Obstetrics

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

ELSEVIER GLOBAL MEDICAL NEWS

SAN FRANCISCO — Long-term neurologic impairment among twin-to-twin transfusion syndrome survivors is mediated by perinatal factors but not by mode of treatment, reported Dr. Lisa Ortqvist at the annual meeting of the Society for Maternal-Fetal Medicine.

Gestational age at delivery, 1-minute Apgar score, and Quintero staging each independently predicted severe neurologic abnormalities over time in a cohort of twin-to-twin-transfusion syndrome (TTTS) survivors treated with either endoscopic laser surgery or serial amnioreduction, said Dr. Ortqvist of Paris-Ouest University (France). Neither treatment modality independently predicted neurologic outcome over time, she said.

The population for this study included 135 children born to mothers who had been enrolled in the randomized Eurofetus trial, which compared aggressive serial amnioreduction for severe TTTS with fetoscopic laser ablation therapy (N. Engl. J. Med. 2004;351:136-44).

The Eurofetus trial results demonstrated a survival advantage associated with fetoscopic laser surgery with a lower risk of brain injury. The current investigation sought to evaluate the long-term neurodevelopmental outcome of children who survived beyond 6 months in both study arms, Dr. Ortqvist explained.

The study included 80 children from the laser therapy arm (29 donors, 51 recipients) and 55 children in the amnioreduction arm (29 donors, 26 recipients) followed for a median 5.3 years. Outcome data included physician-reported results from annual physical examinations and standardized neuroevaluations, parent-completed Ages and Stages Questionnaires yearly from ages 2 through 5 years, and cognitive evaluation at age 6 years using the Wechsler Intelligence Scale for Children.

Using the clinical data, the investigators classified the children into one of three groups based on degree of neurologic impairment. Group 1 included children with normal physical and neurologic examinations; group 2 included children with minor neurologic abnormalities, such as strabismus or mildly delayed motor/speech development; and group 3 included children with major neurologic abnormalities, such as cerebral palsy, hemiparesis, or spastic quadriplegia. Of the initial cohort, 11.5% were classified as having major neurologic problems, not including the children lost to follow-up, said Dr. Ortqvist.

In univariate analysis, Quintero staging, gestational age at delivery, female gender, and 1- and 5-minute Apgar scores were predictive of major neurologic problems, while procedure type, donor/recipient status, birth weight, and arterial pH values were not, Dr. Ortqvist reported.

In the multivariate analysis, “if we considered that the children lost to follow-up did not have major neurologic problems, only Quintero staging, gestational age at delivery, and 1-minute Apgar scores demonstrated a significant association with major neurodevelopmental problems,” she said.

Although there was no significant difference in neurologic impairment between laser treatment and amnioreduction, “Endoscopic laser surgery is associated with increased survival overall, and as such is associated with improved survival without long-term neurological impairment,” Dr. Ortqvist concluded.

SAN FRANCISCO — Long-term neurologic impairment among twin-to-twin transfusion syndrome survivors is mediated by perinatal factors but not by mode of treatment, reported Dr. Lisa Ortqvist at the annual meeting of the Society for Maternal-Fetal Medicine.

Gestational age at delivery, 1-minute Apgar score, and Quintero staging each independently predicted severe neurologic abnormalities over time in a cohort of twin-to-twin-transfusion syndrome (TTTS) survivors treated with either endoscopic laser surgery or serial amnioreduction, said Dr. Ortqvist of Paris-Ouest University (France). Neither treatment modality independently predicted neurologic outcome over time, she said.

The population for this study included 135 children born to mothers who had been enrolled in the randomized Eurofetus trial, which compared aggressive serial amnioreduction for severe TTTS with fetoscopic laser ablation therapy (N. Engl. J. Med. 2004;351:136-44).

The Eurofetus trial results demonstrated a survival advantage associated with fetoscopic laser surgery with a lower risk of brain injury. The current investigation sought to evaluate the long-term neurodevelopmental outcome of children who survived beyond 6 months in both study arms, Dr. Ortqvist explained.

The study included 80 children from the laser therapy arm (29 donors, 51 recipients) and 55 children in the amnioreduction arm (29 donors, 26 recipients) followed for a median 5.3 years. Outcome data included physician-reported results from annual physical examinations and standardized neuroevaluations, parent-completed Ages and Stages Questionnaires yearly from ages 2 through 5 years, and cognitive evaluation at age 6 years using the Wechsler Intelligence Scale for Children.

