Obstetrics

Progesterone appears to reduce the rate of preterm delivery in asymptomatic women found to have a short cervix on transvaginal ultrasound performed midway through gestation.

However, progesterone does not reduce the rate of preterm delivery in another group of high-risk women–those carrying twins, researchers in two separate randomized clinical trials reported

Since the 2003 publication of a report that weekly injections of 17 α-hydroxyprogesterone (17P) decreased the rate of recurrent preterm birth, numerous studies have been undertaken to assess the hormone's potential benefit in different high-risk populations. Now, Dr. Eduardo B. Fonseca of King's College Hospital, London, and his associates have evaluated the effect of 200-mg vaginal capsules of micronized progesterone in women who were found at routine midtrimester ultrasound screening to have a short cervix (15 mm or less).

The researchers tested the vaginal formulation of progesterone because of its enhanced bioavailability and reduced incidence of adverse effects, compared with the oral formulation. They chose a high dose rather than the 100-mg dose used in previous studies, because they considered women with a short cervix to be at very high risk for preterm delivery.

The study subjects were 250 women treated at maternity hospitals in London, Santiago (Chile), and São Paulo (Brazil). The rate of spontaneous preterm delivery was 19% in those who had been randomly assigned to use progesterone capsules from 24 weeks' gestation until delivery, compared with 34% in those who had used placebo capsules.

This finding demonstrates that daily vaginal administration of progesterone significantly decreases the rate of preterm delivery in women with a short cervix, Dr. Fonseca and his associates said (N. Engl. J. Med. 2007;357:462-9).

Similar results were seen across most subgroups of subjects, including those who had previously delivered prematurely. However, in the small number of twin pregnancies (24) included in this study, the progesterone treatment was associated with only a nonsignificant reduction in preterm delivery.

In the second study, Dr. Dwight J. Rouse of the University of Alabama, Birmingham, and his associates assessed weekly 250-mg IM injections of 17P in 661 women pregnant with twins. The study population was drawn from a broad geographic area and was racially and ethnically diverse. Two-thirds of the women had conceived spontaneously.

The subjects were randomly assigned to receive either active injections or placebo beginning at 20 weeks' gestation and were followed at 14 sites across the United States.

The rates of preterm delivery or fetal death did not differ significantly between the group receiving 17P (42%) and those receiving placebo (37%). The mean gestational age at delivery also did not differ significantly, nor did the proportion of deliveries that occurred at 28 weeks, 32 weeks, or 36 weeks.

The rates of obstetric interventions such as tocolysis, cervical cerclage, and cesarean section also were similar between the two groups, as were the rates of adverse neonatal outcomes such as major congenital malformations. The composite outcome of serious adverse events including respiratory distress syndrome, severe intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, severe retinopathy of prematurity, and sepsis also was similar between the two groups.

Side effects from the injections were frequent in both groups, and three women discontinued injections because of intense local reactions.

The findings, which “are generalizable to most women in the United States who are pregnant with twins,” demonstrate that 17P doesn't lower the rate of preterm birth, prolong gestation, or improve fetal or neonatal outcomes in twin pregnancies, Dr. Rouse and his associates said (N. Engl. J. Med. 2007:357:454-61).

In an editorial comment accompanying these reports, Dr. Jim G. Thornton of the University of Nottingham (England) said that much more information is needed if progesterone is to be used widely to curtail preterm delivery in women found to have a short cervix. In particular, the possible risks associated with daily vaginal administration of medication must be rigorously evaluated in women who are already susceptible to preterm delivery.

“Even if progesterone therapy is effective for some women who are at risk of preterm labor, reliable evidence is needed about long-term effects on the children before it could be widely recommended,” he noted (N. Engl. J. Med. 2007;357:499-501).

“There are at least 14 ongoing trials involving women with high-risk pregnancies (both singleton and twin) that aim to recruit a total of more than 5,000 women, and I am aware of at least 2 more currently awaiting funding decisions. These should have ample power to test the effect of progesterone on important fetal outcomes as well as any differential effect in twin gestations, and long-term follow-up of the surviving children will provide important additional information,” Dr. Thornton added.

Progesterone appears to reduce the rate of preterm delivery in asymptomatic women found to have a short cervix on transvaginal ultrasound performed midway through gestation.

However, progesterone does not reduce the rate of preterm delivery in another group of high-risk women–those carrying twins, researchers in two separate randomized clinical trials reported

Since the 2003 publication of a report that weekly injections of 17 α-hydroxyprogesterone (17P) decreased the rate of recurrent preterm birth, numerous studies have been undertaken to assess the hormone's potential benefit in different high-risk populations. Now, Dr. Eduardo B. Fonseca of King's College Hospital, London, and his associates have evaluated the effect of 200-mg vaginal capsules of micronized progesterone in women who were found at routine midtrimester ultrasound screening to have a short cervix (15 mm or less).

The researchers tested the vaginal formulation of progesterone because of its enhanced bioavailability and reduced incidence of adverse effects, compared with the oral formulation. They chose a high dose rather than the 100-mg dose used in previous studies, because they considered women with a short cervix to be at very high risk for preterm delivery.

The study subjects were 250 women treated at maternity hospitals in London, Santiago (Chile), and São Paulo (Brazil). The rate of spontaneous preterm delivery was 19% in those who had been randomly assigned to use progesterone capsules from 24 weeks' gestation until delivery, compared with 34% in those who had used placebo capsules.

This finding demonstrates that daily vaginal administration of progesterone significantly decreases the rate of preterm delivery in women with a short cervix, Dr. Fonseca and his associates said (N. Engl. J. Med. 2007;357:462-9).

Similar results were seen across most subgroups of subjects, including those who had previously delivered prematurely. However, in the small number of twin pregnancies (24) included in this study, the progesterone treatment was associated with only a nonsignificant reduction in preterm delivery.

In the second study, Dr. Dwight J. Rouse of the University of Alabama, Birmingham, and his associates assessed weekly 250-mg IM injections of 17P in 661 women pregnant with twins. The study population was drawn from a broad geographic area and was racially and ethnically diverse. Two-thirds of the women had conceived spontaneously.

The subjects were randomly assigned to receive either active injections or placebo beginning at 20 weeks' gestation and were followed at 14 sites across the United States.

The rates of preterm delivery or fetal death did not differ significantly between the group receiving 17P (42%) and those receiving placebo (37%). The mean gestational age at delivery also did not differ significantly, nor did the proportion of deliveries that occurred at 28 weeks, 32 weeks, or 36 weeks.

The rates of obstetric interventions such as tocolysis, cervical cerclage, and cesarean section also were similar between the two groups, as were the rates of adverse neonatal outcomes such as major congenital malformations. The composite outcome of serious adverse events including respiratory distress syndrome, severe intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, severe retinopathy of prematurity, and sepsis also was similar between the two groups.

Side effects from the injections were frequent in both groups, and three women discontinued injections because of intense local reactions.

The findings, which “are generalizable to most women in the United States who are pregnant with twins,” demonstrate that 17P doesn't lower the rate of preterm birth, prolong gestation, or improve fetal or neonatal outcomes in twin pregnancies, Dr. Rouse and his associates said (N. Engl. J. Med. 2007:357:454-61).

In an editorial comment accompanying these reports, Dr. Jim G. Thornton of the University of Nottingham (England) said that much more information is needed if progesterone is to be used widely to curtail preterm delivery in women found to have a short cervix. In particular, the possible risks associated with daily vaginal administration of medication must be rigorously evaluated in women who are already susceptible to preterm delivery.

“Even if progesterone therapy is effective for some women who are at risk of preterm labor, reliable evidence is needed about long-term effects on the children before it could be widely recommended,” he noted (N. Engl. J. Med. 2007;357:499-501).

“There are at least 14 ongoing trials involving women with high-risk pregnancies (both singleton and twin) that aim to recruit a total of more than 5,000 women, and I am aware of at least 2 more currently awaiting funding decisions. These should have ample power to test the effect of progesterone on important fetal outcomes as well as any differential effect in twin gestations, and long-term follow-up of the surviving children will provide important additional information,” Dr. Thornton added.

Progesterone appears to reduce the rate of preterm delivery in asymptomatic women found to have a short cervix on transvaginal ultrasound performed midway through gestation.

However, progesterone does not reduce the rate of preterm delivery in another group of high-risk women–those carrying twins, researchers in two separate randomized clinical trials reported

Since the 2003 publication of a report that weekly injections of 17 α-hydroxyprogesterone (17P) decreased the rate of recurrent preterm birth, numerous studies have been undertaken to assess the hormone's potential benefit in different high-risk populations. Now, Dr. Eduardo B. Fonseca of King's College Hospital, London, and his associates have evaluated the effect of 200-mg vaginal capsules of micronized progesterone in women who were found at routine midtrimester ultrasound screening to have a short cervix (15 mm or less).

The researchers tested the vaginal formulation of progesterone because of its enhanced bioavailability and reduced incidence of adverse effects, compared with the oral formulation. They chose a high dose rather than the 100-mg dose used in previous studies, because they considered women with a short cervix to be at very high risk for preterm delivery.

The study subjects were 250 women treated at maternity hospitals in London, Santiago (Chile), and São Paulo (Brazil). The rate of spontaneous preterm delivery was 19% in those who had been randomly assigned to use progesterone capsules from 24 weeks' gestation until delivery, compared with 34% in those who had used placebo capsules.

This finding demonstrates that daily vaginal administration of progesterone significantly decreases the rate of preterm delivery in women with a short cervix, Dr. Fonseca and his associates said (N. Engl. J. Med. 2007;357:462-9).

Similar results were seen across most subgroups of subjects, including those who had previously delivered prematurely. However, in the small number of twin pregnancies (24) included in this study, the progesterone treatment was associated with only a nonsignificant reduction in preterm delivery.

