Obstetrics

SAN DIEGO – A formal, two-question screening tool identified significantly more pregnant women in abusive relationships than did questions formulated by physicians to conform to guidelines of the American College of Obstetricians and Gynecologists, a study has found.

The two questions from the Women's Abuse Screening Tool (short form) are:

▸ In general, how would you describe your relationship? (A lot of tension, some tension, or no tension?)

▸ Do you and your partner work out arguments with a lot of difficulty, some difficulty, or no difficulty?

Dr. Tiffany A. Moore Simas and associates at the University of Massachusetts, Worcester, screened 136 prenatal patients with both the formal questions and informal physician prompts. (Guidelines from ACOG recommend asking about violence and trauma during prenatal visits; however, no formal questions are specified.)

Results were presented in poster form at the ACOG's annual meeting. Six patients (4.4%) who were experiencing intimate partner violence in their current relationships were identified by both screening methods. An additional 10 patients (7.4%) were detected only by the two questions from the Women's Abuse Screening Tool.

Six patients refused to participate in domestic violence screening. Of the total 16 patients in violent relationships, 5 separated from their partners during pregnancy.

Dr. Moore Simas and colleagues concluded that the two-question screen is “valid, reliable, easy, and unobtrusive.”

The other six questions in the long form of the Women's Abuse Screening Tool that may be used to make a more comprehensive assessment (answers for each are Occasionally, Sometimes, Never) are:

▸ Do arguments ever result in your feeling down or bad about yourself?

▸ Do arguments ever result in hitting, kicking, or pushing?

▸ Do you ever feel frightened by what your partner says or does?

▸ Has your partner ever abused you physically?

▸ Has your partner ever abused you emotionally?

▸ Has your partner ever abused you sexually?

SAN DIEGO – A formal, two-question screening tool identified significantly more pregnant women in abusive relationships than did questions formulated by physicians to conform to guidelines of the American College of Obstetricians and Gynecologists, a study has found.

The two questions from the Women's Abuse Screening Tool (short form) are:

▸ In general, how would you describe your relationship? (A lot of tension, some tension, or no tension?)

▸ Do you and your partner work out arguments with a lot of difficulty, some difficulty, or no difficulty?

Dr. Tiffany A. Moore Simas and associates at the University of Massachusetts, Worcester, screened 136 prenatal patients with both the formal questions and informal physician prompts. (Guidelines from ACOG recommend asking about violence and trauma during prenatal visits; however, no formal questions are specified.)

Results were presented in poster form at the ACOG's annual meeting. Six patients (4.4%) who were experiencing intimate partner violence in their current relationships were identified by both screening methods. An additional 10 patients (7.4%) were detected only by the two questions from the Women's Abuse Screening Tool.

Six patients refused to participate in domestic violence screening. Of the total 16 patients in violent relationships, 5 separated from their partners during pregnancy.

Dr. Moore Simas and colleagues concluded that the two-question screen is “valid, reliable, easy, and unobtrusive.”

The other six questions in the long form of the Women's Abuse Screening Tool that may be used to make a more comprehensive assessment (answers for each are Occasionally, Sometimes, Never) are:

▸ Do arguments ever result in your feeling down or bad about yourself?

▸ Do arguments ever result in hitting, kicking, or pushing?

▸ Do you ever feel frightened by what your partner says or does?

▸ Has your partner ever abused you physically?

▸ Has your partner ever abused you emotionally?

▸ Has your partner ever abused you sexually?

SAN DIEGO – A formal, two-question screening tool identified significantly more pregnant women in abusive relationships than did questions formulated by physicians to conform to guidelines of the American College of Obstetricians and Gynecologists, a study has found.

The two questions from the Women's Abuse Screening Tool (short form) are:

▸ In general, how would you describe your relationship? (A lot of tension, some tension, or no tension?)

▸ Do you and your partner work out arguments with a lot of difficulty, some difficulty, or no difficulty?

Dr. Tiffany A. Moore Simas and associates at the University of Massachusetts, Worcester, screened 136 prenatal patients with both the formal questions and informal physician prompts. (Guidelines from ACOG recommend asking about violence and trauma during prenatal visits; however, no formal questions are specified.)

Results were presented in poster form at the ACOG's annual meeting. Six patients (4.4%) who were experiencing intimate partner violence in their current relationships were identified by both screening methods. An additional 10 patients (7.4%) were detected only by the two questions from the Women's Abuse Screening Tool.

Six patients refused to participate in domestic violence screening. Of the total 16 patients in violent relationships, 5 separated from their partners during pregnancy.

Dr. Moore Simas and colleagues concluded that the two-question screen is “valid, reliable, easy, and unobtrusive.”

The other six questions in the long form of the Women's Abuse Screening Tool that may be used to make a more comprehensive assessment (answers for each are Occasionally, Sometimes, Never) are:

▸ Do arguments ever result in your feeling down or bad about yourself?

▸ Do arguments ever result in hitting, kicking, or pushing?

▸ Do you ever feel frightened by what your partner says or does?

▸ Has your partner ever abused you physically?

▸ Has your partner ever abused you emotionally?

▸ Has your partner ever abused you sexually?

SAN DIEGO – Rare is the pregnant patient whose obstetrician fails to ask whether she cleans her cat's litter, yet few are asked about conditions that pose far greater risks to them and their babies than toxoplasmosis: depression and partner abuse.

The risk of peripartum depression is 1 in 10, with consequences for mother and fetus that can be profound.

Domestic violence kills more pregnant women than any single medical complication of pregnancy.

Yet both conditions are underdiagnosed and undertreated, according to speakers at the annual meeting of the American College of Obstetricians and Gynecologists.

“As ob.gyns., we need to look at the bigger picture and understand that good prenatal and postpartum care involve a focus not just on our patients' physical health but also on their emotional and psychological health,” said Dr. Stanley Zinberg, deputy executive vice president of ACOG and vice president for practice activities.

Dr. Sharon T. Phelan, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, said she believes priorities may need to be restructured.

“It's interesting that we have laws in effect that we have to offer all women screening for certain birth defects that have a rate far lower than 10%. Yet 10% is the rate of peripartum depression,” she said.

For Dr. Paul Gluck, the need to screen for depression in perinatal visits became clear when he conducted a pilot survey of 50 obstetricians in the Miami area where he practices and found that just 2 of the respondents asked any questions about patients' mental well-being.

The potential impact of such screening struck home when he gave a longtime patient a depression screening tool as part of a research project and learned she was severely depressed.

“I'd been seeing her for years. It never dawned on me she was depressed,” he said during an ACOG press briefing.

Six weeks after he prescribed the patient an antidepressant, he received “the most beautiful letter” that he said changed his practice.

“I didn't realize how depressed I really was,” the patient wrote. “I didn't realize how much life I was missing. … The sun shines brighter.”

“I did as much good for this woman as for the woman I take to surgery to perform a hysterectomy,” Dr. Gluck said. “This is something we can be diagnosing and treating within the scope of an ob.gyn. practice.”

Dr. Zinberg said maternal depression seems to get little attention, “except when tragedies occur such as Andrea Yates [the Texas mother with postpartum depression who drowned her children] or when celebrities are involved.”

Postpartum psychosis, suicide, and homocide are only the most visible consequences of maternal depression, emphasized Dr. Phelan.

Depressed women self-medicate with cigarettes, alcohol, and other drugs. Their depression often prevents them from seeking prenatal care or following advice for a healthy pregnancy. They are more prone than are other women to preterm labor, delivery of small-for-gestational-age infants, and even fetal death. As mothers, they may be inattentive and have trouble bonding with their infants, while struggling to find energy and focus to care for their older children.

Screening tools are often helpful in spotting these patients, since many symptoms of depression overlap with normal occurrences in pregnancy and new parenthood, including fatigue, sleep problems, changes in appetite, and mood swings.

Dr. Gluck said that he has implemented a multipronged approach to screening.

His general intake questionnaire now includes two mental health questions: “Do you feel down or depressed?” and “Do you not enjoy doing things you used to enjoy?”

He has trained his nurses to weave several questions about psychological well-being into the conversation while patients are being weighed and having their blood pressure taken. For example, they will say, “How are things going in your life? Are you feeling down at all?”

If either the intake form or the nurse indicates there might be reason to suspect a patient has depression, he uses a validated, 20-question screening tool. Patients found to have suicidal ideation are handled as “a medical emergency as much as a ruptured appendix.” He refers to a trusted network of mental health professionals.

He refers other patients for psychotherapy and/or prescribes antidepressants himself, although he is fully supportive of colleagues who refer all patients with depression to mental health professionals. Not all ob.gyns. feel comfortable managing psychotropic medications, but all should make the effort to find out if their patients are depressed, he said.

“I think it's very important that we're the ones doing the screening. We're the ones who have contact with women throughout their pregnancies and … throughout their whole lifetimes,” he said.