Using the clinical data, the investigators classified the children into one of three groups based on degree of neurologic impairment. Group 1 included children with normal physical and neurologic examinations; group 2 included children with minor neurologic abnormalities, such as strabismus or mildly delayed motor/speech development; and group 3 included children with major neurologic abnormalities, such as cerebral palsy, hemiparesis, or spastic quadriplegia. Of the initial cohort, 11.5% were classified as having major neurologic problems, not including the children lost to follow-up, said Dr. Ortqvist.

In univariate analysis, Quintero staging, gestational age at delivery, female gender, and 1- and 5-minute Apgar scores were predictive of major neurologic problems, while procedure type, donor/recipient status, birth weight, and arterial pH values were not, Dr. Ortqvist reported.

In the multivariate analysis, “if we considered that the children lost to follow-up did not have major neurologic problems, only Quintero staging, gestational age at delivery, and 1-minute Apgar scores demonstrated a significant association with major neurodevelopmental problems,” she said.

Although there was no significant difference in neurologic impairment between laser treatment and amnioreduction, “Endoscopic laser surgery is associated with increased survival overall, and as such is associated with improved survival without long-term neurological impairment,” Dr. Ortqvist concluded.

SAN FRANCISCO — Long-term neurologic impairment among twin-to-twin transfusion syndrome survivors is mediated by perinatal factors but not by mode of treatment, reported Dr. Lisa Ortqvist at the annual meeting of the Society for Maternal-Fetal Medicine.

Gestational age at delivery, 1-minute Apgar score, and Quintero staging each independently predicted severe neurologic abnormalities over time in a cohort of twin-to-twin-transfusion syndrome (TTTS) survivors treated with either endoscopic laser surgery or serial amnioreduction, said Dr. Ortqvist of Paris-Ouest University (France). Neither treatment modality independently predicted neurologic outcome over time, she said.

The population for this study included 135 children born to mothers who had been enrolled in the randomized Eurofetus trial, which compared aggressive serial amnioreduction for severe TTTS with fetoscopic laser ablation therapy (N. Engl. J. Med. 2004;351:136-44).

The Eurofetus trial results demonstrated a survival advantage associated with fetoscopic laser surgery with a lower risk of brain injury. The current investigation sought to evaluate the long-term neurodevelopmental outcome of children who survived beyond 6 months in both study arms, Dr. Ortqvist explained.

The study included 80 children from the laser therapy arm (29 donors, 51 recipients) and 55 children in the amnioreduction arm (29 donors, 26 recipients) followed for a median 5.3 years. Outcome data included physician-reported results from annual physical examinations and standardized neuroevaluations, parent-completed Ages and Stages Questionnaires yearly from ages 2 through 5 years, and cognitive evaluation at age 6 years using the Wechsler Intelligence Scale for Children.

Using the clinical data, the investigators classified the children into one of three groups based on degree of neurologic impairment. Group 1 included children with normal physical and neurologic examinations; group 2 included children with minor neurologic abnormalities, such as strabismus or mildly delayed motor/speech development; and group 3 included children with major neurologic abnormalities, such as cerebral palsy, hemiparesis, or spastic quadriplegia. Of the initial cohort, 11.5% were classified as having major neurologic problems, not including the children lost to follow-up, said Dr. Ortqvist.

In univariate analysis, Quintero staging, gestational age at delivery, female gender, and 1- and 5-minute Apgar scores were predictive of major neurologic problems, while procedure type, donor/recipient status, birth weight, and arterial pH values were not, Dr. Ortqvist reported.

In the multivariate analysis, “if we considered that the children lost to follow-up did not have major neurologic problems, only Quintero staging, gestational age at delivery, and 1-minute Apgar scores demonstrated a significant association with major neurodevelopmental problems,” she said.

Although there was no significant difference in neurologic impairment between laser treatment and amnioreduction, “Endoscopic laser surgery is associated with increased survival overall, and as such is associated with improved survival without long-term neurological impairment,” Dr. Ortqvist concluded.