In the second study, Dr. Dwight J. Rouse of the University of Alabama, Birmingham, and his associates assessed weekly 250-mg IM injections of 17P in 661 women pregnant with twins. The study population was drawn from a broad geographic area and was racially and ethnically diverse. Two-thirds of the women had conceived spontaneously.

The subjects were randomly assigned to receive either active injections or placebo beginning at 20 weeks' gestation and were followed at 14 sites across the United States.

The rates of preterm delivery or fetal death did not differ significantly between the group receiving 17P (42%) and those receiving placebo (37%). The mean gestational age at delivery also did not differ significantly, nor did the proportion of deliveries that occurred at 28 weeks, 32 weeks, or 36 weeks.

The rates of obstetric interventions such as tocolysis, cervical cerclage, and cesarean section also were similar between the two groups, as were the rates of adverse neonatal outcomes such as major congenital malformations. The composite outcome of serious adverse events including respiratory distress syndrome, severe intraventricular hemorrhage, periventricular leukomalacia, necrotizing enterocolitis, bronchopulmonary dysplasia, severe retinopathy of prematurity, and sepsis also was similar between the two groups.

Side effects from the injections were frequent in both groups, and three women discontinued injections because of intense local reactions.

The findings, which “are generalizable to most women in the United States who are pregnant with twins,” demonstrate that 17P doesn't lower the rate of preterm birth, prolong gestation, or improve fetal or neonatal outcomes in twin pregnancies, Dr. Rouse and his associates said (N. Engl. J. Med. 2007:357:454-61).

In an editorial comment accompanying these reports, Dr. Jim G. Thornton of the University of Nottingham (England) said that much more information is needed if progesterone is to be used widely to curtail preterm delivery in women found to have a short cervix. In particular, the possible risks associated with daily vaginal administration of medication must be rigorously evaluated in women who are already susceptible to preterm delivery.

“Even if progesterone therapy is effective for some women who are at risk of preterm labor, reliable evidence is needed about long-term effects on the children before it could be widely recommended,” he noted (N. Engl. J. Med. 2007;357:499-501).

“There are at least 14 ongoing trials involving women with high-risk pregnancies (both singleton and twin) that aim to recruit a total of more than 5,000 women, and I am aware of at least 2 more currently awaiting funding decisions. These should have ample power to test the effect of progesterone on important fetal outcomes as well as any differential effect in twin gestations, and long-term follow-up of the surviving children will provide important additional information,” Dr. Thornton added.

SAN FRANCISCO – Don't assume the presence of twin-twin transfusion syndrome if you see discordant sizes and weights in a monochorionic twin pregnancy; consider unequal placental sharing and other potential causes, Dr. Vickie A. Feldstein said.

Sometimes called “selective intrauterine growth restriction,” unequal placental sharing occurs when twins who share one placenta don't divide the placental resources equally so that one twin gets less circulation and nutrition.

“Twins in utero, like twins on the outside, don't necessarily share well,” she said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Monochorionic twins typically get followed closely (at least every 2 weeks) in the last two trimesters because of the risk for twin-twin transfusion syndrome, which affects 15% of monochorionic twins and causes fetal death in up to 70% of cases if untreated.

Every ultrasound report from serial surveillance of monochorionic twins should include an estimate of percent weight discordance, said Dr. Feldstein, professor of clinical radiology and obstetrics, gynecology, and reproductive sciences at the university. To calculate percent weight discordance, take the estimated weight of the larger twin, subtract the estimated weight of the smaller twin, divide the sum by the weight of the larger twin, and multiply by 100.

If the discordance “is more than 15%, we're a little bit attentive,” she said. Discordance of 20% or more is cause for concern.

A 20% discordance may stabilize, with the twins following their own growth charts and ending up healthy but slightly different sizes. “This is one of the reasons I never refer to these as identical twins,” she noted.

If the discordance continues to increase, however, look for the cord insertion sites by ultrasound. With unequal placental sharing, typically the larger twin has a central cord insertion, and the smaller twin has a marginal cord insertion.

“If you do Dopplers of the cords of these twins, in general the twin with the better piece of placenta and central cord has normal umbilical artery Dopplers, and the smaller growth-restricted twin tends to have higher-resistance Dopplers from very early on,” Dr. Feldstein said.

If the smaller twin starts to fall off of its growth chart, early delivery may be in order.

All monochorionic twins have connections between arteries, veins, or an artery in one twin and a vein in the other. An artery in one twin draining into a vein of the other, bringing oxygenated blood to its sibling, is definitive for twin-twin transfusion syndrome. An artery-to-artery connection is protective for twin-twin transfusion syndrome. The difference affects how the patient should be counseled.

A diagnosis of twin-twin transfusion syndrome requires not just discordant sizes/weights but also the presence of polyhydramnios in one fetal sac and oligohydramnios in the other. The variability of twin-twin transfusion syndrome cases in age of onset, severity, acuity, and degree of discordance in size, weight, and amniotic fluid volumes can make it hard to recognize.

Unequal placental sharing and twin-twin transfusion syndrome can occur separately or concurrently. “I think of monochorionic placentas like snowflakes. They're all different, and anatomy is crucial,” she said.

If one twin has oligohydramnios and the other has normal amniotic fluid volume, it may be a case of unequal placental sharing, or there may be a more common problem such as a renal anomaly or rupture of membranes.

“We have a fair number of patients referred in for 'twin-twin transfusion syndrome,' and it turns out that one twin has ruptured membranes and there isn't twin-twin transfusion syndrome at all,” Dr. Mary E. Norton said in a joint presentation with Dr. Feldstein. “It's important to think about the common things that can cause oligohydramnios,” said Dr. Norton, director of perinatal medicine and genetics and professor of obstetrics, gynecology, and reproductive sciences at UCSF.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Don't assume the presence of twin-twin transfusion syndrome if you see discordant sizes and weights in a monochorionic twin pregnancy; consider unequal placental sharing and other potential causes, Dr. Vickie A. Feldstein said.

Sometimes called “selective intrauterine growth restriction,” unequal placental sharing occurs when twins who share one placenta don't divide the placental resources equally so that one twin gets less circulation and nutrition.

“Twins in utero, like twins on the outside, don't necessarily share well,” she said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Monochorionic twins typically get followed closely (at least every 2 weeks) in the last two trimesters because of the risk for twin-twin transfusion syndrome, which affects 15% of monochorionic twins and causes fetal death in up to 70% of cases if untreated.

Every ultrasound report from serial surveillance of monochorionic twins should include an estimate of percent weight discordance, said Dr. Feldstein, professor of clinical radiology and obstetrics, gynecology, and reproductive sciences at the university. To calculate percent weight discordance, take the estimated weight of the larger twin, subtract the estimated weight of the smaller twin, divide the sum by the weight of the larger twin, and multiply by 100.

If the discordance “is more than 15%, we're a little bit attentive,” she said. Discordance of 20% or more is cause for concern.

A 20% discordance may stabilize, with the twins following their own growth charts and ending up healthy but slightly different sizes. “This is one of the reasons I never refer to these as identical twins,” she noted.

If the discordance continues to increase, however, look for the cord insertion sites by ultrasound. With unequal placental sharing, typically the larger twin has a central cord insertion, and the smaller twin has a marginal cord insertion.

“If you do Dopplers of the cords of these twins, in general the twin with the better piece of placenta and central cord has normal umbilical artery Dopplers, and the smaller growth-restricted twin tends to have higher-resistance Dopplers from very early on,” Dr. Feldstein said.

If the smaller twin starts to fall off of its growth chart, early delivery may be in order.

All monochorionic twins have connections between arteries, veins, or an artery in one twin and a vein in the other. An artery in one twin draining into a vein of the other, bringing oxygenated blood to its sibling, is definitive for twin-twin transfusion syndrome. An artery-to-artery connection is protective for twin-twin transfusion syndrome. The difference affects how the patient should be counseled.

A diagnosis of twin-twin transfusion syndrome requires not just discordant sizes/weights but also the presence of polyhydramnios in one fetal sac and oligohydramnios in the other. The variability of twin-twin transfusion syndrome cases in age of onset, severity, acuity, and degree of discordance in size, weight, and amniotic fluid volumes can make it hard to recognize.

Unequal placental sharing and twin-twin transfusion syndrome can occur separately or concurrently. “I think of monochorionic placentas like snowflakes. They're all different, and anatomy is crucial,” she said.

If one twin has oligohydramnios and the other has normal amniotic fluid volume, it may be a case of unequal placental sharing, or there may be a more common problem such as a renal anomaly or rupture of membranes.

“We have a fair number of patients referred in for 'twin-twin transfusion syndrome,' and it turns out that one twin has ruptured membranes and there isn't twin-twin transfusion syndrome at all,” Dr. Mary E. Norton said in a joint presentation with Dr. Feldstein. “It's important to think about the common things that can cause oligohydramnios,” said Dr. Norton, director of perinatal medicine and genetics and professor of obstetrics, gynecology, and reproductive sciences at UCSF.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO – Don't assume the presence of twin-twin transfusion syndrome if you see discordant sizes and weights in a monochorionic twin pregnancy; consider unequal placental sharing and other potential causes, Dr. Vickie A. Feldstein said.

Sometimes called “selective intrauterine growth restriction,” unequal placental sharing occurs when twins who share one placenta don't divide the placental resources equally so that one twin gets less circulation and nutrition.

“Twins in utero, like twins on the outside, don't necessarily share well,” she said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Monochorionic twins typically get followed closely (at least every 2 weeks) in the last two trimesters because of the risk for twin-twin transfusion syndrome, which affects 15% of monochorionic twins and causes fetal death in up to 70% of cases if untreated.

