Obstetrics

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — A woman's prediction of the number of children she will have in her lifetime often falls short, Dr. Kristie Keeton said in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

An Internet survey asked women who said they had completed childbearing to look back to their first pregnancy and their thoughts at that time about how many children they planned to have.

Among 458 women who said they had planned on having one or two children, 41% were accurate, 16% had fewer children than they planned, and 42% had more children than expected, reported Dr. Keeton of the University of Michigan, Ann Arbor, and her associates.

Among women who had more children than predicted, 68% had three or more children.

The findings have implications for counseling of women who request cesarean delivery, which is a growing phenomenon, Dr. Keeton said in an interview at the poster.

A recent State of the Science statement by the National Institutes of Health said that “Cesarean delivery on maternal request is not recommended for women desiring several children,” she noted.

The risks of placenta previa, accreta, and surgical complications increase with each C-section.

The current study suggests that at the time of first pregnancy, women are unable to predict their final parity.

This information should be incorporated into counseling of women who desire a primary elective C-section, Dr. Keeton said.

The U.S. C-section rate for 2005 was over 30%, the highest rate ever, according to preliminary data from the National Center for Health Statistics, she noted.

Women in the present study were more likely to accurately predict their parity if they were older at the time of first pregnancy (25 years vs. 21 years) and if they had two siblings instead of three.

One flaw of the study design was that it could not take into account the potential for recall bias affecting respondents' answers. Also, although all women said they had completed childbearing, it is possible that some may have future pregnancies, which would increase the proportion of respondents who underpredicted the number of children they would have.

Perhaps because the survey was conducted over the Internet, the demographics of the respondents were not representative of the general population: 74% of the women were white, 69% had at least some college education, and 70% were married or had a domestic partner. The mean age of respondents was 39 years.

SAN FRANCISCO — A woman's prediction of the number of children she will have in her lifetime often falls short, Dr. Kristie Keeton said in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

An Internet survey asked women who said they had completed childbearing to look back to their first pregnancy and their thoughts at that time about how many children they planned to have.

Among 458 women who said they had planned on having one or two children, 41% were accurate, 16% had fewer children than they planned, and 42% had more children than expected, reported Dr. Keeton of the University of Michigan, Ann Arbor, and her associates.

Among women who had more children than predicted, 68% had three or more children.

The findings have implications for counseling of women who request cesarean delivery, which is a growing phenomenon, Dr. Keeton said in an interview at the poster.

A recent State of the Science statement by the National Institutes of Health said that “Cesarean delivery on maternal request is not recommended for women desiring several children,” she noted.

The risks of placenta previa, accreta, and surgical complications increase with each C-section.

The current study suggests that at the time of first pregnancy, women are unable to predict their final parity.

This information should be incorporated into counseling of women who desire a primary elective C-section, Dr. Keeton said.

The U.S. C-section rate for 2005 was over 30%, the highest rate ever, according to preliminary data from the National Center for Health Statistics, she noted.

Women in the present study were more likely to accurately predict their parity if they were older at the time of first pregnancy (25 years vs. 21 years) and if they had two siblings instead of three.

One flaw of the study design was that it could not take into account the potential for recall bias affecting respondents' answers. Also, although all women said they had completed childbearing, it is possible that some may have future pregnancies, which would increase the proportion of respondents who underpredicted the number of children they would have.

Perhaps because the survey was conducted over the Internet, the demographics of the respondents were not representative of the general population: 74% of the women were white, 69% had at least some college education, and 70% were married or had a domestic partner. The mean age of respondents was 39 years.

SAN FRANCISCO — A woman's prediction of the number of children she will have in her lifetime often falls short, Dr. Kristie Keeton said in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

An Internet survey asked women who said they had completed childbearing to look back to their first pregnancy and their thoughts at that time about how many children they planned to have.

Among 458 women who said they had planned on having one or two children, 41% were accurate, 16% had fewer children than they planned, and 42% had more children than expected, reported Dr. Keeton of the University of Michigan, Ann Arbor, and her associates.

Among women who had more children than predicted, 68% had three or more children.

The findings have implications for counseling of women who request cesarean delivery, which is a growing phenomenon, Dr. Keeton said in an interview at the poster.

A recent State of the Science statement by the National Institutes of Health said that “Cesarean delivery on maternal request is not recommended for women desiring several children,” she noted.

The risks of placenta previa, accreta, and surgical complications increase with each C-section.

The current study suggests that at the time of first pregnancy, women are unable to predict their final parity.

This information should be incorporated into counseling of women who desire a primary elective C-section, Dr. Keeton said.

The U.S. C-section rate for 2005 was over 30%, the highest rate ever, according to preliminary data from the National Center for Health Statistics, she noted.

Women in the present study were more likely to accurately predict their parity if they were older at the time of first pregnancy (25 years vs. 21 years) and if they had two siblings instead of three.

One flaw of the study design was that it could not take into account the potential for recall bias affecting respondents' answers. Also, although all women said they had completed childbearing, it is possible that some may have future pregnancies, which would increase the proportion of respondents who underpredicted the number of children they would have.

Perhaps because the survey was conducted over the Internet, the demographics of the respondents were not representative of the general population: 74% of the women were white, 69% had at least some college education, and 70% were married or had a domestic partner. The mean age of respondents was 39 years.

RENO, NEV. — Significant racial differences in proinflammatory biomarkers during pregnancy may help to illuminate reasons for disparate rates of preterm birth between black and white women, according to speakers at the annual meeting of the Society for Gynecologic Investigation.

In one study, researchers seeking to establish normal ranges of serum C-reactive protein (CRP) during pregnancy discovered that mean CRP values were elevated for both black and white women, establishing that normal pregnancy is an inflammatory state.

Surprisingly, however, they found that serum CRP values were much higher for black women than for white women, independent of maternal weight, and these differences persisted from earliest pregnancy through 26 weeks' gestation—the last point at which they were measured in the study.

“[By using a multivariate analysis model] … we discovered that black race and sociodemographic characteristics were the strongest predictors of elevated CRP values [in pregnancy],” reported Dr. Amy H. Picklesimer, a fellow in maternal-fetal medicine at the University of North Carolina, Chapel Hill.

Meanwhile, a second study found highly significant differences in concentrations of tumor necrosis factor-α (TNA-α) in black women who gave birth at less than 37 weeks, compared with black women who gave birth at term, but no differences between white women with preterm and those with term deliveries.

“These findings alone do not explain the racial difference in preterm birth rates between blacks and whites,” Dr. Ramkumar Menon said, referring to the results of his study conducted at the Perinatal Research Center of Nashville, Tenn., in conjunction with Vanderbilt University, Nashville, and the North Atlantic Neuro Epidemiologic Alliance of Aarhus University (Denmark).

“However, they do suggest a substantial racial difference in one of the important hypothesized pathways,” he said.

The two studies were featured in an oral scientific session on parturition.

Dr. Picklesimer and associates conducted a secondary analysis of a cross-sectional study of 775 women aimed at assessing oral health in pregnancy. Highly sensitive ELISA assays were used to characterize CRP values in serum specimens drawn prior to 26 weeks in the cohort, which consisted of 48% white women, 46% black women, and 6% women of other ethnicities.

CRP is an acute-phase reactant produced in response to stress, trauma, or other stimuli. In nonpregnant women, it is increasingly viewed as an important noninvasive marker of vascular inflammation relevant to cardiovascular disease, with a threshold of more than 3 mg/L deemed to indicate high risk, she said.

The median serum CRP in pregnant women surpassed that threshold, at 4.8 mg/L, with an interquartile range of 0.63–15.7 mg/L.

Among white women, median CRP values were significantly higher in the second trimester than in the first.

Black women had much higher values than white women at enrollment (7.68 mg/L vs. 2.59 mg/L), and these values remained persistently elevated in the second trimester.

Statistical analysis determined that black race was the characteristic most strongly associated with CRP values in the 75th percentile, along with maternal weight at enrollment, eligibility for the Women, Infants and Children nutrition program or food stamps, lack of private insurance, unmarried status, and previous preterm birth.

A multivariate analysis confirmed the independent association of black race and socioeconomic factors, even when statistical adjustment was made for known associations such as maternal weight.

“The most important implication of our result is to caution investigators and clinicians in their interpretations of CRP values in pregnant women and to illuminate the important influence that socioeconomic characteristics seem to have on these values,” Dr. Picklesimer said.