BOSTON — A diagnosis of maternal depression any time between 1 year before and 9 years after giving birth is a risk factor for attention-deficit/hyperactivity disorder in school-age children, according to a study presented at a meeting of the Society for Research in Child Development.

In addition, the likelihood of an attention-deficit/hyperactivity disorder (ADHD) diagnosis in children is directly related to the chronicity of depression in the mother, said Anne Guevremont, M.Ed., a research fellow at the Manitoba Centre for Health Policy at the University of Manitoba, Winnipeg

Although previous studies have linked maternal depression to ADHD in children, none have specifically investigated whether and to what degree the timing of maternal depression has an impact on the relationship, Ms. Guevremont said.

Through computerized health care user files from the Manitoba health department, Ms. Guevremont and senior researcher Marni Brownell, Ph.D., reviewed data on 12,323 children born between April 1993 and March 1994 whose mothers were living in Manitoba the year before the child's birth and for whom follow-up information was available until the child was 7-9 years old.

The investigators ascertained the presence of maternal depression by hospital or physician claims for this diagnosis and categorized the depression into one of five groups according to the child's age at the time of the mother's diagnosis: within 1 year before birth, within 1 year after birth, between 1 and 3 years old, 4-6 years old, and 7-9 years old.

Approximately 36% of the mothers in the study had a diagnosis of depression during at least one time period, Ms. Guevremont reported in a poster presentation. Among the children, approximately 5% had a physician diagnosis of ADHD when they were 7-9 years old, she said.

With respect to chronicity, the investigators considered each time period in which a mother had a diagnosis of depression and counted the total number of years that the mother had the diagnosis outside of that time period, according to Ms. Guevremont. “Approximately 16% of the mothers had a depression diagnosis in 1 year only, while 8% of the mothers received a depression diagnosis in 2 years and 12% in 3 or more years,” she said.

In analyses of the effect of the timing and chronicity of maternal depression on child ADHD, children with depressed mothers were approximately 1.5-2 times more likely to have an ADHD diagnosis than children of nondepressed mothers, said Ms. Guevremont, noting that the odds ratio was highest, at 2.18, for mothers diagnosed with depression in the year before the child's birth. This finding “confirms the need to look for maternal depression at every stage of motherhood, including the prenatal period,” she said. “The prenatal period is an excellent time to screen for depression, as the vast majority of mothers seek prenatal care before their child's birth.”

In addition, the chronicity of depression was significant in each model, and the odds of a child being diagnosed with ADHD were higher for each additional year a mother was diagnosed with depression, regardless of the timing of the diagnosis, said Ms. Guevremont. The interaction between chronicity and timing was significant among children whose mothers were diagnosed in the year before birth, in the year after birth, or when the child was between 1 and 3. Children whose mothers were diagnosed during these periods and who had longer durations of depression were most vulnerable to an ADHD diagnosis, the results showed.

“Clearly, the number of years with a depression diagnosis is particularly important, and should be taken into consideration by clinicians caring for both mothers and their children,” Ms. Guevremont said. “The earlier depressed mothers are recognized and treated, the better for the health of both the mother and her children. Intervention at multiple time periods is possible and needed.” For example, in addition to prenatal screening, “another opportunity for screening is when mothers seek physicians for the children's behavior problems,” she said.

The study is limited by the potential for underreporting of both maternal depression and child ADHD, Ms. Guevremont noted. “Some physicians may not know a mother is depressed and therefore would not diagnose the condition if symptoms are not reported,” she stated.

BOSTON — A diagnosis of maternal depression any time between 1 year before and 9 years after giving birth is a risk factor for attention-deficit/hyperactivity disorder in school-age children, according to a study presented at a meeting of the Society for Research in Child Development.

In addition, the likelihood of an attention-deficit/hyperactivity disorder (ADHD) diagnosis in children is directly related to the chronicity of depression in the mother, said Anne Guevremont, M.Ed., a research fellow at the Manitoba Centre for Health Policy at the University of Manitoba, Winnipeg

Although previous studies have linked maternal depression to ADHD in children, none have specifically investigated whether and to what degree the timing of maternal depression has an impact on the relationship, Ms. Guevremont said.

Through computerized health care user files from the Manitoba health department, Ms. Guevremont and senior researcher Marni Brownell, Ph.D., reviewed data on 12,323 children born between April 1993 and March 1994 whose mothers were living in Manitoba the year before the child's birth and for whom follow-up information was available until the child was 7-9 years old.