Screening for intimate partner violence was also highlighted at the meeting, including an award-winning paper by Dr. Jennifer Ballard Dwan, a maternal-fetal medicine fellow at Brown University, Providence, R.I.

Dr. Dwan compared screening for toxoplasmosis, which has an estimated incidence of 0.001%, with intimate partner violence, which occurs in approximately 4%-8% of pregnancies.

Among 324 randomly selected pregnant women seen at private and public clinics, 68% were asked about cat exposure and 16% were screened for intimate partner violence. Of note, 15% of women screened positive for domestic violence when asked, she said.

Women attending public clinics were far more likely to be screened for domestic violence than were privately insured women, while the reverse was true for screening about cat exposure.

During the press briefing, Dr. Phelan said she “almost … worries more” about middle- to higher-income women being missed during depression screening as well. When it's a 16-year-old who's in a crisis pregnancy, people are more likely to accept that she might be depressed, she said.

Old myths die hard when it comes to a married, economically stable woman with a “very planned pregnancy” who becomes depressed. “There's an idea that if she were strong, she could overcome it,” certainly without taking a medication that has a remote chance of harming her baby.

“I don't see us hesitating to tell the overweight, type 2 diabetic patient [to take her diabetes medication],” said Dr. Phelan.

SAN DIEGO – Rare is the pregnant patient whose obstetrician fails to ask whether she cleans her cat's litter, yet few are asked about conditions that pose far greater risks to them and their babies than toxoplasmosis: depression and partner abuse.

The risk of peripartum depression is 1 in 10, with consequences for mother and fetus that can be profound.

Domestic violence kills more pregnant women than any single medical complication of pregnancy.

Yet both conditions are underdiagnosed and undertreated, according to speakers at the annual meeting of the American College of Obstetricians and Gynecologists.

“As ob.gyns., we need to look at the bigger picture and understand that good prenatal and postpartum care involve a focus not just on our patients' physical health but also on their emotional and psychological health,” said Dr. Stanley Zinberg, deputy executive vice president of ACOG and vice president for practice activities.

Dr. Sharon T. Phelan, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, said she believes priorities may need to be restructured.

“It's interesting that we have laws in effect that we have to offer all women screening for certain birth defects that have a rate far lower than 10%. Yet 10% is the rate of peripartum depression,” she said.

For Dr. Paul Gluck, the need to screen for depression in perinatal visits became clear when he conducted a pilot survey of 50 obstetricians in the Miami area where he practices and found that just 2 of the respondents asked any questions about patients' mental well-being.

The potential impact of such screening struck home when he gave a longtime patient a depression screening tool as part of a research project and learned she was severely depressed.

“I'd been seeing her for years. It never dawned on me she was depressed,” he said during an ACOG press briefing.

Six weeks after he prescribed the patient an antidepressant, he received “the most beautiful letter” that he said changed his practice.

“I didn't realize how depressed I really was,” the patient wrote. “I didn't realize how much life I was missing. … The sun shines brighter.”

“I did as much good for this woman as for the woman I take to surgery to perform a hysterectomy,” Dr. Gluck said. “This is something we can be diagnosing and treating within the scope of an ob.gyn. practice.”

Dr. Zinberg said maternal depression seems to get little attention, “except when tragedies occur such as Andrea Yates [the Texas mother with postpartum depression who drowned her children] or when celebrities are involved.”

Postpartum psychosis, suicide, and homocide are only the most visible consequences of maternal depression, emphasized Dr. Phelan.

Depressed women self-medicate with cigarettes, alcohol, and other drugs. Their depression often prevents them from seeking prenatal care or following advice for a healthy pregnancy. They are more prone than are other women to preterm labor, delivery of small-for-gestational-age infants, and even fetal death. As mothers, they may be inattentive and have trouble bonding with their infants, while struggling to find energy and focus to care for their older children.

Screening tools are often helpful in spotting these patients, since many symptoms of depression overlap with normal occurrences in pregnancy and new parenthood, including fatigue, sleep problems, changes in appetite, and mood swings.

Dr. Gluck said that he has implemented a multipronged approach to screening.

His general intake questionnaire now includes two mental health questions: “Do you feel down or depressed?” and “Do you not enjoy doing things you used to enjoy?”

He has trained his nurses to weave several questions about psychological well-being into the conversation while patients are being weighed and having their blood pressure taken. For example, they will say, “How are things going in your life? Are you feeling down at all?”

If either the intake form or the nurse indicates there might be reason to suspect a patient has depression, he uses a validated, 20-question screening tool. Patients found to have suicidal ideation are handled as “a medical emergency as much as a ruptured appendix.” He refers to a trusted network of mental health professionals.

He refers other patients for psychotherapy and/or prescribes antidepressants himself, although he is fully supportive of colleagues who refer all patients with depression to mental health professionals. Not all ob.gyns. feel comfortable managing psychotropic medications, but all should make the effort to find out if their patients are depressed, he said.

“I think it's very important that we're the ones doing the screening. We're the ones who have contact with women throughout their pregnancies and … throughout their whole lifetimes,” he said.

Screening for intimate partner violence was also highlighted at the meeting, including an award-winning paper by Dr. Jennifer Ballard Dwan, a maternal-fetal medicine fellow at Brown University, Providence, R.I.

Dr. Dwan compared screening for toxoplasmosis, which has an estimated incidence of 0.001%, with intimate partner violence, which occurs in approximately 4%-8% of pregnancies.

Among 324 randomly selected pregnant women seen at private and public clinics, 68% were asked about cat exposure and 16% were screened for intimate partner violence. Of note, 15% of women screened positive for domestic violence when asked, she said.

Women attending public clinics were far more likely to be screened for domestic violence than were privately insured women, while the reverse was true for screening about cat exposure.

During the press briefing, Dr. Phelan said she “almost … worries more” about middle- to higher-income women being missed during depression screening as well. When it's a 16-year-old who's in a crisis pregnancy, people are more likely to accept that she might be depressed, she said.

Old myths die hard when it comes to a married, economically stable woman with a “very planned pregnancy” who becomes depressed. “There's an idea that if she were strong, she could overcome it,” certainly without taking a medication that has a remote chance of harming her baby.

“I don't see us hesitating to tell the overweight, type 2 diabetic patient [to take her diabetes medication],” said Dr. Phelan.

SAN DIEGO – Rare is the pregnant patient whose obstetrician fails to ask whether she cleans her cat's litter, yet few are asked about conditions that pose far greater risks to them and their babies than toxoplasmosis: depression and partner abuse.

The risk of peripartum depression is 1 in 10, with consequences for mother and fetus that can be profound.

Domestic violence kills more pregnant women than any single medical complication of pregnancy.

Yet both conditions are underdiagnosed and undertreated, according to speakers at the annual meeting of the American College of Obstetricians and Gynecologists.

“As ob.gyns., we need to look at the bigger picture and understand that good prenatal and postpartum care involve a focus not just on our patients' physical health but also on their emotional and psychological health,” said Dr. Stanley Zinberg, deputy executive vice president of ACOG and vice president for practice activities.

Dr. Sharon T. Phelan, professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, said she believes priorities may need to be restructured.

“It's interesting that we have laws in effect that we have to offer all women screening for certain birth defects that have a rate far lower than 10%. Yet 10% is the rate of peripartum depression,” she said.

For Dr. Paul Gluck, the need to screen for depression in perinatal visits became clear when he conducted a pilot survey of 50 obstetricians in the Miami area where he practices and found that just 2 of the respondents asked any questions about patients' mental well-being.

The potential impact of such screening struck home when he gave a longtime patient a depression screening tool as part of a research project and learned she was severely depressed.

“I'd been seeing her for years. It never dawned on me she was depressed,” he said during an ACOG press briefing.

Six weeks after he prescribed the patient an antidepressant, he received “the most beautiful letter” that he said changed his practice.

“I didn't realize how depressed I really was,” the patient wrote. “I didn't realize how much life I was missing. … The sun shines brighter.”

“I did as much good for this woman as for the woman I take to surgery to perform a hysterectomy,” Dr. Gluck said. “This is something we can be diagnosing and treating within the scope of an ob.gyn. practice.”

Dr. Zinberg said maternal depression seems to get little attention, “except when tragedies occur such as Andrea Yates [the Texas mother with postpartum depression who drowned her children] or when celebrities are involved.”

Postpartum psychosis, suicide, and homocide are only the most visible consequences of maternal depression, emphasized Dr. Phelan.

Depressed women self-medicate with cigarettes, alcohol, and other drugs. Their depression often prevents them from seeking prenatal care or following advice for a healthy pregnancy. They are more prone than are other women to preterm labor, delivery of small-for-gestational-age infants, and even fetal death. As mothers, they may be inattentive and have trouble bonding with their infants, while struggling to find energy and focus to care for their older children.

Screening tools are often helpful in spotting these patients, since many symptoms of depression overlap with normal occurrences in pregnancy and new parenthood, including fatigue, sleep problems, changes in appetite, and mood swings.

Dr. Gluck said that he has implemented a multipronged approach to screening.