She postulated that genetic polymorphisms could play a role in the disparity.

“Another explanation may lie in the broader social and environmental differences observed between racial groups … [with] elevated CRP [resulting] from chronic stress caused by a lifetime of socioeconomic disadvantages,” Dr. Picklesimer said.

Dr. Menon's group examined inflammatory markers during active labor in the amniotic fluid of 158 women (52 black women and 106 white women) who spontaneously delivered prior to 37 weeks and 175 women (87 black women and 88 white women) who delivered spontaneously at 37 weeks or beyond.

No significant differences were seen between black and white women in terms of demographic or clinical features such as fever.

Among all women, TNF-α concentrations were higher in amniotic fluid from preterm births; however, this difference was almost fully accounted for by black women.

Black women who gave birth early had a 22.5-fold increase in TNF-α concentration, compared with black women who had term deliveries, but there was no significant difference between white women who had preterm or at term deliveries.

The same pattern was seen in soluble TNF-receptor concentrations, Dr. Menon reported.

A high degree of disparity between black and white women in the molar ratio of TNF-α and soluble TNF-receptor concentration “may be indicative of a TNF-α-mediated pathological process of preterm birth in blacks, but maybe not in whites,” he said at the meeting.

RENO, NEV. — Significant racial differences in proinflammatory biomarkers during pregnancy may help to illuminate reasons for disparate rates of preterm birth between black and white women, according to speakers at the annual meeting of the Society for Gynecologic Investigation.

In one study, researchers seeking to establish normal ranges of serum C-reactive protein (CRP) during pregnancy discovered that mean CRP values were elevated for both black and white women, establishing that normal pregnancy is an inflammatory state.

Surprisingly, however, they found that serum CRP values were much higher for black women than for white women, independent of maternal weight, and these differences persisted from earliest pregnancy through 26 weeks' gestation—the last point at which they were measured in the study.

“[By using a multivariate analysis model] … we discovered that black race and sociodemographic characteristics were the strongest predictors of elevated CRP values [in pregnancy],” reported Dr. Amy H. Picklesimer, a fellow in maternal-fetal medicine at the University of North Carolina, Chapel Hill.

Meanwhile, a second study found highly significant differences in concentrations of tumor necrosis factor-α (TNA-α) in black women who gave birth at less than 37 weeks, compared with black women who gave birth at term, but no differences between white women with preterm and those with term deliveries.

“These findings alone do not explain the racial difference in preterm birth rates between blacks and whites,” Dr. Ramkumar Menon said, referring to the results of his study conducted at the Perinatal Research Center of Nashville, Tenn., in conjunction with Vanderbilt University, Nashville, and the North Atlantic Neuro Epidemiologic Alliance of Aarhus University (Denmark).

“However, they do suggest a substantial racial difference in one of the important hypothesized pathways,” he said.

The two studies were featured in an oral scientific session on parturition.

Dr. Picklesimer and associates conducted a secondary analysis of a cross-sectional study of 775 women aimed at assessing oral health in pregnancy. Highly sensitive ELISA assays were used to characterize CRP values in serum specimens drawn prior to 26 weeks in the cohort, which consisted of 48% white women, 46% black women, and 6% women of other ethnicities.

CRP is an acute-phase reactant produced in response to stress, trauma, or other stimuli. In nonpregnant women, it is increasingly viewed as an important noninvasive marker of vascular inflammation relevant to cardiovascular disease, with a threshold of more than 3 mg/L deemed to indicate high risk, she said.

The median serum CRP in pregnant women surpassed that threshold, at 4.8 mg/L, with an interquartile range of 0.63–15.7 mg/L.

Among white women, median CRP values were significantly higher in the second trimester than in the first.

Black women had much higher values than white women at enrollment (7.68 mg/L vs. 2.59 mg/L), and these values remained persistently elevated in the second trimester.

Statistical analysis determined that black race was the characteristic most strongly associated with CRP values in the 75th percentile, along with maternal weight at enrollment, eligibility for the Women, Infants and Children nutrition program or food stamps, lack of private insurance, unmarried status, and previous preterm birth.

A multivariate analysis confirmed the independent association of black race and socioeconomic factors, even when statistical adjustment was made for known associations such as maternal weight.

“The most important implication of our result is to caution investigators and clinicians in their interpretations of CRP values in pregnant women and to illuminate the important influence that socioeconomic characteristics seem to have on these values,” Dr. Picklesimer said.

She postulated that genetic polymorphisms could play a role in the disparity.

“Another explanation may lie in the broader social and environmental differences observed between racial groups … [with] elevated CRP [resulting] from chronic stress caused by a lifetime of socioeconomic disadvantages,” Dr. Picklesimer said.

Dr. Menon's group examined inflammatory markers during active labor in the amniotic fluid of 158 women (52 black women and 106 white women) who spontaneously delivered prior to 37 weeks and 175 women (87 black women and 88 white women) who delivered spontaneously at 37 weeks or beyond.

No significant differences were seen between black and white women in terms of demographic or clinical features such as fever.

Among all women, TNF-α concentrations were higher in amniotic fluid from preterm births; however, this difference was almost fully accounted for by black women.

Black women who gave birth early had a 22.5-fold increase in TNF-α concentration, compared with black women who had term deliveries, but there was no significant difference between white women who had preterm or at term deliveries.

The same pattern was seen in soluble TNF-receptor concentrations, Dr. Menon reported.

A high degree of disparity between black and white women in the molar ratio of TNF-α and soluble TNF-receptor concentration “may be indicative of a TNF-α-mediated pathological process of preterm birth in blacks, but maybe not in whites,” he said at the meeting.

RENO, NEV. — Significant racial differences in proinflammatory biomarkers during pregnancy may help to illuminate reasons for disparate rates of preterm birth between black and white women, according to speakers at the annual meeting of the Society for Gynecologic Investigation.

In one study, researchers seeking to establish normal ranges of serum C-reactive protein (CRP) during pregnancy discovered that mean CRP values were elevated for both black and white women, establishing that normal pregnancy is an inflammatory state.

Surprisingly, however, they found that serum CRP values were much higher for black women than for white women, independent of maternal weight, and these differences persisted from earliest pregnancy through 26 weeks' gestation—the last point at which they were measured in the study.

“[By using a multivariate analysis model] … we discovered that black race and sociodemographic characteristics were the strongest predictors of elevated CRP values [in pregnancy],” reported Dr. Amy H. Picklesimer, a fellow in maternal-fetal medicine at the University of North Carolina, Chapel Hill.

Meanwhile, a second study found highly significant differences in concentrations of tumor necrosis factor-α (TNA-α) in black women who gave birth at less than 37 weeks, compared with black women who gave birth at term, but no differences between white women with preterm and those with term deliveries.

“These findings alone do not explain the racial difference in preterm birth rates between blacks and whites,” Dr. Ramkumar Menon said, referring to the results of his study conducted at the Perinatal Research Center of Nashville, Tenn., in conjunction with Vanderbilt University, Nashville, and the North Atlantic Neuro Epidemiologic Alliance of Aarhus University (Denmark).

“However, they do suggest a substantial racial difference in one of the important hypothesized pathways,” he said.

The two studies were featured in an oral scientific session on parturition.

Dr. Picklesimer and associates conducted a secondary analysis of a cross-sectional study of 775 women aimed at assessing oral health in pregnancy. Highly sensitive ELISA assays were used to characterize CRP values in serum specimens drawn prior to 26 weeks in the cohort, which consisted of 48% white women, 46% black women, and 6% women of other ethnicities.

CRP is an acute-phase reactant produced in response to stress, trauma, or other stimuli. In nonpregnant women, it is increasingly viewed as an important noninvasive marker of vascular inflammation relevant to cardiovascular disease, with a threshold of more than 3 mg/L deemed to indicate high risk, she said.

The median serum CRP in pregnant women surpassed that threshold, at 4.8 mg/L, with an interquartile range of 0.63–15.7 mg/L.

Among white women, median CRP values were significantly higher in the second trimester than in the first.

Black women had much higher values than white women at enrollment (7.68 mg/L vs. 2.59 mg/L), and these values remained persistently elevated in the second trimester.

Statistical analysis determined that black race was the characteristic most strongly associated with CRP values in the 75th percentile, along with maternal weight at enrollment, eligibility for the Women, Infants and Children nutrition program or food stamps, lack of private insurance, unmarried status, and previous preterm birth.

