Obstetrics

RIVIERA MAYA, MEXICO — Expect the unexpected during a fetal ultrasound exam, and if you find it, be kind but unambiguous in describing your observations and concerns.

“The ambiguity we sometimes use to try and soften what we are saying doesn't change the message, but it can change the interpretation,” Dr. Nancy Chescheir said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“If there is no fetal heart activity, tell the patient her baby's heart is not beating and that the fetus has died. If you see findings suggestive of a fetal anomaly, describe exactly what you see, express your concern, and refer the patient to an expert as quickly as possible,” said Dr. Chescheir, the Betty and Lonnie S. Burnett Professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn.

Many diagnoses of fetal demise or anomaly will be discovered during a detailed anatomic scan ordered on the basis of some increased risk, including a poor past pregnancy outcome, family history of genetic disorders, or abnormal early biomarker studies. In these cases, the patient probably already has an idea that there may be a serious problem.

“The patient is already suspicious. They watch the ultrasound; they may have had scans before, and they know what fetal heart activity looks like. If you are certain of the diagnosis of fetal demise, be very kind, do it in private, but be unambiguous about what you are seeing.”

In cases of uncertainty, the 5–10–20 rules can be a help, Dr. Chescheir said. “If you have a 5-mm crown-rump length, you have to see a heartbeat or you have a dead baby. There's no need to have her come back in 48 hours for a repeat scan or to do hormone levels.”

If the fetus measures only 4.5 mm from crown to rump, however, you should ask the woman to come back for a repeat scan when you anticipate a length of 5 mm. “You will probably have to wait at least 3 days to see this growth. If at that time, you have a 5-mm length and still no heartbeat, make the diagnosis and get on with your therapeutic options.”

For a gestational sac with a mean diameter of 10 mm, you must see a yolk sac; if you don't, the pregnancy is not viable. Similarly, for a 20-mm mean gestational sac, you must see a fetal pole. The absence of one means the pregnancy is not viable, Dr. Chescheir said at the meeting, which was sponsored by Boston University.

Surveys about patient satisfaction with fetal ultrasound diagnosis agree on one thing, Dr. Chescheir said: Women don't appreciate the delay between the moment a problem is identified and the moment the doctor communicates the problem.

“They really don't like it if the sonographer is not allowed to say anything during the exam,” Dr. Chescheir said. “If the sonographer is fairly certain about a fetal demise, she should be able to say something. You may not want her making the diagnosis, but she should be allowed to tell the patient something.”

Having very clear office procedures can avert problems in this area, she said.

RIVIERA MAYA, MEXICO — Expect the unexpected during a fetal ultrasound exam, and if you find it, be kind but unambiguous in describing your observations and concerns.

“The ambiguity we sometimes use to try and soften what we are saying doesn't change the message, but it can change the interpretation,” Dr. Nancy Chescheir said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“If there is no fetal heart activity, tell the patient her baby's heart is not beating and that the fetus has died. If you see findings suggestive of a fetal anomaly, describe exactly what you see, express your concern, and refer the patient to an expert as quickly as possible,” said Dr. Chescheir, the Betty and Lonnie S. Burnett Professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn.

Many diagnoses of fetal demise or anomaly will be discovered during a detailed anatomic scan ordered on the basis of some increased risk, including a poor past pregnancy outcome, family history of genetic disorders, or abnormal early biomarker studies. In these cases, the patient probably already has an idea that there may be a serious problem.

“The patient is already suspicious. They watch the ultrasound; they may have had scans before, and they know what fetal heart activity looks like. If you are certain of the diagnosis of fetal demise, be very kind, do it in private, but be unambiguous about what you are seeing.”

In cases of uncertainty, the 5–10–20 rules can be a help, Dr. Chescheir said. “If you have a 5-mm crown-rump length, you have to see a heartbeat or you have a dead baby. There's no need to have her come back in 48 hours for a repeat scan or to do hormone levels.”

If the fetus measures only 4.5 mm from crown to rump, however, you should ask the woman to come back for a repeat scan when you anticipate a length of 5 mm. “You will probably have to wait at least 3 days to see this growth. If at that time, you have a 5-mm length and still no heartbeat, make the diagnosis and get on with your therapeutic options.”

For a gestational sac with a mean diameter of 10 mm, you must see a yolk sac; if you don't, the pregnancy is not viable. Similarly, for a 20-mm mean gestational sac, you must see a fetal pole. The absence of one means the pregnancy is not viable, Dr. Chescheir said at the meeting, which was sponsored by Boston University.

Surveys about patient satisfaction with fetal ultrasound diagnosis agree on one thing, Dr. Chescheir said: Women don't appreciate the delay between the moment a problem is identified and the moment the doctor communicates the problem.

“They really don't like it if the sonographer is not allowed to say anything during the exam,” Dr. Chescheir said. “If the sonographer is fairly certain about a fetal demise, she should be able to say something. You may not want her making the diagnosis, but she should be allowed to tell the patient something.”

Having very clear office procedures can avert problems in this area, she said.

RIVIERA MAYA, MEXICO — Expect the unexpected during a fetal ultrasound exam, and if you find it, be kind but unambiguous in describing your observations and concerns.

“The ambiguity we sometimes use to try and soften what we are saying doesn't change the message, but it can change the interpretation,” Dr. Nancy Chescheir said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

“If there is no fetal heart activity, tell the patient her baby's heart is not beating and that the fetus has died. If you see findings suggestive of a fetal anomaly, describe exactly what you see, express your concern, and refer the patient to an expert as quickly as possible,” said Dr. Chescheir, the Betty and Lonnie S. Burnett Professor of obstetrics and gynecology at Vanderbilt University, Nashville, Tenn.

Many diagnoses of fetal demise or anomaly will be discovered during a detailed anatomic scan ordered on the basis of some increased risk, including a poor past pregnancy outcome, family history of genetic disorders, or abnormal early biomarker studies. In these cases, the patient probably already has an idea that there may be a serious problem.

“The patient is already suspicious. They watch the ultrasound; they may have had scans before, and they know what fetal heart activity looks like. If you are certain of the diagnosis of fetal demise, be very kind, do it in private, but be unambiguous about what you are seeing.”

In cases of uncertainty, the 5–10–20 rules can be a help, Dr. Chescheir said. “If you have a 5-mm crown-rump length, you have to see a heartbeat or you have a dead baby. There's no need to have her come back in 48 hours for a repeat scan or to do hormone levels.”

If the fetus measures only 4.5 mm from crown to rump, however, you should ask the woman to come back for a repeat scan when you anticipate a length of 5 mm. “You will probably have to wait at least 3 days to see this growth. If at that time, you have a 5-mm length and still no heartbeat, make the diagnosis and get on with your therapeutic options.”

For a gestational sac with a mean diameter of 10 mm, you must see a yolk sac; if you don't, the pregnancy is not viable. Similarly, for a 20-mm mean gestational sac, you must see a fetal pole. The absence of one means the pregnancy is not viable, Dr. Chescheir said at the meeting, which was sponsored by Boston University.

Surveys about patient satisfaction with fetal ultrasound diagnosis agree on one thing, Dr. Chescheir said: Women don't appreciate the delay between the moment a problem is identified and the moment the doctor communicates the problem.

“They really don't like it if the sonographer is not allowed to say anything during the exam,” Dr. Chescheir said. “If the sonographer is fairly certain about a fetal demise, she should be able to say something. You may not want her making the diagnosis, but she should be allowed to tell the patient something.”

Having very clear office procedures can avert problems in this area, she said.

NEW YORK — Any pregnant woman who has anti-Ro/La antibodies should have weekly fetal echocardiograms beginning at 16 weeks' gestation to look for possible signs of congenital heart block, Dr. Jill P. Buyon said at a rheumatology meeting sponsored by New York University.

During pregnancy these autoantibodies, typically found in high titers in patients with systemic lupus erythematosus and Sjögren's syndrome but also in some asymptomatic individuals, begin to cross the placenta as early as 11 weeks. The autoantibodies accumulate in the fetal circulation and are associated with the development of various manifestations of neonatal lupus, particularly prolongation of the mechanical PR interval and congenital atrioventricular block.

The importance of early detection of these autoantibodies in the fetus is underscored by the fact that once third-degree, or complete, heart block has developed, it is irreversible with current therapies, according to Dr. Buyon, professor of medicine, department of rheumatology, New York University, New York City.

Moreover, anti-Ro/La congenital heart block carries a 20% mortality, and at present the majority of children who survive need a pacemaker.

Intense research interest therefore is focused on identifying markers of early cardiac injury, at a point before fibrosis and scarring are permanent, and on the potential for therapeutic interventions to reverse early changes.

The use of cardiac monitoring to detect prolongations of the PR interval greater than 150 milliseconds was recently evaluated in the observational PR Interval and Dexamethasone Evaluation (PRIDE) study of pregnant women who were positive for anti-Ro and/or anti-La antibodies. The study also attempted to provide some data on outcomes following the administration of steroids.

Fetal echocardiography was performed weekly between weeks 16 and 26, and then biweekly between weeks 26 and 34, according to Dr. Buyon, one of the study investigators. She and her colleagues were looking for prolongation of the PR interval, evidence of tricuspid regurgitation, and unexplained atrial echodensities.

