Obstetrics

SAN DIEGO — Routine use of an enema during the first stage of labor significantly prolonged the time to delivery in a randomized trial conducted at the Carolinas Medical Center in Charlotte, N.C.

Although routine enemas have been abandoned in many hospitals, anecdotal beliefs persist that the procedure enhances uterine stimulation, makes for a “cleaner delivery,” and reduces neonatal wound infections, Dr. Noellee T. Clarke said.

Labor and delivery nurses in some regions hold to the notion that enemas for this purpose are best administered “high and hot and a hell of a lot,” she noted following the oral presentation of her study.

To see if enemas do reduce labor time, Dr. Clarke and coinvestigator Dr. Todd R. Jenkins conducted a trial that randomized 152 women in uncomplicated early labor at their institution either to undergo an enema or to have no enema on admission. At baseline, women in the two groups were similar in terms of parity, age, and other relevant variables.

Enemas were performed using a standard protocol (1 L water plus two packets of castile soap at a mean cervical dilatation of 3.6 cm). Mean time to delivery was 505 minutes in 75 women who received enemas, vs. 393 minutes in 77 women who did not receive an enema, for a highly statistically significant difference of 112 minutes.

Intrapartum infection rates were 12.3% among patients receiving enemas and 2.7% for those receiving no enema; however, this difference lost its significance when investigators controlled for differences in duration of membrane rupture.

No differences were seen between groups in epidural use, delivery mode, or presence of meconium, she said at the annual meeting of the American College of Obstetricians and Gynecologists.

Women who underwent a routine enema had less fecal soiling at delivery, observed in 8 of 75 (11%) in the enema group vs. 23 of 77 (30%) in the group that received no enema.

Dr. Clarke said the study results were accepted by some, but not all, labor and delivery nurses on her service. “I was unpopular a little bit,” she said in response to a question following her presentation.

SAN DIEGO — Routine use of an enema during the first stage of labor significantly prolonged the time to delivery in a randomized trial conducted at the Carolinas Medical Center in Charlotte, N.C.

Although routine enemas have been abandoned in many hospitals, anecdotal beliefs persist that the procedure enhances uterine stimulation, makes for a “cleaner delivery,” and reduces neonatal wound infections, Dr. Noellee T. Clarke said.

Labor and delivery nurses in some regions hold to the notion that enemas for this purpose are best administered “high and hot and a hell of a lot,” she noted following the oral presentation of her study.

To see if enemas do reduce labor time, Dr. Clarke and coinvestigator Dr. Todd R. Jenkins conducted a trial that randomized 152 women in uncomplicated early labor at their institution either to undergo an enema or to have no enema on admission. At baseline, women in the two groups were similar in terms of parity, age, and other relevant variables.

Enemas were performed using a standard protocol (1 L water plus two packets of castile soap at a mean cervical dilatation of 3.6 cm). Mean time to delivery was 505 minutes in 75 women who received enemas, vs. 393 minutes in 77 women who did not receive an enema, for a highly statistically significant difference of 112 minutes.

Intrapartum infection rates were 12.3% among patients receiving enemas and 2.7% for those receiving no enema; however, this difference lost its significance when investigators controlled for differences in duration of membrane rupture.

No differences were seen between groups in epidural use, delivery mode, or presence of meconium, she said at the annual meeting of the American College of Obstetricians and Gynecologists.

Women who underwent a routine enema had less fecal soiling at delivery, observed in 8 of 75 (11%) in the enema group vs. 23 of 77 (30%) in the group that received no enema.

Dr. Clarke said the study results were accepted by some, but not all, labor and delivery nurses on her service. “I was unpopular a little bit,” she said in response to a question following her presentation.

SAN DIEGO — Routine use of an enema during the first stage of labor significantly prolonged the time to delivery in a randomized trial conducted at the Carolinas Medical Center in Charlotte, N.C.

Although routine enemas have been abandoned in many hospitals, anecdotal beliefs persist that the procedure enhances uterine stimulation, makes for a “cleaner delivery,” and reduces neonatal wound infections, Dr. Noellee T. Clarke said.

Labor and delivery nurses in some regions hold to the notion that enemas for this purpose are best administered “high and hot and a hell of a lot,” she noted following the oral presentation of her study.

To see if enemas do reduce labor time, Dr. Clarke and coinvestigator Dr. Todd R. Jenkins conducted a trial that randomized 152 women in uncomplicated early labor at their institution either to undergo an enema or to have no enema on admission. At baseline, women in the two groups were similar in terms of parity, age, and other relevant variables.

Enemas were performed using a standard protocol (1 L water plus two packets of castile soap at a mean cervical dilatation of 3.6 cm). Mean time to delivery was 505 minutes in 75 women who received enemas, vs. 393 minutes in 77 women who did not receive an enema, for a highly statistically significant difference of 112 minutes.

Intrapartum infection rates were 12.3% among patients receiving enemas and 2.7% for those receiving no enema; however, this difference lost its significance when investigators controlled for differences in duration of membrane rupture.

No differences were seen between groups in epidural use, delivery mode, or presence of meconium, she said at the annual meeting of the American College of Obstetricians and Gynecologists.

Women who underwent a routine enema had less fecal soiling at delivery, observed in 8 of 75 (11%) in the enema group vs. 23 of 77 (30%) in the group that received no enema.

Dr. Clarke said the study results were accepted by some, but not all, labor and delivery nurses on her service. “I was unpopular a little bit,” she said in response to a question following her presentation.

Maternal obesity before pregnancy significantly increased the risk for offspring with anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele in a large study.

D. Kim Waller, Ph.D., of the University of Texas School of Public Health, Houston, and her associates used data from the National Birth Defects Prevention Study to assess whether maternal weight affected risk for several categories of structural birth defects. This is the first study to report a link between maternal obesity and these five types of defects using sufficient sample sizes of 150 or more cases.

More than half of American women aged 20–39 years are estimated to be overweight (with a body mass index [kg/m

The investigators analyzed data on 10,249 babies born with structural birth defects in eight states between 1997 and 2002, as well as 4,065 control subjects representative of the general population.

Maternal obesity was found to raise the risk for spina bifida and heart defects, confirming the findings of previous studies. It also significantly increased the risk for anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele, with odds ratios ranging from 1.3 to 1.6. Maternal obesity also carried a borderline increase in risk for cleft palate, the researchers said (Arch. Pediatr. Adolesc. Med. 2007;161:745-50).

Maternal overweight significantly increased the risk for heart defects, hypospadias, and omphalocele, and slightly raised the risk for craniosynostosis.

Unlike previous studies, this analysis failed to demonstrate an association between maternal obesity and anencephaly, hydrocephaly, or cleft lip. However, this finding may have been the result of chance, because the number of cases of these three birth defects was relatively low.

Maternal obesity before pregnancy significantly increased the risk for offspring with anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele in a large study.

D. Kim Waller, Ph.D., of the University of Texas School of Public Health, Houston, and her associates used data from the National Birth Defects Prevention Study to assess whether maternal weight affected risk for several categories of structural birth defects. This is the first study to report a link between maternal obesity and these five types of defects using sufficient sample sizes of 150 or more cases.

More than half of American women aged 20–39 years are estimated to be overweight (with a body mass index [kg/m

The investigators analyzed data on 10,249 babies born with structural birth defects in eight states between 1997 and 2002, as well as 4,065 control subjects representative of the general population.

Maternal obesity was found to raise the risk for spina bifida and heart defects, confirming the findings of previous studies. It also significantly increased the risk for anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele, with odds ratios ranging from 1.3 to 1.6. Maternal obesity also carried a borderline increase in risk for cleft palate, the researchers said (Arch. Pediatr. Adolesc. Med. 2007;161:745-50).

Maternal overweight significantly increased the risk for heart defects, hypospadias, and omphalocele, and slightly raised the risk for craniosynostosis.

Unlike previous studies, this analysis failed to demonstrate an association between maternal obesity and anencephaly, hydrocephaly, or cleft lip. However, this finding may have been the result of chance, because the number of cases of these three birth defects was relatively low.

Maternal obesity before pregnancy significantly increased the risk for offspring with anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele in a large study.

D. Kim Waller, Ph.D., of the University of Texas School of Public Health, Houston, and her associates used data from the National Birth Defects Prevention Study to assess whether maternal weight affected risk for several categories of structural birth defects. This is the first study to report a link between maternal obesity and these five types of defects using sufficient sample sizes of 150 or more cases.

More than half of American women aged 20–39 years are estimated to be overweight (with a body mass index [kg/m

The investigators analyzed data on 10,249 babies born with structural birth defects in eight states between 1997 and 2002, as well as 4,065 control subjects representative of the general population.

Maternal obesity was found to raise the risk for spina bifida and heart defects, confirming the findings of previous studies. It also significantly increased the risk for anorectal atresia, hypospadias, limb reduction defects, diaphragmatic hernia, and omphalocele, with odds ratios ranging from 1.3 to 1.6. Maternal obesity also carried a borderline increase in risk for cleft palate, the researchers said (Arch. Pediatr. Adolesc. Med. 2007;161:745-50).

Maternal overweight significantly increased the risk for heart defects, hypospadias, and omphalocele, and slightly raised the risk for craniosynostosis.