A multivariate analysis confirmed the independent association of black race and socioeconomic factors, even when statistical adjustment was made for known associations such as maternal weight.

“The most important implication of our result is to caution investigators and clinicians in their interpretations of CRP values in pregnant women and to illuminate the important influence that socioeconomic characteristics seem to have on these values,” Dr. Picklesimer said.

She postulated that genetic polymorphisms could play a role in the disparity.

“Another explanation may lie in the broader social and environmental differences observed between racial groups … [with] elevated CRP [resulting] from chronic stress caused by a lifetime of socioeconomic disadvantages,” Dr. Picklesimer said.

Dr. Menon's group examined inflammatory markers during active labor in the amniotic fluid of 158 women (52 black women and 106 white women) who spontaneously delivered prior to 37 weeks and 175 women (87 black women and 88 white women) who delivered spontaneously at 37 weeks or beyond.

No significant differences were seen between black and white women in terms of demographic or clinical features such as fever.

Among all women, TNF-α concentrations were higher in amniotic fluid from preterm births; however, this difference was almost fully accounted for by black women.

Black women who gave birth early had a 22.5-fold increase in TNF-α concentration, compared with black women who had term deliveries, but there was no significant difference between white women who had preterm or at term deliveries.

The same pattern was seen in soluble TNF-receptor concentrations, Dr. Menon reported.

A high degree of disparity between black and white women in the molar ratio of TNF-α and soluble TNF-receptor concentration “may be indicative of a TNF-α-mediated pathological process of preterm birth in blacks, but maybe not in whites,” he said at the meeting.

RENO, NEV. — Five key factors predicted successful external cephalic version in a meta-analysis of 43 primary articles describing 8,089 cases, reported Dr. Marjolein Kok at the annual meeting of the Society for Gynecologic Investigation.

Predictors of success, in order, included the following:

▸ Uterine relaxation (odds ratio 19; 95% confidence interval 3.1–3.9).

▸ Nonengagement (OR 10; CI 6.6–15).

▸ Palpable fetal head (OR 9.4; CI 6.0–15).

▸ Multiparity (OR 3.5; CI 3.1–3.9).

▸ Maternal weight less than 65 kg (OR 1.8; CI 1.2–2.6).

Most studies included in the review were prospective cohort studies, said Dr. Kok in an interview at the meeting, where she presented her findings in poster form.

Studies were reviewed from Medline, Embase, Cochrane Library, and manual searching of bibliographies of known primary and review articles. Articles were included if they reported on both potential clinical prognosticators and external cephalic version success rates.

The final conclusions not only illuminated factors associated with success but offer a way to weigh the importance of each factor. For example, a relaxed uterus is 20 times more likely to predict success, making it a more important prognostic variable than maternal weight.

Dr. Kok, an obstetrician and registrar at the Academic Medical Center in Amsterdam, was assisted in the study by colleagues in the ob.gyn. department at her institution and by Dr. Ben Willem Mol of Maxima Medical Centre Veldhoven in the Netherlands.

RENO, NEV. — Five key factors predicted successful external cephalic version in a meta-analysis of 43 primary articles describing 8,089 cases, reported Dr. Marjolein Kok at the annual meeting of the Society for Gynecologic Investigation.

Predictors of success, in order, included the following:

▸ Uterine relaxation (odds ratio 19; 95% confidence interval 3.1–3.9).

▸ Nonengagement (OR 10; CI 6.6–15).

▸ Palpable fetal head (OR 9.4; CI 6.0–15).

▸ Multiparity (OR 3.5; CI 3.1–3.9).

▸ Maternal weight less than 65 kg (OR 1.8; CI 1.2–2.6).

Most studies included in the review were prospective cohort studies, said Dr. Kok in an interview at the meeting, where she presented her findings in poster form.

Studies were reviewed from Medline, Embase, Cochrane Library, and manual searching of bibliographies of known primary and review articles. Articles were included if they reported on both potential clinical prognosticators and external cephalic version success rates.

The final conclusions not only illuminated factors associated with success but offer a way to weigh the importance of each factor. For example, a relaxed uterus is 20 times more likely to predict success, making it a more important prognostic variable than maternal weight.

Dr. Kok, an obstetrician and registrar at the Academic Medical Center in Amsterdam, was assisted in the study by colleagues in the ob.gyn. department at her institution and by Dr. Ben Willem Mol of Maxima Medical Centre Veldhoven in the Netherlands.

RENO, NEV. — Five key factors predicted successful external cephalic version in a meta-analysis of 43 primary articles describing 8,089 cases, reported Dr. Marjolein Kok at the annual meeting of the Society for Gynecologic Investigation.

Predictors of success, in order, included the following:

▸ Uterine relaxation (odds ratio 19; 95% confidence interval 3.1–3.9).

▸ Nonengagement (OR 10; CI 6.6–15).

▸ Palpable fetal head (OR 9.4; CI 6.0–15).

▸ Multiparity (OR 3.5; CI 3.1–3.9).

▸ Maternal weight less than 65 kg (OR 1.8; CI 1.2–2.6).

Most studies included in the review were prospective cohort studies, said Dr. Kok in an interview at the meeting, where she presented her findings in poster form.

Studies were reviewed from Medline, Embase, Cochrane Library, and manual searching of bibliographies of known primary and review articles. Articles were included if they reported on both potential clinical prognosticators and external cephalic version success rates.

The final conclusions not only illuminated factors associated with success but offer a way to weigh the importance of each factor. For example, a relaxed uterus is 20 times more likely to predict success, making it a more important prognostic variable than maternal weight.

Dr. Kok, an obstetrician and registrar at the Academic Medical Center in Amsterdam, was assisted in the study by colleagues in the ob.gyn. department at her institution and by Dr. Ben Willem Mol of Maxima Medical Centre Veldhoven in the Netherlands.

BOSTON — Long-term use of nonsteroidal anti-inflammatory drugs other than aspirin may significantly reduce breast cancer risk in African American and Caucasian women, according to data from a multiethnic study.

Among women overall, however, no associations were seen between breast cancer risk and the use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), Jasmeet Gill, Ph.D., reported at the annual international conference of the American Association for Cancer Research.

Previous studies looking at NSAID use and breast cancer have yielded mixed results, said Dr. Gill, a postdoctoral fellow at the University of Hawaii, Honolulu. “Although the relationship between cyclooxygenase-2 expression and breast cancer has been shown to be biologically plausible, the use of NSAIDs to reduce the risk of breast cancer is not well established,” she said.

Dr. Gill and her colleagues identified 4,010 incident breast cancer cases among American women who participated in the University of Hawaii/University of Southern California Multiethnic Cohort Study from 1993 to 2002, and reviewed NSAID exposure data gleaned from a self-administered questionnaire completed at baseline. The study includes African Americans, Caucasians, Japanese, native Hawaiians, and Hispanics from Hawaii and Los Angeles County.

Cox regression analyses showed no association overall between breast cancer risk and duration of aspirin use, other NSAID use for 6 or more years, or total NSAID use for 11 or more years. Neither were there consistent associations between medication use and breast cancer risk across strata of ethnicity, body mass index, tumor stage, or patient age, Dr. Gill reported in a poster presentation.

“The only associations observed were for other NSAID use among African American and Caucasian women,” she said. The use of NSAIDs other than aspirin for 6 or more years was associated with a 54% reduction in breast cancer risk among African American women and a 31% reduction in risk among Caucasian women.

“It is unclear why aspirin use was not associated with breast cancer risk reduction as has been shown in other studies, although we are intrigued by the reduced risk associated with other NSAID use in African American and Caucasian women,” Dr. Gill said. She had no financial disclosures related to her presentation.

BOSTON — Long-term use of nonsteroidal anti-inflammatory drugs other than aspirin may significantly reduce breast cancer risk in African American and Caucasian women, according to data from a multiethnic study.

Among women overall, however, no associations were seen between breast cancer risk and the use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), Jasmeet Gill, Ph.D., reported at the annual international conference of the American Association for Cancer Research.

Previous studies looking at NSAID use and breast cancer have yielded mixed results, said Dr. Gill, a postdoctoral fellow at the University of Hawaii, Honolulu. “Although the relationship between cyclooxygenase-2 expression and breast cancer has been shown to be biologically plausible, the use of NSAIDs to reduce the risk of breast cancer is not well established,” she said.