The investigators ascertained the presence of maternal depression by hospital or physician claims for this diagnosis and categorized the depression into one of five groups according to the child's age at the time of the mother's diagnosis: within 1 year before birth, within 1 year after birth, between 1 and 3 years old, 4-6 years old, and 7-9 years old.

Approximately 36% of the mothers in the study had a diagnosis of depression during at least one time period, Ms. Guevremont reported in a poster presentation. Among the children, approximately 5% had a physician diagnosis of ADHD when they were 7-9 years old, she said.

With respect to chronicity, the investigators considered each time period in which a mother had a diagnosis of depression and counted the total number of years that the mother had the diagnosis outside of that time period, according to Ms. Guevremont. “Approximately 16% of the mothers had a depression diagnosis in 1 year only, while 8% of the mothers received a depression diagnosis in 2 years and 12% in 3 or more years,” she said.

In analyses of the effect of the timing and chronicity of maternal depression on child ADHD, children with depressed mothers were approximately 1.5-2 times more likely to have an ADHD diagnosis than children of nondepressed mothers, said Ms. Guevremont, noting that the odds ratio was highest, at 2.18, for mothers diagnosed with depression in the year before the child's birth. This finding “confirms the need to look for maternal depression at every stage of motherhood, including the prenatal period,” she said. “The prenatal period is an excellent time to screen for depression, as the vast majority of mothers seek prenatal care before their child's birth.”

In addition, the chronicity of depression was significant in each model, and the odds of a child being diagnosed with ADHD were higher for each additional year a mother was diagnosed with depression, regardless of the timing of the diagnosis, said Ms. Guevremont. The interaction between chronicity and timing was significant among children whose mothers were diagnosed in the year before birth, in the year after birth, or when the child was between 1 and 3. Children whose mothers were diagnosed during these periods and who had longer durations of depression were most vulnerable to an ADHD diagnosis, the results showed.

“Clearly, the number of years with a depression diagnosis is particularly important, and should be taken into consideration by clinicians caring for both mothers and their children,” Ms. Guevremont said. “The earlier depressed mothers are recognized and treated, the better for the health of both the mother and her children. Intervention at multiple time periods is possible and needed.” For example, in addition to prenatal screening, “another opportunity for screening is when mothers seek physicians for the children's behavior problems,” she said.

The study is limited by the potential for underreporting of both maternal depression and child ADHD, Ms. Guevremont noted. “Some physicians may not know a mother is depressed and therefore would not diagnose the condition if symptoms are not reported,” she stated.

BOSTON — A diagnosis of maternal depression any time between 1 year before and 9 years after giving birth is a risk factor for attention-deficit/hyperactivity disorder in school-age children, according to a study presented at a meeting of the Society for Research in Child Development.

In addition, the likelihood of an attention-deficit/hyperactivity disorder (ADHD) diagnosis in children is directly related to the chronicity of depression in the mother, said Anne Guevremont, M.Ed., a research fellow at the Manitoba Centre for Health Policy at the University of Manitoba, Winnipeg

Although previous studies have linked maternal depression to ADHD in children, none have specifically investigated whether and to what degree the timing of maternal depression has an impact on the relationship, Ms. Guevremont said.

Through computerized health care user files from the Manitoba health department, Ms. Guevremont and senior researcher Marni Brownell, Ph.D., reviewed data on 12,323 children born between April 1993 and March 1994 whose mothers were living in Manitoba the year before the child's birth and for whom follow-up information was available until the child was 7-9 years old.

The investigators ascertained the presence of maternal depression by hospital or physician claims for this diagnosis and categorized the depression into one of five groups according to the child's age at the time of the mother's diagnosis: within 1 year before birth, within 1 year after birth, between 1 and 3 years old, 4-6 years old, and 7-9 years old.

Approximately 36% of the mothers in the study had a diagnosis of depression during at least one time period, Ms. Guevremont reported in a poster presentation. Among the children, approximately 5% had a physician diagnosis of ADHD when they were 7-9 years old, she said.

With respect to chronicity, the investigators considered each time period in which a mother had a diagnosis of depression and counted the total number of years that the mother had the diagnosis outside of that time period, according to Ms. Guevremont. “Approximately 16% of the mothers had a depression diagnosis in 1 year only, while 8% of the mothers received a depression diagnosis in 2 years and 12% in 3 or more years,” she said.