Every ultrasound report from serial surveillance of monochorionic twins should include an estimate of percent weight discordance, said Dr. Feldstein, professor of clinical radiology and obstetrics, gynecology, and reproductive sciences at the university. To calculate percent weight discordance, take the estimated weight of the larger twin, subtract the estimated weight of the smaller twin, divide the sum by the weight of the larger twin, and multiply by 100.

If the discordance “is more than 15%, we're a little bit attentive,” she said. Discordance of 20% or more is cause for concern.

A 20% discordance may stabilize, with the twins following their own growth charts and ending up healthy but slightly different sizes. “This is one of the reasons I never refer to these as identical twins,” she noted.

If the discordance continues to increase, however, look for the cord insertion sites by ultrasound. With unequal placental sharing, typically the larger twin has a central cord insertion, and the smaller twin has a marginal cord insertion.

“If you do Dopplers of the cords of these twins, in general the twin with the better piece of placenta and central cord has normal umbilical artery Dopplers, and the smaller growth-restricted twin tends to have higher-resistance Dopplers from very early on,” Dr. Feldstein said.

If the smaller twin starts to fall off of its growth chart, early delivery may be in order.

All monochorionic twins have connections between arteries, veins, or an artery in one twin and a vein in the other. An artery in one twin draining into a vein of the other, bringing oxygenated blood to its sibling, is definitive for twin-twin transfusion syndrome. An artery-to-artery connection is protective for twin-twin transfusion syndrome. The difference affects how the patient should be counseled.

A diagnosis of twin-twin transfusion syndrome requires not just discordant sizes/weights but also the presence of polyhydramnios in one fetal sac and oligohydramnios in the other. The variability of twin-twin transfusion syndrome cases in age of onset, severity, acuity, and degree of discordance in size, weight, and amniotic fluid volumes can make it hard to recognize.

Unequal placental sharing and twin-twin transfusion syndrome can occur separately or concurrently. “I think of monochorionic placentas like snowflakes. They're all different, and anatomy is crucial,” she said.

If one twin has oligohydramnios and the other has normal amniotic fluid volume, it may be a case of unequal placental sharing, or there may be a more common problem such as a renal anomaly or rupture of membranes.

“We have a fair number of patients referred in for 'twin-twin transfusion syndrome,' and it turns out that one twin has ruptured membranes and there isn't twin-twin transfusion syndrome at all,” Dr. Mary E. Norton said in a joint presentation with Dr. Feldstein. “It's important to think about the common things that can cause oligohydramnios,” said Dr. Norton, director of perinatal medicine and genetics and professor of obstetrics, gynecology, and reproductive sciences at UCSF.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Data clearly show that women who develop gestational diabetes get cardiovascular disease at much earlier ages–often in their early-to-mid-40s–and should be targeted with preventive management, Dr. Darcy B. Carr said at the annual scientific sessions of the American Diabetes Association.

“Women with prior gestational diabetes should be screened earlier for cardiovascular risk factors, and we should take this opportunity to target them with more interventions aimed at reducing their risk,” said Dr. Carr, of the division of maternal-fetal medicine at the University of Washington, Seattle.

This increased early risk is largely–though perhaps not completely–due to the fact that women who develop gestational diabetes are at increased risk of type 2 diabetes, Dr. Carr said.

“I am sure there are women who do not develop diabetes who still have the cardiovascular risk,” she said.

Studies have shown that one-third to one-half of women with gestational diabetes will develop type 2 diabetes within 5 years, and that 70% will develop type 2 diabetes within 10 years.

Studies have also shown that individuals with gestational diabetes have a higher risk of metabolic syndrome, have more markers of vascular endothelial inflammation after their pregnancy, and also have a greater likelihood of hypertension.

The Nurses Health Study, in which more than 117,000 women were followed for 20 years, was able to demonstrate that the risk of cardiovascular disease (CVD) was tied to the development of type 2 diabetes.

But the study also found that CVD seemed to precede the type 2 diabetes, so that the risk of stroke and myocardial infarction was two to nearly four times times higher in the women who had gestational diabetes even before they were diagnosed with type 2 diabetes, Dr. Carr said (Diabetes Care 2002;25:1129-34).

In a more recent study, Dr. Carr and colleagues looked at data from a study of women with at least two first-degree relatives with type 2 diabetes (Diabetes Care 2006;29:2078-83).

They found that of the 332 women in the study who reported having had gestational diabetes, 93% later developed type 2 diabetes.

That compared with 63% of the 662 patients who had given birth but who had not developed gestational diabetes. The women with gestational diabetes were also diagnosed with type 2 diabetes at a much younger age, a mean of 37 years versus a mean of 46 years.

The study revealed that the women with a history of gestational diabetes were not only more likely to develop coronary artery disease, 12% versus 11%, but also more likely to have a stroke, 6% versus 5%.

But the most important finding of the study was how young the women with a history of gestational diabetes were when they had these events, Dr. Carr said.

The mean age at which the women with gestational diabetes developed their coronary artery disease was 45 years, compared with 52 years for those without gestational diabetes, and the mean age of stroke was 50 years, versus 57 years.

“I think this study has significant implications for women with gestational diabetes,” Dr. Carr said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Data clearly show that women who develop gestational diabetes get cardiovascular disease at much earlier ages–often in their early-to-mid-40s–and should be targeted with preventive management, Dr. Darcy B. Carr said at the annual scientific sessions of the American Diabetes Association.

“Women with prior gestational diabetes should be screened earlier for cardiovascular risk factors, and we should take this opportunity to target them with more interventions aimed at reducing their risk,” said Dr. Carr, of the division of maternal-fetal medicine at the University of Washington, Seattle.

This increased early risk is largely–though perhaps not completely–due to the fact that women who develop gestational diabetes are at increased risk of type 2 diabetes, Dr. Carr said.

“I am sure there are women who do not develop diabetes who still have the cardiovascular risk,” she said.

Studies have shown that one-third to one-half of women with gestational diabetes will develop type 2 diabetes within 5 years, and that 70% will develop type 2 diabetes within 10 years.

Studies have also shown that individuals with gestational diabetes have a higher risk of metabolic syndrome, have more markers of vascular endothelial inflammation after their pregnancy, and also have a greater likelihood of hypertension.

The Nurses Health Study, in which more than 117,000 women were followed for 20 years, was able to demonstrate that the risk of cardiovascular disease (CVD) was tied to the development of type 2 diabetes.

But the study also found that CVD seemed to precede the type 2 diabetes, so that the risk of stroke and myocardial infarction was two to nearly four times times higher in the women who had gestational diabetes even before they were diagnosed with type 2 diabetes, Dr. Carr said (Diabetes Care 2002;25:1129-34).

In a more recent study, Dr. Carr and colleagues looked at data from a study of women with at least two first-degree relatives with type 2 diabetes (Diabetes Care 2006;29:2078-83).

They found that of the 332 women in the study who reported having had gestational diabetes, 93% later developed type 2 diabetes.

That compared with 63% of the 662 patients who had given birth but who had not developed gestational diabetes. The women with gestational diabetes were also diagnosed with type 2 diabetes at a much younger age, a mean of 37 years versus a mean of 46 years.

The study revealed that the women with a history of gestational diabetes were not only more likely to develop coronary artery disease, 12% versus 11%, but also more likely to have a stroke, 6% versus 5%.

But the most important finding of the study was how young the women with a history of gestational diabetes were when they had these events, Dr. Carr said.

The mean age at which the women with gestational diabetes developed their coronary artery disease was 45 years, compared with 52 years for those without gestational diabetes, and the mean age of stroke was 50 years, versus 57 years.

“I think this study has significant implications for women with gestational diabetes,” Dr. Carr said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Data clearly show that women who develop gestational diabetes get cardiovascular disease at much earlier ages–often in their early-to-mid-40s–and should be targeted with preventive management, Dr. Darcy B. Carr said at the annual scientific sessions of the American Diabetes Association.

“Women with prior gestational diabetes should be screened earlier for cardiovascular risk factors, and we should take this opportunity to target them with more interventions aimed at reducing their risk,” said Dr. Carr, of the division of maternal-fetal medicine at the University of Washington, Seattle.

This increased early risk is largely–though perhaps not completely–due to the fact that women who develop gestational diabetes are at increased risk of type 2 diabetes, Dr. Carr said.

“I am sure there are women who do not develop diabetes who still have the cardiovascular risk,” she said.

Studies have shown that one-third to one-half of women with gestational diabetes will develop type 2 diabetes within 5 years, and that 70% will develop type 2 diabetes within 10 years.

Studies have also shown that individuals with gestational diabetes have a higher risk of metabolic syndrome, have more markers of vascular endothelial inflammation after their pregnancy, and also have a greater likelihood of hypertension.

The Nurses Health Study, in which more than 117,000 women were followed for 20 years, was able to demonstrate that the risk of cardiovascular disease (CVD) was tied to the development of type 2 diabetes.

But the study also found that CVD seemed to precede the type 2 diabetes, so that the risk of stroke and myocardial infarction was two to nearly four times times higher in the women who had gestational diabetes even before they were diagnosed with type 2 diabetes, Dr. Carr said (Diabetes Care 2002;25:1129-34).

In a more recent study, Dr. Carr and colleagues looked at data from a study of women with at least two first-degree relatives with type 2 diabetes (Diabetes Care 2006;29:2078-83).

They found that of the 332 women in the study who reported having had gestational diabetes, 93% later developed type 2 diabetes.

That compared with 63% of the 662 patients who had given birth but who had not developed gestational diabetes. The women with gestational diabetes were also diagnosed with type 2 diabetes at a much younger age, a mean of 37 years versus a mean of 46 years.

The study revealed that the women with a history of gestational diabetes were not only more likely to develop coronary artery disease, 12% versus 11%, but also more likely to have a stroke, 6% versus 5%.