Unlike previous studies, this analysis failed to demonstrate an association between maternal obesity and anencephaly, hydrocephaly, or cleft lip. However, this finding may have been the result of chance, because the number of cases of these three birth defects was relatively low.

SAN FRANCISCO — Physicians should demand that first-trimester ultrasounds of twins document whether they share a placenta or have separate placentas, Dr. Vickie E. Feldstein said at a meeting on antepartum and intrapartum management.

Monochorionic twins, who share a placenta, face higher risks than dichorionic twins, and management differs based on chorionicity. It's much easier to determine chorionicity in the first trimester than in the second, she said at the meeting sponsored by the University of California, San Francisco.

“Most of the women with twins that I see in the second trimester were picked up as having twins sometime in their first trimester by somebody, and often all they've been told is there are “two sacs.' Sometimes that's all the information that's been recorded” in the patient's record, said Dr. Feldstein, professor of clinical radiology and ob.gyn. at the university. “Two sacs” does not differentiate between dichorionic twins or higher-risk monochorionic, diamniotic twins.

The first essential step is to look for twins during that first-trimester ultrasound, Dr. Mary E. Norton added in a joint presentation with Dr. Feldstein.

“It's really important any time you put the transducer down on your patients in pregnancy to make a conscious effort to think about how many embryos or fetuses are there,” said Dr. Norton, director of perinatal medicine and genetics and professor of ob.gyn. at the university. “It's an embarrassing mistake for anyone to make to miss an entire fetus, but it happens a lot.”

If you see one fetus, don't be distracted by looking at it. Remember to sweep the ultrasound transducer up, down, forward and backward to image the whole uterus, and consciously think about counting how many fetuses are there, she advised. For twins, look for the number of placentas, take a picture, and document it.

Monochorionic twins necessarily are monozygotic or so-called “identical” twins. Dichorionic twins can be monozygotic or dizygotic twins.

Monochorionic twins are at greater risk for discordant growth, anomalies, preterm labor, and death. Only monochorionic twins can develop twin-twin transfusion syndrome. If one twin dies in utero, that greatly increases the risks for the other twin in monochorionic but not in dichorionic pregnancies.

Be sure to look for twins after in vitro fertilization, Dr. Norton said. “Monozygotic twinning is more common than one might think after IVF.” Approximately 2% of embryos split into twins after conventional IVF, or up to 5%–10% after blastocyst transfer. “Just because someone had two embryos implanted by IVF does not mean that they have to be dichorionic twins” if twins are present, she said.

Monochorionic twins get followed at her institution every 2–3 weeks in the second trimester to watch for amniotic fluid discordance or evidence of twin-twin transfusion syndrome. Dichorionic twins that are growing appropriately are seen every 6 weeks. Chorionicity can be difficult to determine in the second trimester if all that's seen on ultrasound is a single placental mass, which could be a fused dichorionic pregnancy or a monochorionic pregnancy. There are clues that can help, if a patient's record doesn't include a placenta count, Dr. Feldstein said.

Ask the patient if she has a first-trimester ultrasound—she may pull one out of her pocketbook, in Dr. Feldstein's experience. If two fetuses are of the opposite sex, they must have two placentas, she said. If they're the same sex, this could be either a monochorionic or dichorionic pregnancy.

A “twin peak” sign and thicker membrane on ultrasound suggest two placentas fused together. If you don't see the twin peak sign and only a thin membrane, it's likely a monochorionic pregnancy. A thin membrane can be hard to visualize.

If you can find the two umbilical cord insertion sites and turn on color Doppler, look for an artery-to-artery connection—a telltale sign of a shared placenta.

SAN FRANCISCO — Physicians should demand that first-trimester ultrasounds of twins document whether they share a placenta or have separate placentas, Dr. Vickie E. Feldstein said at a meeting on antepartum and intrapartum management.

Monochorionic twins, who share a placenta, face higher risks than dichorionic twins, and management differs based on chorionicity. It's much easier to determine chorionicity in the first trimester than in the second, she said at the meeting sponsored by the University of California, San Francisco.

“Most of the women with twins that I see in the second trimester were picked up as having twins sometime in their first trimester by somebody, and often all they've been told is there are “two sacs.' Sometimes that's all the information that's been recorded” in the patient's record, said Dr. Feldstein, professor of clinical radiology and ob.gyn. at the university. “Two sacs” does not differentiate between dichorionic twins or higher-risk monochorionic, diamniotic twins.

The first essential step is to look for twins during that first-trimester ultrasound, Dr. Mary E. Norton added in a joint presentation with Dr. Feldstein.

“It's really important any time you put the transducer down on your patients in pregnancy to make a conscious effort to think about how many embryos or fetuses are there,” said Dr. Norton, director of perinatal medicine and genetics and professor of ob.gyn. at the university. “It's an embarrassing mistake for anyone to make to miss an entire fetus, but it happens a lot.”

If you see one fetus, don't be distracted by looking at it. Remember to sweep the ultrasound transducer up, down, forward and backward to image the whole uterus, and consciously think about counting how many fetuses are there, she advised. For twins, look for the number of placentas, take a picture, and document it.

Monochorionic twins necessarily are monozygotic or so-called “identical” twins. Dichorionic twins can be monozygotic or dizygotic twins.

Monochorionic twins are at greater risk for discordant growth, anomalies, preterm labor, and death. Only monochorionic twins can develop twin-twin transfusion syndrome. If one twin dies in utero, that greatly increases the risks for the other twin in monochorionic but not in dichorionic pregnancies.

Be sure to look for twins after in vitro fertilization, Dr. Norton said. “Monozygotic twinning is more common than one might think after IVF.” Approximately 2% of embryos split into twins after conventional IVF, or up to 5%–10% after blastocyst transfer. “Just because someone had two embryos implanted by IVF does not mean that they have to be dichorionic twins” if twins are present, she said.

Monochorionic twins get followed at her institution every 2–3 weeks in the second trimester to watch for amniotic fluid discordance or evidence of twin-twin transfusion syndrome. Dichorionic twins that are growing appropriately are seen every 6 weeks. Chorionicity can be difficult to determine in the second trimester if all that's seen on ultrasound is a single placental mass, which could be a fused dichorionic pregnancy or a monochorionic pregnancy. There are clues that can help, if a patient's record doesn't include a placenta count, Dr. Feldstein said.

Ask the patient if she has a first-trimester ultrasound—she may pull one out of her pocketbook, in Dr. Feldstein's experience. If two fetuses are of the opposite sex, they must have two placentas, she said. If they're the same sex, this could be either a monochorionic or dichorionic pregnancy.

A “twin peak” sign and thicker membrane on ultrasound suggest two placentas fused together. If you don't see the twin peak sign and only a thin membrane, it's likely a monochorionic pregnancy. A thin membrane can be hard to visualize.

If you can find the two umbilical cord insertion sites and turn on color Doppler, look for an artery-to-artery connection—a telltale sign of a shared placenta.

SAN FRANCISCO — Physicians should demand that first-trimester ultrasounds of twins document whether they share a placenta or have separate placentas, Dr. Vickie E. Feldstein said at a meeting on antepartum and intrapartum management.

Monochorionic twins, who share a placenta, face higher risks than dichorionic twins, and management differs based on chorionicity. It's much easier to determine chorionicity in the first trimester than in the second, she said at the meeting sponsored by the University of California, San Francisco.

“Most of the women with twins that I see in the second trimester were picked up as having twins sometime in their first trimester by somebody, and often all they've been told is there are “two sacs.' Sometimes that's all the information that's been recorded” in the patient's record, said Dr. Feldstein, professor of clinical radiology and ob.gyn. at the university. “Two sacs” does not differentiate between dichorionic twins or higher-risk monochorionic, diamniotic twins.

The first essential step is to look for twins during that first-trimester ultrasound, Dr. Mary E. Norton added in a joint presentation with Dr. Feldstein.

“It's really important any time you put the transducer down on your patients in pregnancy to make a conscious effort to think about how many embryos or fetuses are there,” said Dr. Norton, director of perinatal medicine and genetics and professor of ob.gyn. at the university. “It's an embarrassing mistake for anyone to make to miss an entire fetus, but it happens a lot.”

If you see one fetus, don't be distracted by looking at it. Remember to sweep the ultrasound transducer up, down, forward and backward to image the whole uterus, and consciously think about counting how many fetuses are there, she advised. For twins, look for the number of placentas, take a picture, and document it.

Monochorionic twins necessarily are monozygotic or so-called “identical” twins. Dichorionic twins can be monozygotic or dizygotic twins.

Monochorionic twins are at greater risk for discordant growth, anomalies, preterm labor, and death. Only monochorionic twins can develop twin-twin transfusion syndrome. If one twin dies in utero, that greatly increases the risks for the other twin in monochorionic but not in dichorionic pregnancies.

Be sure to look for twins after in vitro fertilization, Dr. Norton said. “Monozygotic twinning is more common than one might think after IVF.” Approximately 2% of embryos split into twins after conventional IVF, or up to 5%–10% after blastocyst transfer. “Just because someone had two embryos implanted by IVF does not mean that they have to be dichorionic twins” if twins are present, she said.