In analyses of the effect of the timing and chronicity of maternal depression on child ADHD, children with depressed mothers were approximately 1.5-2 times more likely to have an ADHD diagnosis than children of nondepressed mothers, said Ms. Guevremont, noting that the odds ratio was highest, at 2.18, for mothers diagnosed with depression in the year before the child's birth. This finding “confirms the need to look for maternal depression at every stage of motherhood, including the prenatal period,” she said. “The prenatal period is an excellent time to screen for depression, as the vast majority of mothers seek prenatal care before their child's birth.”

In addition, the chronicity of depression was significant in each model, and the odds of a child being diagnosed with ADHD were higher for each additional year a mother was diagnosed with depression, regardless of the timing of the diagnosis, said Ms. Guevremont. The interaction between chronicity and timing was significant among children whose mothers were diagnosed in the year before birth, in the year after birth, or when the child was between 1 and 3. Children whose mothers were diagnosed during these periods and who had longer durations of depression were most vulnerable to an ADHD diagnosis, the results showed.

“Clearly, the number of years with a depression diagnosis is particularly important, and should be taken into consideration by clinicians caring for both mothers and their children,” Ms. Guevremont said. “The earlier depressed mothers are recognized and treated, the better for the health of both the mother and her children. Intervention at multiple time periods is possible and needed.” For example, in addition to prenatal screening, “another opportunity for screening is when mothers seek physicians for the children's behavior problems,” she said.

The study is limited by the potential for underreporting of both maternal depression and child ADHD, Ms. Guevremont noted. “Some physicians may not know a mother is depressed and therefore would not diagnose the condition if symptoms are not reported,” she stated.

LOS ANGELES — The recent evidence suggests that many pregnant women who are hypothyroid are not picked up as such by their medical providers, to the detriment of the mother and child, Dr. Jorge H. Mestman said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

The experts cannot seem to reach a consensus on whether pregnant women should be screened routinely for thyroid disease, but even hypothyroidism that is subclinical prior to pregnancy appears to have quite a severe, negative impact on the pregnancy and the child, said Dr. Mestman, director of the Center for Diabetes and Metabolic Diseases at the University of Southern California, Los Angeles.

“There is no agreement,” Dr. Mestman said. “This is going to be up to you. You have to decide in your office if you are going to check everybody for thyroid disease in the same way as for diabetes.”

One important new study might not have been seen by many in the obstetrics community because it was published in an endocrinology journal, he noted.

The investigators in the study attempted to see if the strategy of identifying women at high risk of thyroid disease (those with a personal or family history) and performing thyroid testing only in those women would pick up most cases.

They enrolled 1,560 pregnant women on their first prenatal visit, and tested their thyroid function to determine whether they had thyroid antibodies. A total of 40 of the women were found to have elevated thyroid-stimulating hormone (TSH) levels, and 28 (70%)of those were in the high-risk group. That is, they had a personal history of thyroid disease or an autoimmune disease, or a family history of thyroid disease. But the other 12 women had no history and would not therefore have received testing according to the protocol being examined by the study. Thus, these 12 hypothyroid women (30%) would have been missed, the investigators said (J. Clin. Endocrinol. Metab. 2007;92:203-7).

Chronic thyroiditis has an incidence in women of child-bearing age of between 5% and 20%, Dr. Mestman said. Subclinical hypothyroidism—a normal thyroxine (T4) level but an elevated TSH—may have an incidence of 2%.

Many studies have shown that hypothyroidism, even subclinical hypothyroidism, is associated with greater risk of miscarriage and premature delivery, anywhere from a two- to fivefold higher risk.

One study that looked at the children of mothers who were hypothyroid during pregnancy found that at age 7-9 years those children had a mean IQ that was 4 points lower than that of a group of control children. The mean IQ of children of women who were hypothyroid during pregnancy and not treated was 7 points lower (N. Engl. J. Med. 1999;341:549-55).

The detrimental effects of hypothyroidism presumably occur because the mother produces all the thyroid hormone for her fetus during the first trimester at least, and fetal brains have been shown to have thyroid hormone receptors.