His general intake questionnaire now includes two mental health questions: “Do you feel down or depressed?” and “Do you not enjoy doing things you used to enjoy?”

He has trained his nurses to weave several questions about psychological well-being into the conversation while patients are being weighed and having their blood pressure taken. For example, they will say, “How are things going in your life? Are you feeling down at all?”

If either the intake form or the nurse indicates there might be reason to suspect a patient has depression, he uses a validated, 20-question screening tool. Patients found to have suicidal ideation are handled as “a medical emergency as much as a ruptured appendix.” He refers to a trusted network of mental health professionals.

He refers other patients for psychotherapy and/or prescribes antidepressants himself, although he is fully supportive of colleagues who refer all patients with depression to mental health professionals. Not all ob.gyns. feel comfortable managing psychotropic medications, but all should make the effort to find out if their patients are depressed, he said.

“I think it's very important that we're the ones doing the screening. We're the ones who have contact with women throughout their pregnancies and … throughout their whole lifetimes,” he said.

Screening for intimate partner violence was also highlighted at the meeting, including an award-winning paper by Dr. Jennifer Ballard Dwan, a maternal-fetal medicine fellow at Brown University, Providence, R.I.

Dr. Dwan compared screening for toxoplasmosis, which has an estimated incidence of 0.001%, with intimate partner violence, which occurs in approximately 4%-8% of pregnancies.

Among 324 randomly selected pregnant women seen at private and public clinics, 68% were asked about cat exposure and 16% were screened for intimate partner violence. Of note, 15% of women screened positive for domestic violence when asked, she said.

Women attending public clinics were far more likely to be screened for domestic violence than were privately insured women, while the reverse was true for screening about cat exposure.

During the press briefing, Dr. Phelan said she “almost … worries more” about middle- to higher-income women being missed during depression screening as well. When it's a 16-year-old who's in a crisis pregnancy, people are more likely to accept that she might be depressed, she said.

Old myths die hard when it comes to a married, economically stable woman with a “very planned pregnancy” who becomes depressed. “There's an idea that if she were strong, she could overcome it,” certainly without taking a medication that has a remote chance of harming her baby.

“I don't see us hesitating to tell the overweight, type 2 diabetic patient [to take her diabetes medication],” said Dr. Phelan.

ANAHEIM, CALIF. – Women admitted to the hospital for nephrolithiasis in pregnancy have a nearly 80% elevated risk of preterm delivery, according to a retrospective cohort study of more than 2,000 cases in Washington State over 16 years.

The finding, announced at the annual meeting of the American Urological Association, may prompt more definitive treatment of small, asymptomatic kidney stones in women of childbearing age, especially those planning pregnancy.

Small case series dating back to the 1980s have raised the possibility that kidney stones during pregnancy may have an impact on birth outcomes, but the study conducted at the University of Washington in Seattle is believed to be the first large-scale attempt to track cases to delivery.

Dr. Mia A. Swartz and associates in the department of urology used birth certificate data and hospital discharge records to link peripartum records of 2,239 women who had been admitted to hospitals within the previous 9 months with a diagnosis of nephrolithiasis. These records were matched in a 3:1 ratio with 6,729 women of the same age who gave birth the same years.

The incidence of nephrolithiasis requiring hospital admission in pregnant women was 0.17%. The diagnosis was more frequently seen in white women, those with hypertension, and those with renal disease. Nearly 26% received at least one procedure for nephrolithiasis during hospitalization–most frequently, ureteral stents.

Women hospitalized with nephrolithiasis were significantly more likely to have a diagnosis of pyelonephritis at delivery. However, when investigators statistically controlled for the presence of pyelonephritis, relative risk of delivery at or before 37 weeks remained 1.79 (1.51-2.13).

About 10% of women admitted for kidney stones at any point in pregnancy gave birth early, compared with 6.4% of control women, a highly statistically significant difference.

Neither the trimester during which the nephrolithiasis admission occurred, nor the treatment procedure administered, influenced the results.

Use of tocolytics was highly correlated with preterm birth in the nephrolithiasis cohort, suggesting that the finding represents true preterm labor, rather than induction of early labor to permit treatment of symptomatic kidney stones, Dr. Swartz said during her podium presentation.

The database study captured only women who delivered a live infant after a hospital admission for nephrolithiasis, missing those treated on an outpatient basis and any who miscarried early in pregnancy, she noted. Further, “it was underpowered to detect rare outcomes, such as infant death.”

Dr. Swartz said that while a large, prospective study would be useful, the findings have “important implications.”

“I believe it provides a basis for counseling women with nephrolithiasis during pregnancy and may prompt definitive management or treatment of small, asymptomatic stones in women planning pregnancy,” she said.

An audience member questioned that conclusion, saying many young women have small, asymptomatic stones that may not require treatment, “even if they are recurrent stone formers.”

The session moderator, Dr. John D. Denstedt, interjected that his institution takes “a little more proactive approach” that appears to be justified based on the new University of Washington findings.

“We get into a full discussion with these patients with asymptomatic … stones and what the implications would be if the stone would become symptomatic in pregnancy,” said Dr. Denstedt, professor and chief of surgery at the University of Western Ontario in London.

The shock wave machine is not an option during pregnancy, he said. As a result, many such patients opt for shock wave lithotripsy in advance of becoming pregnant, Dr. Denstedt added.

ANAHEIM, CALIF. – Women admitted to the hospital for nephrolithiasis in pregnancy have a nearly 80% elevated risk of preterm delivery, according to a retrospective cohort study of more than 2,000 cases in Washington State over 16 years.

The finding, announced at the annual meeting of the American Urological Association, may prompt more definitive treatment of small, asymptomatic kidney stones in women of childbearing age, especially those planning pregnancy.

Small case series dating back to the 1980s have raised the possibility that kidney stones during pregnancy may have an impact on birth outcomes, but the study conducted at the University of Washington in Seattle is believed to be the first large-scale attempt to track cases to delivery.

Dr. Mia A. Swartz and associates in the department of urology used birth certificate data and hospital discharge records to link peripartum records of 2,239 women who had been admitted to hospitals within the previous 9 months with a diagnosis of nephrolithiasis. These records were matched in a 3:1 ratio with 6,729 women of the same age who gave birth the same years.

The incidence of nephrolithiasis requiring hospital admission in pregnant women was 0.17%. The diagnosis was more frequently seen in white women, those with hypertension, and those with renal disease. Nearly 26% received at least one procedure for nephrolithiasis during hospitalization–most frequently, ureteral stents.

Women hospitalized with nephrolithiasis were significantly more likely to have a diagnosis of pyelonephritis at delivery. However, when investigators statistically controlled for the presence of pyelonephritis, relative risk of delivery at or before 37 weeks remained 1.79 (1.51-2.13).

About 10% of women admitted for kidney stones at any point in pregnancy gave birth early, compared with 6.4% of control women, a highly statistically significant difference.

Neither the trimester during which the nephrolithiasis admission occurred, nor the treatment procedure administered, influenced the results.

Use of tocolytics was highly correlated with preterm birth in the nephrolithiasis cohort, suggesting that the finding represents true preterm labor, rather than induction of early labor to permit treatment of symptomatic kidney stones, Dr. Swartz said during her podium presentation.

The database study captured only women who delivered a live infant after a hospital admission for nephrolithiasis, missing those treated on an outpatient basis and any who miscarried early in pregnancy, she noted. Further, “it was underpowered to detect rare outcomes, such as infant death.”

Dr. Swartz said that while a large, prospective study would be useful, the findings have “important implications.”

“I believe it provides a basis for counseling women with nephrolithiasis during pregnancy and may prompt definitive management or treatment of small, asymptomatic stones in women planning pregnancy,” she said.

An audience member questioned that conclusion, saying many young women have small, asymptomatic stones that may not require treatment, “even if they are recurrent stone formers.”

The session moderator, Dr. John D. Denstedt, interjected that his institution takes “a little more proactive approach” that appears to be justified based on the new University of Washington findings.

“We get into a full discussion with these patients with asymptomatic … stones and what the implications would be if the stone would become symptomatic in pregnancy,” said Dr. Denstedt, professor and chief of surgery at the University of Western Ontario in London.

The shock wave machine is not an option during pregnancy, he said. As a result, many such patients opt for shock wave lithotripsy in advance of becoming pregnant, Dr. Denstedt added.

ANAHEIM, CALIF. – Women admitted to the hospital for nephrolithiasis in pregnancy have a nearly 80% elevated risk of preterm delivery, according to a retrospective cohort study of more than 2,000 cases in Washington State over 16 years.

The finding, announced at the annual meeting of the American Urological Association, may prompt more definitive treatment of small, asymptomatic kidney stones in women of childbearing age, especially those planning pregnancy.

Small case series dating back to the 1980s have raised the possibility that kidney stones during pregnancy may have an impact on birth outcomes, but the study conducted at the University of Washington in Seattle is believed to be the first large-scale attempt to track cases to delivery.