Dr. Gill and her colleagues identified 4,010 incident breast cancer cases among American women who participated in the University of Hawaii/University of Southern California Multiethnic Cohort Study from 1993 to 2002, and reviewed NSAID exposure data gleaned from a self-administered questionnaire completed at baseline. The study includes African Americans, Caucasians, Japanese, native Hawaiians, and Hispanics from Hawaii and Los Angeles County.

Cox regression analyses showed no association overall between breast cancer risk and duration of aspirin use, other NSAID use for 6 or more years, or total NSAID use for 11 or more years. Neither were there consistent associations between medication use and breast cancer risk across strata of ethnicity, body mass index, tumor stage, or patient age, Dr. Gill reported in a poster presentation.

“The only associations observed were for other NSAID use among African American and Caucasian women,” she said. The use of NSAIDs other than aspirin for 6 or more years was associated with a 54% reduction in breast cancer risk among African American women and a 31% reduction in risk among Caucasian women.

“It is unclear why aspirin use was not associated with breast cancer risk reduction as has been shown in other studies, although we are intrigued by the reduced risk associated with other NSAID use in African American and Caucasian women,” Dr. Gill said. She had no financial disclosures related to her presentation.

BOSTON — Long-term use of nonsteroidal anti-inflammatory drugs other than aspirin may significantly reduce breast cancer risk in African American and Caucasian women, according to data from a multiethnic study.

Among women overall, however, no associations were seen between breast cancer risk and the use of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs), Jasmeet Gill, Ph.D., reported at the annual international conference of the American Association for Cancer Research.

Previous studies looking at NSAID use and breast cancer have yielded mixed results, said Dr. Gill, a postdoctoral fellow at the University of Hawaii, Honolulu. “Although the relationship between cyclooxygenase-2 expression and breast cancer has been shown to be biologically plausible, the use of NSAIDs to reduce the risk of breast cancer is not well established,” she said.

Dr. Gill and her colleagues identified 4,010 incident breast cancer cases among American women who participated in the University of Hawaii/University of Southern California Multiethnic Cohort Study from 1993 to 2002, and reviewed NSAID exposure data gleaned from a self-administered questionnaire completed at baseline. The study includes African Americans, Caucasians, Japanese, native Hawaiians, and Hispanics from Hawaii and Los Angeles County.

Cox regression analyses showed no association overall between breast cancer risk and duration of aspirin use, other NSAID use for 6 or more years, or total NSAID use for 11 or more years. Neither were there consistent associations between medication use and breast cancer risk across strata of ethnicity, body mass index, tumor stage, or patient age, Dr. Gill reported in a poster presentation.

“The only associations observed were for other NSAID use among African American and Caucasian women,” she said. The use of NSAIDs other than aspirin for 6 or more years was associated with a 54% reduction in breast cancer risk among African American women and a 31% reduction in risk among Caucasian women.

“It is unclear why aspirin use was not associated with breast cancer risk reduction as has been shown in other studies, although we are intrigued by the reduced risk associated with other NSAID use in African American and Caucasian women,” Dr. Gill said. She had no financial disclosures related to her presentation.

SAN FRANCISCO — The first step in preparing a diabetic woman for pregnancy is recognizing that she has diabetes before she conceives.

Women with type 2 diabetes often don't get diagnosed until pregnancy, when it's too late to reduce the risk of congenital anomalies through better glycemic control, Dr. Ingrid Block said at a meeting on diabetes and endocrinology sponsored by the University of California, San Francisco.

Congenital anomalies in infants of diabetic mothers occur as early as 5 weeks after the mother's last menstrual period (for caudal regression) and as late as 8 weeks after the last period (for cardiac anomalies).

“If you don't sit down with that patient and ensure that she plans her pregnancy and that she has good glycemic control before conception, you run the risk that she'll find out she's 8 weeks pregnant and she has missed the opportunity” to avoid these congenital anomalies, said Dr. Block, of the university.

With any new female patients, pay attention to their obstetric histories, she urged. If a nondiabetic woman has delivered a large baby or had gestational diabetes, she's at increased risk for developing type 2 diabetes and should be screened for it periodically.

Congenital anomalies occur in 6%–10% of pregnancies among diabetic women with uncontrolled hyperglycemia, compared with an incidence of 2% in nondiabetic women. Emphasize effective contraception until diabetes patients achieve stable glycemia, Dr. Block said.

Preconception counseling and care should help women optimize glycemic control before pregnancy, which significantly reduces the risks of anomalies and fetal death, studies have shown. Women with type 2 diabetes should transition before conception from managing their diabetes using diet alone or oral therapies to using insulin, she added. Identification and treatment of long-term complications of diabetes—such as retinopathy, nephropathy, neuropathy, hypertension, and coronary artery disease—will give physicians an opportunity to warn some patients about difficult or nonviable pregnancies.

Diabetic women with early renal failure are unlikely to have viable pregnancies, for example, but renal transplant has allowed some of these women to have successful pregnancies and deliveries. A diabetic woman with preconception hypertension and proteinuria over 500 mg in 24 hours should be informed of her significant risk for preeclampsia and preterm delivery, which could mean weeks in the neonatal intensive care unit.

“That is a very stressful experience for the baby and the parents,” Dr. Block said.

At her institution, women with type 1 or type 2 diabetes who want to become pregnant get tests for hemoglobin HbA_1c and TSH levels, 24-hour urine protein, and serum creatinine. They also get an ECG, and patients at high risk for coronary artery disease undergo noninvasive stress tests. Referrals for ophthalmologic evaluation, nutrition therapy, and a review of diabetes self-care skills are routine. Every patient gets a glucagon emergency kit if she doesn't already have one, and starts prenatal vitamins.

Any women with type 1 diabetes who are on regular insulin are switched to aspart or lispro forms of insulin. Women with type 2 diabetes stop oral hypoglycemics and start insulin. If they are on ACE inhibitor therapy, type 2 diabetes patients stop the drug and switch to labetalol or methyldopa.

It's important to know how much support the woman has at home, and how involved the father is in the pregnancy.

Start these patients on frequent glucose monitoring before meals and 60–90 minutes after eating, with a blood glucose check at 2 a.m., she said. Before pregnancy, aim for a fasting blood glucose less than 105 mg/dL, a 1-hour postprandial level below 155 mg/dL, and a 2 a.m. level below 120 mg/dL. During pregnancy, aim for a fasting blood glucose below 95 mg/dL, a 1-hour postprandial level less than 140 mg/dL, and a 2 a.m. level below 120 mg/dL.

SAN FRANCISCO — The first step in preparing a diabetic woman for pregnancy is recognizing that she has diabetes before she conceives.

Women with type 2 diabetes often don't get diagnosed until pregnancy, when it's too late to reduce the risk of congenital anomalies through better glycemic control, Dr. Ingrid Block said at a meeting on diabetes and endocrinology sponsored by the University of California, San Francisco.

Congenital anomalies in infants of diabetic mothers occur as early as 5 weeks after the mother's last menstrual period (for caudal regression) and as late as 8 weeks after the last period (for cardiac anomalies).

“If you don't sit down with that patient and ensure that she plans her pregnancy and that she has good glycemic control before conception, you run the risk that she'll find out she's 8 weeks pregnant and she has missed the opportunity” to avoid these congenital anomalies, said Dr. Block, of the university.

With any new female patients, pay attention to their obstetric histories, she urged. If a nondiabetic woman has delivered a large baby or had gestational diabetes, she's at increased risk for developing type 2 diabetes and should be screened for it periodically.

Congenital anomalies occur in 6%–10% of pregnancies among diabetic women with uncontrolled hyperglycemia, compared with an incidence of 2% in nondiabetic women. Emphasize effective contraception until diabetes patients achieve stable glycemia, Dr. Block said.

Preconception counseling and care should help women optimize glycemic control before pregnancy, which significantly reduces the risks of anomalies and fetal death, studies have shown. Women with type 2 diabetes should transition before conception from managing their diabetes using diet alone or oral therapies to using insulin, she added. Identification and treatment of long-term complications of diabetes—such as retinopathy, nephropathy, neuropathy, hypertension, and coronary artery disease—will give physicians an opportunity to warn some patients about difficult or nonviable pregnancies.

Diabetic women with early renal failure are unlikely to have viable pregnancies, for example, but renal transplant has allowed some of these women to have successful pregnancies and deliveries. A diabetic woman with preconception hypertension and proteinuria over 500 mg in 24 hours should be informed of her significant risk for preeclampsia and preterm delivery, which could mean weeks in the neonatal intensive care unit.