During the first trimester, T4 levels need to increase by 50%, which is why women who may be subclinical before conception can run into trouble. They cannot compensate for the increased demand.

By the second and third trimester, T4 levels return to normal; however, some women who become hypothyroid during the first trimester will become hypothyroid again after delivery. Those women will become hyperthyroid for the first 3 months after delivery, and then hypothyroid for approximately another 6 months. Of those, about 30% will become clinically hypothyroid within 5 years. All of these women should be followed for thyroid function after their pregnancy, Dr. Mestman said. The pattern can occur even after spontaneous abortion.

The good news is that treatment prevents pregnancy complications, Dr. Mestman said. In a series of 88 hypothyroid women seen at his institution, the pregnancy complication rate of those who never became euthyroid during their pregnancy was 32% (6 of 19 patients), compared with a rate of 17% in those women who became euthyroid but only after 20 weeks' gestation (7 of 42), and 5% in those who became euthyroid before 20 weeks (1 of 21).

One of the tragedies they observed in that series of women concerned the 30% who were already on levothyroxine prior to their pregnancy, Dr. Mestman said. Some of them were told to stop all medications when they became pregnant and they stopped their thyroid medication.

Another, more recent study also looked at the pregnancy complication rate in women who were euthyroid but who had thyroid peroxidase antibodies. They treated half of a group of 115 antibody-positive women with levothyroxine, and compared those women with 869 pregnant women who were antibody negative.

The treated antibody-positive women had a miscarriage rate of 3%, similar to the rate in the control group, 2%. But the untreated antibody-positive women had a rate of 14%. The treated women had a premature delivery rate of 7%, similar to the 8% for the control group. That compared with a rate of 22% for the untreated women.

Given those findings, Dr. Mestman recommended that antibody-positive euthyroid women who are pregnant should be treated. The treatment should include a prenatal vitamin with 150 mcg of iodine, because there is some suggestion that many Americans may no longer get adequate iodine in their diet. And they should have their TSH and T4 levels monitored every 4-6 weeks during the first 20 weeks of pregnancy.

After 20 weeks, they should have their TSH and T4 measured once at 28 weeks. In addition, they should be treated with 50-75 mcg a day of levothyroxine. If the patient is already on levothyroxine at the time, the dose should be increased by 25 mcg.

“Early treatment prevents all the known complications,” Dr. Mestman said.

LOS ANGELES — The recent evidence suggests that many pregnant women who are hypothyroid are not picked up as such by their medical providers, to the detriment of the mother and child, Dr. Jorge H. Mestman said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

The experts cannot seem to reach a consensus on whether pregnant women should be screened routinely for thyroid disease, but even hypothyroidism that is subclinical prior to pregnancy appears to have quite a severe, negative impact on the pregnancy and the child, said Dr. Mestman, director of the Center for Diabetes and Metabolic Diseases at the University of Southern California, Los Angeles.

“There is no agreement,” Dr. Mestman said. “This is going to be up to you. You have to decide in your office if you are going to check everybody for thyroid disease in the same way as for diabetes.”

One important new study might not have been seen by many in the obstetrics community because it was published in an endocrinology journal, he noted.

The investigators in the study attempted to see if the strategy of identifying women at high risk of thyroid disease (those with a personal or family history) and performing thyroid testing only in those women would pick up most cases.

They enrolled 1,560 pregnant women on their first prenatal visit, and tested their thyroid function to determine whether they had thyroid antibodies. A total of 40 of the women were found to have elevated thyroid-stimulating hormone (TSH) levels, and 28 (70%)of those were in the high-risk group. That is, they had a personal history of thyroid disease or an autoimmune disease, or a family history of thyroid disease. But the other 12 women had no history and would not therefore have received testing according to the protocol being examined by the study. Thus, these 12 hypothyroid women (30%) would have been missed, the investigators said (J. Clin. Endocrinol. Metab. 2007;92:203-7).

Chronic thyroiditis has an incidence in women of child-bearing age of between 5% and 20%, Dr. Mestman said. Subclinical hypothyroidism—a normal thyroxine (T4) level but an elevated TSH—may have an incidence of 2%.

Many studies have shown that hypothyroidism, even subclinical hypothyroidism, is associated with greater risk of miscarriage and premature delivery, anywhere from a two- to fivefold higher risk.