Monochorionic twins get followed at her institution every 2–3 weeks in the second trimester to watch for amniotic fluid discordance or evidence of twin-twin transfusion syndrome. Dichorionic twins that are growing appropriately are seen every 6 weeks. Chorionicity can be difficult to determine in the second trimester if all that's seen on ultrasound is a single placental mass, which could be a fused dichorionic pregnancy or a monochorionic pregnancy. There are clues that can help, if a patient's record doesn't include a placenta count, Dr. Feldstein said.

Ask the patient if she has a first-trimester ultrasound—she may pull one out of her pocketbook, in Dr. Feldstein's experience. If two fetuses are of the opposite sex, they must have two placentas, she said. If they're the same sex, this could be either a monochorionic or dichorionic pregnancy.

A “twin peak” sign and thicker membrane on ultrasound suggest two placentas fused together. If you don't see the twin peak sign and only a thin membrane, it's likely a monochorionic pregnancy. A thin membrane can be hard to visualize.

If you can find the two umbilical cord insertion sites and turn on color Doppler, look for an artery-to-artery connection—a telltale sign of a shared placenta.

OTTAWA — Women whose infants were delivered by a cesarean section had a nearly ninefold higher risk of developing a postpartum venous thromboembolism, compared with women who had a vaginal delivery, based on a review of more than 80,000 deliveries in Canada during a 6-year period.

In addition, the median time to the onset of symptoms from venous thromboembolism (VTE) was 5 days after delivery, a time when most of the women had already been discharged and were home.

“It's therefore important to educate women about the signs and symptoms of VTE so that they can get timely medical care and reduce the risk of morbidity and mortality from VTE,” Dr. Tannys Vance said at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada.

The study also found that the overall rate of VTE in all postpartum women was 0.05%, similar to the rate in previously reported studies from other populations.

But before now there were few data on the incidence in women after cesarean sections, compared with those who had vaginal deliveries, said Dr. Vance, an ob.gyn. at the University of Alberta, Edmonton.

The study reviewed records for 80,365 women who gave birth at any of five hospitals in the Edmonton region during January 1999-June 2005.

Dr. Vance and her associates identified 39 confirmed episodes of VTE that occurred within 3 months of delivery. The most common presentations were deep vein thrombosis (13 cases), pulmonary embolism (12 cases), and pelvic vein thrombosis (12 cases).

The average age of these women was 29 years. The median time of diagnosis was 9 days after delivery, a median of 4 days after symptoms first appeared.

The incidence of VTE following a cesarean section was 0.14%, compared with a 0.026% rate following vaginal delivery. Translated into an odds ratio, VTE after surgical delivery was 8.9 times more likely than after vaginal delivery, she said.

Other factors that significantly boosted the risk of VTE included hospitalization before delivery, bed rest before delivery, a history of peripartum blood transfusions, a history of thrombophilia, proteinuria occurring after 20 weeks' gestation, and multiple gestations.

OTTAWA — Women whose infants were delivered by a cesarean section had a nearly ninefold higher risk of developing a postpartum venous thromboembolism, compared with women who had a vaginal delivery, based on a review of more than 80,000 deliveries in Canada during a 6-year period.

In addition, the median time to the onset of symptoms from venous thromboembolism (VTE) was 5 days after delivery, a time when most of the women had already been discharged and were home.

“It's therefore important to educate women about the signs and symptoms of VTE so that they can get timely medical care and reduce the risk of morbidity and mortality from VTE,” Dr. Tannys Vance said at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada.

The study also found that the overall rate of VTE in all postpartum women was 0.05%, similar to the rate in previously reported studies from other populations.

But before now there were few data on the incidence in women after cesarean sections, compared with those who had vaginal deliveries, said Dr. Vance, an ob.gyn. at the University of Alberta, Edmonton.

The study reviewed records for 80,365 women who gave birth at any of five hospitals in the Edmonton region during January 1999-June 2005.

Dr. Vance and her associates identified 39 confirmed episodes of VTE that occurred within 3 months of delivery. The most common presentations were deep vein thrombosis (13 cases), pulmonary embolism (12 cases), and pelvic vein thrombosis (12 cases).

The average age of these women was 29 years. The median time of diagnosis was 9 days after delivery, a median of 4 days after symptoms first appeared.

The incidence of VTE following a cesarean section was 0.14%, compared with a 0.026% rate following vaginal delivery. Translated into an odds ratio, VTE after surgical delivery was 8.9 times more likely than after vaginal delivery, she said.

Other factors that significantly boosted the risk of VTE included hospitalization before delivery, bed rest before delivery, a history of peripartum blood transfusions, a history of thrombophilia, proteinuria occurring after 20 weeks' gestation, and multiple gestations.

OTTAWA — Women whose infants were delivered by a cesarean section had a nearly ninefold higher risk of developing a postpartum venous thromboembolism, compared with women who had a vaginal delivery, based on a review of more than 80,000 deliveries in Canada during a 6-year period.

In addition, the median time to the onset of symptoms from venous thromboembolism (VTE) was 5 days after delivery, a time when most of the women had already been discharged and were home.

“It's therefore important to educate women about the signs and symptoms of VTE so that they can get timely medical care and reduce the risk of morbidity and mortality from VTE,” Dr. Tannys Vance said at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada.

The study also found that the overall rate of VTE in all postpartum women was 0.05%, similar to the rate in previously reported studies from other populations.

But before now there were few data on the incidence in women after cesarean sections, compared with those who had vaginal deliveries, said Dr. Vance, an ob.gyn. at the University of Alberta, Edmonton.

The study reviewed records for 80,365 women who gave birth at any of five hospitals in the Edmonton region during January 1999-June 2005.

Dr. Vance and her associates identified 39 confirmed episodes of VTE that occurred within 3 months of delivery. The most common presentations were deep vein thrombosis (13 cases), pulmonary embolism (12 cases), and pelvic vein thrombosis (12 cases).

The average age of these women was 29 years. The median time of diagnosis was 9 days after delivery, a median of 4 days after symptoms first appeared.

The incidence of VTE following a cesarean section was 0.14%, compared with a 0.026% rate following vaginal delivery. Translated into an odds ratio, VTE after surgical delivery was 8.9 times more likely than after vaginal delivery, she said.

Other factors that significantly boosted the risk of VTE included hospitalization before delivery, bed rest before delivery, a history of peripartum blood transfusions, a history of thrombophilia, proteinuria occurring after 20 weeks' gestation, and multiple gestations.

BANFF, ALTA. — Initial conservative treatment of post-dural puncture headache, with delayed placement of a blood patch, may increase the likelihood of early treatment success, Dr. Paul Tan suggested at the annual meeting of the Society of Obstetric Anesthesia and Perinatology.

“One of the explanations for this is that local anesthetics are still residual in the epidural space and can inhibit the coagulation of the blood that's given in the blood patch,” said Dr. Tan of the Cleveland Clinic in an interview.

The study he presented reviewed 130 patients who received therapeutic epidural blood patches (EPB) for post-dural puncture headache. Forty-seven (36%) of the patients required a repeat EPB. In exploring factors that might be associated with the need for a repeat EPB, including body mass index, parity, needle type, amount of blood injected in the first EPB, time from dural puncture to headache onset, and time from headache onset to first EPB, the authors found that the time measurements were the only independent predictors of first EPB success.

“To my knowledge this is the first time that both the time from puncture to headache onset, and the time from headache onset to first blood patch, have been looked at separately,” he said, adding that although the time from puncture to headache onset is not modifiable, information about it can help in counseling patients. “If the patient develops a headache quickly after the puncture, they should be counseled it is likely the first blood patch will fail, and they may need more than one,” he said.

These patients can also be encouraged to undertake a trial of conservative treatment measures such as intravenous hydration, caffeine, and oral pain medications in an effort to delay placement of the first blood patch, he added.

Study patients needing a second EPB had a mean time from puncture to headache onset of 10 hours, and a mean of 16 hours from headache onset to placement of the first patch, compared with 17 hours and 29 hours, respectively, in those not needing a second patch.

“A doubling of the time from puncture to headache onset resulted in a 46% reduction in the odds of the patient needing a repeat patch, and a doubling of the time from headache onset to first blood patch resulted in a 41% reduction in the odds of needing a repeat patch,” he said.

Dr. Tan suggested that the shorter times associated with needing a repeat patch could also be a marker for the severity of the dural puncture, and that the self-limiting nature of post-dural puncture headache could explain why the longer time interval resulted in less requirement for a repeat blood patch.

BANFF, ALTA. — Initial conservative treatment of post-dural puncture headache, with delayed placement of a blood patch, may increase the likelihood of early treatment success, Dr. Paul Tan suggested at the annual meeting of the Society of Obstetric Anesthesia and Perinatology.

“One of the explanations for this is that local anesthetics are still residual in the epidural space and can inhibit the coagulation of the blood that's given in the blood patch,” said Dr. Tan of the Cleveland Clinic in an interview.

The study he presented reviewed 130 patients who received therapeutic epidural blood patches (EPB) for post-dural puncture headache. Forty-seven (36%) of the patients required a repeat EPB. In exploring factors that might be associated with the need for a repeat EPB, including body mass index, parity, needle type, amount of blood injected in the first EPB, time from dural puncture to headache onset, and time from headache onset to first EPB, the authors found that the time measurements were the only independent predictors of first EPB success.