Dr. Mia A. Swartz and associates in the department of urology used birth certificate data and hospital discharge records to link peripartum records of 2,239 women who had been admitted to hospitals within the previous 9 months with a diagnosis of nephrolithiasis. These records were matched in a 3:1 ratio with 6,729 women of the same age who gave birth the same years.

The incidence of nephrolithiasis requiring hospital admission in pregnant women was 0.17%. The diagnosis was more frequently seen in white women, those with hypertension, and those with renal disease. Nearly 26% received at least one procedure for nephrolithiasis during hospitalization–most frequently, ureteral stents.

Women hospitalized with nephrolithiasis were significantly more likely to have a diagnosis of pyelonephritis at delivery. However, when investigators statistically controlled for the presence of pyelonephritis, relative risk of delivery at or before 37 weeks remained 1.79 (1.51-2.13).

About 10% of women admitted for kidney stones at any point in pregnancy gave birth early, compared with 6.4% of control women, a highly statistically significant difference.

Neither the trimester during which the nephrolithiasis admission occurred, nor the treatment procedure administered, influenced the results.

Use of tocolytics was highly correlated with preterm birth in the nephrolithiasis cohort, suggesting that the finding represents true preterm labor, rather than induction of early labor to permit treatment of symptomatic kidney stones, Dr. Swartz said during her podium presentation.

The database study captured only women who delivered a live infant after a hospital admission for nephrolithiasis, missing those treated on an outpatient basis and any who miscarried early in pregnancy, she noted. Further, “it was underpowered to detect rare outcomes, such as infant death.”

Dr. Swartz said that while a large, prospective study would be useful, the findings have “important implications.”

“I believe it provides a basis for counseling women with nephrolithiasis during pregnancy and may prompt definitive management or treatment of small, asymptomatic stones in women planning pregnancy,” she said.

An audience member questioned that conclusion, saying many young women have small, asymptomatic stones that may not require treatment, “even if they are recurrent stone formers.”

The session moderator, Dr. John D. Denstedt, interjected that his institution takes “a little more proactive approach” that appears to be justified based on the new University of Washington findings.

“We get into a full discussion with these patients with asymptomatic … stones and what the implications would be if the stone would become symptomatic in pregnancy,” said Dr. Denstedt, professor and chief of surgery at the University of Western Ontario in London.

The shock wave machine is not an option during pregnancy, he said. As a result, many such patients opt for shock wave lithotripsy in advance of becoming pregnant, Dr. Denstedt added.

SAN FRANCISCO – Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor-and-delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan.

The key to managing positive rapid HIV tests in labor is to be prepared, she stressed. Health care providers should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, said Dr. Cohan, medical director of the Bay Area Perinatal AIDS Center.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor-and-delivery wards–not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said. Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and avoid an episiotomy if you can, to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the procedure. Giving antiretrovirals 3-4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, but incorporating HIV testing into nurses' routine intake procedures actually boosted the prenatal testing rate to 93%.

SAN FRANCISCO – Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor-and-delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan.

The key to managing positive rapid HIV tests in labor is to be prepared, she stressed. Health care providers should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, said Dr. Cohan, medical director of the Bay Area Perinatal AIDS Center.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor-and-delivery wards–not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said. Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and avoid an episiotomy if you can, to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the procedure. Giving antiretrovirals 3-4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, but incorporating HIV testing into nurses' routine intake procedures actually boosted the prenatal testing rate to 93%.

SAN FRANCISCO – Giving a rapid HIV test to a woman in labor can help prevent transmission to the newborn, but it's just the first step, Dr. Deborah Cohan said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

A recent study of labor-and-delivery suites in Illinois hospitals found that all had rapid HIV tests available but only a small percentage had adequate supplies of intravenous zidovudine (AZT) to give to mothers with positive results. “They were ready, but not quite ready,” said Dr. Cohan.

The key to managing positive rapid HIV tests in labor is to be prepared, she stressed. Health care providers should have easy access to a written protocol and to HIV consultants. The Centers for Disease Control and Prevention's free Perinatal HIV Hotline can provide both and is reachable around the clock at 888-448-8765, said Dr. Cohan, medical director of the Bay Area Perinatal AIDS Center.

Hospital pharmacies should stock adequate supplies of antiretrovirals for use on labor-and-delivery wards–not only AZT in both intravenous and liquid formulations so that both the mother and the baby can be treated, but also oral nevirapine in 200-mg doses. Patient education materials should be handy as well.

When a rapid HIV test reads positive, “Often people think, 'Oh, I need to tell the mother,' but you need to tell the pharmacy first,” Dr. Cohan advised. Alert the pharmacy about the need for antiretroviral therapy and think about the best mode of delivery for this patient. Alert the patient's nurse, and then tell the patient about the positive result and your recommendations for treatment and delivery.

All positive results should be treated as true positives because “there's no way to guess which might be false positives,” she noted. A 66% rate of transmission for an HIV-positive mother to the newborn can be reduced to less than a 10% risk with intrapartum and/or neonatal antiretroviral therapy. “It's probably less than a 5% risk” with therapy, she said. Start maternal antiretroviral therapy, and alert your pediatric colleagues to decide on a neonatal regimen. “The Perinatal Hotline can help with this as well,” Dr. Cohan added.

To minimize risk of vertical transmission, reduce the duration of rupture of membranes or labor, avoid fetal scalp electrodes or fetal scalp sampling, avoid forceps and vacuum deliveries if possible, and avoid an episiotomy if you can, to reduce the baby's exposure to maternal blood.

A cesarean section is indicated if the pregnancy is at 38 weeks' gestation with no ruptured membranes and no labor, and you can initiate maternal antiretroviral therapy before the procedure. Giving antiretrovirals 3-4 hours before C-section allows time for adequate drug levels in the mother and in umbilical cord blood.

If a woman comes in prior to 38 weeks to rule out labor, and she's not in labor and the membranes are intact but a rapid HIV test is positive, consider hospitalizing her to give intravenous antiretroviral therapy and then deliver by C-section at 38 weeks, Dr. Cohan suggested.

“We've had very good luck at getting the viral load substantially lower even after just a few days of antiretrovirals,” she said.

Six rapid HIV tests have been approved that give same-day results. All require confirmatory testing for diagnosis. The rapid tests are useful for women in labor who have had no prenatal care or who did not get an HIV test during their prenatal care. Numerous studies have shown rapid HIV testing in labor is cost-effective, Dr. Cohan said.

It's a good idea to evaluate the prenatal HIV testing rate at your institution, she suggested. At San Francisco General Hospital, where Dr. Cohan practices, “we thought we were doing fine” until a study showed they were testing only 52% of pregnant women for HIV.

The hospital lost its dedicated HIV test counselor because of budget cuts, but incorporating HIV testing into nurses' routine intake procedures actually boosted the prenatal testing rate to 93%.

BANFF, ALTA. — Compared with systemic analgesia, the use of combined spinal epidural analgesia for external cephalic version is associated with a more rapid return of a reactive fetal heart rate tracing, according to findings presented by Dr. Jeanette Bauchat at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“CSE [combined spinal epidural] may provide more immediate reassurance of fetal well-being following ECV [external cephalic version],” said Dr. Bauchat of Northwestern University, Chicago.

“Obviously we'd like to provide some pain control during this procedure but we want to ensure a safe analgesic technique,” Dr. Bauchat said.

In her study, 94 women undergoing ECV for breech presentation at 36 weeks' gestation were randomized to either CSE, consisting of intrathecal bupivacaine (2.5 mg) plus fentanyl (15 mcg), or systemic fentanyl (50 mcg intravenously). Fetal heart rate (FHR) tracings were evaluated for 30 minutes before the procedure and for 60 minutes afterward, for degree of variability, number of accelerations, number and type of decelerations and time to reactivity (TTR). TTR was defined as the time from initiation of analgesia to the development of two 15-beat accelerations of 15 seconds duration, occurring within 20 minutes of each other.

There were no differences noted between the groups for all aspects of fetal heart rate except TTR, which was significantly shorter in the CSE group (13 minutes compared with 39 minutes), reported Dr. Bauchat.

“Overall, 27% experienced some form of deceleration in both groups,” she said. “Post procedure, all the fetal heart rate tracings except for two ultimately returned to their baseline values. These two resulted in emergency cesarean deliveries—one in each group—for persistent nonreassuring decelerations.” A knot in the umbilical cord was identified in the CSE case, she added.

BANFF, ALTA. — Compared with systemic analgesia, the use of combined spinal epidural analgesia for external cephalic version is associated with a more rapid return of a reactive fetal heart rate tracing, according to findings presented by Dr. Jeanette Bauchat at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“CSE [combined spinal epidural] may provide more immediate reassurance of fetal well-being following ECV [external cephalic version],” said Dr. Bauchat of Northwestern University, Chicago.

“Obviously we'd like to provide some pain control during this procedure but we want to ensure a safe analgesic technique,” Dr. Bauchat said.