“That is a very stressful experience for the baby and the parents,” Dr. Block said.

At her institution, women with type 1 or type 2 diabetes who want to become pregnant get tests for hemoglobin HbA_1c and TSH levels, 24-hour urine protein, and serum creatinine. They also get an ECG, and patients at high risk for coronary artery disease undergo noninvasive stress tests. Referrals for ophthalmologic evaluation, nutrition therapy, and a review of diabetes self-care skills are routine. Every patient gets a glucagon emergency kit if she doesn't already have one, and starts prenatal vitamins.

Any women with type 1 diabetes who are on regular insulin are switched to aspart or lispro forms of insulin. Women with type 2 diabetes stop oral hypoglycemics and start insulin. If they are on ACE inhibitor therapy, type 2 diabetes patients stop the drug and switch to labetalol or methyldopa.

It's important to know how much support the woman has at home, and how involved the father is in the pregnancy.

Start these patients on frequent glucose monitoring before meals and 60–90 minutes after eating, with a blood glucose check at 2 a.m., she said. Before pregnancy, aim for a fasting blood glucose less than 105 mg/dL, a 1-hour postprandial level below 155 mg/dL, and a 2 a.m. level below 120 mg/dL. During pregnancy, aim for a fasting blood glucose below 95 mg/dL, a 1-hour postprandial level less than 140 mg/dL, and a 2 a.m. level below 120 mg/dL.

SAN FRANCISCO — The first step in preparing a diabetic woman for pregnancy is recognizing that she has diabetes before she conceives.

Women with type 2 diabetes often don't get diagnosed until pregnancy, when it's too late to reduce the risk of congenital anomalies through better glycemic control, Dr. Ingrid Block said at a meeting on diabetes and endocrinology sponsored by the University of California, San Francisco.

Congenital anomalies in infants of diabetic mothers occur as early as 5 weeks after the mother's last menstrual period (for caudal regression) and as late as 8 weeks after the last period (for cardiac anomalies).

“If you don't sit down with that patient and ensure that she plans her pregnancy and that she has good glycemic control before conception, you run the risk that she'll find out she's 8 weeks pregnant and she has missed the opportunity” to avoid these congenital anomalies, said Dr. Block, of the university.

With any new female patients, pay attention to their obstetric histories, she urged. If a nondiabetic woman has delivered a large baby or had gestational diabetes, she's at increased risk for developing type 2 diabetes and should be screened for it periodically.

Congenital anomalies occur in 6%–10% of pregnancies among diabetic women with uncontrolled hyperglycemia, compared with an incidence of 2% in nondiabetic women. Emphasize effective contraception until diabetes patients achieve stable glycemia, Dr. Block said.

Preconception counseling and care should help women optimize glycemic control before pregnancy, which significantly reduces the risks of anomalies and fetal death, studies have shown. Women with type 2 diabetes should transition before conception from managing their diabetes using diet alone or oral therapies to using insulin, she added. Identification and treatment of long-term complications of diabetes—such as retinopathy, nephropathy, neuropathy, hypertension, and coronary artery disease—will give physicians an opportunity to warn some patients about difficult or nonviable pregnancies.

Diabetic women with early renal failure are unlikely to have viable pregnancies, for example, but renal transplant has allowed some of these women to have successful pregnancies and deliveries. A diabetic woman with preconception hypertension and proteinuria over 500 mg in 24 hours should be informed of her significant risk for preeclampsia and preterm delivery, which could mean weeks in the neonatal intensive care unit.

“That is a very stressful experience for the baby and the parents,” Dr. Block said.

At her institution, women with type 1 or type 2 diabetes who want to become pregnant get tests for hemoglobin HbA_1c and TSH levels, 24-hour urine protein, and serum creatinine. They also get an ECG, and patients at high risk for coronary artery disease undergo noninvasive stress tests. Referrals for ophthalmologic evaluation, nutrition therapy, and a review of diabetes self-care skills are routine. Every patient gets a glucagon emergency kit if she doesn't already have one, and starts prenatal vitamins.

Any women with type 1 diabetes who are on regular insulin are switched to aspart or lispro forms of insulin. Women with type 2 diabetes stop oral hypoglycemics and start insulin. If they are on ACE inhibitor therapy, type 2 diabetes patients stop the drug and switch to labetalol or methyldopa.

It's important to know how much support the woman has at home, and how involved the father is in the pregnancy.

Start these patients on frequent glucose monitoring before meals and 60–90 minutes after eating, with a blood glucose check at 2 a.m., she said. Before pregnancy, aim for a fasting blood glucose less than 105 mg/dL, a 1-hour postprandial level below 155 mg/dL, and a 2 a.m. level below 120 mg/dL. During pregnancy, aim for a fasting blood glucose below 95 mg/dL, a 1-hour postprandial level less than 140 mg/dL, and a 2 a.m. level below 120 mg/dL.

SAN FRANCISCO — Gestational weight at diagnosis and proportion of selective coagulations are predictive of perioperative prognosis in severe twin-to-twin transfusion syndrome treated by fetoscopic laser surgery, Dr. Julien Stirnemann said at the annual meeting of the Society for Maternal-Fetal Medicine.

The finding could improve risk stratification and counseling for patients undergoing the fetal intervention, said Dr. Stirnemann, of CHI Poissy Saint Germain in Paris.

In recent years, fetoscopic laser coagulation of the vascular anastomoses has significantly improved survival odds of affected infants in twin-to-twin transfusion syndrome (TTTS), one of the most complex pathologies in multiple gestation, Dr. Stirnemann said.

The current study looked at factors associated with a perioperative outcome in 323 consecutive monochorionic pregnancies complicated with severe TTTS and treated with selective laser coagulation. The selective laser surgery allows for the precise identification of vascular anastomoses vs. the nonselective technique, which targets all vessels crossing the intertwin membrane, he said.

The primary and secondary study outcomes were survival for more than 28 days of one or both twins, respectively, without severe impairment. For purposes of the investigation, severe impairment was defined as at least one of the following: intraventricular hemorrhage stage 3 or 4, periventricular leukomalacia, bronchopulmonary dysplasia, persistent renal failure at 28 days, or surgical necrotizing enterocolitis, Dr. Stirnemann said.

The maternal and pregnancy-related variables considered in the analysis included gestational age at diagnosis, Quintero staging, estimated fetal weight, and cervical length. The surgery-related factors included the need for a transplacental approach, the number and type (selective or nonselective) of coagulations, the percentage of selectivity per procedure (ratio of selective coagulations to the total number of coagulations), and the volume of amniotic fluid drained per procedure.

The overall survival rates were 65% for at least one twin and 28% for both twins, Dr. Stirnemann reported.

In a univariate analysis of survival without impairment of at least one twin, age at diagnosis, Quintero stage 1 or 2, estimated fetal weight (donor and recipient), number of selective coagulations above four, percentage of selectivity above 60%, and volume of drained amniotic fluid reached significance, he said. In multivariate analysis using stepwise logistic regression, “only recipients' estimated fetal weight and number of selective coagulations higher than four reach significance in the model, with odds ratios of 2.2 and 1.9, respectively,” he stated.

When the same analyses were conducted to assess survival without impairment of both twins, “favorable factors in the univariate analysis were maternal age, gestational age at diagnosis, Quintero stages 1 and 2, estimated fetal weight (donors and recipients), number of coagulations higher than seven, number of selective coagulations higher than four, and percentage of selectivity above 60%,” said Dr. Stirnemann. “Previous history of miscarriage and transplacental approach were significant adverse factors.”

In the multivariate analysis for this outcome, “donors' estimated fetal weight and percentage of selectivity above 60% were independent predictive factors of survival without impairment, with odds ratios of 1.95 and 1.85, respectively,” said Dr. Stirnemann. Additionally, history of miscarriage was a significant adverse factor for survival, with an odds ratio of 0.3, he said.

“Awareness of these prognostic factors should become part of the discussion when counseling patients about the risks associated with fetal intervention by laser photocoagulation for twin-to-twin transfusion syndrome,” he concluded.

SAN FRANCISCO — Gestational weight at diagnosis and proportion of selective coagulations are predictive of perioperative prognosis in severe twin-to-twin transfusion syndrome treated by fetoscopic laser surgery, Dr. Julien Stirnemann said at the annual meeting of the Society for Maternal-Fetal Medicine.