But the most important finding of the study was how young the women with a history of gestational diabetes were when they had these events, Dr. Carr said.

The mean age at which the women with gestational diabetes developed their coronary artery disease was 45 years, compared with 52 years for those without gestational diabetes, and the mean age of stroke was 50 years, versus 57 years.

“I think this study has significant implications for women with gestational diabetes,” Dr. Carr said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – Pregnant women with diabetes have a two to four times higher risk of having a child with a birth defect, but a thorough review of a national birth defects registry does not show that any one type of defect is associated with diabetes, Dr. Adolfo Correa said at the annual scientific sessions of the American Diabetes Association.

The review looked at data from the National Birth Defects Prevention Study, which had reports on 9,778 cases of live births with birth defects and 4,086 control live births, said Dr. Correa, of the division of birth defects and developmental disabilities at the Centers for Disease Control and Prevention, Atlanta.

The analysis found a significantly increased risk of 25 out of 37 categories of defects looked at, with odds ratios of 5.0 or higher for 17 of those categories. However, no one category stood out.

The highest odds ratio was for sacral agenesis, but out of a total of 25 cases, the registry had only 9 babies born to mothers with diabetes. “Pregestational diabetes is associated with an increased risk for a wide variety of defects; the associations are moderate to strong,” he noted.

However, the study found that gestational diabetes had only weak associations with birth defects, and maternal obesity was not associated with birth defects, except when there was also gestational diabetes, he said.

CHICAGO – Pregnant women with diabetes have a two to four times higher risk of having a child with a birth defect, but a thorough review of a national birth defects registry does not show that any one type of defect is associated with diabetes, Dr. Adolfo Correa said at the annual scientific sessions of the American Diabetes Association.

The review looked at data from the National Birth Defects Prevention Study, which had reports on 9,778 cases of live births with birth defects and 4,086 control live births, said Dr. Correa, of the division of birth defects and developmental disabilities at the Centers for Disease Control and Prevention, Atlanta.

The analysis found a significantly increased risk of 25 out of 37 categories of defects looked at, with odds ratios of 5.0 or higher for 17 of those categories. However, no one category stood out.

The highest odds ratio was for sacral agenesis, but out of a total of 25 cases, the registry had only 9 babies born to mothers with diabetes. “Pregestational diabetes is associated with an increased risk for a wide variety of defects; the associations are moderate to strong,” he noted.

However, the study found that gestational diabetes had only weak associations with birth defects, and maternal obesity was not associated with birth defects, except when there was also gestational diabetes, he said.

CHICAGO – Pregnant women with diabetes have a two to four times higher risk of having a child with a birth defect, but a thorough review of a national birth defects registry does not show that any one type of defect is associated with diabetes, Dr. Adolfo Correa said at the annual scientific sessions of the American Diabetes Association.

The review looked at data from the National Birth Defects Prevention Study, which had reports on 9,778 cases of live births with birth defects and 4,086 control live births, said Dr. Correa, of the division of birth defects and developmental disabilities at the Centers for Disease Control and Prevention, Atlanta.

The analysis found a significantly increased risk of 25 out of 37 categories of defects looked at, with odds ratios of 5.0 or higher for 17 of those categories. However, no one category stood out.

The highest odds ratio was for sacral agenesis, but out of a total of 25 cases, the registry had only 9 babies born to mothers with diabetes. “Pregestational diabetes is associated with an increased risk for a wide variety of defects; the associations are moderate to strong,” he noted.

However, the study found that gestational diabetes had only weak associations with birth defects, and maternal obesity was not associated with birth defects, except when there was also gestational diabetes, he said.

CHICAGO – A diet high in fiber and low in fat reduces the risk of gestational diabetes appreciably, as does exercise, Michelle A. Williams, Sc.D., said at the annual scientific sessions of the American Diabetes Association.

The number of observational studies that have shown that diet and exercise can affect the risk of gestational diabetes has reached a critical mass that should be taken seriously, said Dr. Williams, professor of epidemiology at the University of Washington, Seattle.

There is an “impressive consistency” in the data, she said.

“This is a time for action, and we should be thinking about moving toward translational approaches from this research,” she said. “Pregnancy really is an ideal time for promoting healthful activities.”

A connection between a high-fat diet and gestational diabetes was first documented in an observational study in 1997 (Diabetes Care 1997;20:1647-50). Since then, two subsequent studies have confirmed that connection. One study did not, but it involved women in China, where high-fat diets include polyunsaturated fat, she said.

In a United States prospective cohort study by researchers at the University of North Carolina at Chapel Hill, 1,698 pregnant women were asked about their diet. The investigators found that women who had gestational diabetes had a higher-fat diet than those who did not, with a mean percentage of 35% of their total calories from fat, compared with 33% for pregnant women without gestational diabetes (Am. J. Clin. Nutr. 2004:79:479-86). The researchers estimated that a woman with a fat intake of 40% of total calories had more than twice the risk of gestational diabetes than one whose fat intake was 20% of total calories. This was true even when the number of calories remained exactly the same. At the 40% fat level, more than 10% of women could be expected to have gestational diabetes.

In 2004, Dr. Williams' group reported results of a survey suggesting that low vitamin C intake also resulted in increased risk of gestational diabetes. After interviewing 67 patients with gestational diabetes and 260 controls, they reported that women who took fewer than 70 mg of vitamin C a day–an inadequate intake–had a 3.7 times higher risk of gestational diabetes than those who took more (J. Reprod. Med. 2004;49:257-66).

The group followed up that study by actually measuring plasma ascorbic acid in 755 women at an average 13 weeks' gestation. That study showed that the women in the lowest quartile of plasma ascorbic acid had a rate of gestational diabetes of 9%, compared with a rate of 3% in women in the highest quartile (Epidemiology 2004;15:597-604).

Regarding fiber in the diet, a group that looked at Nurses' Health Study data found that when the women had an intake of 22 gm or more of fiber per day prior to their pregnancy, their risk of gestational diabetes was reduced by 33% (Diabetes Care 2006;29:2223-30).

Dr. Williams said she found much the same reduction in risk in her own cohort of 288 cases of gestational diabetes and 444 controls. The data, which have not yet been published, shows that women in the highest quintile for fiber intake had a 40% reduction in risk of gestational diabetes, relative to women in the lowest quintile, and that the risk reduction followed a very linear trend down from the highest quintile. Less than half of the women, cases and controls alike, met the recommendation that the daily diet should include five fruits and vegetables.

“Suffice it to say, if they were consuming five a day, their risk for gestational diabetes would [have been] reduced quite substantially,” she said.

Six observational studies have shown a benefit from exercise before and during pregnancy, Dr. Williams said. One found a risk reduction of 47% when women who were obese exercised during pregnancy (Am. J. Epidemiol. 1997;146:961-65).

Analysis of her own data on 155 cases and 386 controls showed a 55% reduction in risk of gestational diabetes in those women who reported that they engaged in regular leisure time physical activity prior to their pregnancy. Leisure time physical activity during pregnancy resulted in a 48% reduction in risk, she added.

Dr. Williams' data also address the question of whether activity must be vigorous to produce a benefit, or whether it can be moderate, she said. Her analysis found that risk was reduced by 71% when that activity was vigorous, but risk was reduced by only 35% with moderate activity, such as walking.

In observational studies, it is probably impossible to control the analysis completely for variables that may confound the investigators' conclusions, hard as the researchers may try, Dr. Williams noted.

CHICAGO – A diet high in fiber and low in fat reduces the risk of gestational diabetes appreciably, as does exercise, Michelle A. Williams, Sc.D., said at the annual scientific sessions of the American Diabetes Association.

The number of observational studies that have shown that diet and exercise can affect the risk of gestational diabetes has reached a critical mass that should be taken seriously, said Dr. Williams, professor of epidemiology at the University of Washington, Seattle.

There is an “impressive consistency” in the data, she said.

“This is a time for action, and we should be thinking about moving toward translational approaches from this research,” she said. “Pregnancy really is an ideal time for promoting healthful activities.”

A connection between a high-fat diet and gestational diabetes was first documented in an observational study in 1997 (Diabetes Care 1997;20:1647-50). Since then, two subsequent studies have confirmed that connection. One study did not, but it involved women in China, where high-fat diets include polyunsaturated fat, she said.

In a United States prospective cohort study by researchers at the University of North Carolina at Chapel Hill, 1,698 pregnant women were asked about their diet. The investigators found that women who had gestational diabetes had a higher-fat diet than those who did not, with a mean percentage of 35% of their total calories from fat, compared with 33% for pregnant women without gestational diabetes (Am. J. Clin. Nutr. 2004:79:479-86). The researchers estimated that a woman with a fat intake of 40% of total calories had more than twice the risk of gestational diabetes than one whose fat intake was 20% of total calories. This was true even when the number of calories remained exactly the same. At the 40% fat level, more than 10% of women could be expected to have gestational diabetes.

In 2004, Dr. Williams' group reported results of a survey suggesting that low vitamin C intake also resulted in increased risk of gestational diabetes. After interviewing 67 patients with gestational diabetes and 260 controls, they reported that women who took fewer than 70 mg of vitamin C a day–an inadequate intake–had a 3.7 times higher risk of gestational diabetes than those who took more (J. Reprod. Med. 2004;49:257-66).

The group followed up that study by actually measuring plasma ascorbic acid in 755 women at an average 13 weeks' gestation. That study showed that the women in the lowest quartile of plasma ascorbic acid had a rate of gestational diabetes of 9%, compared with a rate of 3% in women in the highest quartile (Epidemiology 2004;15:597-604).

Regarding fiber in the diet, a group that looked at Nurses' Health Study data found that when the women had an intake of 22 gm or more of fiber per day prior to their pregnancy, their risk of gestational diabetes was reduced by 33% (Diabetes Care 2006;29:2223-30).