Among the 88 patients who completed an evaluable course, there were three cases of third-degree heart block.

One of these patients had a normal PR interval, but some tricuspid regurgitation was noted at 17 weeks and atrial echodensity, at 22 weeks. A week later the fetus was in third-degree heart block and, despite treatment with maternal dexamethasone, 4 mg/day, severe hydrops developed and the pregnancy was terminated.

The second fetus had a normal PR interval between weeks 16 and 18 along with mild tricuspid regurgitation at week 17. The mother missed an appointment and, by the next time she was seen, third-degree block had developed in the fetus. This persisted despite administration of dexamethasone, and the child continued to be followed after birth (Arthritis Rheum. 2006;54:S689).

The third fetus also had a normal PR interval at 18 weeks, but 10 days later the fetus was in third-degree block and hydropic. Treatment with dexamethasone was unsuccessful, and the pregnancy was terminated at 20.5 weeks.

First-degree block was detected in an additional three fetuses. In one, the PR was normal at weeks 16–18, was prolonged at week 19, and normalized within 7 days of dexamethasone treatment.

The second had a prolonged PR interval at week 22 that resolved within 3 days of dexamethasone treatment. These two patients both had normal electrocardiograms at birth.

The third fetus had normal PR intervals throughout gestation but an electrocardiogram at birth showed first-degree block that has persisted to age 3 years.

Dexamethasone was also used in nine cases of second-degree block. Of these, four fetuses progressed to third-degree block, four remained in second, and only one was born in normal sinus rhythm. “This was a little disappointing,” Dr. Buyon said.

Of the 79 neonates for whom birth electrocardiograms were available, 78 were normal, and all 46 for whom 1-year follow-up electrocardiograms were available were normal, she said.

In conclusion, the study suggests the following, according to Dr. Buyon:

▸ First-degree block in utero is reversible with dexamethasone, but if present at birth, close observation by a cardiologist is needed because of the possibility of later progression.

▸ There has not been evidence of conduction abnormalities developing later in neonates whose electrocardiogram was normal at birth.

▸ Advanced cardiomyopathy can occur within 7 days of a normal PR interval, so even weekly evaluation may not be sufficient.

▸ Tricuspid regurgitation may be an important early marker of injury.

Dexamethasone treatment poses significant hazards to both mother and fetus, with maternal risks including diabetes and hypertension, and fetal risks including intrauterine growth retardation, adrenal suppression, and decreased brain growth. Moreover, as was seen in PRIDE, efficacy is hardly guaranteed. Accordingly, other therapeutic approaches are being investigated, including inhibition of transforming growth factor-β to limit fibrosis and prophylaxis with intravenous immune globulin (see box).

Next: Will IVIG Prevent Heart Block?

Intravenous immune globulin (IVIG) has a history of safely being used in pregnancy, primarily for autoimmune thrombocytopenia and immune deficiency syndromes. A few cases of successful use in congenital heart block have also been reported.

To determine if this prophylactic approach could reliably decrease the placental transport of anti-SS-A/Ro and anti-SS-B/La antibodies, the Preventive IVIG Therapy for Congenital Heart Block (PITCH) trial is now enrolling patients.

Sponsored by New York University School of Medicine and the Alliance for Lupus Research, the trial aims to enroll 19 women who are antibody positive and have already had a child with congenital heart block or a rash that might have been neonatal lupus. Such mothers are at much higher risk of having another child with congenital heart block than are mothers positive for anti-Ro/La who have not already had an affected child.

Participants will be given 400 mg/kg of IVIG every 3 weeks for a total of five treatments between weeks 12 and 24 of pregnancy.

If fewer than three fetuses develop second- or third-degree heart block, another 35 women will be enrolled in the PITCHtrial.

“Then, if there are fewer than six cases of heart block out of 54, we will be on the way to having a prophylactic therapy,” said Dr. Buyon, who is principal investigator for the trial.

Information about PITCH is available at

http://clinicaltrials.gov/show/NCT00460928

NEW YORK — Any pregnant woman who has anti-Ro/La antibodies should have weekly fetal echocardiograms beginning at 16 weeks' gestation to look for possible signs of congenital heart block, Dr. Jill P. Buyon said at a rheumatology meeting sponsored by New York University.

During pregnancy these autoantibodies, typically found in high titers in patients with systemic lupus erythematosus and Sjögren's syndrome but also in some asymptomatic individuals, begin to cross the placenta as early as 11 weeks. The autoantibodies accumulate in the fetal circulation and are associated with the development of various manifestations of neonatal lupus, particularly prolongation of the mechanical PR interval and congenital atrioventricular block.

The importance of early detection of these autoantibodies in the fetus is underscored by the fact that once third-degree, or complete, heart block has developed, it is irreversible with current therapies, according to Dr. Buyon, professor of medicine, department of rheumatology, New York University, New York City.

Moreover, anti-Ro/La congenital heart block carries a 20% mortality, and at present the majority of children who survive need a pacemaker.

Intense research interest therefore is focused on identifying markers of early cardiac injury, at a point before fibrosis and scarring are permanent, and on the potential for therapeutic interventions to reverse early changes.

The use of cardiac monitoring to detect prolongations of the PR interval greater than 150 milliseconds was recently evaluated in the observational PR Interval and Dexamethasone Evaluation (PRIDE) study of pregnant women who were positive for anti-Ro and/or anti-La antibodies. The study also attempted to provide some data on outcomes following the administration of steroids.

Fetal echocardiography was performed weekly between weeks 16 and 26, and then biweekly between weeks 26 and 34, according to Dr. Buyon, one of the study investigators. She and her colleagues were looking for prolongation of the PR interval, evidence of tricuspid regurgitation, and unexplained atrial echodensities.

Among the 88 patients who completed an evaluable course, there were three cases of third-degree heart block.

One of these patients had a normal PR interval, but some tricuspid regurgitation was noted at 17 weeks and atrial echodensity, at 22 weeks. A week later the fetus was in third-degree heart block and, despite treatment with maternal dexamethasone, 4 mg/day, severe hydrops developed and the pregnancy was terminated.

The second fetus had a normal PR interval between weeks 16 and 18 along with mild tricuspid regurgitation at week 17. The mother missed an appointment and, by the next time she was seen, third-degree block had developed in the fetus. This persisted despite administration of dexamethasone, and the child continued to be followed after birth (Arthritis Rheum. 2006;54:S689).

The third fetus also had a normal PR interval at 18 weeks, but 10 days later the fetus was in third-degree block and hydropic. Treatment with dexamethasone was unsuccessful, and the pregnancy was terminated at 20.5 weeks.

First-degree block was detected in an additional three fetuses. In one, the PR was normal at weeks 16–18, was prolonged at week 19, and normalized within 7 days of dexamethasone treatment.

The second had a prolonged PR interval at week 22 that resolved within 3 days of dexamethasone treatment. These two patients both had normal electrocardiograms at birth.

The third fetus had normal PR intervals throughout gestation but an electrocardiogram at birth showed first-degree block that has persisted to age 3 years.

Dexamethasone was also used in nine cases of second-degree block. Of these, four fetuses progressed to third-degree block, four remained in second, and only one was born in normal sinus rhythm. “This was a little disappointing,” Dr. Buyon said.

Of the 79 neonates for whom birth electrocardiograms were available, 78 were normal, and all 46 for whom 1-year follow-up electrocardiograms were available were normal, she said.

In conclusion, the study suggests the following, according to Dr. Buyon:

▸ First-degree block in utero is reversible with dexamethasone, but if present at birth, close observation by a cardiologist is needed because of the possibility of later progression.

▸ There has not been evidence of conduction abnormalities developing later in neonates whose electrocardiogram was normal at birth.

▸ Advanced cardiomyopathy can occur within 7 days of a normal PR interval, so even weekly evaluation may not be sufficient.

▸ Tricuspid regurgitation may be an important early marker of injury.

Dexamethasone treatment poses significant hazards to both mother and fetus, with maternal risks including diabetes and hypertension, and fetal risks including intrauterine growth retardation, adrenal suppression, and decreased brain growth. Moreover, as was seen in PRIDE, efficacy is hardly guaranteed. Accordingly, other therapeutic approaches are being investigated, including inhibition of transforming growth factor-β to limit fibrosis and prophylaxis with intravenous immune globulin (see box).

Next: Will IVIG Prevent Heart Block?

Intravenous immune globulin (IVIG) has a history of safely being used in pregnancy, primarily for autoimmune thrombocytopenia and immune deficiency syndromes. A few cases of successful use in congenital heart block have also been reported.

To determine if this prophylactic approach could reliably decrease the placental transport of anti-SS-A/Ro and anti-SS-B/La antibodies, the Preventive IVIG Therapy for Congenital Heart Block (PITCH) trial is now enrolling patients.

Sponsored by New York University School of Medicine and the Alliance for Lupus Research, the trial aims to enroll 19 women who are antibody positive and have already had a child with congenital heart block or a rash that might have been neonatal lupus. Such mothers are at much higher risk of having another child with congenital heart block than are mothers positive for anti-Ro/La who have not already had an affected child.

Participants will be given 400 mg/kg of IVIG every 3 weeks for a total of five treatments between weeks 12 and 24 of pregnancy.