In her study, 94 women undergoing ECV for breech presentation at 36 weeks' gestation were randomized to either CSE, consisting of intrathecal bupivacaine (2.5 mg) plus fentanyl (15 mcg), or systemic fentanyl (50 mcg intravenously). Fetal heart rate (FHR) tracings were evaluated for 30 minutes before the procedure and for 60 minutes afterward, for degree of variability, number of accelerations, number and type of decelerations and time to reactivity (TTR). TTR was defined as the time from initiation of analgesia to the development of two 15-beat accelerations of 15 seconds duration, occurring within 20 minutes of each other.

There were no differences noted between the groups for all aspects of fetal heart rate except TTR, which was significantly shorter in the CSE group (13 minutes compared with 39 minutes), reported Dr. Bauchat.

“Overall, 27% experienced some form of deceleration in both groups,” she said. “Post procedure, all the fetal heart rate tracings except for two ultimately returned to their baseline values. These two resulted in emergency cesarean deliveries—one in each group—for persistent nonreassuring decelerations.” A knot in the umbilical cord was identified in the CSE case, she added.

BANFF, ALTA. — Compared with systemic analgesia, the use of combined spinal epidural analgesia for external cephalic version is associated with a more rapid return of a reactive fetal heart rate tracing, according to findings presented by Dr. Jeanette Bauchat at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“CSE [combined spinal epidural] may provide more immediate reassurance of fetal well-being following ECV [external cephalic version],” said Dr. Bauchat of Northwestern University, Chicago.

“Obviously we'd like to provide some pain control during this procedure but we want to ensure a safe analgesic technique,” Dr. Bauchat said.

In her study, 94 women undergoing ECV for breech presentation at 36 weeks' gestation were randomized to either CSE, consisting of intrathecal bupivacaine (2.5 mg) plus fentanyl (15 mcg), or systemic fentanyl (50 mcg intravenously). Fetal heart rate (FHR) tracings were evaluated for 30 minutes before the procedure and for 60 minutes afterward, for degree of variability, number of accelerations, number and type of decelerations and time to reactivity (TTR). TTR was defined as the time from initiation of analgesia to the development of two 15-beat accelerations of 15 seconds duration, occurring within 20 minutes of each other.

There were no differences noted between the groups for all aspects of fetal heart rate except TTR, which was significantly shorter in the CSE group (13 minutes compared with 39 minutes), reported Dr. Bauchat.

“Overall, 27% experienced some form of deceleration in both groups,” she said. “Post procedure, all the fetal heart rate tracings except for two ultimately returned to their baseline values. These two resulted in emergency cesarean deliveries—one in each group—for persistent nonreassuring decelerations.” A knot in the umbilical cord was identified in the CSE case, she added.

OTTAWA — Uterine compression sutures were an effective and relatively easy treatment for hemorrhage following cesarean section in a series of 28 women at one Canadian hospital.

Placement of compression sutures avoided the need for a hysterectomy in 23 of the 28 patients, and seven of the women treated with a uterine compression suture subsequently had uncomplicated, term pregnancies with cesarean delivery, Thomas F. Baskett, M.B., reported in a poster at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada. During 2000–2006, 31,519 deliveries occurred at Dalhousie University in Halifax, N.S. During this period, compression sutures for postpartum uterine hemorrhage were used an average of about once every 1,126 deliveries. All of these were cesarean sections. The rate of suturing for cesareans done during labor was 22 in 4,870 surgeries, a rate of once in every 221 emergency cesareans. The remaining six compression sutures were placed following an elective surgical delivery, a rate of once in every 637 cesareans, Dr. Baskett reported in his poster.

The indications for uterine suturing were atonic postpartum hemorrhage in 25 women, placenta previa in two patients, and partial placenta accreta in one patient. Thirteen of the women also required a blood transfusion, and five received intensive care. Four patients required ligation of their uterine/ovarian artery. Among the 22 women who were in labor at the time of surgery, eight developed postoperative endomyometritis.

In the 25 women with uterine atony, 20 had prolonged labor and dystocia. Many of these 20 women also had associated chorioamnionitis. The exhausted and infected uterus in these patients might not respond to uterotonic drugs, said Dr. Baskett, a professor of ob.gyn. at Dalhousie University. The most common type of suture used was a B-Lynch in 16. Six women received a B-Lynch and square suture, and four got a B-Lynch and vertical suture.

OTTAWA — Uterine compression sutures were an effective and relatively easy treatment for hemorrhage following cesarean section in a series of 28 women at one Canadian hospital.

Placement of compression sutures avoided the need for a hysterectomy in 23 of the 28 patients, and seven of the women treated with a uterine compression suture subsequently had uncomplicated, term pregnancies with cesarean delivery, Thomas F. Baskett, M.B., reported in a poster at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada. During 2000–2006, 31,519 deliveries occurred at Dalhousie University in Halifax, N.S. During this period, compression sutures for postpartum uterine hemorrhage were used an average of about once every 1,126 deliveries. All of these were cesarean sections. The rate of suturing for cesareans done during labor was 22 in 4,870 surgeries, a rate of once in every 221 emergency cesareans. The remaining six compression sutures were placed following an elective surgical delivery, a rate of once in every 637 cesareans, Dr. Baskett reported in his poster.

The indications for uterine suturing were atonic postpartum hemorrhage in 25 women, placenta previa in two patients, and partial placenta accreta in one patient. Thirteen of the women also required a blood transfusion, and five received intensive care. Four patients required ligation of their uterine/ovarian artery. Among the 22 women who were in labor at the time of surgery, eight developed postoperative endomyometritis.

In the 25 women with uterine atony, 20 had prolonged labor and dystocia. Many of these 20 women also had associated chorioamnionitis. The exhausted and infected uterus in these patients might not respond to uterotonic drugs, said Dr. Baskett, a professor of ob.gyn. at Dalhousie University. The most common type of suture used was a B-Lynch in 16. Six women received a B-Lynch and square suture, and four got a B-Lynch and vertical suture.

OTTAWA — Uterine compression sutures were an effective and relatively easy treatment for hemorrhage following cesarean section in a series of 28 women at one Canadian hospital.

Placement of compression sutures avoided the need for a hysterectomy in 23 of the 28 patients, and seven of the women treated with a uterine compression suture subsequently had uncomplicated, term pregnancies with cesarean delivery, Thomas F. Baskett, M.B., reported in a poster at the annual clinical meeting of the Society of Obstetricians and Gynaecologists of Canada. During 2000–2006, 31,519 deliveries occurred at Dalhousie University in Halifax, N.S. During this period, compression sutures for postpartum uterine hemorrhage were used an average of about once every 1,126 deliveries. All of these were cesarean sections. The rate of suturing for cesareans done during labor was 22 in 4,870 surgeries, a rate of once in every 221 emergency cesareans. The remaining six compression sutures were placed following an elective surgical delivery, a rate of once in every 637 cesareans, Dr. Baskett reported in his poster.

The indications for uterine suturing were atonic postpartum hemorrhage in 25 women, placenta previa in two patients, and partial placenta accreta in one patient. Thirteen of the women also required a blood transfusion, and five received intensive care. Four patients required ligation of their uterine/ovarian artery. Among the 22 women who were in labor at the time of surgery, eight developed postoperative endomyometritis.

In the 25 women with uterine atony, 20 had prolonged labor and dystocia. Many of these 20 women also had associated chorioamnionitis. The exhausted and infected uterus in these patients might not respond to uterotonic drugs, said Dr. Baskett, a professor of ob.gyn. at Dalhousie University. The most common type of suture used was a B-Lynch in 16. Six women received a B-Lynch and square suture, and four got a B-Lynch and vertical suture.

SAN FRANCISCO — Pregnant women who have obstructive sleep apnea have a 2.3-fold increased risk of gestational diabetes and a 4.2-fold increased risk of pregnancy-induced hypertension, compared with women without the sleep disorder, according to a poster presentation at the International Conference of the American Thoracic Society.

Previous research has suggested that obstructive sleep apnea (OSA) may induce systemic hypertension and diabetes mellitus in the general population, but the connection was much less clear in pregnant women, investigator Dr. Michael S. Nolledo of the Robert Wood Johnson Medical School, Princeton, N.J., said in a press briefing.

“A lot of times for patients who are pregnant and for ob.gyns., sleep-disordered breathing is not on the radar screen,” he said. When a woman who is pregnant goes to see her obstetrician, the physician asks a zillion things but almost never inquires about risk factors for sleep apnea.

Dr. Nolledo suggested that physicians dealing with women with gestational diabetes or pregnancy-induced hypertension (PIH) should inquire about sleep-disordered breathing, especially because OSA is so simple to treat with continuous positive airway pressure (CPAP).

“It may be a condition that you need treatment for just for the time you're carrying your baby,” Dr. Nolledo commented. “Once you deliver, the sleep apnea may resolve.”

Dr. Nolledo acknowledged, however, that his study contains no direct evidence that treating sleep apnea will improve PIH or gestational diabetes.