The finding could improve risk stratification and counseling for patients undergoing the fetal intervention, said Dr. Stirnemann, of CHI Poissy Saint Germain in Paris.

In recent years, fetoscopic laser coagulation of the vascular anastomoses has significantly improved survival odds of affected infants in twin-to-twin transfusion syndrome (TTTS), one of the most complex pathologies in multiple gestation, Dr. Stirnemann said.

The current study looked at factors associated with a perioperative outcome in 323 consecutive monochorionic pregnancies complicated with severe TTTS and treated with selective laser coagulation. The selective laser surgery allows for the precise identification of vascular anastomoses vs. the nonselective technique, which targets all vessels crossing the intertwin membrane, he said.

The primary and secondary study outcomes were survival for more than 28 days of one or both twins, respectively, without severe impairment. For purposes of the investigation, severe impairment was defined as at least one of the following: intraventricular hemorrhage stage 3 or 4, periventricular leukomalacia, bronchopulmonary dysplasia, persistent renal failure at 28 days, or surgical necrotizing enterocolitis, Dr. Stirnemann said.

The maternal and pregnancy-related variables considered in the analysis included gestational age at diagnosis, Quintero staging, estimated fetal weight, and cervical length. The surgery-related factors included the need for a transplacental approach, the number and type (selective or nonselective) of coagulations, the percentage of selectivity per procedure (ratio of selective coagulations to the total number of coagulations), and the volume of amniotic fluid drained per procedure.

The overall survival rates were 65% for at least one twin and 28% for both twins, Dr. Stirnemann reported.

In a univariate analysis of survival without impairment of at least one twin, age at diagnosis, Quintero stage 1 or 2, estimated fetal weight (donor and recipient), number of selective coagulations above four, percentage of selectivity above 60%, and volume of drained amniotic fluid reached significance, he said. In multivariate analysis using stepwise logistic regression, “only recipients' estimated fetal weight and number of selective coagulations higher than four reach significance in the model, with odds ratios of 2.2 and 1.9, respectively,” he stated.

When the same analyses were conducted to assess survival without impairment of both twins, “favorable factors in the univariate analysis were maternal age, gestational age at diagnosis, Quintero stages 1 and 2, estimated fetal weight (donors and recipients), number of coagulations higher than seven, number of selective coagulations higher than four, and percentage of selectivity above 60%,” said Dr. Stirnemann. “Previous history of miscarriage and transplacental approach were significant adverse factors.”

In the multivariate analysis for this outcome, “donors' estimated fetal weight and percentage of selectivity above 60% were independent predictive factors of survival without impairment, with odds ratios of 1.95 and 1.85, respectively,” said Dr. Stirnemann. Additionally, history of miscarriage was a significant adverse factor for survival, with an odds ratio of 0.3, he said.

“Awareness of these prognostic factors should become part of the discussion when counseling patients about the risks associated with fetal intervention by laser photocoagulation for twin-to-twin transfusion syndrome,” he concluded.

SAN FRANCISCO — Gestational weight at diagnosis and proportion of selective coagulations are predictive of perioperative prognosis in severe twin-to-twin transfusion syndrome treated by fetoscopic laser surgery, Dr. Julien Stirnemann said at the annual meeting of the Society for Maternal-Fetal Medicine.

The finding could improve risk stratification and counseling for patients undergoing the fetal intervention, said Dr. Stirnemann, of CHI Poissy Saint Germain in Paris.

In recent years, fetoscopic laser coagulation of the vascular anastomoses has significantly improved survival odds of affected infants in twin-to-twin transfusion syndrome (TTTS), one of the most complex pathologies in multiple gestation, Dr. Stirnemann said.

The current study looked at factors associated with a perioperative outcome in 323 consecutive monochorionic pregnancies complicated with severe TTTS and treated with selective laser coagulation. The selective laser surgery allows for the precise identification of vascular anastomoses vs. the nonselective technique, which targets all vessels crossing the intertwin membrane, he said.

The primary and secondary study outcomes were survival for more than 28 days of one or both twins, respectively, without severe impairment. For purposes of the investigation, severe impairment was defined as at least one of the following: intraventricular hemorrhage stage 3 or 4, periventricular leukomalacia, bronchopulmonary dysplasia, persistent renal failure at 28 days, or surgical necrotizing enterocolitis, Dr. Stirnemann said.

The maternal and pregnancy-related variables considered in the analysis included gestational age at diagnosis, Quintero staging, estimated fetal weight, and cervical length. The surgery-related factors included the need for a transplacental approach, the number and type (selective or nonselective) of coagulations, the percentage of selectivity per procedure (ratio of selective coagulations to the total number of coagulations), and the volume of amniotic fluid drained per procedure.

The overall survival rates were 65% for at least one twin and 28% for both twins, Dr. Stirnemann reported.

In a univariate analysis of survival without impairment of at least one twin, age at diagnosis, Quintero stage 1 or 2, estimated fetal weight (donor and recipient), number of selective coagulations above four, percentage of selectivity above 60%, and volume of drained amniotic fluid reached significance, he said. In multivariate analysis using stepwise logistic regression, “only recipients' estimated fetal weight and number of selective coagulations higher than four reach significance in the model, with odds ratios of 2.2 and 1.9, respectively,” he stated.

When the same analyses were conducted to assess survival without impairment of both twins, “favorable factors in the univariate analysis were maternal age, gestational age at diagnosis, Quintero stages 1 and 2, estimated fetal weight (donors and recipients), number of coagulations higher than seven, number of selective coagulations higher than four, and percentage of selectivity above 60%,” said Dr. Stirnemann. “Previous history of miscarriage and transplacental approach were significant adverse factors.”

In the multivariate analysis for this outcome, “donors' estimated fetal weight and percentage of selectivity above 60% were independent predictive factors of survival without impairment, with odds ratios of 1.95 and 1.85, respectively,” said Dr. Stirnemann. Additionally, history of miscarriage was a significant adverse factor for survival, with an odds ratio of 0.3, he said.

“Awareness of these prognostic factors should become part of the discussion when counseling patients about the risks associated with fetal intervention by laser photocoagulation for twin-to-twin transfusion syndrome,” he concluded.

SAN FRANCISCO — Pregnant women with type 1 diabetes mellitus were more likely to improve glycemic control and less likely to deliver by cesarean section if they used insulin pumps rather than self-injections of insulin, Dr. Yvonne W. Cheng said.

Among 60 women in the pump group, 25% had hemoglobin A1c (HbA1c) values below 6%, compared with 13% of 628 women in the injection group of a retrospective cohort study, she reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Half of women in the pump group delivered by C-section, compared with a 63% C-section rate in the injection group, said Dr. Cheng of the University of California, San Francisco, and her associates.

After controlling for the effects of maternal age, parity, ethnicity, body mass index, gestational weight gain, and gestational age at enrollment in the California Diabetes and Pregnancy Program, women in the pump group were three times as likely to have HbA1c values below 6% and were half as likely to have a C-section, compared with the injection group.

The conclusions support results from one previous study in 2004 that found improved glycemic control with use of an insulin pump instead of injections by pregnant women with type 1 diabetes mellitus.

Three other studies in 1988, 2000, and 2005 found no significant differences in results among groups, she noted.

All the previous studies were smaller than the present study, with only 11-36 patients in the pump groups.

The current study also found that women in the pump group were more likely to be white, to speak English as their primary language, and to have a higher education level than did women in the injection group.

“We need to address the disparity of insulin pump use in type 1 diabetes mellitus patients of different socioeconomic and racial/ethnic groups,” the authors commented.

In terms of rate of preterm delivery, rate of large-for-gestational-age babies, or rate of admissions to intensive care nurseries, the researchers found that there were no differences between the pump and injections groups.

“In nonpregnant diabetics, most people are switching over to pumps” because studies have shown better glycemic control, Dr. Cheng said in an interview at her poster.

The pump provides continuous release of insulin, functioning more like the pancreas than do timed injections of insulin.

In order to be candidates for insulin pumps, women must be able to count carbohydrates, operate the machine, and program it.

“It's a very select group of women,” she said.

Dr. Cheng disclosed that she has no association with companies that make either insulin pumps or injection products.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Pregnant women with type 1 diabetes mellitus were more likely to improve glycemic control and less likely to deliver by cesarean section if they used insulin pumps rather than self-injections of insulin, Dr. Yvonne W. Cheng said.