Dr. Williams said she found much the same reduction in risk in her own cohort of 288 cases of gestational diabetes and 444 controls. The data, which have not yet been published, shows that women in the highest quintile for fiber intake had a 40% reduction in risk of gestational diabetes, relative to women in the lowest quintile, and that the risk reduction followed a very linear trend down from the highest quintile. Less than half of the women, cases and controls alike, met the recommendation that the daily diet should include five fruits and vegetables.

“Suffice it to say, if they were consuming five a day, their risk for gestational diabetes would [have been] reduced quite substantially,” she said.

Six observational studies have shown a benefit from exercise before and during pregnancy, Dr. Williams said. One found a risk reduction of 47% when women who were obese exercised during pregnancy (Am. J. Epidemiol. 1997;146:961-65).

Analysis of her own data on 155 cases and 386 controls showed a 55% reduction in risk of gestational diabetes in those women who reported that they engaged in regular leisure time physical activity prior to their pregnancy. Leisure time physical activity during pregnancy resulted in a 48% reduction in risk, she added.

Dr. Williams' data also address the question of whether activity must be vigorous to produce a benefit, or whether it can be moderate, she said. Her analysis found that risk was reduced by 71% when that activity was vigorous, but risk was reduced by only 35% with moderate activity, such as walking.

In observational studies, it is probably impossible to control the analysis completely for variables that may confound the investigators' conclusions, hard as the researchers may try, Dr. Williams noted.

CHICAGO – A diet high in fiber and low in fat reduces the risk of gestational diabetes appreciably, as does exercise, Michelle A. Williams, Sc.D., said at the annual scientific sessions of the American Diabetes Association.

The number of observational studies that have shown that diet and exercise can affect the risk of gestational diabetes has reached a critical mass that should be taken seriously, said Dr. Williams, professor of epidemiology at the University of Washington, Seattle.

There is an “impressive consistency” in the data, she said.

“This is a time for action, and we should be thinking about moving toward translational approaches from this research,” she said. “Pregnancy really is an ideal time for promoting healthful activities.”

A connection between a high-fat diet and gestational diabetes was first documented in an observational study in 1997 (Diabetes Care 1997;20:1647-50). Since then, two subsequent studies have confirmed that connection. One study did not, but it involved women in China, where high-fat diets include polyunsaturated fat, she said.

In a United States prospective cohort study by researchers at the University of North Carolina at Chapel Hill, 1,698 pregnant women were asked about their diet. The investigators found that women who had gestational diabetes had a higher-fat diet than those who did not, with a mean percentage of 35% of their total calories from fat, compared with 33% for pregnant women without gestational diabetes (Am. J. Clin. Nutr. 2004:79:479-86). The researchers estimated that a woman with a fat intake of 40% of total calories had more than twice the risk of gestational diabetes than one whose fat intake was 20% of total calories. This was true even when the number of calories remained exactly the same. At the 40% fat level, more than 10% of women could be expected to have gestational diabetes.

In 2004, Dr. Williams' group reported results of a survey suggesting that low vitamin C intake also resulted in increased risk of gestational diabetes. After interviewing 67 patients with gestational diabetes and 260 controls, they reported that women who took fewer than 70 mg of vitamin C a day–an inadequate intake–had a 3.7 times higher risk of gestational diabetes than those who took more (J. Reprod. Med. 2004;49:257-66).

The group followed up that study by actually measuring plasma ascorbic acid in 755 women at an average 13 weeks' gestation. That study showed that the women in the lowest quartile of plasma ascorbic acid had a rate of gestational diabetes of 9%, compared with a rate of 3% in women in the highest quartile (Epidemiology 2004;15:597-604).

Regarding fiber in the diet, a group that looked at Nurses' Health Study data found that when the women had an intake of 22 gm or more of fiber per day prior to their pregnancy, their risk of gestational diabetes was reduced by 33% (Diabetes Care 2006;29:2223-30).

Dr. Williams said she found much the same reduction in risk in her own cohort of 288 cases of gestational diabetes and 444 controls. The data, which have not yet been published, shows that women in the highest quintile for fiber intake had a 40% reduction in risk of gestational diabetes, relative to women in the lowest quintile, and that the risk reduction followed a very linear trend down from the highest quintile. Less than half of the women, cases and controls alike, met the recommendation that the daily diet should include five fruits and vegetables.

“Suffice it to say, if they were consuming five a day, their risk for gestational diabetes would [have been] reduced quite substantially,” she said.

Six observational studies have shown a benefit from exercise before and during pregnancy, Dr. Williams said. One found a risk reduction of 47% when women who were obese exercised during pregnancy (Am. J. Epidemiol. 1997;146:961-65).

Analysis of her own data on 155 cases and 386 controls showed a 55% reduction in risk of gestational diabetes in those women who reported that they engaged in regular leisure time physical activity prior to their pregnancy. Leisure time physical activity during pregnancy resulted in a 48% reduction in risk, she added.

Dr. Williams' data also address the question of whether activity must be vigorous to produce a benefit, or whether it can be moderate, she said. Her analysis found that risk was reduced by 71% when that activity was vigorous, but risk was reduced by only 35% with moderate activity, such as walking.

In observational studies, it is probably impossible to control the analysis completely for variables that may confound the investigators' conclusions, hard as the researchers may try, Dr. Williams noted.

SAN FRANCISCO – With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours. “She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud's phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of all cases.

SAN FRANCISCO – With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours. “She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud's phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of all cases.

SAN FRANCISCO – With only a handful of case reports in the medical literature, Raynaud's phenomenon of the nipples isn't the first thing that physicians think of when a breast-feeding mother complains of nipple pain.

If there are no signs of infection and no cracks or fissures on the nipples, consider this rare cause of nipple pain, especially if the woman has a history of Raynaud's syndrome, Sharon R. Wiener said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The pain from this vasospasm of the nipples while breast-feeding usually is bilateral, severe, and a spasm-like throb. The nipple usually turns very white but may be blue, purple, or red, said Ms. Wiener, a certified nurse-midwife at the university.

This problem has been misdiagnosed as a candidal infection. Among 12 women in a 2004 case report who ultimately were diagnosed with Raynaud's phenomenon of the nipples, 8 had been treated for candidiasis of the breast. Following them for 4 months and diligently taking detailed histories led to the correct diagnosis and treatment, she said.

A recent patient seen by Ms. Wiener said she had been diagnosed with Raynaud's syndrome about 5 years before her pregnancy. She complained of episodes in which her nipples would become cold and then go into spasms for many hours. “She was very concerned, appropriately, that she was going to have difficulty breast-feeding,” Ms. Wiener said.

Sending patients in whom you suspect this problem to a lactation consultant to identify poor latch can support the diagnosis. Alternatively, try applying a cold compress or ice to the nipple to see if it triggers the phenomenon.

It's important to prepare the woman for the effect this may have. “I've done this twice. In one case, I got a dramatic response,” she said. “I know this sounds horrible,” but it's preferable to prescribing treatment without a firm diagnosis.

The treatment of choice is the calcium channel blocker nifedipine, 5 mg b.i.d. for 2 weeks. “It's very quick acting” and a vasodilator, she said. “The handful that I have treated have responded very well and didn't need a repeat of the prescription. Why that is, I can't tell you.”

Raynaud's phenomenon of the nipples has been associated with factors that restrict the blood vessels, including rheumatologic diseases, endocrine diseases, autoimmune diseases, cigarettes, and caffeine.

Advise the patient to avoid exposure to cold, vasoconstricting medications, nicotine, and caffeine. In mild cases, warm compresses or warm showers may suffice as treatment. Topical nitroglycerine appears to be effective treatment in half of all cases.

SAN DIEGO – Results from a large randomized trial indicate that greater degrees of breast-feeding exclusivity do not lead to lower levels of allergic sensitization, Dr. Bruce D. Mazer reported in a poster presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In fact, the study provides some indication that breast-feeding may actually increase sensitization to several common allergens, according to Dr. Mazer of McGill University, Montreal, and his coinvestigators. “There are a lot of good reasons to breast-feed, but prevention of allergic sensitization is not one of them,” Dr. Mazer said in an interview.

The study involved a secondary analysis of the Promotion of Breast-Feeding Intervention Trial (PROBIT) in which 17,046 healthy newborns and their mothers seen at 31 maternity hospitals in the Republic of Belarus were randomized (hospital by hospital) to receive either standard instruction on infant nutrition or enrollment in a program modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children's Fund, which emphasizes health-care worker assistance with initiating and maintaining lactation and breast-feeding.

Among the original findings of that study were that infants of women randomized to the program were far more likely to receive their nutrition exclusively by breast-feeding at follow-up at 3 months and 6 months of age than were infants of women receiving standard instruction.

When these children reached the age of 6.5 years, 13,889 mother-child pairs were identified and approached for further study, which included skin-prick testing and an assessment of allergic symptoms and diagnoses based on the International Study of Asthma and Allergy in Childhood (ISAAC) questionnaire. More than 99% of the mother-child pairs completed the questionnaire, and 11,145 of the children (80%) underwent skin-prick testing.

There were no significant differences between children who had been assigned to the program and those in the control group in their answers to any of the ISAAC questions. In addition, after adjustment for which maternity hospital they had been seen in, there were no significant differences in the percentages of children who tested positive to any of five common allergens.

The investigators noted that six of the maternity hospitals had unusually high rates of positive skin-prick tests. When data from those suspect sites were eliminated from the analysis, the investigators found that children in the program were significantly more likely to have positive skin-prick tests to dust mites, cats, birch pollen, and Alternaria, but not to mixed northern grasses.