The study relied on data from the 2003 National Inpatient Sample, sponsored by the Agency for Healthcare Research and Quality.

This large database includes all inpatient records from a sample of about 20% of U.S. community short-stay hospitals and provides weights to calculate national estimates.

Using this database, the investigators calculated that there were 3,979,840 deliveries in the United States in 2003, of which 167,227 were complicated by gestational diabetes and 300,902 were complicated by PIH.

The overall rate of sleep apnea for these women was 1.14/10,000—but that rate was 4.01/10,000 among women with gestational diabetes and 5.52/10,000 among women with PIH.

When controlled for age and race, women with sleep apnea were 3.5 times more likely to develop gestational diabetes; when controlled for obesity, the odds ratio was still 2.3.

Similarly, the odds ratio for PIH in women with sleep apnea was 6.6 when controlling for age and race, and 4.2 after also controlling for obesity.

In an interview, Dr. Nolledo acknowledged that the overall rate of OSA recorded in the database—just over 1/10,000, or 0.01%—is much lower than the 2%–4% rate of OSA estimated for the general population.

He attributed this in part to the fact that physicians often don't think to ask their pregnant patients about sleep-disordered breathing.

An alternative explanation for the results is that physicians may ask about sleep-disordered breathing more frequently when faced with patients with gestational diabetes or PIH, he said, and that this alone can account for the apparent increases in risk.

SAN FRANCISCO — Pregnant women who have obstructive sleep apnea have a 2.3-fold increased risk of gestational diabetes and a 4.2-fold increased risk of pregnancy-induced hypertension, compared with women without the sleep disorder, according to a poster presentation at the International Conference of the American Thoracic Society.

Previous research has suggested that obstructive sleep apnea (OSA) may induce systemic hypertension and diabetes mellitus in the general population, but the connection was much less clear in pregnant women, investigator Dr. Michael S. Nolledo of the Robert Wood Johnson Medical School, Princeton, N.J., said in a press briefing.

“A lot of times for patients who are pregnant and for ob.gyns., sleep-disordered breathing is not on the radar screen,” he said. When a woman who is pregnant goes to see her obstetrician, the physician asks a zillion things but almost never inquires about risk factors for sleep apnea.

Dr. Nolledo suggested that physicians dealing with women with gestational diabetes or pregnancy-induced hypertension (PIH) should inquire about sleep-disordered breathing, especially because OSA is so simple to treat with continuous positive airway pressure (CPAP).

“It may be a condition that you need treatment for just for the time you're carrying your baby,” Dr. Nolledo commented. “Once you deliver, the sleep apnea may resolve.”

Dr. Nolledo acknowledged, however, that his study contains no direct evidence that treating sleep apnea will improve PIH or gestational diabetes.

The study relied on data from the 2003 National Inpatient Sample, sponsored by the Agency for Healthcare Research and Quality.

This large database includes all inpatient records from a sample of about 20% of U.S. community short-stay hospitals and provides weights to calculate national estimates.

Using this database, the investigators calculated that there were 3,979,840 deliveries in the United States in 2003, of which 167,227 were complicated by gestational diabetes and 300,902 were complicated by PIH.

The overall rate of sleep apnea for these women was 1.14/10,000—but that rate was 4.01/10,000 among women with gestational diabetes and 5.52/10,000 among women with PIH.

When controlled for age and race, women with sleep apnea were 3.5 times more likely to develop gestational diabetes; when controlled for obesity, the odds ratio was still 2.3.

Similarly, the odds ratio for PIH in women with sleep apnea was 6.6 when controlling for age and race, and 4.2 after also controlling for obesity.

In an interview, Dr. Nolledo acknowledged that the overall rate of OSA recorded in the database—just over 1/10,000, or 0.01%—is much lower than the 2%–4% rate of OSA estimated for the general population.

He attributed this in part to the fact that physicians often don't think to ask their pregnant patients about sleep-disordered breathing.

An alternative explanation for the results is that physicians may ask about sleep-disordered breathing more frequently when faced with patients with gestational diabetes or PIH, he said, and that this alone can account for the apparent increases in risk.

SAN FRANCISCO — Pregnant women who have obstructive sleep apnea have a 2.3-fold increased risk of gestational diabetes and a 4.2-fold increased risk of pregnancy-induced hypertension, compared with women without the sleep disorder, according to a poster presentation at the International Conference of the American Thoracic Society.

Previous research has suggested that obstructive sleep apnea (OSA) may induce systemic hypertension and diabetes mellitus in the general population, but the connection was much less clear in pregnant women, investigator Dr. Michael S. Nolledo of the Robert Wood Johnson Medical School, Princeton, N.J., said in a press briefing.

“A lot of times for patients who are pregnant and for ob.gyns., sleep-disordered breathing is not on the radar screen,” he said. When a woman who is pregnant goes to see her obstetrician, the physician asks a zillion things but almost never inquires about risk factors for sleep apnea.

Dr. Nolledo suggested that physicians dealing with women with gestational diabetes or pregnancy-induced hypertension (PIH) should inquire about sleep-disordered breathing, especially because OSA is so simple to treat with continuous positive airway pressure (CPAP).

“It may be a condition that you need treatment for just for the time you're carrying your baby,” Dr. Nolledo commented. “Once you deliver, the sleep apnea may resolve.”

Dr. Nolledo acknowledged, however, that his study contains no direct evidence that treating sleep apnea will improve PIH or gestational diabetes.

The study relied on data from the 2003 National Inpatient Sample, sponsored by the Agency for Healthcare Research and Quality.

This large database includes all inpatient records from a sample of about 20% of U.S. community short-stay hospitals and provides weights to calculate national estimates.

Using this database, the investigators calculated that there were 3,979,840 deliveries in the United States in 2003, of which 167,227 were complicated by gestational diabetes and 300,902 were complicated by PIH.

The overall rate of sleep apnea for these women was 1.14/10,000—but that rate was 4.01/10,000 among women with gestational diabetes and 5.52/10,000 among women with PIH.

When controlled for age and race, women with sleep apnea were 3.5 times more likely to develop gestational diabetes; when controlled for obesity, the odds ratio was still 2.3.

Similarly, the odds ratio for PIH in women with sleep apnea was 6.6 when controlling for age and race, and 4.2 after also controlling for obesity.

In an interview, Dr. Nolledo acknowledged that the overall rate of OSA recorded in the database—just over 1/10,000, or 0.01%—is much lower than the 2%–4% rate of OSA estimated for the general population.

He attributed this in part to the fact that physicians often don't think to ask their pregnant patients about sleep-disordered breathing.

An alternative explanation for the results is that physicians may ask about sleep-disordered breathing more frequently when faced with patients with gestational diabetes or PIH, he said, and that this alone can account for the apparent increases in risk.

Two large-scale studies of the possible teratogenic effects of selective serotonin reuptake inhibitors have concluded that the absolute risk of birth defects related to the drugs is small.

Neither study could confirm previously reported associations between SSRIs and heart defects. Both suggested that a few individual SSRIs might raise the risk of a few specific defects, but these malformations are so rare that even a large increase in risk would still put the chance of having an affected child at well under 1%, the researchers said in separate reports.

In the first report, Carol Louik, Sc.D., of Boston University's Slone Epidemiology Center, and associates analyzed data from the center's Birth Defects Study, an ongoing case-control surveillance program of a wide range of malformations, which covers areas surrounding Boston, Philadelphia, Toronto, San Diego, and a portion of New York State. The researchers focused on births that occurred between 1993 and 2004, which included 9,849 neonates with malformations and 5,860 neonates without malformations who served as controls.

They found no association between maternal use of SSRIs during pregnancy and heart defects as a whole, nor was there any association with craniosynostosis, omphalocele, or neural tube defects. However, the use of sertraline raised the risk of a single heart defect (cardiac septal defect), based on 13 cases, and the use of paroxetine raised the risk of another single heart defect (right ventricular outflow tract obstruction), based on 6 cases.

In addition, the data “suggested” possible links between sertraline and both anal atresia and limb-reduction defects, and possible links between paroxetine and both neural-tube defects and clubfoot.

Despite the relatively large study population, the investigators said they had limited numbers to evaluate associations between rare outcomes and exposures. “We included results based on small numbers of exposed subjects in order to allow other researchers to compare their observations with ours, but we caution that these estimates should not be interpreted as strong evidence of increased risks,” Dr. Louik and associates said (N. Engl. J. Med. 2007;356:2675–83).

In any case, “it is important to keep in perspective that the absolute risks of these rare defects are small. For example, the baseline prevalences of anal atresia and right ventricular outflow tract obstruction defects are each estimated to be about 5.5 cases per 10,000 live births; thus, even if a specific SSRI increased rates by a factor of four, the risk of having an affected child would still be only 0.2%,” they noted.

