner,” “I wanted to be pregnant later,” “I wanted to be pregnant then,” or “I didn't want to be pregnant then or at any time in the future.”

Pregnancies were classified as intended if the mothers had wanted them then or sooner and as unintended if they said they wanted them later or not at all.

Analysis of the survey responses determined that 58% of the pregnancies were intended, while 42% were unintended, Dr. Cheng reported at the annual meeting of the Association of Reproductive Health Professionals.

Among women with intended pregnancies, 16% said they wanted their pregnancy sooner and 42% said they wanted their pregnancy then.

Among women with unintended pregnancies, 31% said they wanted their pregnancies later and 11% said they didn't want to be pregnant then or ever.

“We also looked at maternal behaviors and risk factors, and the group whose pregnancies were unwanted really fared much worse,” Dr. Cheng said. A total of 86% of the mothers whose pregnancies were unwanted did not take folic acid daily, 44% initiated prenatal care after the first trimester, and about 24% smoked during pregnancy.

Post partum, 37% did not breast-feed, 30% smoked, 27% reported depression, and 50% did not place their babies on their backs to sleep.

Moreover, 11% of women in this group reported a history of physical abuse.

In contrast, significantly lower percentages of women with intended pregnancies reported unhealthy behaviors. For example, among mothers in this group, 87% initiated prenatal care during the first trimester, 81% breast-fed, and 69% placed their babies on their backs for sleep.

A total of 10% of babies born to mothers whose pregnancies were unwanted were low birth weight, as were 7% of babies born to mothers whose pregnancies were intended.

The survey also found that 43% of the women were using birth control at the time they became pregnant.

“Discouragingly, the fact that this many women were using birth control and became pregnant anyway suggests inconsistent or improper use of contraceptives,” Dr. Cheng noted.

Among the women who did not use birth control, most said they did not think they could get pregnant at that time. Other reasons for failure to use contraceptives included cost and difficulties in obtaining birth control supplies, she noted.

Improving women's access to education about contraception will help couples better plan pregnancies and increase the rates of intended pregnancies, and counseling, particularly with the inclusion of the partner, can help clarify common misconceptions about birth control, she said.

Unwanted and mistimed births remain a huge educational challenge and opportunity for family planning organizations and specialists, Dr. Cheng concluded.