If fewer than three fetuses develop second- or third-degree heart block, another 35 women will be enrolled in the PITCHtrial.

“Then, if there are fewer than six cases of heart block out of 54, we will be on the way to having a prophylactic therapy,” said Dr. Buyon, who is principal investigator for the trial.

Information about PITCH is available at

http://clinicaltrials.gov/show/NCT00460928

NEW YORK — Any pregnant woman who has anti-Ro/La antibodies should have weekly fetal echocardiograms beginning at 16 weeks' gestation to look for possible signs of congenital heart block, Dr. Jill P. Buyon said at a rheumatology meeting sponsored by New York University.

During pregnancy these autoantibodies, typically found in high titers in patients with systemic lupus erythematosus and Sjögren's syndrome but also in some asymptomatic individuals, begin to cross the placenta as early as 11 weeks. The autoantibodies accumulate in the fetal circulation and are associated with the development of various manifestations of neonatal lupus, particularly prolongation of the mechanical PR interval and congenital atrioventricular block.

The importance of early detection of these autoantibodies in the fetus is underscored by the fact that once third-degree, or complete, heart block has developed, it is irreversible with current therapies, according to Dr. Buyon, professor of medicine, department of rheumatology, New York University, New York City.

Moreover, anti-Ro/La congenital heart block carries a 20% mortality, and at present the majority of children who survive need a pacemaker.

Intense research interest therefore is focused on identifying markers of early cardiac injury, at a point before fibrosis and scarring are permanent, and on the potential for therapeutic interventions to reverse early changes.

The use of cardiac monitoring to detect prolongations of the PR interval greater than 150 milliseconds was recently evaluated in the observational PR Interval and Dexamethasone Evaluation (PRIDE) study of pregnant women who were positive for anti-Ro and/or anti-La antibodies. The study also attempted to provide some data on outcomes following the administration of steroids.

Fetal echocardiography was performed weekly between weeks 16 and 26, and then biweekly between weeks 26 and 34, according to Dr. Buyon, one of the study investigators. She and her colleagues were looking for prolongation of the PR interval, evidence of tricuspid regurgitation, and unexplained atrial echodensities.

Among the 88 patients who completed an evaluable course, there were three cases of third-degree heart block.

One of these patients had a normal PR interval, but some tricuspid regurgitation was noted at 17 weeks and atrial echodensity, at 22 weeks. A week later the fetus was in third-degree heart block and, despite treatment with maternal dexamethasone, 4 mg/day, severe hydrops developed and the pregnancy was terminated.

The second fetus had a normal PR interval between weeks 16 and 18 along with mild tricuspid regurgitation at week 17. The mother missed an appointment and, by the next time she was seen, third-degree block had developed in the fetus. This persisted despite administration of dexamethasone, and the child continued to be followed after birth (Arthritis Rheum. 2006;54:S689).

The third fetus also had a normal PR interval at 18 weeks, but 10 days later the fetus was in third-degree block and hydropic. Treatment with dexamethasone was unsuccessful, and the pregnancy was terminated at 20.5 weeks.

First-degree block was detected in an additional three fetuses. In one, the PR was normal at weeks 16–18, was prolonged at week 19, and normalized within 7 days of dexamethasone treatment.

The second had a prolonged PR interval at week 22 that resolved within 3 days of dexamethasone treatment. These two patients both had normal electrocardiograms at birth.

The third fetus had normal PR intervals throughout gestation but an electrocardiogram at birth showed first-degree block that has persisted to age 3 years.

Dexamethasone was also used in nine cases of second-degree block. Of these, four fetuses progressed to third-degree block, four remained in second, and only one was born in normal sinus rhythm. “This was a little disappointing,” Dr. Buyon said.

Of the 79 neonates for whom birth electrocardiograms were available, 78 were normal, and all 46 for whom 1-year follow-up electrocardiograms were available were normal, she said.

In conclusion, the study suggests the following, according to Dr. Buyon:

▸ First-degree block in utero is reversible with dexamethasone, but if present at birth, close observation by a cardiologist is needed because of the possibility of later progression.

▸ There has not been evidence of conduction abnormalities developing later in neonates whose electrocardiogram was normal at birth.

▸ Advanced cardiomyopathy can occur within 7 days of a normal PR interval, so even weekly evaluation may not be sufficient.

▸ Tricuspid regurgitation may be an important early marker of injury.

Dexamethasone treatment poses significant hazards to both mother and fetus, with maternal risks including diabetes and hypertension, and fetal risks including intrauterine growth retardation, adrenal suppression, and decreased brain growth. Moreover, as was seen in PRIDE, efficacy is hardly guaranteed. Accordingly, other therapeutic approaches are being investigated, including inhibition of transforming growth factor-β to limit fibrosis and prophylaxis with intravenous immune globulin (see box).

Next: Will IVIG Prevent Heart Block?

Intravenous immune globulin (IVIG) has a history of safely being used in pregnancy, primarily for autoimmune thrombocytopenia and immune deficiency syndromes. A few cases of successful use in congenital heart block have also been reported.

To determine if this prophylactic approach could reliably decrease the placental transport of anti-SS-A/Ro and anti-SS-B/La antibodies, the Preventive IVIG Therapy for Congenital Heart Block (PITCH) trial is now enrolling patients.

Sponsored by New York University School of Medicine and the Alliance for Lupus Research, the trial aims to enroll 19 women who are antibody positive and have already had a child with congenital heart block or a rash that might have been neonatal lupus. Such mothers are at much higher risk of having another child with congenital heart block than are mothers positive for anti-Ro/La who have not already had an affected child.

Participants will be given 400 mg/kg of IVIG every 3 weeks for a total of five treatments between weeks 12 and 24 of pregnancy.

If fewer than three fetuses develop second- or third-degree heart block, another 35 women will be enrolled in the PITCHtrial.

“Then, if there are fewer than six cases of heart block out of 54, we will be on the way to having a prophylactic therapy,” said Dr. Buyon, who is principal investigator for the trial.

Information about PITCH is available at

http://clinicaltrials.gov/show/NCT00460928

BETHESDA, MD. — A small study of hydrotherapy in labor has documented a significant decrease in anxiety, a fall in stress hormones and unexpectedly, a fall in oxytocin levels and a decrease in uterine contraction frequency, Rebecca Benfield, Ph.D., reported at a meeting sponsored by the National Institutes of Health's Pain Consortium.

Dr. Benfield, a certified nurse-midwife, has long seen benefit in bathing during labor: Women enjoy it and feel better as their pain and anxiety are decreased.

She and others have not known, however, exactly what lies behind the maternal response to hydrotherapy—the psychophysiologic mechanisms of action, for instance, and the possible effects on uterine contractility.

The recently completed study was the first, she said, in which plasma stress hormones were measured during immersion. The findings suggest that the therapy warrants attention in a randomized controlled trial and further investigation as an intervention for labor dysfunction, reported Dr. Benfield, associate professor of nursing and clinical assistant professor of obstetrics and gynecology at East Carolina University in Greenville, N.C.

Eleven healthy women in spontaneous active labor (cervical dilatation of 3–6 cm) at term were immersed to the xiphoid in 37° C water for 1 hour.

Blood samples were drawn before immersion and repeated at 15 and 45 minutes of hydrotherapy. Fetal heart rate and uterine contractions were monitored, and visual analog scales for anxiety and pain were administered before each blood draw. No analgesia was administered during the study.

Mean anxiety scores decreased from 51 mm (on a scale of 100 mm) to 33 mm at 15 minutes and 29 mm at 45 minutes. Pain also decreased, with the changes more significant in women with higher baseline pain scores vs. those with lower baseline pain scores, Dr. Benfield and her associates at East Carolina University reported in a poster presentation.

Statistically significant decreases in vasopressin (from a mean of 5.1 pg/mL at baseline to 4 pg/mL at both 15 and 45 minutes), oxytocin (from approximately 193 pg/mL at baseline to 153 pg/mL at 15 minutes and 154 pg/mL at 30 minutes), and cortisol were among the other changes.

Cortisol decreased twice as much after 15 minutes for the high baseline pain group (a mean decrease of 6.2 mcg/dL), compared with the low baseline pain group (a mean decrease of 3.1 mcg/dL).

The level of beta-endorphins increased significantly, but surprisingly, levels of epinephrine and norepinephrine did not change significantly, Dr. Benfield reported.

All women had a positive plasma volume shift (+4.1% at 15 minutes and at 45 minutes) that was positively correlated with contraction duration, while contraction frequency decreased significantly.

Contraction intensity was not measured, she said in an interview, and is therefore “a missing piece” in the understanding of hydrotherapy's effect on labor contractility.

Hydrotherapy “probably, however, will pan out to be a potentially good intervention for women with high levels of pain and those who are having some type of dysfunctional [labor] pattern … because theoretically it should provide better perfusion to the uterus,” Dr. Benfield said.

Thus far, she said, it appears that the “immersion effect—the hydrostatic pressure of the water—is what's driving the physiologic changes,” she said.

The results may also demonstrate two physiologic roles of oxytocin: its traditional role in uterine contractility and a novel role as an antistress hormone, according to Dr. Edward R. Newton, a coinvestigator for the study.