In the second study, Sura Alwan of the University of British Columbia, Vancouver, and associates analyzed data from the National Birth Defects Prevention Study on infants born between 1997 and 2002 in eight study sites throughout the United States. This included 9,622 neonates with birth defects and 4,092 without birth defects who served as controls.

Again, no associations were found between SSRIs and most of the birth defects assessed, including heart defects as a group. However, a small but significant association was found between paroxetine use and right ventricular outflow tract obstruction, based on six cases.

There also were small but significant associations with anencephaly (based on 9 exposed neonates), craniosynostosis (based on 24 exposed neonates), and omphalocele (based on 11 exposed neonates).

“Our study did not show an increased risk of most birth defects, and SSRI exposure was present in only a small number of cases of certain defects. The absolute risks associated with SSRIs appear small in comparison with the baseline risks of birth defects that exist in every pregnancy,” the researchers reported (N. Engl. J. Med. 2007;356:2684–92).

In an editorial comment accompanying this report, Dr. Michael F. Greene of Massachusetts General Hospital, Boston, said the findings of both studies make it clear that “neither SSRIs as a group nor individual SSRIs are major teratogens.” Even with the association found between paroxetine and right ventricular outflow obstruction, the malformation is so rare and the number of neonates exposed to the drug so small that the absolute incidence in exposed neonates “is unlikely to exceed 1%, and the incidence of all congenital heart defects is unlikely to exceed 2%,” he noted (N. Engl. J. Med. 2007;356:2732–3).

Two large-scale studies of the possible teratogenic effects of selective serotonin reuptake inhibitors have concluded that the absolute risk of birth defects related to the drugs is small.

Neither study could confirm previously reported associations between SSRIs and heart defects. Both suggested that a few individual SSRIs might raise the risk of a few specific defects, but these malformations are so rare that even a large increase in risk would still put the chance of having an affected child at well under 1%, the researchers said in separate reports.

In the first report, Carol Louik, Sc.D., of Boston University's Slone Epidemiology Center, and associates analyzed data from the center's Birth Defects Study, an ongoing case-control surveillance program of a wide range of malformations, which covers areas surrounding Boston, Philadelphia, Toronto, San Diego, and a portion of New York State. The researchers focused on births that occurred between 1993 and 2004, which included 9,849 neonates with malformations and 5,860 neonates without malformations who served as controls.

They found no association between maternal use of SSRIs during pregnancy and heart defects as a whole, nor was there any association with craniosynostosis, omphalocele, or neural tube defects. However, the use of sertraline raised the risk of a single heart defect (cardiac septal defect), based on 13 cases, and the use of paroxetine raised the risk of another single heart defect (right ventricular outflow tract obstruction), based on 6 cases.

In addition, the data “suggested” possible links between sertraline and both anal atresia and limb-reduction defects, and possible links between paroxetine and both neural-tube defects and clubfoot.

Despite the relatively large study population, the investigators said they had limited numbers to evaluate associations between rare outcomes and exposures. “We included results based on small numbers of exposed subjects in order to allow other researchers to compare their observations with ours, but we caution that these estimates should not be interpreted as strong evidence of increased risks,” Dr. Louik and associates said (N. Engl. J. Med. 2007;356:2675–83).

In any case, “it is important to keep in perspective that the absolute risks of these rare defects are small. For example, the baseline prevalences of anal atresia and right ventricular outflow tract obstruction defects are each estimated to be about 5.5 cases per 10,000 live births; thus, even if a specific SSRI increased rates by a factor of four, the risk of having an affected child would still be only 0.2%,” they noted.

In the second study, Sura Alwan of the University of British Columbia, Vancouver, and associates analyzed data from the National Birth Defects Prevention Study on infants born between 1997 and 2002 in eight study sites throughout the United States. This included 9,622 neonates with birth defects and 4,092 without birth defects who served as controls.

Again, no associations were found between SSRIs and most of the birth defects assessed, including heart defects as a group. However, a small but significant association was found between paroxetine use and right ventricular outflow tract obstruction, based on six cases.

There also were small but significant associations with anencephaly (based on 9 exposed neonates), craniosynostosis (based on 24 exposed neonates), and omphalocele (based on 11 exposed neonates).

“Our study did not show an increased risk of most birth defects, and SSRI exposure was present in only a small number of cases of certain defects. The absolute risks associated with SSRIs appear small in comparison with the baseline risks of birth defects that exist in every pregnancy,” the researchers reported (N. Engl. J. Med. 2007;356:2684–92).

In an editorial comment accompanying this report, Dr. Michael F. Greene of Massachusetts General Hospital, Boston, said the findings of both studies make it clear that “neither SSRIs as a group nor individual SSRIs are major teratogens.” Even with the association found between paroxetine and right ventricular outflow obstruction, the malformation is so rare and the number of neonates exposed to the drug so small that the absolute incidence in exposed neonates “is unlikely to exceed 1%, and the incidence of all congenital heart defects is unlikely to exceed 2%,” he noted (N. Engl. J. Med. 2007;356:2732–3).

Two large-scale studies of the possible teratogenic effects of selective serotonin reuptake inhibitors have concluded that the absolute risk of birth defects related to the drugs is small.

Neither study could confirm previously reported associations between SSRIs and heart defects. Both suggested that a few individual SSRIs might raise the risk of a few specific defects, but these malformations are so rare that even a large increase in risk would still put the chance of having an affected child at well under 1%, the researchers said in separate reports.

In the first report, Carol Louik, Sc.D., of Boston University's Slone Epidemiology Center, and associates analyzed data from the center's Birth Defects Study, an ongoing case-control surveillance program of a wide range of malformations, which covers areas surrounding Boston, Philadelphia, Toronto, San Diego, and a portion of New York State. The researchers focused on births that occurred between 1993 and 2004, which included 9,849 neonates with malformations and 5,860 neonates without malformations who served as controls.

They found no association between maternal use of SSRIs during pregnancy and heart defects as a whole, nor was there any association with craniosynostosis, omphalocele, or neural tube defects. However, the use of sertraline raised the risk of a single heart defect (cardiac septal defect), based on 13 cases, and the use of paroxetine raised the risk of another single heart defect (right ventricular outflow tract obstruction), based on 6 cases.

In addition, the data “suggested” possible links between sertraline and both anal atresia and limb-reduction defects, and possible links between paroxetine and both neural-tube defects and clubfoot.

Despite the relatively large study population, the investigators said they had limited numbers to evaluate associations between rare outcomes and exposures. “We included results based on small numbers of exposed subjects in order to allow other researchers to compare their observations with ours, but we caution that these estimates should not be interpreted as strong evidence of increased risks,” Dr. Louik and associates said (N. Engl. J. Med. 2007;356:2675–83).

In any case, “it is important to keep in perspective that the absolute risks of these rare defects are small. For example, the baseline prevalences of anal atresia and right ventricular outflow tract obstruction defects are each estimated to be about 5.5 cases per 10,000 live births; thus, even if a specific SSRI increased rates by a factor of four, the risk of having an affected child would still be only 0.2%,” they noted.

In the second study, Sura Alwan of the University of British Columbia, Vancouver, and associates analyzed data from the National Birth Defects Prevention Study on infants born between 1997 and 2002 in eight study sites throughout the United States. This included 9,622 neonates with birth defects and 4,092 without birth defects who served as controls.

Again, no associations were found between SSRIs and most of the birth defects assessed, including heart defects as a group. However, a small but significant association was found between paroxetine use and right ventricular outflow tract obstruction, based on six cases.

There also were small but significant associations with anencephaly (based on 9 exposed neonates), craniosynostosis (based on 24 exposed neonates), and omphalocele (based on 11 exposed neonates).

“Our study did not show an increased risk of most birth defects, and SSRI exposure was present in only a small number of cases of certain defects. The absolute risks associated with SSRIs appear small in comparison with the baseline risks of birth defects that exist in every pregnancy,” the researchers reported (N. Engl. J. Med. 2007;356:2684–92).

In an editorial comment accompanying this report, Dr. Michael F. Greene of Massachusetts General Hospital, Boston, said the findings of both studies make it clear that “neither SSRIs as a group nor individual SSRIs are major teratogens.” Even with the association found between paroxetine and right ventricular outflow obstruction, the malformation is so rare and the number of neonates exposed to the drug so small that the absolute incidence in exposed neonates “is unlikely to exceed 1%, and the incidence of all congenital heart defects is unlikely to exceed 2%,” he noted (N. Engl. J. Med. 2007;356:2732–3).

LAS VEGAS — Patients who present with localized erythema near the site of a tick bite should not necessarily be referred for laboratory tests, Dr. Jana Hercogova said at a dermatology seminar sponsored by Skin Disease Education Foundation.

In fact, a tick bite followed by a local skin reaction should simply be examined in 1 week and, if the redness persists, treated with antibiotics, said Dr. Hercogova of Charles University, Prague.

Dr. Hercogova said that physicians treating pregnant women should consider the gestational age when choosing treatment. In the first trimester, she advised using penicillin G 20 million U/day for 2 days, with oral antibiotics as an option for the following 2 weeks. If infection is suspected to have begun in the second or third trimester, she said she uses only oral antibiotics—mainly penicillin derivatives.