“To my knowledge this is the first time that both the time from puncture to headache onset, and the time from headache onset to first blood patch, have been looked at separately,” he said, adding that although the time from puncture to headache onset is not modifiable, information about it can help in counseling patients. “If the patient develops a headache quickly after the puncture, they should be counseled it is likely the first blood patch will fail, and they may need more than one,” he said.

These patients can also be encouraged to undertake a trial of conservative treatment measures such as intravenous hydration, caffeine, and oral pain medications in an effort to delay placement of the first blood patch, he added.

Study patients needing a second EPB had a mean time from puncture to headache onset of 10 hours, and a mean of 16 hours from headache onset to placement of the first patch, compared with 17 hours and 29 hours, respectively, in those not needing a second patch.

“A doubling of the time from puncture to headache onset resulted in a 46% reduction in the odds of the patient needing a repeat patch, and a doubling of the time from headache onset to first blood patch resulted in a 41% reduction in the odds of needing a repeat patch,” he said.

Dr. Tan suggested that the shorter times associated with needing a repeat patch could also be a marker for the severity of the dural puncture, and that the self-limiting nature of post-dural puncture headache could explain why the longer time interval resulted in less requirement for a repeat blood patch.

BANFF, ALTA. — Initial conservative treatment of post-dural puncture headache, with delayed placement of a blood patch, may increase the likelihood of early treatment success, Dr. Paul Tan suggested at the annual meeting of the Society of Obstetric Anesthesia and Perinatology.

“One of the explanations for this is that local anesthetics are still residual in the epidural space and can inhibit the coagulation of the blood that's given in the blood patch,” said Dr. Tan of the Cleveland Clinic in an interview.

The study he presented reviewed 130 patients who received therapeutic epidural blood patches (EPB) for post-dural puncture headache. Forty-seven (36%) of the patients required a repeat EPB. In exploring factors that might be associated with the need for a repeat EPB, including body mass index, parity, needle type, amount of blood injected in the first EPB, time from dural puncture to headache onset, and time from headache onset to first EPB, the authors found that the time measurements were the only independent predictors of first EPB success.

“To my knowledge this is the first time that both the time from puncture to headache onset, and the time from headache onset to first blood patch, have been looked at separately,” he said, adding that although the time from puncture to headache onset is not modifiable, information about it can help in counseling patients. “If the patient develops a headache quickly after the puncture, they should be counseled it is likely the first blood patch will fail, and they may need more than one,” he said.

These patients can also be encouraged to undertake a trial of conservative treatment measures such as intravenous hydration, caffeine, and oral pain medications in an effort to delay placement of the first blood patch, he added.

Study patients needing a second EPB had a mean time from puncture to headache onset of 10 hours, and a mean of 16 hours from headache onset to placement of the first patch, compared with 17 hours and 29 hours, respectively, in those not needing a second patch.

“A doubling of the time from puncture to headache onset resulted in a 46% reduction in the odds of the patient needing a repeat patch, and a doubling of the time from headache onset to first blood patch resulted in a 41% reduction in the odds of needing a repeat patch,” he said.

Dr. Tan suggested that the shorter times associated with needing a repeat patch could also be a marker for the severity of the dural puncture, and that the self-limiting nature of post-dural puncture headache could explain why the longer time interval resulted in less requirement for a repeat blood patch.

OTTAWA — Delivery more than 72 hours after preterm premature rupture of membranes was associated with a significantly reduced rate of neonatal morbidity in a retrospective review of more than 1,500 pregnancies at one Canadian center.

Induced or surgical delivery within 72 hours of preterm premature rupture of membranes (PPROM) was considered aggressive management, and delivery beyond 72 hours was considered conservative management.

“A policy of conservative management for advanced gestational age at PPROM will reduce severe infant morbidity at up to 32 weeks' gestation, and reduces moderate morbidity at up to 36 weeks,” Dr. Dan Nayot said at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Our data suggest taking a watch-and-wait approach through 36 weeks,” said Dr. Nayot, who performed this analysis while at the University of Western Ontario in London; he is now an ob.gyn. at the University of Toronto.

This finding, drawn from 10 years of data collected at a regional tertiary-care hospital in London, contrasts with what has become common practice at many centers in the United States, where aggressive induction of delivery is often used for PPROM after 32 weeks' gestation, noted Dr. Bryan Richardson, chairman of the department of ob.gyn. at the University of Western Ontario and senior researcher for this study.

“There has never been a randomized, controlled trial, but studies of data from the U.S. suggest there's no benefit from delaying delivery after 32 weeks' gestational age. A problem with those data is that they come from patient populations that are largely public institution-based, with patients from lower socioeconomic levels, and this may introduce possible confounders,” Dr. Richardson said in an interview. The London data come from what may be a more representative population mix, he said.

The study used data collected on all deliveries at St. Joseph's Health Care from 1996 to 2005. During that time there were 1,535 pregnancies where PPROM occurred after 24 weeks' and before 37 weeks' gestation and involved a singleton pregnancy with no major anomalies. These pregnancies accounted for 4.3% of all deliveries during this period. The analysis divided the PPROM deliveries into three subgroups: those that occurred during weeks 25–28, those during weeks 29–32, and those during weeks 33–36.

PPROM most often occurred at 33–36 weeks' gestational age and accounted for 72% of all episodes. PPROM was next most common during weeks 29–32 (19% of all episodes), and was least common during weeks 25–28 (10% of all episodes [total is 101% because of rounding]). Aggressive management was most frequent for near-term PPROM; 90% of all pregnancies with PPROM at 33–36 weeks were delivered within 72 hours. Aggressive delivery was used for 58% of PPROM deliveries during weeks 29–32, and in 33% of episodes during weeks 25–28.

Within both the near-term and preterm subgroups, earlier delivery was used more often for older gestational ages. In the 33- to 36-week group, the average age of the infants delivered within 72 hours was 35.2 weeks vs. 34.0 weeks in the conservative group. In the 29- to 32-week group, the average age of the infants who had aggressive delivery was 30.9 weeks vs. 30.5 weeks in those managed conservatively. In the pregnancies that had PPROM during weeks 25–28, the average age at delivery was 26.5 weeks in both subgroups.

Severe infant comorbidities included bronchopulmonary dysplasia, intraventricular hemorrhage grades 3 or 4, periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity grades 3 or 4, and perinatal death. Moderate comorbidities were respiratory distress syndrome, intraventricular hemorrhage grades 1 or 2, retinopathy of prematurity grades 1 or 2, and sepsis.

In pregnancies that had PPROM during 25–28 weeks or 29–32 weeks, aggressive management led to a significantly higher incidence of severe perinatal outcomes, Dr. Nayot said. (See graph.) In pregnancies that had PPROM at 29–32 weeks or 33–36 weeks, aggressive management significantly boosted the incidence of moderate perinatal comorbidities.

ELSEVIER GLOBAL MEDICAL NEWS

OTTAWA — Delivery more than 72 hours after preterm premature rupture of membranes was associated with a significantly reduced rate of neonatal morbidity in a retrospective review of more than 1,500 pregnancies at one Canadian center.

Induced or surgical delivery within 72 hours of preterm premature rupture of membranes (PPROM) was considered aggressive management, and delivery beyond 72 hours was considered conservative management.

“A policy of conservative management for advanced gestational age at PPROM will reduce severe infant morbidity at up to 32 weeks' gestation, and reduces moderate morbidity at up to 36 weeks,” Dr. Dan Nayot said at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Our data suggest taking a watch-and-wait approach through 36 weeks,” said Dr. Nayot, who performed this analysis while at the University of Western Ontario in London; he is now an ob.gyn. at the University of Toronto.

This finding, drawn from 10 years of data collected at a regional tertiary-care hospital in London, contrasts with what has become common practice at many centers in the United States, where aggressive induction of delivery is often used for PPROM after 32 weeks' gestation, noted Dr. Bryan Richardson, chairman of the department of ob.gyn. at the University of Western Ontario and senior researcher for this study.

“There has never been a randomized, controlled trial, but studies of data from the U.S. suggest there's no benefit from delaying delivery after 32 weeks' gestational age. A problem with those data is that they come from patient populations that are largely public institution-based, with patients from lower socioeconomic levels, and this may introduce possible confounders,” Dr. Richardson said in an interview. The London data come from what may be a more representative population mix, he said.

The study used data collected on all deliveries at St. Joseph's Health Care from 1996 to 2005. During that time there were 1,535 pregnancies where PPROM occurred after 24 weeks' and before 37 weeks' gestation and involved a singleton pregnancy with no major anomalies. These pregnancies accounted for 4.3% of all deliveries during this period. The analysis divided the PPROM deliveries into three subgroups: those that occurred during weeks 25–28, those during weeks 29–32, and those during weeks 33–36.

PPROM most often occurred at 33–36 weeks' gestational age and accounted for 72% of all episodes. PPROM was next most common during weeks 29–32 (19% of all episodes), and was least common during weeks 25–28 (10% of all episodes [total is 101% because of rounding]). Aggressive management was most frequent for near-term PPROM; 90% of all pregnancies with PPROM at 33–36 weeks were delivered within 72 hours. Aggressive delivery was used for 58% of PPROM deliveries during weeks 29–32, and in 33% of episodes during weeks 25–28.