“Our results underline the importance of seeking other explanations for the recent epidemic of allergy and asthma, and of investigating other potential etiologic factors to develop and test new preventive interventions,” the investigators concluded.

SAN DIEGO – Results from a large randomized trial indicate that greater degrees of breast-feeding exclusivity do not lead to lower levels of allergic sensitization, Dr. Bruce D. Mazer reported in a poster presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In fact, the study provides some indication that breast-feeding may actually increase sensitization to several common allergens, according to Dr. Mazer of McGill University, Montreal, and his coinvestigators. “There are a lot of good reasons to breast-feed, but prevention of allergic sensitization is not one of them,” Dr. Mazer said in an interview.

The study involved a secondary analysis of the Promotion of Breast-Feeding Intervention Trial (PROBIT) in which 17,046 healthy newborns and their mothers seen at 31 maternity hospitals in the Republic of Belarus were randomized (hospital by hospital) to receive either standard instruction on infant nutrition or enrollment in a program modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children's Fund, which emphasizes health-care worker assistance with initiating and maintaining lactation and breast-feeding.

Among the original findings of that study were that infants of women randomized to the program were far more likely to receive their nutrition exclusively by breast-feeding at follow-up at 3 months and 6 months of age than were infants of women receiving standard instruction.

When these children reached the age of 6.5 years, 13,889 mother-child pairs were identified and approached for further study, which included skin-prick testing and an assessment of allergic symptoms and diagnoses based on the International Study of Asthma and Allergy in Childhood (ISAAC) questionnaire. More than 99% of the mother-child pairs completed the questionnaire, and 11,145 of the children (80%) underwent skin-prick testing.

There were no significant differences between children who had been assigned to the program and those in the control group in their answers to any of the ISAAC questions. In addition, after adjustment for which maternity hospital they had been seen in, there were no significant differences in the percentages of children who tested positive to any of five common allergens.

The investigators noted that six of the maternity hospitals had unusually high rates of positive skin-prick tests. When data from those suspect sites were eliminated from the analysis, the investigators found that children in the program were significantly more likely to have positive skin-prick tests to dust mites, cats, birch pollen, and Alternaria, but not to mixed northern grasses.

“Our results underline the importance of seeking other explanations for the recent epidemic of allergy and asthma, and of investigating other potential etiologic factors to develop and test new preventive interventions,” the investigators concluded.

SAN DIEGO – Results from a large randomized trial indicate that greater degrees of breast-feeding exclusivity do not lead to lower levels of allergic sensitization, Dr. Bruce D. Mazer reported in a poster presentation at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

In fact, the study provides some indication that breast-feeding may actually increase sensitization to several common allergens, according to Dr. Mazer of McGill University, Montreal, and his coinvestigators. “There are a lot of good reasons to breast-feed, but prevention of allergic sensitization is not one of them,” Dr. Mazer said in an interview.

The study involved a secondary analysis of the Promotion of Breast-Feeding Intervention Trial (PROBIT) in which 17,046 healthy newborns and their mothers seen at 31 maternity hospitals in the Republic of Belarus were randomized (hospital by hospital) to receive either standard instruction on infant nutrition or enrollment in a program modeled on the Baby-Friendly Hospital Initiative of the World Health Organization and United Nations Children's Fund, which emphasizes health-care worker assistance with initiating and maintaining lactation and breast-feeding.

Among the original findings of that study were that infants of women randomized to the program were far more likely to receive their nutrition exclusively by breast-feeding at follow-up at 3 months and 6 months of age than were infants of women receiving standard instruction.

When these children reached the age of 6.5 years, 13,889 mother-child pairs were identified and approached for further study, which included skin-prick testing and an assessment of allergic symptoms and diagnoses based on the International Study of Asthma and Allergy in Childhood (ISAAC) questionnaire. More than 99% of the mother-child pairs completed the questionnaire, and 11,145 of the children (80%) underwent skin-prick testing.

There were no significant differences between children who had been assigned to the program and those in the control group in their answers to any of the ISAAC questions. In addition, after adjustment for which maternity hospital they had been seen in, there were no significant differences in the percentages of children who tested positive to any of five common allergens.

The investigators noted that six of the maternity hospitals had unusually high rates of positive skin-prick tests. When data from those suspect sites were eliminated from the analysis, the investigators found that children in the program were significantly more likely to have positive skin-prick tests to dust mites, cats, birch pollen, and Alternaria, but not to mixed northern grasses.

“Our results underline the importance of seeking other explanations for the recent epidemic of allergy and asthma, and of investigating other potential etiologic factors to develop and test new preventive interventions,” the investigators concluded.

SAN DIEGO – Almost a quarter of 505 women with hyperemesis gravidarum reported voluntarily terminating at least one pregnancy solely because of the severity of the condition, an international survey found.

More than 12% of women said they had terminated more than one pregnancy secondary to hyperemesis gravidarum (HG), and 30% said they feared future pregnancies because of the extreme nausea and vomiting they suffered previously in pregnancy.

Rates of termination among the 344 American women (27%) were roughly equal to rates of the group as a whole, which had about a 25% termination rate. “It was quite startling,” Dr. Borzouyeh Poursharif said of the finding concerning pregnancy termination.

Dr. Poursharif, a research fellow at the University of Southern California, Los Angeles, along with coinvestigators from USC and the National Institute of Child Health and Human Development's perinatology research branch in Detroit, analyzed registry data and results of an online survey conducted by the Hyperemesis Education and Research Foundation. They reported their results in a series of three posters at the annual meeting of the American College of Obstetricians and Gynecologists.

Among women who had terminated at least one pregnancy because of the condition, 60% perceived a “negative health provider attitude,” vs. 28% of those who did not voluntarily terminate a pregnancy, suggesting that physicians may benefit from more education about the severity of the condition and potentially effective treatments and psychosocial support measures, said Dr. Poursharif.

Compared with those who did not terminate pregnancies, women who terminated were less likely to report family or career dysfunction, decreased physical activity, or eating problems, reflecting “the burden of HG on women's lives,” the authors concluded.

Among 819 women from 31 countries who registered with the foundation, nearly half reported losing 10%-20% of their prepregnancy weight; only 16% reported losing 5% or less of their prepregnancy weight.

Generally, HG is defined as severe nausea, vomiting and associated symptoms, and a loss of greater than 5% of body weight.

More than a quarter of the women had lost at least 15% of their prepregnancy weight, a cutoff associated with severe complications both during and after pregnancy, Dr. Poursharif said in an interview at the meeting.

One in five women in the registry reported that their symptoms continued until term or beyond.

The 214 women with the greatest weight loss (more than 15%) faced a fivefold elevated risk of renal failure and retinal hemorrhage and fourfold elevated risk of liver dysfunction. Other complications significantly elevated in this group included the diagnosis of gall bladder disease in pregnancy, hematemesis, and neurologic changes.

They were more likely to have received inpatient treatment, intravenous fluids, total parenteral nutrition, and prescriptions for the medication ondansetron (Zofran). This group also experienced significantly more complications, which lasted more than 1 month beyond pregnancy, including nausea, digestive problems, gallbladder disease, insomnia, muscle pain, and food aversions.

Dr. Poursharif emphasized that neither the database nor the online survey results are considered to be representative of all women with HG. “We think that these were people who were so sick, they were desperate enough to search online, [where they] found this site and answered the surveys,” he said.

However, he noted that the findings do portray a surprisingly severe portrait of women suffering extreme cases of HG and highlight the need for more research into the true prevalence of the condition in its more extreme forms.

The database revealed that more than 20 treatment options were used by 765 women in 1,193 pregnancies.

Intravenous hydration, antihistamines, bed rest, and alternative therapies (acupuncture, herbal medicines, homeopathy, antinausea wristbands, and chiropractic) were used most frequently over a 20-year period, with the use of ondansetron dramatically increasing since 1990.

SAN DIEGO – Almost a quarter of 505 women with hyperemesis gravidarum reported voluntarily terminating at least one pregnancy solely because of the severity of the condition, an international survey found.

More than 12% of women said they had terminated more than one pregnancy secondary to hyperemesis gravidarum (HG), and 30% said they feared future pregnancies because of the extreme nausea and vomiting they suffered previously in pregnancy.

Rates of termination among the 344 American women (27%) were roughly equal to rates of the group as a whole, which had about a 25% termination rate. “It was quite startling,” Dr. Borzouyeh Poursharif said of the finding concerning pregnancy termination.

Dr. Poursharif, a research fellow at the University of Southern California, Los Angeles, along with coinvestigators from USC and the National Institute of Child Health and Human Development's perinatology research branch in Detroit, analyzed registry data and results of an online survey conducted by the Hyperemesis Education and Research Foundation. They reported their results in a series of three posters at the annual meeting of the American College of Obstetricians and Gynecologists.

Among women who had terminated at least one pregnancy because of the condition, 60% perceived a “negative health provider attitude,” vs. 28% of those who did not voluntarily terminate a pregnancy, suggesting that physicians may benefit from more education about the severity of the condition and potentially effective treatments and psychosocial support measures, said Dr. Poursharif.

Compared with those who did not terminate pregnancies, women who terminated were less likely to report family or career dysfunction, decreased physical activity, or eating problems, reflecting “the burden of HG on women's lives,” the authors concluded.

Among 819 women from 31 countries who registered with the foundation, nearly half reported losing 10%-20% of their prepregnancy weight; only 16% reported losing 5% or less of their prepregnancy weight.

Generally, HG is defined as severe nausea, vomiting and associated symptoms, and a loss of greater than 5% of body weight.

More than a quarter of the women had lost at least 15% of their prepregnancy weight, a cutoff associated with severe complications both during and after pregnancy, Dr. Poursharif said in an interview at the meeting.

One in five women in the registry reported that their symptoms continued until term or beyond.