Physicians should also be familiar with macular and annular erythema migrans, she noted, adding that patients with morphea should also be tested for Borrelia infection. However, she cautioned, “we should treat the patient without [serologic] evidence if we see a clinically clear case.”

If tests are done and come back positive for Lyme disease, she recommended treating the patient with doxycycline or penicillin, depending on whether Ehrlichia coinfection is present.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

LAS VEGAS — Patients who present with localized erythema near the site of a tick bite should not necessarily be referred for laboratory tests, Dr. Jana Hercogova said at a dermatology seminar sponsored by Skin Disease Education Foundation.

In fact, a tick bite followed by a local skin reaction should simply be examined in 1 week and, if the redness persists, treated with antibiotics, said Dr. Hercogova of Charles University, Prague.

Dr. Hercogova said that physicians treating pregnant women should consider the gestational age when choosing treatment. In the first trimester, she advised using penicillin G 20 million U/day for 2 days, with oral antibiotics as an option for the following 2 weeks. If infection is suspected to have begun in the second or third trimester, she said she uses only oral antibiotics—mainly penicillin derivatives.

Physicians should also be familiar with macular and annular erythema migrans, she noted, adding that patients with morphea should also be tested for Borrelia infection. However, she cautioned, “we should treat the patient without [serologic] evidence if we see a clinically clear case.”

If tests are done and come back positive for Lyme disease, she recommended treating the patient with doxycycline or penicillin, depending on whether Ehrlichia coinfection is present.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

LAS VEGAS — Patients who present with localized erythema near the site of a tick bite should not necessarily be referred for laboratory tests, Dr. Jana Hercogova said at a dermatology seminar sponsored by Skin Disease Education Foundation.

In fact, a tick bite followed by a local skin reaction should simply be examined in 1 week and, if the redness persists, treated with antibiotics, said Dr. Hercogova of Charles University, Prague.

Dr. Hercogova said that physicians treating pregnant women should consider the gestational age when choosing treatment. In the first trimester, she advised using penicillin G 20 million U/day for 2 days, with oral antibiotics as an option for the following 2 weeks. If infection is suspected to have begun in the second or third trimester, she said she uses only oral antibiotics—mainly penicillin derivatives.

Physicians should also be familiar with macular and annular erythema migrans, she noted, adding that patients with morphea should also be tested for Borrelia infection. However, she cautioned, “we should treat the patient without [serologic] evidence if we see a clinically clear case.”

If tests are done and come back positive for Lyme disease, she recommended treating the patient with doxycycline or penicillin, depending on whether Ehrlichia coinfection is present.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

KANSAS CITY, MO. — A staff and bilingual patient education program dramatically increased immunizations for pregnant women in Suffolk County, New York.

But progress in this massive county of 1.3 million residents could be thwarted by state legislation banning the use of vaccines containing thimerosal, Mary Koslap-Petraco said at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

A staff education program was developed for obstetricians, nurse-practitioners, and registered nurses at prenatal clinics in all eight primary health centers and three satellite offices run by the Suffolk County Department of Health Services (DHS). The nursing staff then developed a bilingual teaching program in Spanish and English for the women attending the clinics.

The largest ethnic group in the county is Hispanic, many of whom are immigrants, followed by African American, white, Asian, and Native American. All of the patients were enrolled in the Medicaid prenatal assistance program.

Immunization status was checked for each pregnant woman for three targeted vaccines: tetanus and diphtheria (Td), hepatitis A/B, and influenza. Each woman was then offered an immunization, and given vaccine-specific education. A written immunization record was provided for each patient to take home, noting when her next vaccination was due.

“When we started this program, we really didn't vaccinate pregnant women with much more than flu shots, if we even did that,” said Ms. Koslap-Petraco, a certified pediatric nurse-practitioner, and coordinator of child health for Suffolk County, Hauppauge, N.Y.

In 2005, 954 flu shots and no Td or hepatitis vaccines were administered. In 2006, those numbers jumped to 1,381 influenza, 505 Td, and 1,307 hepatitis A/B vaccines.

Vaccination of pregnant women remains unsupported among many health care professionals, and the current legislative climate provides yet another reason not to vaccinate. In 2006, New York, Missouri, and Washington joined California, Delaware, Illinois, and Iowa in enacting legislation that would restrict the use of thimerosal-containing vaccines. The law is not effective in New York until July 1, 2008.

But Suffolk County passed its own local ordinance in 2006 prohibiting thimerosal-containing vaccines for children up to age 4 years and pregnant women who attend county health centers. The local law caused many nurses to stop immunizing pregnant women for influenza once the supply of thimerosal-free vaccine ran out, Ms. Koslap-Petraco said.

KANSAS CITY, MO. — A staff and bilingual patient education program dramatically increased immunizations for pregnant women in Suffolk County, New York.

But progress in this massive county of 1.3 million residents could be thwarted by state legislation banning the use of vaccines containing thimerosal, Mary Koslap-Petraco said at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

A staff education program was developed for obstetricians, nurse-practitioners, and registered nurses at prenatal clinics in all eight primary health centers and three satellite offices run by the Suffolk County Department of Health Services (DHS). The nursing staff then developed a bilingual teaching program in Spanish and English for the women attending the clinics.

The largest ethnic group in the county is Hispanic, many of whom are immigrants, followed by African American, white, Asian, and Native American. All of the patients were enrolled in the Medicaid prenatal assistance program.

Immunization status was checked for each pregnant woman for three targeted vaccines: tetanus and diphtheria (Td), hepatitis A/B, and influenza. Each woman was then offered an immunization, and given vaccine-specific education. A written immunization record was provided for each patient to take home, noting when her next vaccination was due.

“When we started this program, we really didn't vaccinate pregnant women with much more than flu shots, if we even did that,” said Ms. Koslap-Petraco, a certified pediatric nurse-practitioner, and coordinator of child health for Suffolk County, Hauppauge, N.Y.

In 2005, 954 flu shots and no Td or hepatitis vaccines were administered. In 2006, those numbers jumped to 1,381 influenza, 505 Td, and 1,307 hepatitis A/B vaccines.

Vaccination of pregnant women remains unsupported among many health care professionals, and the current legislative climate provides yet another reason not to vaccinate. In 2006, New York, Missouri, and Washington joined California, Delaware, Illinois, and Iowa in enacting legislation that would restrict the use of thimerosal-containing vaccines. The law is not effective in New York until July 1, 2008.

But Suffolk County passed its own local ordinance in 2006 prohibiting thimerosal-containing vaccines for children up to age 4 years and pregnant women who attend county health centers. The local law caused many nurses to stop immunizing pregnant women for influenza once the supply of thimerosal-free vaccine ran out, Ms. Koslap-Petraco said.

KANSAS CITY, MO. — A staff and bilingual patient education program dramatically increased immunizations for pregnant women in Suffolk County, New York.

But progress in this massive county of 1.3 million residents could be thwarted by state legislation banning the use of vaccines containing thimerosal, Mary Koslap-Petraco said at the National Immunization Conference sponsored by the Centers for Disease Control and Prevention.

A staff education program was developed for obstetricians, nurse-practitioners, and registered nurses at prenatal clinics in all eight primary health centers and three satellite offices run by the Suffolk County Department of Health Services (DHS). The nursing staff then developed a bilingual teaching program in Spanish and English for the women attending the clinics.

The largest ethnic group in the county is Hispanic, many of whom are immigrants, followed by African American, white, Asian, and Native American. All of the patients were enrolled in the Medicaid prenatal assistance program.

Immunization status was checked for each pregnant woman for three targeted vaccines: tetanus and diphtheria (Td), hepatitis A/B, and influenza. Each woman was then offered an immunization, and given vaccine-specific education. A written immunization record was provided for each patient to take home, noting when her next vaccination was due.

“When we started this program, we really didn't vaccinate pregnant women with much more than flu shots, if we even did that,” said Ms. Koslap-Petraco, a certified pediatric nurse-practitioner, and coordinator of child health for Suffolk County, Hauppauge, N.Y.

In 2005, 954 flu shots and no Td or hepatitis vaccines were administered. In 2006, those numbers jumped to 1,381 influenza, 505 Td, and 1,307 hepatitis A/B vaccines.

Vaccination of pregnant women remains unsupported among many health care professionals, and the current legislative climate provides yet another reason not to vaccinate. In 2006, New York, Missouri, and Washington joined California, Delaware, Illinois, and Iowa in enacting legislation that would restrict the use of thimerosal-containing vaccines. The law is not effective in New York until July 1, 2008.

But Suffolk County passed its own local ordinance in 2006 prohibiting thimerosal-containing vaccines for children up to age 4 years and pregnant women who attend county health centers. The local law caused many nurses to stop immunizing pregnant women for influenza once the supply of thimerosal-free vaccine ran out, Ms. Koslap-Petraco said.