Within both the near-term and preterm subgroups, earlier delivery was used more often for older gestational ages. In the 33- to 36-week group, the average age of the infants delivered within 72 hours was 35.2 weeks vs. 34.0 weeks in the conservative group. In the 29- to 32-week group, the average age of the infants who had aggressive delivery was 30.9 weeks vs. 30.5 weeks in those managed conservatively. In the pregnancies that had PPROM during weeks 25–28, the average age at delivery was 26.5 weeks in both subgroups.

Severe infant comorbidities included bronchopulmonary dysplasia, intraventricular hemorrhage grades 3 or 4, periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity grades 3 or 4, and perinatal death. Moderate comorbidities were respiratory distress syndrome, intraventricular hemorrhage grades 1 or 2, retinopathy of prematurity grades 1 or 2, and sepsis.

In pregnancies that had PPROM during 25–28 weeks or 29–32 weeks, aggressive management led to a significantly higher incidence of severe perinatal outcomes, Dr. Nayot said. (See graph.) In pregnancies that had PPROM at 29–32 weeks or 33–36 weeks, aggressive management significantly boosted the incidence of moderate perinatal comorbidities.

ELSEVIER GLOBAL MEDICAL NEWS

OTTAWA — Delivery more than 72 hours after preterm premature rupture of membranes was associated with a significantly reduced rate of neonatal morbidity in a retrospective review of more than 1,500 pregnancies at one Canadian center.

Induced or surgical delivery within 72 hours of preterm premature rupture of membranes (PPROM) was considered aggressive management, and delivery beyond 72 hours was considered conservative management.

“A policy of conservative management for advanced gestational age at PPROM will reduce severe infant morbidity at up to 32 weeks' gestation, and reduces moderate morbidity at up to 36 weeks,” Dr. Dan Nayot said at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Our data suggest taking a watch-and-wait approach through 36 weeks,” said Dr. Nayot, who performed this analysis while at the University of Western Ontario in London; he is now an ob.gyn. at the University of Toronto.

This finding, drawn from 10 years of data collected at a regional tertiary-care hospital in London, contrasts with what has become common practice at many centers in the United States, where aggressive induction of delivery is often used for PPROM after 32 weeks' gestation, noted Dr. Bryan Richardson, chairman of the department of ob.gyn. at the University of Western Ontario and senior researcher for this study.

“There has never been a randomized, controlled trial, but studies of data from the U.S. suggest there's no benefit from delaying delivery after 32 weeks' gestational age. A problem with those data is that they come from patient populations that are largely public institution-based, with patients from lower socioeconomic levels, and this may introduce possible confounders,” Dr. Richardson said in an interview. The London data come from what may be a more representative population mix, he said.

The study used data collected on all deliveries at St. Joseph's Health Care from 1996 to 2005. During that time there were 1,535 pregnancies where PPROM occurred after 24 weeks' and before 37 weeks' gestation and involved a singleton pregnancy with no major anomalies. These pregnancies accounted for 4.3% of all deliveries during this period. The analysis divided the PPROM deliveries into three subgroups: those that occurred during weeks 25–28, those during weeks 29–32, and those during weeks 33–36.

PPROM most often occurred at 33–36 weeks' gestational age and accounted for 72% of all episodes. PPROM was next most common during weeks 29–32 (19% of all episodes), and was least common during weeks 25–28 (10% of all episodes [total is 101% because of rounding]). Aggressive management was most frequent for near-term PPROM; 90% of all pregnancies with PPROM at 33–36 weeks were delivered within 72 hours. Aggressive delivery was used for 58% of PPROM deliveries during weeks 29–32, and in 33% of episodes during weeks 25–28.

Within both the near-term and preterm subgroups, earlier delivery was used more often for older gestational ages. In the 33- to 36-week group, the average age of the infants delivered within 72 hours was 35.2 weeks vs. 34.0 weeks in the conservative group. In the 29- to 32-week group, the average age of the infants who had aggressive delivery was 30.9 weeks vs. 30.5 weeks in those managed conservatively. In the pregnancies that had PPROM during weeks 25–28, the average age at delivery was 26.5 weeks in both subgroups.

Severe infant comorbidities included bronchopulmonary dysplasia, intraventricular hemorrhage grades 3 or 4, periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity grades 3 or 4, and perinatal death. Moderate comorbidities were respiratory distress syndrome, intraventricular hemorrhage grades 1 or 2, retinopathy of prematurity grades 1 or 2, and sepsis.

In pregnancies that had PPROM during 25–28 weeks or 29–32 weeks, aggressive management led to a significantly higher incidence of severe perinatal outcomes, Dr. Nayot said. (See graph.) In pregnancies that had PPROM at 29–32 weeks or 33–36 weeks, aggressive management significantly boosted the incidence of moderate perinatal comorbidities.

ELSEVIER GLOBAL MEDICAL NEWS

PITTSBURGH — Misdiagnosis of bipolar disorder in the postpartum period may be quite common, Dr. Verinder Sharma and his associates said in a poster presentation at the Seventh International Conference on Bipolar Disorder.

Among 56 women consecutively referred for evaluation of postpartum depression, structured instruments—including the Structured Clinical Interview for DSM-IV—revealed that more than half actually had bipolar disorder. Of those 30 women, 13 had bipolar I disorder, 1 had bipolar II disorder, and 16 had bipolar disorder not otherwise specified, reported Dr. Sharma, a gynecologic psychiatrist at Regional Mental Health Care, London, Ont.

“When people think about postpartum [mental] disorders, they're thinking about the blues, about depression, or psychosis. How many are thinking about postpartum hypomania? There isn't the awareness,” he said in an interview at the meeting, sponsored by the University of Pittsburgh.

Misdiagnosis of bipolar disorder as unipolar depression is a well-documented phenomenon in the psychiatric literature, and a couple of studies have now shown that episodes of hypomania occur in approximately 15% of all postpartum women. Indeed, among women at increased genetic risk, the combination of hormonal changes and sleep deprivation can serve as triggers for a hypomanic or manic episode. “There is no time in a woman's life when the risk of a hypomanic episode is [as] high as the postpartum period,” Dr. Sharma remarked.

Clinically, it may be difficult to distinguish normal feelings of elation from those of abnormal mood elevation. Women should be asked if they have felt as if their minds were racing, whether they have increased energy and increased levels of goal-directed activity—cleaning the house, for example—despite a lack of sleep, or if they have been spending more money than usual.

Anecdotally, Dr. Sharma said, some patients have confided to him about having intense sexual desire during these episodes. “We don't typically elicit these symptoms, but I think they are there,” he commented.

The Mood Disorder Questionnaire has not been validated for the postpartum period, but it can be a valuable assessment tool. There is a caveat: The DSM-IV requires a distinct 4-day period of persistently elevated, expansive, or irritable mood among the diagnostic criteria for hypomania, but in Dr. Sharma's experience those periods tend to be shorter among postpartum women.

“In actual clinical practice, around 2 days is what I'm seeing,” he explained.

It is important to ask women about a family history of mood disorders, particularly of depression, mania, or psychosis. A positive family history for bipolar disorder or psychosis places a woman at extremely high risk for bipolarity during the postpartum period.

Dr. Sharma's study also revealed that bipolarity is not the only psychiatric problem that tends to be missed among postpartum women: Comorbid anxiety disorder also was found in 16 of the 30 women with bipolar disorder (53%) and in 11 of the 26 women (42%) with major depressive disorder. And, while none of the women were found to have current substance abuse problems, a lifetime history of substance abuse disorder was found in five patients in the bipolar group (16%) and four of the unipolar depressed patients (15%).

“[Postpartum] women should also be screened for anxiety disorders and substance use disorders,” Dr. Sharma said.

PITTSBURGH — Misdiagnosis of bipolar disorder in the postpartum period may be quite common, Dr. Verinder Sharma and his associates said in a poster presentation at the Seventh International Conference on Bipolar Disorder.

Among 56 women consecutively referred for evaluation of postpartum depression, structured instruments—including the Structured Clinical Interview for DSM-IV—revealed that more than half actually had bipolar disorder. Of those 30 women, 13 had bipolar I disorder, 1 had bipolar II disorder, and 16 had bipolar disorder not otherwise specified, reported Dr. Sharma, a gynecologic psychiatrist at Regional Mental Health Care, London, Ont.

“When people think about postpartum [mental] disorders, they're thinking about the blues, about depression, or psychosis. How many are thinking about postpartum hypomania? There isn't the awareness,” he said in an interview at the meeting, sponsored by the University of Pittsburgh.

Misdiagnosis of bipolar disorder as unipolar depression is a well-documented phenomenon in the psychiatric literature, and a couple of studies have now shown that episodes of hypomania occur in approximately 15% of all postpartum women. Indeed, among women at increased genetic risk, the combination of hormonal changes and sleep deprivation can serve as triggers for a hypomanic or manic episode. “There is no time in a woman's life when the risk of a hypomanic episode is [as] high as the postpartum period,” Dr. Sharma remarked.

Clinically, it may be difficult to distinguish normal feelings of elation from those of abnormal mood elevation. Women should be asked if they have felt as if their minds were racing, whether they have increased energy and increased levels of goal-directed activity—cleaning the house, for example—despite a lack of sleep, or if they have been spending more money than usual.