Although the study's sample size is too small to draw any conclusions about labor outcomes, no maternal or neonatal infections were attributed to the bathing, the researchers said.

BETHESDA, MD. — A small study of hydrotherapy in labor has documented a significant decrease in anxiety, a fall in stress hormones and unexpectedly, a fall in oxytocin levels and a decrease in uterine contraction frequency, Rebecca Benfield, Ph.D., reported at a meeting sponsored by the National Institutes of Health's Pain Consortium.

Dr. Benfield, a certified nurse-midwife, has long seen benefit in bathing during labor: Women enjoy it and feel better as their pain and anxiety are decreased.

She and others have not known, however, exactly what lies behind the maternal response to hydrotherapy—the psychophysiologic mechanisms of action, for instance, and the possible effects on uterine contractility.

The recently completed study was the first, she said, in which plasma stress hormones were measured during immersion. The findings suggest that the therapy warrants attention in a randomized controlled trial and further investigation as an intervention for labor dysfunction, reported Dr. Benfield, associate professor of nursing and clinical assistant professor of obstetrics and gynecology at East Carolina University in Greenville, N.C.

Eleven healthy women in spontaneous active labor (cervical dilatation of 3–6 cm) at term were immersed to the xiphoid in 37° C water for 1 hour.

Blood samples were drawn before immersion and repeated at 15 and 45 minutes of hydrotherapy. Fetal heart rate and uterine contractions were monitored, and visual analog scales for anxiety and pain were administered before each blood draw. No analgesia was administered during the study.

Mean anxiety scores decreased from 51 mm (on a scale of 100 mm) to 33 mm at 15 minutes and 29 mm at 45 minutes. Pain also decreased, with the changes more significant in women with higher baseline pain scores vs. those with lower baseline pain scores, Dr. Benfield and her associates at East Carolina University reported in a poster presentation.

Statistically significant decreases in vasopressin (from a mean of 5.1 pg/mL at baseline to 4 pg/mL at both 15 and 45 minutes), oxytocin (from approximately 193 pg/mL at baseline to 153 pg/mL at 15 minutes and 154 pg/mL at 30 minutes), and cortisol were among the other changes.

Cortisol decreased twice as much after 15 minutes for the high baseline pain group (a mean decrease of 6.2 mcg/dL), compared with the low baseline pain group (a mean decrease of 3.1 mcg/dL).

The level of beta-endorphins increased significantly, but surprisingly, levels of epinephrine and norepinephrine did not change significantly, Dr. Benfield reported.

All women had a positive plasma volume shift (+4.1% at 15 minutes and at 45 minutes) that was positively correlated with contraction duration, while contraction frequency decreased significantly.

Contraction intensity was not measured, she said in an interview, and is therefore “a missing piece” in the understanding of hydrotherapy's effect on labor contractility.

Hydrotherapy “probably, however, will pan out to be a potentially good intervention for women with high levels of pain and those who are having some type of dysfunctional [labor] pattern … because theoretically it should provide better perfusion to the uterus,” Dr. Benfield said.

Thus far, she said, it appears that the “immersion effect—the hydrostatic pressure of the water—is what's driving the physiologic changes,” she said.

The results may also demonstrate two physiologic roles of oxytocin: its traditional role in uterine contractility and a novel role as an antistress hormone, according to Dr. Edward R. Newton, a coinvestigator for the study.

Although the study's sample size is too small to draw any conclusions about labor outcomes, no maternal or neonatal infections were attributed to the bathing, the researchers said.

BETHESDA, MD. — A small study of hydrotherapy in labor has documented a significant decrease in anxiety, a fall in stress hormones and unexpectedly, a fall in oxytocin levels and a decrease in uterine contraction frequency, Rebecca Benfield, Ph.D., reported at a meeting sponsored by the National Institutes of Health's Pain Consortium.

Dr. Benfield, a certified nurse-midwife, has long seen benefit in bathing during labor: Women enjoy it and feel better as their pain and anxiety are decreased.

She and others have not known, however, exactly what lies behind the maternal response to hydrotherapy—the psychophysiologic mechanisms of action, for instance, and the possible effects on uterine contractility.

The recently completed study was the first, she said, in which plasma stress hormones were measured during immersion. The findings suggest that the therapy warrants attention in a randomized controlled trial and further investigation as an intervention for labor dysfunction, reported Dr. Benfield, associate professor of nursing and clinical assistant professor of obstetrics and gynecology at East Carolina University in Greenville, N.C.

Eleven healthy women in spontaneous active labor (cervical dilatation of 3–6 cm) at term were immersed to the xiphoid in 37° C water for 1 hour.

Blood samples were drawn before immersion and repeated at 15 and 45 minutes of hydrotherapy. Fetal heart rate and uterine contractions were monitored, and visual analog scales for anxiety and pain were administered before each blood draw. No analgesia was administered during the study.

Mean anxiety scores decreased from 51 mm (on a scale of 100 mm) to 33 mm at 15 minutes and 29 mm at 45 minutes. Pain also decreased, with the changes more significant in women with higher baseline pain scores vs. those with lower baseline pain scores, Dr. Benfield and her associates at East Carolina University reported in a poster presentation.

Statistically significant decreases in vasopressin (from a mean of 5.1 pg/mL at baseline to 4 pg/mL at both 15 and 45 minutes), oxytocin (from approximately 193 pg/mL at baseline to 153 pg/mL at 15 minutes and 154 pg/mL at 30 minutes), and cortisol were among the other changes.

Cortisol decreased twice as much after 15 minutes for the high baseline pain group (a mean decrease of 6.2 mcg/dL), compared with the low baseline pain group (a mean decrease of 3.1 mcg/dL).

The level of beta-endorphins increased significantly, but surprisingly, levels of epinephrine and norepinephrine did not change significantly, Dr. Benfield reported.

All women had a positive plasma volume shift (+4.1% at 15 minutes and at 45 minutes) that was positively correlated with contraction duration, while contraction frequency decreased significantly.

Contraction intensity was not measured, she said in an interview, and is therefore “a missing piece” in the understanding of hydrotherapy's effect on labor contractility.

Hydrotherapy “probably, however, will pan out to be a potentially good intervention for women with high levels of pain and those who are having some type of dysfunctional [labor] pattern … because theoretically it should provide better perfusion to the uterus,” Dr. Benfield said.

Thus far, she said, it appears that the “immersion effect—the hydrostatic pressure of the water—is what's driving the physiologic changes,” she said.

The results may also demonstrate two physiologic roles of oxytocin: its traditional role in uterine contractility and a novel role as an antistress hormone, according to Dr. Edward R. Newton, a coinvestigator for the study.

Although the study's sample size is too small to draw any conclusions about labor outcomes, no maternal or neonatal infections were attributed to the bathing, the researchers said.

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, suggests a recent study.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk (adjusted odds ratio 0.84), compared with no hormonal contraceptive use. In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998, and who were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, suggests a recent study.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk (adjusted odds ratio 0.84), compared with no hormonal contraceptive use. In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998, and who were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

The androgenicity of the progestin component of hormonal contraceptives used before pregnancy may affect risk for gestational diabetes mellitus, suggests a recent study.

In a nested case-control study of 724 women with a live singleton birth, the use of only low-androgen hormonal contraceptives for at least 6 months in the 5 years before pregnancy was associated with a 16% reduction in gestational diabetes mellitus (GDM) risk (adjusted odds ratio 0.84), compared with no hormonal contraceptive use. In addition, the use of a high-androgen hormonal contraceptive for at least 6 months—regardless of whether low-androgen contraceptives were also used—in the 5 years before pregnancy was associated with a 43% increase in GDM risk (adjusted odds ratio 1.43), reported Monique M. Hedderson, Ph.D., of the Kaiser Permanente Medical Care Program of Northern California, Oakland, and her colleagues.

Women who used Loestrin—the highest-androgen oral contraceptive—had the greatest increase in GDM risk (adjusted odds ratio 1.99), the investigators noted (Diabetes Care 2007;30:1062–8).

The findings remained essentially unchanged when the data analyses were repeated after excluding women who used nonoral hormonal contraceptives.

The 356 case patients and 368 controls were part of a multiethnic cohort of more than 14,000 women who delivered between Jan. 1, 1996, and June 30, 1998, and who were screened for GDM between 24 and 28 weeks' gestation. Patients were diagnosed with GDM if at least two of four plasma glucose values obtained during a 100-g, 3-hour oral glucose tolerance test were abnormal by National Diabetes Data Group criteria.

For oral contraceptives, high androgenicity was defined as androgenic activity of at least 0.47 mg of methyl testosterone equivalents per 28 days. Among nonoral hormonal contraceptives, Norplant was considered high androgen because it contains levonorgestrel, which has high androgenic activity; depo-medroxyprogesterone acetate contraceptives were considered low androgen because they contain medroxyprogesterone, which has low androgenic activity.

There was some evidence in this study that the duration of contraceptive use also played a role in GDM risk: A greater reduction in GDM risk was seen with longer duration of low-androgen contraceptives. No clear trend emerged in regard to duration of use of high-androgen contraceptives. “However, the statistical precision of our results was not great, and, given no true associations, chance alone plausibly could have been responsible for those we did observe,” the authors noted.