The 214 women with the greatest weight loss (more than 15%) faced a fivefold elevated risk of renal failure and retinal hemorrhage and fourfold elevated risk of liver dysfunction. Other complications significantly elevated in this group included the diagnosis of gall bladder disease in pregnancy, hematemesis, and neurologic changes.

They were more likely to have received inpatient treatment, intravenous fluids, total parenteral nutrition, and prescriptions for the medication ondansetron (Zofran). This group also experienced significantly more complications, which lasted more than 1 month beyond pregnancy, including nausea, digestive problems, gallbladder disease, insomnia, muscle pain, and food aversions.

Dr. Poursharif emphasized that neither the database nor the online survey results are considered to be representative of all women with HG. “We think that these were people who were so sick, they were desperate enough to search online, [where they] found this site and answered the surveys,” he said.

However, he noted that the findings do portray a surprisingly severe portrait of women suffering extreme cases of HG and highlight the need for more research into the true prevalence of the condition in its more extreme forms.

The database revealed that more than 20 treatment options were used by 765 women in 1,193 pregnancies.

Intravenous hydration, antihistamines, bed rest, and alternative therapies (acupuncture, herbal medicines, homeopathy, antinausea wristbands, and chiropractic) were used most frequently over a 20-year period, with the use of ondansetron dramatically increasing since 1990.

SAN DIEGO – Almost a quarter of 505 women with hyperemesis gravidarum reported voluntarily terminating at least one pregnancy solely because of the severity of the condition, an international survey found.

More than 12% of women said they had terminated more than one pregnancy secondary to hyperemesis gravidarum (HG), and 30% said they feared future pregnancies because of the extreme nausea and vomiting they suffered previously in pregnancy.

Rates of termination among the 344 American women (27%) were roughly equal to rates of the group as a whole, which had about a 25% termination rate. “It was quite startling,” Dr. Borzouyeh Poursharif said of the finding concerning pregnancy termination.

Dr. Poursharif, a research fellow at the University of Southern California, Los Angeles, along with coinvestigators from USC and the National Institute of Child Health and Human Development's perinatology research branch in Detroit, analyzed registry data and results of an online survey conducted by the Hyperemesis Education and Research Foundation. They reported their results in a series of three posters at the annual meeting of the American College of Obstetricians and Gynecologists.

Among women who had terminated at least one pregnancy because of the condition, 60% perceived a “negative health provider attitude,” vs. 28% of those who did not voluntarily terminate a pregnancy, suggesting that physicians may benefit from more education about the severity of the condition and potentially effective treatments and psychosocial support measures, said Dr. Poursharif.

Compared with those who did not terminate pregnancies, women who terminated were less likely to report family or career dysfunction, decreased physical activity, or eating problems, reflecting “the burden of HG on women's lives,” the authors concluded.

Among 819 women from 31 countries who registered with the foundation, nearly half reported losing 10%-20% of their prepregnancy weight; only 16% reported losing 5% or less of their prepregnancy weight.

Generally, HG is defined as severe nausea, vomiting and associated symptoms, and a loss of greater than 5% of body weight.

More than a quarter of the women had lost at least 15% of their prepregnancy weight, a cutoff associated with severe complications both during and after pregnancy, Dr. Poursharif said in an interview at the meeting.

One in five women in the registry reported that their symptoms continued until term or beyond.

The 214 women with the greatest weight loss (more than 15%) faced a fivefold elevated risk of renal failure and retinal hemorrhage and fourfold elevated risk of liver dysfunction. Other complications significantly elevated in this group included the diagnosis of gall bladder disease in pregnancy, hematemesis, and neurologic changes.

They were more likely to have received inpatient treatment, intravenous fluids, total parenteral nutrition, and prescriptions for the medication ondansetron (Zofran). This group also experienced significantly more complications, which lasted more than 1 month beyond pregnancy, including nausea, digestive problems, gallbladder disease, insomnia, muscle pain, and food aversions.

Dr. Poursharif emphasized that neither the database nor the online survey results are considered to be representative of all women with HG. “We think that these were people who were so sick, they were desperate enough to search online, [where they] found this site and answered the surveys,” he said.

However, he noted that the findings do portray a surprisingly severe portrait of women suffering extreme cases of HG and highlight the need for more research into the true prevalence of the condition in its more extreme forms.

The database revealed that more than 20 treatment options were used by 765 women in 1,193 pregnancies.

Intravenous hydration, antihistamines, bed rest, and alternative therapies (acupuncture, herbal medicines, homeopathy, antinausea wristbands, and chiropractic) were used most frequently over a 20-year period, with the use of ondansetron dramatically increasing since 1990.

CHICAGO – A review of births at a large health maintenance organization suggests the incidence of gestational diabetes is declining, but it is being offset by an increase in preexisting diabetes.

“There is some good news that gestational diabetes mellitus [GDM] appears to have declined about 15% within our study period,” Jean M. Lawrence, Sc.D., said at the annual scientific sessions of the American Diabetes Association. “But the bad news is that we saw a doubling of preexisting diabetes in the study.”

“We don't know whether this is an increase in the prevalence of diabetes or an increasing in screening and diagnosis of previously undiagnosed diabetes,” said Dr. Lawrence, an epidemiologist in the department of research and evaluation at Kaiser Permanente Southern California, Pasadena. “Overall, though, we saw little change in the proportion of pregnancies with the mother and fetus exposed to diabetes during the pregnancy.”

In her study, Dr. Lawrence and colleagues looked at all of the births at 11 Kaiser Permanente hospitals in Southern California from 1999 to 2005, with a total of 209,532 deliveries of infants who were at 20 weeks' gestation or later.

Overall, 8% of the births were to mothers with diabetes, either gestational or preexisting, in each of the years reviewed, with a peak of almost 9% in 2000, and a slight decline totaling less than 1% since then.

The annual prevalence of GDM also peaked in 2000, at the rate of 7.01 cases per 100 women delivered. After that it declined steadily, to a rate of 6.32 cases per 100 women delivered in 2005.

At the same time, the annual prevalence of preexisting diabetes increased steadily from a rate of 1.08 cases per 100 in 1999 to a rate of 2.80 per 100 in 2005.

After adjusting for maternal age and race/ethnicity, the investigators found that GDM declined during the study period at an average annual rate of 4%, whereas preexisting diabetes increased by an average of 15% annually, Dr. Lawrence said.

Both types of diabetes were more common in women of other races than they were in non-Hispanic white women.

Asian women had the highest annual prevalence of GDM, with about double the prevalence of white women.

Black women had the highest annual prevalence of preexisting diabetes, with a 43% higher prevalence than white women.

“We saw changes in all the groups,” Dr. Lawrence said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – A review of births at a large health maintenance organization suggests the incidence of gestational diabetes is declining, but it is being offset by an increase in preexisting diabetes.

“There is some good news that gestational diabetes mellitus [GDM] appears to have declined about 15% within our study period,” Jean M. Lawrence, Sc.D., said at the annual scientific sessions of the American Diabetes Association. “But the bad news is that we saw a doubling of preexisting diabetes in the study.”

“We don't know whether this is an increase in the prevalence of diabetes or an increasing in screening and diagnosis of previously undiagnosed diabetes,” said Dr. Lawrence, an epidemiologist in the department of research and evaluation at Kaiser Permanente Southern California, Pasadena. “Overall, though, we saw little change in the proportion of pregnancies with the mother and fetus exposed to diabetes during the pregnancy.”

In her study, Dr. Lawrence and colleagues looked at all of the births at 11 Kaiser Permanente hospitals in Southern California from 1999 to 2005, with a total of 209,532 deliveries of infants who were at 20 weeks' gestation or later.

Overall, 8% of the births were to mothers with diabetes, either gestational or preexisting, in each of the years reviewed, with a peak of almost 9% in 2000, and a slight decline totaling less than 1% since then.

The annual prevalence of GDM also peaked in 2000, at the rate of 7.01 cases per 100 women delivered. After that it declined steadily, to a rate of 6.32 cases per 100 women delivered in 2005.

At the same time, the annual prevalence of preexisting diabetes increased steadily from a rate of 1.08 cases per 100 in 1999 to a rate of 2.80 per 100 in 2005.

After adjusting for maternal age and race/ethnicity, the investigators found that GDM declined during the study period at an average annual rate of 4%, whereas preexisting diabetes increased by an average of 15% annually, Dr. Lawrence said.

Both types of diabetes were more common in women of other races than they were in non-Hispanic white women.

Asian women had the highest annual prevalence of GDM, with about double the prevalence of white women.

Black women had the highest annual prevalence of preexisting diabetes, with a 43% higher prevalence than white women.

“We saw changes in all the groups,” Dr. Lawrence said.

ELSEVIER GLOBAL MEDICAL NEWS

CHICAGO – A review of births at a large health maintenance organization suggests the incidence of gestational diabetes is declining, but it is being offset by an increase in preexisting diabetes.

“There is some good news that gestational diabetes mellitus [GDM] appears to have declined about 15% within our study period,” Jean M. Lawrence, Sc.D., said at the annual scientific sessions of the American Diabetes Association. “But the bad news is that we saw a doubling of preexisting diabetes in the study.”

“We don't know whether this is an increase in the prevalence of diabetes or an increasing in screening and diagnosis of previously undiagnosed diabetes,” said Dr. Lawrence, an epidemiologist in the department of research and evaluation at Kaiser Permanente Southern California, Pasadena. “Overall, though, we saw little change in the proportion of pregnancies with the mother and fetus exposed to diabetes during the pregnancy.”

In her study, Dr. Lawrence and colleagues looked at all of the births at 11 Kaiser Permanente hospitals in Southern California from 1999 to 2005, with a total of 209,532 deliveries of infants who were at 20 weeks' gestation or later.