Anecdotally, Dr. Sharma said, some patients have confided to him about having intense sexual desire during these episodes. “We don't typically elicit these symptoms, but I think they are there,” he commented.

The Mood Disorder Questionnaire has not been validated for the postpartum period, but it can be a valuable assessment tool. There is a caveat: The DSM-IV requires a distinct 4-day period of persistently elevated, expansive, or irritable mood among the diagnostic criteria for hypomania, but in Dr. Sharma's experience those periods tend to be shorter among postpartum women.

“In actual clinical practice, around 2 days is what I'm seeing,” he explained.

It is important to ask women about a family history of mood disorders, particularly of depression, mania, or psychosis. A positive family history for bipolar disorder or psychosis places a woman at extremely high risk for bipolarity during the postpartum period.

Dr. Sharma's study also revealed that bipolarity is not the only psychiatric problem that tends to be missed among postpartum women: Comorbid anxiety disorder also was found in 16 of the 30 women with bipolar disorder (53%) and in 11 of the 26 women (42%) with major depressive disorder. And, while none of the women were found to have current substance abuse problems, a lifetime history of substance abuse disorder was found in five patients in the bipolar group (16%) and four of the unipolar depressed patients (15%).

“[Postpartum] women should also be screened for anxiety disorders and substance use disorders,” Dr. Sharma said.

PITTSBURGH — Misdiagnosis of bipolar disorder in the postpartum period may be quite common, Dr. Verinder Sharma and his associates said in a poster presentation at the Seventh International Conference on Bipolar Disorder.

Among 56 women consecutively referred for evaluation of postpartum depression, structured instruments—including the Structured Clinical Interview for DSM-IV—revealed that more than half actually had bipolar disorder. Of those 30 women, 13 had bipolar I disorder, 1 had bipolar II disorder, and 16 had bipolar disorder not otherwise specified, reported Dr. Sharma, a gynecologic psychiatrist at Regional Mental Health Care, London, Ont.

“When people think about postpartum [mental] disorders, they're thinking about the blues, about depression, or psychosis. How many are thinking about postpartum hypomania? There isn't the awareness,” he said in an interview at the meeting, sponsored by the University of Pittsburgh.

Misdiagnosis of bipolar disorder as unipolar depression is a well-documented phenomenon in the psychiatric literature, and a couple of studies have now shown that episodes of hypomania occur in approximately 15% of all postpartum women. Indeed, among women at increased genetic risk, the combination of hormonal changes and sleep deprivation can serve as triggers for a hypomanic or manic episode. “There is no time in a woman's life when the risk of a hypomanic episode is [as] high as the postpartum period,” Dr. Sharma remarked.

Clinically, it may be difficult to distinguish normal feelings of elation from those of abnormal mood elevation. Women should be asked if they have felt as if their minds were racing, whether they have increased energy and increased levels of goal-directed activity—cleaning the house, for example—despite a lack of sleep, or if they have been spending more money than usual.

Anecdotally, Dr. Sharma said, some patients have confided to him about having intense sexual desire during these episodes. “We don't typically elicit these symptoms, but I think they are there,” he commented.

The Mood Disorder Questionnaire has not been validated for the postpartum period, but it can be a valuable assessment tool. There is a caveat: The DSM-IV requires a distinct 4-day period of persistently elevated, expansive, or irritable mood among the diagnostic criteria for hypomania, but in Dr. Sharma's experience those periods tend to be shorter among postpartum women.

“In actual clinical practice, around 2 days is what I'm seeing,” he explained.

It is important to ask women about a family history of mood disorders, particularly of depression, mania, or psychosis. A positive family history for bipolar disorder or psychosis places a woman at extremely high risk for bipolarity during the postpartum period.

Dr. Sharma's study also revealed that bipolarity is not the only psychiatric problem that tends to be missed among postpartum women: Comorbid anxiety disorder also was found in 16 of the 30 women with bipolar disorder (53%) and in 11 of the 26 women (42%) with major depressive disorder. And, while none of the women were found to have current substance abuse problems, a lifetime history of substance abuse disorder was found in five patients in the bipolar group (16%) and four of the unipolar depressed patients (15%).

“[Postpartum] women should also be screened for anxiety disorders and substance use disorders,” Dr. Sharma said.

SAN FRANCISCO — Many new mothers are leery of taking antibiotics while breast-feeding, but their fears are unfounded, Dr. Natali Aziz said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Most of the commonly used antimicrobials are safe in breast-feeding and very few are controversial or contraindicated.

Take the time to review the risks and benefits of antibiotics for a new mother who needs the medicine. “Many times we can dispel the fears and rumors that patients might have heard,” said Dr. Aziz of the university.

Penicillins, cephalosporins, macrolides, and aminoglycosides all are safe in breast-feeding. The only potential side effects observed in infants who breast-feed from mothers taking these antibiotics are changes in intestinal flora that may cause loose stools or diarrhea.

Some controversy around whether to take quinolones or metronidazole while breast-feeding has been resolved in favor of the drugs' safety.

The quinolone ofloxacin raised concerns after it was associated with arthropathy in juvenile animals, but the risk of arthropathy in infants breast-feeding from mothers on short courses of the medication is extremely low, she said. In a review of more than 7,000 children on chronic quinolone therapy, only 10 developed an arthropathy-like syndrome.

The American Academy of Pediatrics has declared ofloxacin safe for breast-feeding, she added.

Metronidazole has been associated with carcinogenesis in rodents, but the drug does not increase the rate of adverse events in breast-fed infants and no studies have found cancer to be associated with breast-feeding in humans. The worst the data show is a statistical trend toward relatively benign side effects—loose stools or candidal colonization may develop in infants breast-feeding from women on metronidazole.

The American Academy of Pediatrics rates metronidazole safe while breast-feeding, with one caveat. Because a large percentage of the metronidazole ends up in a woman's breast milk, she should consider discarding some milk after a dose.

“So women who are taking a 2-gram dose, for example for trichomonas treatment, should express and discard milk for up to 24 hours” before resuming breast-feeding, Dr. Aziz said.

Chloramphenicol is one of the rare antibiotics contraindicated during breast-feeding because it may cause bone marrow suppression. In addition, the drug can induce “gray-baby syndrome”—a decrease in hepatic enzyme function leading to hypotension, cyanosis, and even death.

Chronic use of tetracyclines is not recommended because this can stain the immature teeth of infants. Short-term use, however, is approved by numerous organizations, Dr. Aziz said.

Women taking a 2-gram dose of metronidazole should express and discard milk for up to 24 hours. DR. AZIZ

Safe Drugs During Breast-Feeding

Acyclovir

Amoxicillin

Aztreonam

Cefazolin

Cefotaxime

Cefoxitin

Cefprozil

Ceftazidime

Ceftriaxone

Chloroquine

Ciprofloxacin

Clindamycin

Dapsone

Erythromycin

Ethambutol

Fluconazole

Gentamicin

Isoniazid

Kanamycin

Nitrofurantoin

Ofloxacin

Quinidine

Quinine

Rifampin

Streptomycin

Sulbactam

Sulfadiazine

Sulfisoxazole

Tetracycline

Trimethoprim-sulfamethoxazole

Source: American Academy of Pediatrics Committee on Drugs, 2001

SAN FRANCISCO — Many new mothers are leery of taking antibiotics while breast-feeding, but their fears are unfounded, Dr. Natali Aziz said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Most of the commonly used antimicrobials are safe in breast-feeding and very few are controversial or contraindicated.

Take the time to review the risks and benefits of antibiotics for a new mother who needs the medicine. “Many times we can dispel the fears and rumors that patients might have heard,” said Dr. Aziz of the university.

Penicillins, cephalosporins, macrolides, and aminoglycosides all are safe in breast-feeding. The only potential side effects observed in infants who breast-feed from mothers taking these antibiotics are changes in intestinal flora that may cause loose stools or diarrhea.

Some controversy around whether to take quinolones or metronidazole while breast-feeding has been resolved in favor of the drugs' safety.

The quinolone ofloxacin raised concerns after it was associated with arthropathy in juvenile animals, but the risk of arthropathy in infants breast-feeding from mothers on short courses of the medication is extremely low, she said. In a review of more than 7,000 children on chronic quinolone therapy, only 10 developed an arthropathy-like syndrome.

The American Academy of Pediatrics has declared ofloxacin safe for breast-feeding, she added.

Metronidazole has been associated with carcinogenesis in rodents, but the drug does not increase the rate of adverse events in breast-fed infants and no studies have found cancer to be associated with breast-feeding in humans. The worst the data show is a statistical trend toward relatively benign side effects—loose stools or candidal colonization may develop in infants breast-feeding from women on metronidazole.

The American Academy of Pediatrics rates metronidazole safe while breast-feeding, with one caveat. Because a large percentage of the metronidazole ends up in a woman's breast milk, she should consider discarding some milk after a dose.

“So women who are taking a 2-gram dose, for example for trichomonas treatment, should express and discard milk for up to 24 hours” before resuming breast-feeding, Dr. Aziz said.