The risk reduction associated with low-androgen contraceptives was greatest when use was discontinued within 6 months before pregnancy, and the risk increase associated with high-androgen contraceptives was greatest when use was discontinued at least 1 year before pregnancy.

The effect of hormonal contraceptives on GDM risk may vary based on the androgenicity of the progestin component of the contraceptives, but the findings of this study should be interpreted with caution pending additional study, the investigators concluded.

ELSEVIER GLOBAL MEDICAL NEWS

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26–28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan in place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although lifestyle interventions are known to produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26–28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan in place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although lifestyle interventions are known to produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Physicians should take an aggressive approach in treating obese women with gestational diabetes because they have a relatively short time in which to make a difference, Dr. Oded Langer advised at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

Gestational diabetes is generally recognized late in pregnancy, at around 26–28 weeks, and many of these women will deliver by 38 weeks, which means that physicians have only a 10-week window to put an effective treatment plan in place, said Dr. Langer, chairman of the department of obstetrics and gynecology at St. Luke's-Roosevelt Hospital Center in New York.

He suggested that physicians take a practical approach and target the factors that can lead to large-for-gestational-age (LGA) babies and other obstetric complications, and that can be changed within 10 weeks.

An analysis of the possible factors that result in LGA babies among obese mothers with gestational diabetes showed that treatment modality, obesity, mean blood glucose, severity of the disease, parity, previous macrosomia, and weight gain were all independent contributors to LGA births (Am. J. Obstet. Gynecol. 2005;192:1768–76). But among those factors, only three—treatment modality, mean blood glucose, and weight gain—can be modified within 10 weeks, he said.

Physicians need to treat those three factors through the use of insulin or glyburide, as well as modifications in diet and exercise, he said.

However, diet and exercise alone would not make a significant difference in only 10 weeks, Dr. Langer cautioned.

Although lifestyle interventions are known to produce the best results in preventing the development of diabetes, such results are difficult to accomplish in a short time period, he explained.

NEW YORK — Obesity in prepregnancy and early pregnancy is associated with obstetric complications and birth defects, experts said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The risks include obstetric, maternal, fetal, and newborn complications, said Dr. Barak Rosenn, director of obstetrics and maternal-fetal medicine at St. Luke's-Roosevelt Hospital Center in New York. “The more obese you are, the higher the risk for these perinatal complications,” he said.

Growing evidence culled from studies conducted around the world demonstrate that both obesity and overweight lead to an increased risk for complications. For example, a study of more than 800,000 pregnant women with singleton pregnancies in Sweden showed that women who were morbidly obese—those with a body mass index of 40 or greater—at their first prenatal visit had significantly worse outcomes, compared with normal weight women— those with a BMI of 26 or less.

Morbidly obese women in the study were at an increased risk for several complications, including preeclampsia, stillbirth, cesarean delivery, instrumental delivery, shoulder dystocia, meconium aspiration, early neonatal death, and large-for-gestational-age babies. The associations were similar for women with BMIs between 35.1 and 40, but to a lesser degree (Obstet. Gynecol. 2004;103:219–24).

A similar study among more than 280,000 pregnant women with singleton pregnancies in London found that overweight women (BMI 25–29.9) and obese women (BMI 30 or greater) were at an increased risk of poor outcomes, including preeclampsia, emergency cesarean, wound infection, genital tract infection, and large-for-gestational-age babies (Int. J. Obes. Relat. Metab. Disord. 2001;25:1175–82).

“We see that the increased risk is already evident in overweight women, not just in women who are obese,” Dr. Rosenn said.

Overall, the percentage of complications attributed to obesity in the population has been rising along with the overall obesity epidemic. For example, the percentage of gestational diabetes attributed to obesity has risen from 12.8% during 1980–1984 to 29.6% during 1995–1999. And the percentage of large-for-gestational-age babies attributed to the mother's obesity increased from 16.2% to 25.7% in the same period of time (Am. J. Obstet. Gynecol. 2001;185:845–9).

But the risks associated with obesity in pregnancy don't stop at obstetric complications, according to Dr. E. Albert Reece, dean of the University of Maryland School of Medicine and vice president for medical affairs at the University of Maryland in Baltimore. Obese pregnant women also are at higher risk for giving birth to babies with congenital anomalies, he said.

A population-based, case-control study conducted by researchers from the Centers for Disease Control and Prevention in Atlanta found that infants born to obese women had higher risks for birth defects—including spina bifida, omphalocele, heart defects, and multiple anomalies—than did infants born to normal-weight women (BMI 18.5–24.9). Women who had preexisting diabetes were not included in the study (Pediatrics 2003;111:1152–8).

Several other studies also have shown that obesity in prepregnancy is associated with a slightly increased risk for neural tube defects, Dr. Reece said. The evidence to date also indicates that obesity as a risk factor for birth defects is independent of factors such as diabetes, race/ethnicity, and the presence of folic acid and other nutrients in the diet, he added.

But despite growing evidence linking obesity to obstetric complications and birth defects, researchers still do not understand why obesity increases these risks. There are also unanswered questions about whether maternal metabolic status can be modified to decrease maternal risk and whether the intrauterine environment can be modified to decrease the fetal risk, Dr. Rosenn said.

NEW YORK — Obesity in prepregnancy and early pregnancy is associated with obstetric complications and birth defects, experts said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The risks include obstetric, maternal, fetal, and newborn complications, said Dr. Barak Rosenn, director of obstetrics and maternal-fetal medicine at St. Luke's-Roosevelt Hospital Center in New York. “The more obese you are, the higher the risk for these perinatal complications,” he said.

Growing evidence culled from studies conducted around the world demonstrate that both obesity and overweight lead to an increased risk for complications. For example, a study of more than 800,000 pregnant women with singleton pregnancies in Sweden showed that women who were morbidly obese—those with a body mass index of 40 or greater—at their first prenatal visit had significantly worse outcomes, compared with normal weight women— those with a BMI of 26 or less.

Morbidly obese women in the study were at an increased risk for several complications, including preeclampsia, stillbirth, cesarean delivery, instrumental delivery, shoulder dystocia, meconium aspiration, early neonatal death, and large-for-gestational-age babies. The associations were similar for women with BMIs between 35.1 and 40, but to a lesser degree (Obstet. Gynecol. 2004;103:219–24).

A similar study among more than 280,000 pregnant women with singleton pregnancies in London found that overweight women (BMI 25–29.9) and obese women (BMI 30 or greater) were at an increased risk of poor outcomes, including preeclampsia, emergency cesarean, wound infection, genital tract infection, and large-for-gestational-age babies (Int. J. Obes. Relat. Metab. Disord. 2001;25:1175–82).

“We see that the increased risk is already evident in overweight women, not just in women who are obese,” Dr. Rosenn said.

Overall, the percentage of complications attributed to obesity in the population has been rising along with the overall obesity epidemic. For example, the percentage of gestational diabetes attributed to obesity has risen from 12.8% during 1980–1984 to 29.6% during 1995–1999. And the percentage of large-for-gestational-age babies attributed to the mother's obesity increased from 16.2% to 25.7% in the same period of time (Am. J. Obstet. Gynecol. 2001;185:845–9).

But the risks associated with obesity in pregnancy don't stop at obstetric complications, according to Dr. E. Albert Reece, dean of the University of Maryland School of Medicine and vice president for medical affairs at the University of Maryland in Baltimore. Obese pregnant women also are at higher risk for giving birth to babies with congenital anomalies, he said.

A population-based, case-control study conducted by researchers from the Centers for Disease Control and Prevention in Atlanta found that infants born to obese women had higher risks for birth defects—including spina bifida, omphalocele, heart defects, and multiple anomalies—than did infants born to normal-weight women (BMI 18.5–24.9). Women who had preexisting diabetes were not included in the study (Pediatrics 2003;111:1152–8).

Several other studies also have shown that obesity in prepregnancy is associated with a slightly increased risk for neural tube defects, Dr. Reece said. The evidence to date also indicates that obesity as a risk factor for birth defects is independent of factors such as diabetes, race/ethnicity, and the presence of folic acid and other nutrients in the diet, he added.

But despite growing evidence linking obesity to obstetric complications and birth defects, researchers still do not understand why obesity increases these risks. There are also unanswered questions about whether maternal metabolic status can be modified to decrease maternal risk and whether the intrauterine environment can be modified to decrease the fetal risk, Dr. Rosenn said.

NEW YORK — Obesity in prepregnancy and early pregnancy is associated with obstetric complications and birth defects, experts said at the annual meeting of the Diabetes in Pregnancy Study Group of North America.

The risks include obstetric, maternal, fetal, and newborn complications, said Dr. Barak Rosenn, director of obstetrics and maternal-fetal medicine at St. Luke's-Roosevelt Hospital Center in New York. “The more obese you are, the higher the risk for these perinatal complications,” he said.

Growing evidence culled from studies conducted around the world demonstrate that both obesity and overweight lead to an increased risk for complications. For example, a study of more than 800,000 pregnant women with singleton pregnancies in Sweden showed that women who were morbidly obese—those with a body mass index of 40 or greater—at their first prenatal visit had significantly worse outcomes, compared with normal weight women— those with a BMI of 26 or less.