Among 60 women in the pump group, 25% had hemoglobin A1c (HbA1c) values below 6%, compared with 13% of 628 women in the injection group of a retrospective cohort study, she reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Half of women in the pump group delivered by C-section, compared with a 63% C-section rate in the injection group, said Dr. Cheng of the University of California, San Francisco, and her associates.

After controlling for the effects of maternal age, parity, ethnicity, body mass index, gestational weight gain, and gestational age at enrollment in the California Diabetes and Pregnancy Program, women in the pump group were three times as likely to have HbA1c values below 6% and were half as likely to have a C-section, compared with the injection group.

The conclusions support results from one previous study in 2004 that found improved glycemic control with use of an insulin pump instead of injections by pregnant women with type 1 diabetes mellitus.

Three other studies in 1988, 2000, and 2005 found no significant differences in results among groups, she noted.

All the previous studies were smaller than the present study, with only 11-36 patients in the pump groups.

The current study also found that women in the pump group were more likely to be white, to speak English as their primary language, and to have a higher education level than did women in the injection group.

“We need to address the disparity of insulin pump use in type 1 diabetes mellitus patients of different socioeconomic and racial/ethnic groups,” the authors commented.

In terms of rate of preterm delivery, rate of large-for-gestational-age babies, or rate of admissions to intensive care nurseries, the researchers found that there were no differences between the pump and injections groups.

“In nonpregnant diabetics, most people are switching over to pumps” because studies have shown better glycemic control, Dr. Cheng said in an interview at her poster.

The pump provides continuous release of insulin, functioning more like the pancreas than do timed injections of insulin.

In order to be candidates for insulin pumps, women must be able to count carbohydrates, operate the machine, and program it.

“It's a very select group of women,” she said.

Dr. Cheng disclosed that she has no association with companies that make either insulin pumps or injection products.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Pregnant women with type 1 diabetes mellitus were more likely to improve glycemic control and less likely to deliver by cesarean section if they used insulin pumps rather than self-injections of insulin, Dr. Yvonne W. Cheng said.

Among 60 women in the pump group, 25% had hemoglobin A1c (HbA1c) values below 6%, compared with 13% of 628 women in the injection group of a retrospective cohort study, she reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Half of women in the pump group delivered by C-section, compared with a 63% C-section rate in the injection group, said Dr. Cheng of the University of California, San Francisco, and her associates.

After controlling for the effects of maternal age, parity, ethnicity, body mass index, gestational weight gain, and gestational age at enrollment in the California Diabetes and Pregnancy Program, women in the pump group were three times as likely to have HbA1c values below 6% and were half as likely to have a C-section, compared with the injection group.

The conclusions support results from one previous study in 2004 that found improved glycemic control with use of an insulin pump instead of injections by pregnant women with type 1 diabetes mellitus.

Three other studies in 1988, 2000, and 2005 found no significant differences in results among groups, she noted.

All the previous studies were smaller than the present study, with only 11-36 patients in the pump groups.

The current study also found that women in the pump group were more likely to be white, to speak English as their primary language, and to have a higher education level than did women in the injection group.

“We need to address the disparity of insulin pump use in type 1 diabetes mellitus patients of different socioeconomic and racial/ethnic groups,” the authors commented.

In terms of rate of preterm delivery, rate of large-for-gestational-age babies, or rate of admissions to intensive care nurseries, the researchers found that there were no differences between the pump and injections groups.

“In nonpregnant diabetics, most people are switching over to pumps” because studies have shown better glycemic control, Dr. Cheng said in an interview at her poster.

The pump provides continuous release of insulin, functioning more like the pancreas than do timed injections of insulin.

In order to be candidates for insulin pumps, women must be able to count carbohydrates, operate the machine, and program it.

“It's a very select group of women,” she said.

Dr. Cheng disclosed that she has no association with companies that make either insulin pumps or injection products.

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Ultrasound identification of placental cord insertion sites in monochorionic diamniotic twin gestations can identify pregnancies at higher risk for preterm delivery, twin-to-twin transfusion syndrome, and growth discordance, according to the findings of a retrospective study.

This information can be used to counsel patients with monochorionic diamniotic twin gestations regarding the potential fetal and neonatal morbidity and mortality risks, Dr. John Allbert reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A cohort of 35 twin pregnancies referred by a single perinatologist for targeted ultrasound evaluation between November 2001 and November 2005 was included in the analysis. All of the pregnancies were monochorionic diamniotic and were at less than 22 weeks' gestation at the time of ultrasound. Additionally, at the time of evaluation, both fetuses in all of the pregnancies were anatomically normal and did not meet the criteria for diagnosis of twin-to-twin transfusion syndrome (TTTS), said Dr. Allbert.

Real-time ultrasound was used to locate the placental cord insertions (PCI), and the results were confirmed with color Doppler. The insertions were then categorized as velamentous, marginal (if less than 2 cm from the placental edge), or central (2 cm or more from the edge).

On the basis of the twin pair PCIs, the pregnancies were classified into one of three groups. In group 1, the twin pair PCIs were both central. In group 2, the PCIs were either central and marginal or both marginal, and in group 3, the twin pair PCIs were central and velamentous, Dr. Allbert explained.

Of the 35 pregnancies, 11 were classified into group 1, 17 into group 2, and 7 into group 3. The groups were compared using x2 analysis or Fisher exact test for the following outcome variables: gestational age at delivery, discordant growth, TTTS, need for amnioreduction, selective laser photocoagulation therapy, preterm labor, premature rupture of membranes, perinatal mortality, preeclampsia, and chorioamnionitis.

According to the results, “both marginal and velamentous cord insertions were significantly associated with growth discordance, earlier gestational age at delivery, and a higher incidence of twin-to-twin transfusion syndrome,” said Dr. Allbert.

Specifically, the mean gestational age at delivery in group 1 was 36.4 weeks, compared with 33.6 weeks and 31.6 weeks, in groups 2 and 3, respectively. Growth discordance of at least 20% was not observed in group 1, but did occur in 29.4% and 71.4% of groups 2 and 3, respectively.

Similarly, TTTS did not occur in group 1, but did occur in 35.3% of group 2 pregnancies and in 57.1% of group 3 pregnancies.

For group 1 pregnancies, in which both cord insertion sites were at least 2 cm from the placental edge, “the pregnancy risks appeared to be similar to those of dichorionic twins,” Dr. Allbert concluded.

SAN FRANCISCO — Ultrasound identification of placental cord insertion sites in monochorionic diamniotic twin gestations can identify pregnancies at higher risk for preterm delivery, twin-to-twin transfusion syndrome, and growth discordance, according to the findings of a retrospective study.

This information can be used to counsel patients with monochorionic diamniotic twin gestations regarding the potential fetal and neonatal morbidity and mortality risks, Dr. John Allbert reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A cohort of 35 twin pregnancies referred by a single perinatologist for targeted ultrasound evaluation between November 2001 and November 2005 was included in the analysis. All of the pregnancies were monochorionic diamniotic and were at less than 22 weeks' gestation at the time of ultrasound. Additionally, at the time of evaluation, both fetuses in all of the pregnancies were anatomically normal and did not meet the criteria for diagnosis of twin-to-twin transfusion syndrome (TTTS), said Dr. Allbert.

Real-time ultrasound was used to locate the placental cord insertions (PCI), and the results were confirmed with color Doppler. The insertions were then categorized as velamentous, marginal (if less than 2 cm from the placental edge), or central (2 cm or more from the edge).

On the basis of the twin pair PCIs, the pregnancies were classified into one of three groups. In group 1, the twin pair PCIs were both central. In group 2, the PCIs were either central and marginal or both marginal, and in group 3, the twin pair PCIs were central and velamentous, Dr. Allbert explained.

Of the 35 pregnancies, 11 were classified into group 1, 17 into group 2, and 7 into group 3. The groups were compared using x2 analysis or Fisher exact test for the following outcome variables: gestational age at delivery, discordant growth, TTTS, need for amnioreduction, selective laser photocoagulation therapy, preterm labor, premature rupture of membranes, perinatal mortality, preeclampsia, and chorioamnionitis.

According to the results, “both marginal and velamentous cord insertions were significantly associated with growth discordance, earlier gestational age at delivery, and a higher incidence of twin-to-twin transfusion syndrome,” said Dr. Allbert.