Chloramphenicol is one of the rare antibiotics contraindicated during breast-feeding because it may cause bone marrow suppression. In addition, the drug can induce “gray-baby syndrome”—a decrease in hepatic enzyme function leading to hypotension, cyanosis, and even death.

Chronic use of tetracyclines is not recommended because this can stain the immature teeth of infants. Short-term use, however, is approved by numerous organizations, Dr. Aziz said.

Women taking a 2-gram dose of metronidazole should express and discard milk for up to 24 hours. DR. AZIZ

Safe Drugs During Breast-Feeding

Acyclovir

Amoxicillin

Aztreonam

Cefazolin

Cefotaxime

Cefoxitin

Cefprozil

Ceftazidime

Ceftriaxone

Chloroquine

Ciprofloxacin

Clindamycin

Dapsone

Erythromycin

Ethambutol

Fluconazole

Gentamicin

Isoniazid

Kanamycin

Nitrofurantoin

Ofloxacin

Quinidine

Quinine

Rifampin

Streptomycin

Sulbactam

Sulfadiazine

Sulfisoxazole

Tetracycline

Trimethoprim-sulfamethoxazole

Source: American Academy of Pediatrics Committee on Drugs, 2001

SAN FRANCISCO — Many new mothers are leery of taking antibiotics while breast-feeding, but their fears are unfounded, Dr. Natali Aziz said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Most of the commonly used antimicrobials are safe in breast-feeding and very few are controversial or contraindicated.

Take the time to review the risks and benefits of antibiotics for a new mother who needs the medicine. “Many times we can dispel the fears and rumors that patients might have heard,” said Dr. Aziz of the university.

Penicillins, cephalosporins, macrolides, and aminoglycosides all are safe in breast-feeding. The only potential side effects observed in infants who breast-feed from mothers taking these antibiotics are changes in intestinal flora that may cause loose stools or diarrhea.

Some controversy around whether to take quinolones or metronidazole while breast-feeding has been resolved in favor of the drugs' safety.

The quinolone ofloxacin raised concerns after it was associated with arthropathy in juvenile animals, but the risk of arthropathy in infants breast-feeding from mothers on short courses of the medication is extremely low, she said. In a review of more than 7,000 children on chronic quinolone therapy, only 10 developed an arthropathy-like syndrome.

The American Academy of Pediatrics has declared ofloxacin safe for breast-feeding, she added.

Metronidazole has been associated with carcinogenesis in rodents, but the drug does not increase the rate of adverse events in breast-fed infants and no studies have found cancer to be associated with breast-feeding in humans. The worst the data show is a statistical trend toward relatively benign side effects—loose stools or candidal colonization may develop in infants breast-feeding from women on metronidazole.

The American Academy of Pediatrics rates metronidazole safe while breast-feeding, with one caveat. Because a large percentage of the metronidazole ends up in a woman's breast milk, she should consider discarding some milk after a dose.

“So women who are taking a 2-gram dose, for example for trichomonas treatment, should express and discard milk for up to 24 hours” before resuming breast-feeding, Dr. Aziz said.

Chloramphenicol is one of the rare antibiotics contraindicated during breast-feeding because it may cause bone marrow suppression. In addition, the drug can induce “gray-baby syndrome”—a decrease in hepatic enzyme function leading to hypotension, cyanosis, and even death.

Chronic use of tetracyclines is not recommended because this can stain the immature teeth of infants. Short-term use, however, is approved by numerous organizations, Dr. Aziz said.

Women taking a 2-gram dose of metronidazole should express and discard milk for up to 24 hours. DR. AZIZ

Safe Drugs During Breast-Feeding

Acyclovir

Amoxicillin

Aztreonam

Cefazolin

Cefotaxime

Cefoxitin

Cefprozil

Ceftazidime

Ceftriaxone

Chloroquine

Ciprofloxacin

Clindamycin

Dapsone

Erythromycin

Ethambutol

Fluconazole

Gentamicin

Isoniazid

Kanamycin

Nitrofurantoin

Ofloxacin

Quinidine

Quinine

Rifampin

Streptomycin

Sulbactam

Sulfadiazine

Sulfisoxazole

Tetracycline

Trimethoprim-sulfamethoxazole

Source: American Academy of Pediatrics Committee on Drugs, 2001

The U.S. Food and Drug Administration has launched a Web page, Consumer Health Information for You and Your Family (www.fda.gov/consumerwww.fda.gov/consumer/consumerenews.html

The U.S. Food and Drug Administration has launched a Web page, Consumer Health Information for You and Your Family (www.fda.gov/consumerwww.fda.gov/consumer/consumerenews.html

The U.S. Food and Drug Administration has launched a Web page, Consumer Health Information for You and Your Family (www.fda.gov/consumerwww.fda.gov/consumer/consumerenews.html

SAN FRANCISCO — A simple technique to help manage labor pain is used commonly in the United Kingdom, Scandinavia, and Canada, but is offered to few U.S. women—nitrous oxide, or so-called “laughing gas.”

Administered as a 50/50 blend of oxygen and nitrous oxide, the gas has proved safe for mothers, their babies, and health care personnel in the vicinity of use, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

It's relatively weak as an analgesic, yet useful. One woman who delivered at the university described how it felt to use nitrous oxide during labor by saying, “It still hurts, but I don't care,” recalled Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the university.

“I've heard that more than once. It's not too dissimilar from some reports from women who are using nonpharmacologic methods,” she noted. “They may have rated their pain somewhat highly, but their satisfaction and their ability to cope was improved.”

Her institution has large holding tanks of oxygen and nitrous oxide that get piped into every labor and delivery room. Three cables control the flow—one for each gas, and one to scavenge the gas from the environment and remove it from the room.

The mother controls the application of the gas. She's given a mask and some instructions on its use by the anesthesiologist, midwife, or obstetrician, with ongoing supervision by a nurse. The full effect of nitrous oxide can be felt in 50 seconds.

Because it's simple and fast to start or stop, nitrous oxide is particularly useful through the second stage of labor for multiparous women who arrive in time to deliver but too late to get an epidural, she said. Nitrous oxide also can be used during perineal repair of women who didn't get an epidural.

Very few U.S. medical centers offer nitrous oxide during labor, for reasons that are unclear. “Many, many places are asking us for information about nitrous oxide. We have a protocol for nurses and certified nurse-midwives to administer” nitrous oxide, Ms. Bishop said. The University of Washington is the only other medical center that she knows of that offers nitrous oxide for labor pain.

Dr. Mark A. Rosen, director of obstetric anesthesia at the university and author of a review of nitrous oxide during labor, said in an interview that he has taken informal polls while lecturing at other institutions and conferences. When he asks how many physicians have nitrous oxide available during deliveries at their hospitals, he said, very few raise their hands.

His systematic review of 11 randomized controlled trials of nitrous oxide for labor pain reported that more than half of laboring women in the United Kingdom and Finland use nitrous oxide, which is widely employed and considered safe in Canada, Australia, New Zealand, and many other parts of the world when supervised by physicians, nurses, or midwives (Am. J. Obstet. Gynecol. 2002;186:S110-26).

He also assessed eight controlled trials and eight observational studies for potential adverse outcomes and performed a nonsystematic review of studies on occupational exposure. Potential side effects from nitrous oxide include maternal nausea, vomiting, or poor recall of labor, but it does not seem to affect the fetus, as seen with narcotics.

“Nitrous oxide is not a potent labor analgesic, but it is safe for parturient women, their newborns, and health care workers in attendance during its administration. It appears to provide adequately effective analgesia for many women,” he concluded.

An estimated 6% of U.S. women in labor used nitrous oxide in the decade leading up to 1986, but by the 1990s the use of nitrous oxide in labor had nearly disappeared in the United States, his report noted. “I really don't understand why this simple but weakly effective analgesic doesn't have more use in the United States,” Dr. Rosen said.

Ms. Bishop suggested that habit and tradition have more to do with its use than science. “We develop our own routines within practices, institutions, and countries. It is really not in most cases about what's 'right' or 'best,' just what the decision-makers decide,” she said.

Before she and Dr. Rosen arrived at the university, the director of obstetric anesthesia was an Englishman.

“I imagine he had good experience with nitrous oxide and was comfortable with it,” she speculated. Dr. Rosen trained under his predecessor and also spent some time in England.

A midwife colleague at the University of Michigan told Ms. Bishop that use of nitrous oxide for labor started in Michigan in 1978 when a British physician became chair of obstetric anesthesia. “Its use became quite popular,” but the chair's successor in 1995 removed it as an option, she said.

“We tend in the United States to go with the higher-tech approach to health care—doctors, not midwives, and epidurals, not nitrous oxide—dropping off lower-tech options even though they may still serve a purpose,” Ms. Bishop noted.

Market forces also may play a role in the demise of U.S. use of nitrous oxide for labor, midwife and epidemiologist Judith Rooks suggested in a recent editorial (Birth 2007;34:3-5). “Obstetric use of nitrous oxide in America is similar to that of any older, inexpensive, off-patent, unglamorous, safe and reasonably effective but not highly potent drug. Nitrous oxide is like an 'orphan' drug—little known outside of dentistry, lacking elan and pizzazz, with no companies or influential professional groups that stand to profit by its greater use,” she wrote.

“There is no 'nitrous lobby,'” Ms. Bishop added.