Morbidly obese women in the study were at an increased risk for several complications, including preeclampsia, stillbirth, cesarean delivery, instrumental delivery, shoulder dystocia, meconium aspiration, early neonatal death, and large-for-gestational-age babies. The associations were similar for women with BMIs between 35.1 and 40, but to a lesser degree (Obstet. Gynecol. 2004;103:219–24).

A similar study among more than 280,000 pregnant women with singleton pregnancies in London found that overweight women (BMI 25–29.9) and obese women (BMI 30 or greater) were at an increased risk of poor outcomes, including preeclampsia, emergency cesarean, wound infection, genital tract infection, and large-for-gestational-age babies (Int. J. Obes. Relat. Metab. Disord. 2001;25:1175–82).

“We see that the increased risk is already evident in overweight women, not just in women who are obese,” Dr. Rosenn said.

Overall, the percentage of complications attributed to obesity in the population has been rising along with the overall obesity epidemic. For example, the percentage of gestational diabetes attributed to obesity has risen from 12.8% during 1980–1984 to 29.6% during 1995–1999. And the percentage of large-for-gestational-age babies attributed to the mother's obesity increased from 16.2% to 25.7% in the same period of time (Am. J. Obstet. Gynecol. 2001;185:845–9).

But the risks associated with obesity in pregnancy don't stop at obstetric complications, according to Dr. E. Albert Reece, dean of the University of Maryland School of Medicine and vice president for medical affairs at the University of Maryland in Baltimore. Obese pregnant women also are at higher risk for giving birth to babies with congenital anomalies, he said.

A population-based, case-control study conducted by researchers from the Centers for Disease Control and Prevention in Atlanta found that infants born to obese women had higher risks for birth defects—including spina bifida, omphalocele, heart defects, and multiple anomalies—than did infants born to normal-weight women (BMI 18.5–24.9). Women who had preexisting diabetes were not included in the study (Pediatrics 2003;111:1152–8).

Several other studies also have shown that obesity in prepregnancy is associated with a slightly increased risk for neural tube defects, Dr. Reece said. The evidence to date also indicates that obesity as a risk factor for birth defects is independent of factors such as diabetes, race/ethnicity, and the presence of folic acid and other nutrients in the diet, he added.

But despite growing evidence linking obesity to obstetric complications and birth defects, researchers still do not understand why obesity increases these risks. There are also unanswered questions about whether maternal metabolic status can be modified to decrease maternal risk and whether the intrauterine environment can be modified to decrease the fetal risk, Dr. Rosenn said.

Babies who have been breast-fed for 4 months and then receive certain types of hydrolyzed formula have a significantly lower risk of developing atopic dermatitis, compared with those given a cow's milk-based formula after breast-feeding, according to results of a 3-year randomized German study of more than 2,000 babies.

One case of atopic dermatitis (AD) could be averted if 20–25 babies were fed either one of two types of hydrolyzed formulas rather than cow's milk-based formulas. Use of the hydrolyzed formulas did not affect the incidence of asthma, however.

“The preventive effect [against AD] developed in the first year and persisted into the third year, indicating real disease reduction rather than postponement of disease onset,” wrote the researchers, led by Dr. Andrea von Berg from the pediatrics department at Marien-Hospital, Wesel, Germany.

“Although it remains controversial whether breast-feeding reduces the risk for allergy in high-risk infants, breast-feeding is the gold standard for infant nutrition,” they wrote. “It was therefore not the goal of our study to question this gold standard and show that hydrolyzates are worse or better. Instead, we wanted to evaluate, in case of formula feeding (for whatever reason), which formula would be the best alternative to reduce the risk for (allergic manifestations).”

The researchers enrolled 2,252 infants who had at least one parent or sibling with an atopic syndrome. The infants were randomized into groups fed one of three hydrolyzed formulas (extensively hydrolyzed casein formula and partially or extensively hydrolyzed whey formula). An observational arm of 889 babies exclusively breast-fed was also included (J. Allergy Clin. Immunol. 2007;119:718–25).

Infants were exclusively breast-fed during the first 4 months, with the introduction of solid food postponed until after 4 months. Researchers tracked diagnoses of AD, urticaria, food allergies, and asthma.

After 3 years, 904 babies on formula and 543 babies in the breast-feeding arm remained in the study population.

Compared with those in the cow's milk-based formula group, infants fed the partially hydrolyzed whey formula (odds ratio 0.57) and those fed the extensively hydrolyzed casein formula (odds ratio 0.43) demonstrated at 1 year a significantly reduced risk of developing any of the allergic manifestations studied, after adjustment for family history of AD and asthma, sex, and maternal smoking.

By the third year, that effect was gone for allergic conditions as a whole, but the protective effect persisted to 3 years for AD. The 3-year cumulative risk of developing AD was lower in children fed the partially hydrolyzed whey formula (odds ratio 0.60) and those fed extensively hydrolyzed casein formula (odds ratio 0.53), compared with those in the cow's milk-based formula group.

Analyzing outcomes based on family history, the only significant effect identified was among those with a family history of AD who were fed extensively hydrolyzed casein formulas; such babies were at lower risk of AD than those given cow's milk-based formula (odds ratio 0.53).

“This is indeed the first study to suggest that the allergic phenotype in the family rather than a biparental family history modifies the effect of nutritional intervention and may be considered when deciding which hydrolyzate should be given,” the researchers wrote. On an intention-to-treat basis, feeding 20 infants extensively hydrolyzed casein formula and 25 partially hydrolyzed whey formula averts a single case of AD. In the smaller group with a family history of AD, the numbers were 11 and 51, respectively.

Babies who have been breast-fed for 4 months and then receive certain types of hydrolyzed formula have a significantly lower risk of developing atopic dermatitis, compared with those given a cow's milk-based formula after breast-feeding, according to results of a 3-year randomized German study of more than 2,000 babies.

One case of atopic dermatitis (AD) could be averted if 20–25 babies were fed either one of two types of hydrolyzed formulas rather than cow's milk-based formulas. Use of the hydrolyzed formulas did not affect the incidence of asthma, however.

“The preventive effect [against AD] developed in the first year and persisted into the third year, indicating real disease reduction rather than postponement of disease onset,” wrote the researchers, led by Dr. Andrea von Berg from the pediatrics department at Marien-Hospital, Wesel, Germany.

“Although it remains controversial whether breast-feeding reduces the risk for allergy in high-risk infants, breast-feeding is the gold standard for infant nutrition,” they wrote. “It was therefore not the goal of our study to question this gold standard and show that hydrolyzates are worse or better. Instead, we wanted to evaluate, in case of formula feeding (for whatever reason), which formula would be the best alternative to reduce the risk for (allergic manifestations).”

The researchers enrolled 2,252 infants who had at least one parent or sibling with an atopic syndrome. The infants were randomized into groups fed one of three hydrolyzed formulas (extensively hydrolyzed casein formula and partially or extensively hydrolyzed whey formula). An observational arm of 889 babies exclusively breast-fed was also included (J. Allergy Clin. Immunol. 2007;119:718–25).

Infants were exclusively breast-fed during the first 4 months, with the introduction of solid food postponed until after 4 months. Researchers tracked diagnoses of AD, urticaria, food allergies, and asthma.

After 3 years, 904 babies on formula and 543 babies in the breast-feeding arm remained in the study population.

Compared with those in the cow's milk-based formula group, infants fed the partially hydrolyzed whey formula (odds ratio 0.57) and those fed the extensively hydrolyzed casein formula (odds ratio 0.43) demonstrated at 1 year a significantly reduced risk of developing any of the allergic manifestations studied, after adjustment for family history of AD and asthma, sex, and maternal smoking.

By the third year, that effect was gone for allergic conditions as a whole, but the protective effect persisted to 3 years for AD. The 3-year cumulative risk of developing AD was lower in children fed the partially hydrolyzed whey formula (odds ratio 0.60) and those fed extensively hydrolyzed casein formula (odds ratio 0.53), compared with those in the cow's milk-based formula group.

Analyzing outcomes based on family history, the only significant effect identified was among those with a family history of AD who were fed extensively hydrolyzed casein formulas; such babies were at lower risk of AD than those given cow's milk-based formula (odds ratio 0.53).

“This is indeed the first study to suggest that the allergic phenotype in the family rather than a biparental family history modifies the effect of nutritional intervention and may be considered when deciding which hydrolyzate should be given,” the researchers wrote. On an intention-to-treat basis, feeding 20 infants extensively hydrolyzed casein formula and 25 partially hydrolyzed whey formula averts a single case of AD. In the smaller group with a family history of AD, the numbers were 11 and 51, respectively.

Babies who have been breast-fed for 4 months and then receive certain types of hydrolyzed formula have a significantly lower risk of developing atopic dermatitis, compared with those given a cow's milk-based formula after breast-feeding, according to results of a 3-year randomized German study of more than 2,000 babies.

One case of atopic dermatitis (AD) could be averted if 20–25 babies were fed either one of two types of hydrolyzed formulas rather than cow's milk-based formulas. Use of the hydrolyzed formulas did not affect the incidence of asthma, however.

“The preventive effect [against AD] developed in the first year and persisted into the third year, indicating real disease reduction rather than postponement of disease onset,” wrote the researchers, led by Dr. Andrea von Berg from the pediatrics department at Marien-Hospital, Wesel, Germany.