Specifically, the mean gestational age at delivery in group 1 was 36.4 weeks, compared with 33.6 weeks and 31.6 weeks, in groups 2 and 3, respectively. Growth discordance of at least 20% was not observed in group 1, but did occur in 29.4% and 71.4% of groups 2 and 3, respectively.

Similarly, TTTS did not occur in group 1, but did occur in 35.3% of group 2 pregnancies and in 57.1% of group 3 pregnancies.

For group 1 pregnancies, in which both cord insertion sites were at least 2 cm from the placental edge, “the pregnancy risks appeared to be similar to those of dichorionic twins,” Dr. Allbert concluded.

SAN FRANCISCO — Ultrasound identification of placental cord insertion sites in monochorionic diamniotic twin gestations can identify pregnancies at higher risk for preterm delivery, twin-to-twin transfusion syndrome, and growth discordance, according to the findings of a retrospective study.

This information can be used to counsel patients with monochorionic diamniotic twin gestations regarding the potential fetal and neonatal morbidity and mortality risks, Dr. John Allbert reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

A cohort of 35 twin pregnancies referred by a single perinatologist for targeted ultrasound evaluation between November 2001 and November 2005 was included in the analysis. All of the pregnancies were monochorionic diamniotic and were at less than 22 weeks' gestation at the time of ultrasound. Additionally, at the time of evaluation, both fetuses in all of the pregnancies were anatomically normal and did not meet the criteria for diagnosis of twin-to-twin transfusion syndrome (TTTS), said Dr. Allbert.

Real-time ultrasound was used to locate the placental cord insertions (PCI), and the results were confirmed with color Doppler. The insertions were then categorized as velamentous, marginal (if less than 2 cm from the placental edge), or central (2 cm or more from the edge).

On the basis of the twin pair PCIs, the pregnancies were classified into one of three groups. In group 1, the twin pair PCIs were both central. In group 2, the PCIs were either central and marginal or both marginal, and in group 3, the twin pair PCIs were central and velamentous, Dr. Allbert explained.

Of the 35 pregnancies, 11 were classified into group 1, 17 into group 2, and 7 into group 3. The groups were compared using x2 analysis or Fisher exact test for the following outcome variables: gestational age at delivery, discordant growth, TTTS, need for amnioreduction, selective laser photocoagulation therapy, preterm labor, premature rupture of membranes, perinatal mortality, preeclampsia, and chorioamnionitis.

According to the results, “both marginal and velamentous cord insertions were significantly associated with growth discordance, earlier gestational age at delivery, and a higher incidence of twin-to-twin transfusion syndrome,” said Dr. Allbert.

Specifically, the mean gestational age at delivery in group 1 was 36.4 weeks, compared with 33.6 weeks and 31.6 weeks, in groups 2 and 3, respectively. Growth discordance of at least 20% was not observed in group 1, but did occur in 29.4% and 71.4% of groups 2 and 3, respectively.

Similarly, TTTS did not occur in group 1, but did occur in 35.3% of group 2 pregnancies and in 57.1% of group 3 pregnancies.

For group 1 pregnancies, in which both cord insertion sites were at least 2 cm from the placental edge, “the pregnancy risks appeared to be similar to those of dichorionic twins,” Dr. Allbert concluded.

SAN FRANCISCO — Delivery-related perinatal death rates aren't higher for second twins overall, but they more than double in twins delivered at term, British study results suggest.

Gestational age and birth order of twins made a statistically significant difference in an analysis of data from national registries in England, Northern Ireland, and Wales; the data were collected between 1994 and 2003.

The study included 1,501 cases of intrapartum stillbirth or neonatal death of the second twin but not the first, Dr. Gordon C. Smith reported at the annual meeting of the Society for Maternal-Fetal Medicine.

The risk of death due to intrapartum anoxia or trauma in second twins was three- to fourfold higher at term (at least 36 weeks' gestation), compared with earlier deliveries.

Similarly, risk was found to be fivefold higher in second twins delivered vaginally at term, compared with babies delivered earlier.

No statistically significant increase in risk was seen with cesarean deliveries at term, said Dr. Smith of the University of Cambridge, England.

“Occasionally, the risk of death may be reduced by planned cesarean section” of twins, he said.

One physician in the audience bemoaned the widespread use of cesarean section for delivery of fetuses in breech position and for many other indications.

“Now every second twin at term? Where are we going to stop?” he asked.

Dr. Smith suggested that physicians should try to balance the risks of cesarean section with the potential benefits for each patient in their counseling and management of pregnant women.

It has been well known that vaginal delivery of a second twin carries increased risks because of a number of specific complications like cord prolapse or placental abruption, but data have been mixed on whether the risk of neonatal death increases.

British studies in 2002 and 2005 found an increased risk of perinatal death for the second twin, but a U.S. analysis of 300,000 twin births found no association between birth order and risk of neonatal death.

The previous studies all had fundamental flaws in their analytical approaches that undermined their conclusions, Dr. Smith said.

The present study excluded perinatal deaths due to congenital anomalies.

SAN FRANCISCO — Delivery-related perinatal death rates aren't higher for second twins overall, but they more than double in twins delivered at term, British study results suggest.

Gestational age and birth order of twins made a statistically significant difference in an analysis of data from national registries in England, Northern Ireland, and Wales; the data were collected between 1994 and 2003.

The study included 1,501 cases of intrapartum stillbirth or neonatal death of the second twin but not the first, Dr. Gordon C. Smith reported at the annual meeting of the Society for Maternal-Fetal Medicine.

The risk of death due to intrapartum anoxia or trauma in second twins was three- to fourfold higher at term (at least 36 weeks' gestation), compared with earlier deliveries.

Similarly, risk was found to be fivefold higher in second twins delivered vaginally at term, compared with babies delivered earlier.

No statistically significant increase in risk was seen with cesarean deliveries at term, said Dr. Smith of the University of Cambridge, England.

“Occasionally, the risk of death may be reduced by planned cesarean section” of twins, he said.

One physician in the audience bemoaned the widespread use of cesarean section for delivery of fetuses in breech position and for many other indications.

“Now every second twin at term? Where are we going to stop?” he asked.

Dr. Smith suggested that physicians should try to balance the risks of cesarean section with the potential benefits for each patient in their counseling and management of pregnant women.

It has been well known that vaginal delivery of a second twin carries increased risks because of a number of specific complications like cord prolapse or placental abruption, but data have been mixed on whether the risk of neonatal death increases.

British studies in 2002 and 2005 found an increased risk of perinatal death for the second twin, but a U.S. analysis of 300,000 twin births found no association between birth order and risk of neonatal death.

The previous studies all had fundamental flaws in their analytical approaches that undermined their conclusions, Dr. Smith said.

The present study excluded perinatal deaths due to congenital anomalies.

SAN FRANCISCO — Delivery-related perinatal death rates aren't higher for second twins overall, but they more than double in twins delivered at term, British study results suggest.

Gestational age and birth order of twins made a statistically significant difference in an analysis of data from national registries in England, Northern Ireland, and Wales; the data were collected between 1994 and 2003.

The study included 1,501 cases of intrapartum stillbirth or neonatal death of the second twin but not the first, Dr. Gordon C. Smith reported at the annual meeting of the Society for Maternal-Fetal Medicine.

The risk of death due to intrapartum anoxia or trauma in second twins was three- to fourfold higher at term (at least 36 weeks' gestation), compared with earlier deliveries.

Similarly, risk was found to be fivefold higher in second twins delivered vaginally at term, compared with babies delivered earlier.

No statistically significant increase in risk was seen with cesarean deliveries at term, said Dr. Smith of the University of Cambridge, England.

“Occasionally, the risk of death may be reduced by planned cesarean section” of twins, he said.

One physician in the audience bemoaned the widespread use of cesarean section for delivery of fetuses in breech position and for many other indications.

“Now every second twin at term? Where are we going to stop?” he asked.

Dr. Smith suggested that physicians should try to balance the risks of cesarean section with the potential benefits for each patient in their counseling and management of pregnant women.

It has been well known that vaginal delivery of a second twin carries increased risks because of a number of specific complications like cord prolapse or placental abruption, but data have been mixed on whether the risk of neonatal death increases.

British studies in 2002 and 2005 found an increased risk of perinatal death for the second twin, but a U.S. analysis of 300,000 twin births found no association between birth order and risk of neonatal death.

The previous studies all had fundamental flaws in their analytical approaches that undermined their conclusions, Dr. Smith said.

The present study excluded perinatal deaths due to congenital anomalies.