SAN FRANCISCO — A simple technique to help manage labor pain is used commonly in the United Kingdom, Scandinavia, and Canada, but is offered to few U.S. women—nitrous oxide, or so-called “laughing gas.”

Administered as a 50/50 blend of oxygen and nitrous oxide, the gas has proved safe for mothers, their babies, and health care personnel in the vicinity of use, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

It's relatively weak as an analgesic, yet useful. One woman who delivered at the university described how it felt to use nitrous oxide during labor by saying, “It still hurts, but I don't care,” recalled Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the university.

“I've heard that more than once. It's not too dissimilar from some reports from women who are using nonpharmacologic methods,” she noted. “They may have rated their pain somewhat highly, but their satisfaction and their ability to cope was improved.”

Her institution has large holding tanks of oxygen and nitrous oxide that get piped into every labor and delivery room. Three cables control the flow—one for each gas, and one to scavenge the gas from the environment and remove it from the room.

The mother controls the application of the gas. She's given a mask and some instructions on its use by the anesthesiologist, midwife, or obstetrician, with ongoing supervision by a nurse. The full effect of nitrous oxide can be felt in 50 seconds.

Because it's simple and fast to start or stop, nitrous oxide is particularly useful through the second stage of labor for multiparous women who arrive in time to deliver but too late to get an epidural, she said. Nitrous oxide also can be used during perineal repair of women who didn't get an epidural.

Very few U.S. medical centers offer nitrous oxide during labor, for reasons that are unclear. “Many, many places are asking us for information about nitrous oxide. We have a protocol for nurses and certified nurse-midwives to administer” nitrous oxide, Ms. Bishop said. The University of Washington is the only other medical center that she knows of that offers nitrous oxide for labor pain.

Dr. Mark A. Rosen, director of obstetric anesthesia at the university and author of a review of nitrous oxide during labor, said in an interview that he has taken informal polls while lecturing at other institutions and conferences. When he asks how many physicians have nitrous oxide available during deliveries at their hospitals, he said, very few raise their hands.

His systematic review of 11 randomized controlled trials of nitrous oxide for labor pain reported that more than half of laboring women in the United Kingdom and Finland use nitrous oxide, which is widely employed and considered safe in Canada, Australia, New Zealand, and many other parts of the world when supervised by physicians, nurses, or midwives (Am. J. Obstet. Gynecol. 2002;186:S110-26).

He also assessed eight controlled trials and eight observational studies for potential adverse outcomes and performed a nonsystematic review of studies on occupational exposure. Potential side effects from nitrous oxide include maternal nausea, vomiting, or poor recall of labor, but it does not seem to affect the fetus, as seen with narcotics.

“Nitrous oxide is not a potent labor analgesic, but it is safe for parturient women, their newborns, and health care workers in attendance during its administration. It appears to provide adequately effective analgesia for many women,” he concluded.

An estimated 6% of U.S. women in labor used nitrous oxide in the decade leading up to 1986, but by the 1990s the use of nitrous oxide in labor had nearly disappeared in the United States, his report noted. “I really don't understand why this simple but weakly effective analgesic doesn't have more use in the United States,” Dr. Rosen said.

Ms. Bishop suggested that habit and tradition have more to do with its use than science. “We develop our own routines within practices, institutions, and countries. It is really not in most cases about what's 'right' or 'best,' just what the decision-makers decide,” she said.

Before she and Dr. Rosen arrived at the university, the director of obstetric anesthesia was an Englishman.

“I imagine he had good experience with nitrous oxide and was comfortable with it,” she speculated. Dr. Rosen trained under his predecessor and also spent some time in England.

A midwife colleague at the University of Michigan told Ms. Bishop that use of nitrous oxide for labor started in Michigan in 1978 when a British physician became chair of obstetric anesthesia. “Its use became quite popular,” but the chair's successor in 1995 removed it as an option, she said.

“We tend in the United States to go with the higher-tech approach to health care—doctors, not midwives, and epidurals, not nitrous oxide—dropping off lower-tech options even though they may still serve a purpose,” Ms. Bishop noted.

Market forces also may play a role in the demise of U.S. use of nitrous oxide for labor, midwife and epidemiologist Judith Rooks suggested in a recent editorial (Birth 2007;34:3-5). “Obstetric use of nitrous oxide in America is similar to that of any older, inexpensive, off-patent, unglamorous, safe and reasonably effective but not highly potent drug. Nitrous oxide is like an 'orphan' drug—little known outside of dentistry, lacking elan and pizzazz, with no companies or influential professional groups that stand to profit by its greater use,” she wrote.

“There is no 'nitrous lobby,'” Ms. Bishop added.

SAN FRANCISCO — A simple technique to help manage labor pain is used commonly in the United Kingdom, Scandinavia, and Canada, but is offered to few U.S. women—nitrous oxide, or so-called “laughing gas.”

Administered as a 50/50 blend of oxygen and nitrous oxide, the gas has proved safe for mothers, their babies, and health care personnel in the vicinity of use, Judith T. Bishop said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

It's relatively weak as an analgesic, yet useful. One woman who delivered at the university described how it felt to use nitrous oxide during labor by saying, “It still hurts, but I don't care,” recalled Ms. Bishop, a certified nurse-midwife and professor of ob.gyn. and reproductive sciences at the university.

“I've heard that more than once. It's not too dissimilar from some reports from women who are using nonpharmacologic methods,” she noted. “They may have rated their pain somewhat highly, but their satisfaction and their ability to cope was improved.”

Her institution has large holding tanks of oxygen and nitrous oxide that get piped into every labor and delivery room. Three cables control the flow—one for each gas, and one to scavenge the gas from the environment and remove it from the room.

The mother controls the application of the gas. She's given a mask and some instructions on its use by the anesthesiologist, midwife, or obstetrician, with ongoing supervision by a nurse. The full effect of nitrous oxide can be felt in 50 seconds.

Because it's simple and fast to start or stop, nitrous oxide is particularly useful through the second stage of labor for multiparous women who arrive in time to deliver but too late to get an epidural, she said. Nitrous oxide also can be used during perineal repair of women who didn't get an epidural.

Very few U.S. medical centers offer nitrous oxide during labor, for reasons that are unclear. “Many, many places are asking us for information about nitrous oxide. We have a protocol for nurses and certified nurse-midwives to administer” nitrous oxide, Ms. Bishop said. The University of Washington is the only other medical center that she knows of that offers nitrous oxide for labor pain.

Dr. Mark A. Rosen, director of obstetric anesthesia at the university and author of a review of nitrous oxide during labor, said in an interview that he has taken informal polls while lecturing at other institutions and conferences. When he asks how many physicians have nitrous oxide available during deliveries at their hospitals, he said, very few raise their hands.

His systematic review of 11 randomized controlled trials of nitrous oxide for labor pain reported that more than half of laboring women in the United Kingdom and Finland use nitrous oxide, which is widely employed and considered safe in Canada, Australia, New Zealand, and many other parts of the world when supervised by physicians, nurses, or midwives (Am. J. Obstet. Gynecol. 2002;186:S110-26).

He also assessed eight controlled trials and eight observational studies for potential adverse outcomes and performed a nonsystematic review of studies on occupational exposure. Potential side effects from nitrous oxide include maternal nausea, vomiting, or poor recall of labor, but it does not seem to affect the fetus, as seen with narcotics.

“Nitrous oxide is not a potent labor analgesic, but it is safe for parturient women, their newborns, and health care workers in attendance during its administration. It appears to provide adequately effective analgesia for many women,” he concluded.

An estimated 6% of U.S. women in labor used nitrous oxide in the decade leading up to 1986, but by the 1990s the use of nitrous oxide in labor had nearly disappeared in the United States, his report noted. “I really don't understand why this simple but weakly effective analgesic doesn't have more use in the United States,” Dr. Rosen said.

Ms. Bishop suggested that habit and tradition have more to do with its use than science. “We develop our own routines within practices, institutions, and countries. It is really not in most cases about what's 'right' or 'best,' just what the decision-makers decide,” she said.

Before she and Dr. Rosen arrived at the university, the director of obstetric anesthesia was an Englishman.

“I imagine he had good experience with nitrous oxide and was comfortable with it,” she speculated. Dr. Rosen trained under his predecessor and also spent some time in England.

A midwife colleague at the University of Michigan told Ms. Bishop that use of nitrous oxide for labor started in Michigan in 1978 when a British physician became chair of obstetric anesthesia. “Its use became quite popular,” but the chair's successor in 1995 removed it as an option, she said.

“We tend in the United States to go with the higher-tech approach to health care—doctors, not midwives, and epidurals, not nitrous oxide—dropping off lower-tech options even though they may still serve a purpose,” Ms. Bishop noted.

Market forces also may play a role in the demise of U.S. use of nitrous oxide for labor, midwife and epidemiologist Judith Rooks suggested in a recent editorial (Birth 2007;34:3-5). “Obstetric use of nitrous oxide in America is similar to that of any older, inexpensive, off-patent, unglamorous, safe and reasonably effective but not highly potent drug. Nitrous oxide is like an 'orphan' drug—little known outside of dentistry, lacking elan and pizzazz, with no companies or influential professional groups that stand to profit by its greater use,” she wrote.

“There is no 'nitrous lobby,'” Ms. Bishop added.