“Although it remains controversial whether breast-feeding reduces the risk for allergy in high-risk infants, breast-feeding is the gold standard for infant nutrition,” they wrote. “It was therefore not the goal of our study to question this gold standard and show that hydrolyzates are worse or better. Instead, we wanted to evaluate, in case of formula feeding (for whatever reason), which formula would be the best alternative to reduce the risk for (allergic manifestations).”

The researchers enrolled 2,252 infants who had at least one parent or sibling with an atopic syndrome. The infants were randomized into groups fed one of three hydrolyzed formulas (extensively hydrolyzed casein formula and partially or extensively hydrolyzed whey formula). An observational arm of 889 babies exclusively breast-fed was also included (J. Allergy Clin. Immunol. 2007;119:718–25).

Infants were exclusively breast-fed during the first 4 months, with the introduction of solid food postponed until after 4 months. Researchers tracked diagnoses of AD, urticaria, food allergies, and asthma.

After 3 years, 904 babies on formula and 543 babies in the breast-feeding arm remained in the study population.

Compared with those in the cow's milk-based formula group, infants fed the partially hydrolyzed whey formula (odds ratio 0.57) and those fed the extensively hydrolyzed casein formula (odds ratio 0.43) demonstrated at 1 year a significantly reduced risk of developing any of the allergic manifestations studied, after adjustment for family history of AD and asthma, sex, and maternal smoking.

By the third year, that effect was gone for allergic conditions as a whole, but the protective effect persisted to 3 years for AD. The 3-year cumulative risk of developing AD was lower in children fed the partially hydrolyzed whey formula (odds ratio 0.60) and those fed extensively hydrolyzed casein formula (odds ratio 0.53), compared with those in the cow's milk-based formula group.

Analyzing outcomes based on family history, the only significant effect identified was among those with a family history of AD who were fed extensively hydrolyzed casein formulas; such babies were at lower risk of AD than those given cow's milk-based formula (odds ratio 0.53).

“This is indeed the first study to suggest that the allergic phenotype in the family rather than a biparental family history modifies the effect of nutritional intervention and may be considered when deciding which hydrolyzate should be given,” the researchers wrote. On an intention-to-treat basis, feeding 20 infants extensively hydrolyzed casein formula and 25 partially hydrolyzed whey formula averts a single case of AD. In the smaller group with a family history of AD, the numbers were 11 and 51, respectively.

SAN DIEGO — Women who experience symptoms of allergic rhinitis during early pregnancy are more than six times as likely to have children with allergic rhinitis than are women who have no such symptoms, Dr. Miwa Shinohara said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The results suggest that women should be aggressive in controlling allergic rhinitis symptoms during early pregnancy, with avoidance of allergens providing the best means of control, said Dr. Shinohara, of department of pediatrics at Kochi (Japan) University.

The retrospective cohort study involved 400 women with physician-diagnosed allergic rhinitis and their offspring. When the children were an average of 9.9 months old (range 1.7–18.7 months), the mothers completed a questionnaire about their allergic rhinitis symptoms during pregnancy. The study's primary outcome measure was whether the children themselves had physician-diagnosed allergic rhinitis.

Of the 400 women, 150 recalled having no allergic rhinitis symptoms during pregnancy, 219 recalled having symptoms early in pregnancy, and 173 recalled having symptoms late in pregnancy. (These figures total more than 400 because some women had symptoms both early and late in pregnancy.)

After adjustment for age, gender, month of birth, and the father's history of allergic rhinitis, women who had symptoms early in pregnancy were 6.3 times as likely to have children with allergic rhinitis as women who had no such symptoms. There was no statistically significant increase in the odds ratio for women who had symptoms late in pregnancy.

Additionally, there was no statistically significant association between the mother's symptoms and a diagnosis of bronchial asthma, food allergy, or atopic dermatitis in their children. And there was no statistically significant association between the father's symptoms of allergic rhinitis during pregnancy and the child's allergic rhinitis.

Dr. Shinohara said that the results imply the presence of an epigenetic mechanism for transmitting allergic rhinitis from mother to child, presumably through organ-specific hypersensitivity.

SAN DIEGO — Women who experience symptoms of allergic rhinitis during early pregnancy are more than six times as likely to have children with allergic rhinitis than are women who have no such symptoms, Dr. Miwa Shinohara said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The results suggest that women should be aggressive in controlling allergic rhinitis symptoms during early pregnancy, with avoidance of allergens providing the best means of control, said Dr. Shinohara, of department of pediatrics at Kochi (Japan) University.

The retrospective cohort study involved 400 women with physician-diagnosed allergic rhinitis and their offspring. When the children were an average of 9.9 months old (range 1.7–18.7 months), the mothers completed a questionnaire about their allergic rhinitis symptoms during pregnancy. The study's primary outcome measure was whether the children themselves had physician-diagnosed allergic rhinitis.

Of the 400 women, 150 recalled having no allergic rhinitis symptoms during pregnancy, 219 recalled having symptoms early in pregnancy, and 173 recalled having symptoms late in pregnancy. (These figures total more than 400 because some women had symptoms both early and late in pregnancy.)

After adjustment for age, gender, month of birth, and the father's history of allergic rhinitis, women who had symptoms early in pregnancy were 6.3 times as likely to have children with allergic rhinitis as women who had no such symptoms. There was no statistically significant increase in the odds ratio for women who had symptoms late in pregnancy.

Additionally, there was no statistically significant association between the mother's symptoms and a diagnosis of bronchial asthma, food allergy, or atopic dermatitis in their children. And there was no statistically significant association between the father's symptoms of allergic rhinitis during pregnancy and the child's allergic rhinitis.

Dr. Shinohara said that the results imply the presence of an epigenetic mechanism for transmitting allergic rhinitis from mother to child, presumably through organ-specific hypersensitivity.

SAN DIEGO — Women who experience symptoms of allergic rhinitis during early pregnancy are more than six times as likely to have children with allergic rhinitis than are women who have no such symptoms, Dr. Miwa Shinohara said at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The results suggest that women should be aggressive in controlling allergic rhinitis symptoms during early pregnancy, with avoidance of allergens providing the best means of control, said Dr. Shinohara, of department of pediatrics at Kochi (Japan) University.

The retrospective cohort study involved 400 women with physician-diagnosed allergic rhinitis and their offspring. When the children were an average of 9.9 months old (range 1.7–18.7 months), the mothers completed a questionnaire about their allergic rhinitis symptoms during pregnancy. The study's primary outcome measure was whether the children themselves had physician-diagnosed allergic rhinitis.

Of the 400 women, 150 recalled having no allergic rhinitis symptoms during pregnancy, 219 recalled having symptoms early in pregnancy, and 173 recalled having symptoms late in pregnancy. (These figures total more than 400 because some women had symptoms both early and late in pregnancy.)

After adjustment for age, gender, month of birth, and the father's history of allergic rhinitis, women who had symptoms early in pregnancy were 6.3 times as likely to have children with allergic rhinitis as women who had no such symptoms. There was no statistically significant increase in the odds ratio for women who had symptoms late in pregnancy.

Additionally, there was no statistically significant association between the mother's symptoms and a diagnosis of bronchial asthma, food allergy, or atopic dermatitis in their children. And there was no statistically significant association between the father's symptoms of allergic rhinitis during pregnancy and the child's allergic rhinitis.

Dr. Shinohara said that the results imply the presence of an epigenetic mechanism for transmitting allergic rhinitis from mother to child, presumably through organ-specific hypersensitivity.

BOSTON — Prenatal smoking exposure is associated with significant increases in irritability among newborn girls but not boys, according to a study presented at a meeting of the Society for Research in Child Development.

The fact that significant differences were not evident among male infants in the large, epidemiologic sample might suggest early links to later gender-specific differences in behavioral outcomes, said lead author Rachel L. Paster, a research assistant in the Centers for Behavioral and Preventive Medicine, Brown University, Providence, R.I.

All of the infants exposed to prenatal smoking exhibited increases in muscle tension, compared with unexposed infants, Ms. Paster reported in a poster presentation.

Using data from the New England Cohort of the National Collaborative Perinatal Project (NCPP), Ms. Paster and colleagues examined the effects of smoking during pregnancy on the neurobehavior of male and female newborns in a sample of 991 healthy mother-infant pairs recruited between 1959 and 1962.

As part of the NCPP, smoking was measured prospectively at each prenatal visit and newborn neurobehavior was assessed using the Graham-Rosenblith behavioral examination. For the current investigation, study participants were classified as nonsmokers, moderate smokers (between 1 and 19 cigarettes per day), and heavy smokers (20 or more cigarettes per day).

The investigators reduced the Graham-Rosenblith measure into three subscales—irritability, muscle tone, and response to respiratory occlusion—and then stratified the sample by sex. They used analysis of variance to examine group differences overall and by gender.

“We found significant differences between smoking groups for irritability in females, but not in males,” Ms. Paster reported. “[Least significant difference] tests revealed significant differences between the heavy smoking group and both the moderate and no smoking groups only for female infants, while significant effects of maternal smoking group on muscle tone emerged for both male and female infants.”

Least significant difference tests also showed different patterns of effects for males and females with respect to muscle tone. “For females, the heavy smoking group was significantly different from both the moderate and no smoking groups, while for males, the moderate smoking group differed significantly from the no smoking and heavy smoking groups,” Ms. Paster said.