Overall, 8% of the births were to mothers with diabetes, either gestational or preexisting, in each of the years reviewed, with a peak of almost 9% in 2000, and a slight decline totaling less than 1% since then.

The annual prevalence of GDM also peaked in 2000, at the rate of 7.01 cases per 100 women delivered. After that it declined steadily, to a rate of 6.32 cases per 100 women delivered in 2005.

At the same time, the annual prevalence of preexisting diabetes increased steadily from a rate of 1.08 cases per 100 in 1999 to a rate of 2.80 per 100 in 2005.

After adjusting for maternal age and race/ethnicity, the investigators found that GDM declined during the study period at an average annual rate of 4%, whereas preexisting diabetes increased by an average of 15% annually, Dr. Lawrence said.

Both types of diabetes were more common in women of other races than they were in non-Hispanic white women.

Asian women had the highest annual prevalence of GDM, with about double the prevalence of white women.

Black women had the highest annual prevalence of preexisting diabetes, with a 43% higher prevalence than white women.

“We saw changes in all the groups,” Dr. Lawrence said.

ELSEVIER GLOBAL MEDICAL NEWS

OTTAWA – A gestational age of less than 36 weeks, a relatively high serum level of uric acid, and a history of preeclampsia were all linked to progression of gestational hypertension to preeclampsia in a retrospective study of 280 women at one center.

The findings suggest that “clinical monitoring of these routinely available risk factors in pregnancies complicated by gestational hypertension could provide an easy, inexpensive, and helpful tool for identifying women with gestational hypertension who are at high risk of developing preeclampsia,” Yuquan Wu and his associates reported in a poster at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Gestational hypertension is usually the first clinical feature of preeclampsia, appearing before proteinuria. But it currently remains a challenge for physicians to predict if a woman who develops hypertension after 20 weeks' gestation will progress to preeclampsia, said Mr. Wu, a researcher in the department of ob.gyn. at the University of Montreal, and his associates in their poster.

They reviewed the medical records of all women who received obstetric care and gave birth at Ste-Justine Hospital in Montreal during March 2001-June 2003. They focused on women with a singleton pregnancy diagnosed with gestational hypertension without proteinuria at their initial hospital presentation.

Gestational hypertension was defined as a blood pressure at or above 140/90 mm Hg after 20 weeks' gestation.

Preeclampsia was diagnosed in women with gestational hypertension who also had proteinuria of at least 300 mg in a 24-hour urine collection, or a 1+ on dipstick urinalysis in two samples taken 6 hours apart. The review identified 91 women who reached term with gestational hypertension, and 189 women with preeclampsia. The average age of these women was 30 years.

In a multivariate analysis, each standard-deviation increase in the serum level of uric acid (56.1 micromol/L) boosted the risk of preeclampsia by 78%, and a history of preeclampsia boosted the risk of developing this complication in the current pregnancy by 3.4-fold. The risk of developing preeclampsia was reduced by 47% for each added week of gestational age.

Expressed in terms of dichotomous predictors, a serum uric acid level of at least 300 micromol/L at the first presentation of gestational hypertension raised the risk of preeclampsia 2.6-fold, and a history of preeclampsia raised the risk of a new case 3.2-fold.

Gestational age of less than 36 weeks when gestational hypertension was first diagnosed raised the risk of preeclampsia by 3.6-fold. The risk was elevated with a serum uric acid level of 300 micromol/L or greater even though this level is within the normal range (less than 350 micromol/L).

An additional analysis showed that women who presented with gestational hypertension but had no history of preeclampsia, had a serum uric acid level of less than 300 micromol/L at diagnosis, and were diagnosed at 36 weeks' gestation or after had a 20% risk of progressing to preeclampsia. In contrast, women with a history of preeclampsia who presented with hypertension before 36 weeks' gestation and had a uric acid level of at least 300 micromol/L had an 89% risk of progressing to preeclampsia.

These three markers predicted the risk of progressing from gestational hypertension to preeclampsia with a sensitivity of 82% and a specificity of 85%, Mr. Wu and his associates said in their poster.

OTTAWA – A gestational age of less than 36 weeks, a relatively high serum level of uric acid, and a history of preeclampsia were all linked to progression of gestational hypertension to preeclampsia in a retrospective study of 280 women at one center.

The findings suggest that “clinical monitoring of these routinely available risk factors in pregnancies complicated by gestational hypertension could provide an easy, inexpensive, and helpful tool for identifying women with gestational hypertension who are at high risk of developing preeclampsia,” Yuquan Wu and his associates reported in a poster at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Gestational hypertension is usually the first clinical feature of preeclampsia, appearing before proteinuria. But it currently remains a challenge for physicians to predict if a woman who develops hypertension after 20 weeks' gestation will progress to preeclampsia, said Mr. Wu, a researcher in the department of ob.gyn. at the University of Montreal, and his associates in their poster.

They reviewed the medical records of all women who received obstetric care and gave birth at Ste-Justine Hospital in Montreal during March 2001-June 2003. They focused on women with a singleton pregnancy diagnosed with gestational hypertension without proteinuria at their initial hospital presentation.

Gestational hypertension was defined as a blood pressure at or above 140/90 mm Hg after 20 weeks' gestation.

Preeclampsia was diagnosed in women with gestational hypertension who also had proteinuria of at least 300 mg in a 24-hour urine collection, or a 1+ on dipstick urinalysis in two samples taken 6 hours apart. The review identified 91 women who reached term with gestational hypertension, and 189 women with preeclampsia. The average age of these women was 30 years.

In a multivariate analysis, each standard-deviation increase in the serum level of uric acid (56.1 micromol/L) boosted the risk of preeclampsia by 78%, and a history of preeclampsia boosted the risk of developing this complication in the current pregnancy by 3.4-fold. The risk of developing preeclampsia was reduced by 47% for each added week of gestational age.

Expressed in terms of dichotomous predictors, a serum uric acid level of at least 300 micromol/L at the first presentation of gestational hypertension raised the risk of preeclampsia 2.6-fold, and a history of preeclampsia raised the risk of a new case 3.2-fold.

Gestational age of less than 36 weeks when gestational hypertension was first diagnosed raised the risk of preeclampsia by 3.6-fold. The risk was elevated with a serum uric acid level of 300 micromol/L or greater even though this level is within the normal range (less than 350 micromol/L).

An additional analysis showed that women who presented with gestational hypertension but had no history of preeclampsia, had a serum uric acid level of less than 300 micromol/L at diagnosis, and were diagnosed at 36 weeks' gestation or after had a 20% risk of progressing to preeclampsia. In contrast, women with a history of preeclampsia who presented with hypertension before 36 weeks' gestation and had a uric acid level of at least 300 micromol/L had an 89% risk of progressing to preeclampsia.

These three markers predicted the risk of progressing from gestational hypertension to preeclampsia with a sensitivity of 82% and a specificity of 85%, Mr. Wu and his associates said in their poster.

OTTAWA – A gestational age of less than 36 weeks, a relatively high serum level of uric acid, and a history of preeclampsia were all linked to progression of gestational hypertension to preeclampsia in a retrospective study of 280 women at one center.

The findings suggest that “clinical monitoring of these routinely available risk factors in pregnancies complicated by gestational hypertension could provide an easy, inexpensive, and helpful tool for identifying women with gestational hypertension who are at high risk of developing preeclampsia,” Yuquan Wu and his associates reported in a poster at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Gestational hypertension is usually the first clinical feature of preeclampsia, appearing before proteinuria. But it currently remains a challenge for physicians to predict if a woman who develops hypertension after 20 weeks' gestation will progress to preeclampsia, said Mr. Wu, a researcher in the department of ob.gyn. at the University of Montreal, and his associates in their poster.

They reviewed the medical records of all women who received obstetric care and gave birth at Ste-Justine Hospital in Montreal during March 2001-June 2003. They focused on women with a singleton pregnancy diagnosed with gestational hypertension without proteinuria at their initial hospital presentation.

Gestational hypertension was defined as a blood pressure at or above 140/90 mm Hg after 20 weeks' gestation.

Preeclampsia was diagnosed in women with gestational hypertension who also had proteinuria of at least 300 mg in a 24-hour urine collection, or a 1+ on dipstick urinalysis in two samples taken 6 hours apart. The review identified 91 women who reached term with gestational hypertension, and 189 women with preeclampsia. The average age of these women was 30 years.

In a multivariate analysis, each standard-deviation increase in the serum level of uric acid (56.1 micromol/L) boosted the risk of preeclampsia by 78%, and a history of preeclampsia boosted the risk of developing this complication in the current pregnancy by 3.4-fold. The risk of developing preeclampsia was reduced by 47% for each added week of gestational age.

Expressed in terms of dichotomous predictors, a serum uric acid level of at least 300 micromol/L at the first presentation of gestational hypertension raised the risk of preeclampsia 2.6-fold, and a history of preeclampsia raised the risk of a new case 3.2-fold.

Gestational age of less than 36 weeks when gestational hypertension was first diagnosed raised the risk of preeclampsia by 3.6-fold. The risk was elevated with a serum uric acid level of 300 micromol/L or greater even though this level is within the normal range (less than 350 micromol/L).

An additional analysis showed that women who presented with gestational hypertension but had no history of preeclampsia, had a serum uric acid level of less than 300 micromol/L at diagnosis, and were diagnosed at 36 weeks' gestation or after had a 20% risk of progressing to preeclampsia. In contrast, women with a history of preeclampsia who presented with hypertension before 36 weeks' gestation and had a uric acid level of at least 300 micromol/L had an 89% risk of progressing to preeclampsia.

These three markers predicted the risk of progressing from gestational hypertension to preeclampsia with a sensitivity of 82% and a specificity of 85%, Mr. Wu and his associates said in their poster.