Regarding the irritability findings, excessive irritability could indicate an infant withdrawal syndrome, Ms. Paster noted. Additionally, “irritability could potentially affect bonding and attachment with caregivers and may represent an early link to emotional dysregulation,” she said.

The hypertonicity findings “may be due to acute effects of nicotine and suggests problems with motor control,” Ms. Paster stated.

The findings of this study might be useful in identifying infants at risk for neurodevelopmental deficits and should provide additional incentives for abstaining from smoking during pregnancy, the investigators noted.

BOSTON — Prenatal smoking exposure is associated with significant increases in irritability among newborn girls but not boys, according to a study presented at a meeting of the Society for Research in Child Development.

The fact that significant differences were not evident among male infants in the large, epidemiologic sample might suggest early links to later gender-specific differences in behavioral outcomes, said lead author Rachel L. Paster, a research assistant in the Centers for Behavioral and Preventive Medicine, Brown University, Providence, R.I.

All of the infants exposed to prenatal smoking exhibited increases in muscle tension, compared with unexposed infants, Ms. Paster reported in a poster presentation.

Using data from the New England Cohort of the National Collaborative Perinatal Project (NCPP), Ms. Paster and colleagues examined the effects of smoking during pregnancy on the neurobehavior of male and female newborns in a sample of 991 healthy mother-infant pairs recruited between 1959 and 1962.

As part of the NCPP, smoking was measured prospectively at each prenatal visit and newborn neurobehavior was assessed using the Graham-Rosenblith behavioral examination. For the current investigation, study participants were classified as nonsmokers, moderate smokers (between 1 and 19 cigarettes per day), and heavy smokers (20 or more cigarettes per day).

The investigators reduced the Graham-Rosenblith measure into three subscales—irritability, muscle tone, and response to respiratory occlusion—and then stratified the sample by sex. They used analysis of variance to examine group differences overall and by gender.

“We found significant differences between smoking groups for irritability in females, but not in males,” Ms. Paster reported. “[Least significant difference] tests revealed significant differences between the heavy smoking group and both the moderate and no smoking groups only for female infants, while significant effects of maternal smoking group on muscle tone emerged for both male and female infants.”

Least significant difference tests also showed different patterns of effects for males and females with respect to muscle tone. “For females, the heavy smoking group was significantly different from both the moderate and no smoking groups, while for males, the moderate smoking group differed significantly from the no smoking and heavy smoking groups,” Ms. Paster said.

Regarding the irritability findings, excessive irritability could indicate an infant withdrawal syndrome, Ms. Paster noted. Additionally, “irritability could potentially affect bonding and attachment with caregivers and may represent an early link to emotional dysregulation,” she said.

The hypertonicity findings “may be due to acute effects of nicotine and suggests problems with motor control,” Ms. Paster stated.

The findings of this study might be useful in identifying infants at risk for neurodevelopmental deficits and should provide additional incentives for abstaining from smoking during pregnancy, the investigators noted.

BOSTON — Prenatal smoking exposure is associated with significant increases in irritability among newborn girls but not boys, according to a study presented at a meeting of the Society for Research in Child Development.

The fact that significant differences were not evident among male infants in the large, epidemiologic sample might suggest early links to later gender-specific differences in behavioral outcomes, said lead author Rachel L. Paster, a research assistant in the Centers for Behavioral and Preventive Medicine, Brown University, Providence, R.I.

All of the infants exposed to prenatal smoking exhibited increases in muscle tension, compared with unexposed infants, Ms. Paster reported in a poster presentation.

Using data from the New England Cohort of the National Collaborative Perinatal Project (NCPP), Ms. Paster and colleagues examined the effects of smoking during pregnancy on the neurobehavior of male and female newborns in a sample of 991 healthy mother-infant pairs recruited between 1959 and 1962.

As part of the NCPP, smoking was measured prospectively at each prenatal visit and newborn neurobehavior was assessed using the Graham-Rosenblith behavioral examination. For the current investigation, study participants were classified as nonsmokers, moderate smokers (between 1 and 19 cigarettes per day), and heavy smokers (20 or more cigarettes per day).

The investigators reduced the Graham-Rosenblith measure into three subscales—irritability, muscle tone, and response to respiratory occlusion—and then stratified the sample by sex. They used analysis of variance to examine group differences overall and by gender.

“We found significant differences between smoking groups for irritability in females, but not in males,” Ms. Paster reported. “[Least significant difference] tests revealed significant differences between the heavy smoking group and both the moderate and no smoking groups only for female infants, while significant effects of maternal smoking group on muscle tone emerged for both male and female infants.”

Least significant difference tests also showed different patterns of effects for males and females with respect to muscle tone. “For females, the heavy smoking group was significantly different from both the moderate and no smoking groups, while for males, the moderate smoking group differed significantly from the no smoking and heavy smoking groups,” Ms. Paster said.

Regarding the irritability findings, excessive irritability could indicate an infant withdrawal syndrome, Ms. Paster noted. Additionally, “irritability could potentially affect bonding and attachment with caregivers and may represent an early link to emotional dysregulation,” she said.

The hypertonicity findings “may be due to acute effects of nicotine and suggests problems with motor control,” Ms. Paster stated.

The findings of this study might be useful in identifying infants at risk for neurodevelopmental deficits and should provide additional incentives for abstaining from smoking during pregnancy, the investigators noted.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.

LAS VEGAS — Magnetic resonance images of the fetal chest can be a clinically useful addition to ultrasound to examine lung masses and identify underdeveloped lungs, Dr. Erika Rubesova said at a symposium on emergency medicine sponsored by Stanford (Calif.) University.

With MRI, “You will have a better characterization of the chest masses and you can perform measurements of the lung,” said Dr. Rubesova, a radiologist at the university.

A fetal MRI provides a greater tissue contrast than ultrasound, and features such as lung volume and signal intensity are easier to see, she noted.

As for the safety of a fetal MRI, the safety committee of the Society for Magnetic Resonance Imaging recommends that the risks and benefits of fetal MRI be assessed on a case-by-case basis and that MR procedures are indicated in pregnant women if other nonionizing imaging techniques are inadequate or if the MRI can provide information that could only be otherwise acquired using radiation technology. However, the Food and Drug Administration states that the safety of MR during pregnancy has not been proved definitively, Dr. Rubesova said.

“The FDA does not require a contraindication to the use of MRI for fetal imaging in device labeling,” Dr. Julia Carey-Corrado, an ob.gyn. at the FDA's Center for Devices and Radiological Health, said in an interview. “But the FDA does recommend that device labeling contain the following statement: 'The safety of magnetic resonance examination has not been completely established for embryos and fetuses,'” she said.

“We view ultrasound as the standard of care for fetal imaging, but MR can be viewed as a reasonable second-line imaging modality if you aren't getting enough information from ultrasound and you are concerned about a complex abnormality,” Dr. Carey-Corrado added.

To perform an MRI of the fetal lung, place the patient in the most comfortable position possible and focus on the fetal lung as best you can to minimize the blurriness associated with fetal movement, Dr. Rubesova said.

Dr. Rubesova usually uses 1.5-T and T2-weighted images. “You should be able to see both of the lungs and the airway,” she said. “And the diaphragm sometimes appears as a dark line above the liver.”

Congenital lung lesions fall into three broad categories: congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts.

A congenital cystic adenomatoid malformation (CCAM) usually occurs early in fetal development, and the lesions are categorized based on size. In general, lesions larger than 2 mm are associated with a better prognosis for the infant than smaller lesions, so the ability to measure the lesions based on MRI data is useful for clinicians.

Sequestrations (also known as bronchopulmonary sequestrations) occur when a piece of the developing lung branches off from the main airway (but remains connected to it) and the lung fails to develop normally. Bronchogenic cysts form when a branch of the developing airway separates completely from the main bronchotracheal tree.

Data collected by researchers at Brown University, Providence, R.I., suggest that 1 in 3,000 infants has a congenital lung lesion. These masses compress the developing lung, and they may displace other organs in the chest. Large lung masses may cause fetal heart failure in severe cases because the pressure of the masses causes an abnormal accumulation of fluid around the heart, lungs, or abdomen.

The “horseshoe lung” is a characteristic image that is associated with CCAM, sequestrations, and bronchogenic fistulae. A fetal MRI can show the horseshoe shape of an underdeveloped lung, and the lung masses appear as areas of high signal intensity on a T2-weighted image, Dr. Rubesova noted.

There is no rush to perform fetal lung MRI procedures in cases of large lesions where the prognosis is good and termination of the pregnancy is unlikely, Dr. Rubesova said. The best time to get an accurate fetal MRI of these lesions is late in the third trimester because the fetus has less room to move, so the image is sharper. In these cases, the MRI helps parents and physicians plan for neonatal care that will allow the lungs to develop as completely as possible.

The outcome for most newborns with congenital lung masses is good, although congenital lung hypoplasia accounts for 10%–15% of all neonatal deaths, Dr. Rubesova noted. Sometimes the masses will shrink substantially by the time of birth, and in other cases the lesions can be surgically removed after birth to reduce the risk of recurrent infections such as pneumonia.