One study that looked at the children of mothers who were hypothyroid during pregnancy found that at age 7-9 years those children had a mean IQ that was 4 points lower than that of a group of control children. The mean IQ of children of women who were hypothyroid during pregnancy and not treated was 7 points lower (N. Engl. J. Med. 1999;341:549-55).

The detrimental effects of hypothyroidism presumably occur because the mother produces all the thyroid hormone for her fetus during the first trimester at least, and fetal brains have been shown to have thyroid hormone receptors.

During the first trimester, T4 levels need to increase by 50%, which is why women who may be subclinical before conception can run into trouble. They cannot compensate for the increased demand.

By the second and third trimester, T4 levels return to normal; however, some women who become hypothyroid during the first trimester will become hypothyroid again after delivery. Those women will become hyperthyroid for the first 3 months after delivery, and then hypothyroid for approximately another 6 months. Of those, about 30% will become clinically hypothyroid within 5 years. All of these women should be followed for thyroid function after their pregnancy, Dr. Mestman said. The pattern can occur even after spontaneous abortion.

The good news is that treatment prevents pregnancy complications, Dr. Mestman said. In a series of 88 hypothyroid women seen at his institution, the pregnancy complication rate of those who never became euthyroid during their pregnancy was 32% (6 of 19 patients), compared with a rate of 17% in those women who became euthyroid but only after 20 weeks' gestation (7 of 42), and 5% in those who became euthyroid before 20 weeks (1 of 21).

One of the tragedies they observed in that series of women concerned the 30% who were already on levothyroxine prior to their pregnancy, Dr. Mestman said. Some of them were told to stop all medications when they became pregnant and they stopped their thyroid medication.

Another, more recent study also looked at the pregnancy complication rate in women who were euthyroid but who had thyroid peroxidase antibodies. They treated half of a group of 115 antibody-positive women with levothyroxine, and compared those women with 869 pregnant women who were antibody negative.

The treated antibody-positive women had a miscarriage rate of 3%, similar to the rate in the control group, 2%. But the untreated antibody-positive women had a rate of 14%. The treated women had a premature delivery rate of 7%, similar to the 8% for the control group. That compared with a rate of 22% for the untreated women.

Given those findings, Dr. Mestman recommended that antibody-positive euthyroid women who are pregnant should be treated. The treatment should include a prenatal vitamin with 150 mcg of iodine, because there is some suggestion that many Americans may no longer get adequate iodine in their diet. And they should have their TSH and T4 levels monitored every 4-6 weeks during the first 20 weeks of pregnancy.

After 20 weeks, they should have their TSH and T4 measured once at 28 weeks. In addition, they should be treated with 50-75 mcg a day of levothyroxine. If the patient is already on levothyroxine at the time, the dose should be increased by 25 mcg.

“Early treatment prevents all the known complications,” Dr. Mestman said.

LOS ANGELES — The recent evidence suggests that many pregnant women who are hypothyroid are not picked up as such by their medical providers, to the detriment of the mother and child, Dr. Jorge H. Mestman said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

The experts cannot seem to reach a consensus on whether pregnant women should be screened routinely for thyroid disease, but even hypothyroidism that is subclinical prior to pregnancy appears to have quite a severe, negative impact on the pregnancy and the child, said Dr. Mestman, director of the Center for Diabetes and Metabolic Diseases at the University of Southern California, Los Angeles.

“There is no agreement,” Dr. Mestman said. “This is going to be up to you. You have to decide in your office if you are going to check everybody for thyroid disease in the same way as for diabetes.”

One important new study might not have been seen by many in the obstetrics community because it was published in an endocrinology journal, he noted.

The investigators in the study attempted to see if the strategy of identifying women at high risk of thyroid disease (those with a personal or family history) and performing thyroid testing only in those women would pick up most cases.

They enrolled 1,560 pregnant women on their first prenatal visit, and tested their thyroid function to determine whether they had thyroid antibodies. A total of 40 of the women were found to have elevated thyroid-stimulating hormone (TSH) levels, and 28 (70%)of those were in the high-risk group. That is, they had a personal history of thyroid disease or an autoimmune disease, or a family history of thyroid disease. But the other 12 women had no history and would not therefore have received testing according to the protocol being examined by the study. Thus, these 12 hypothyroid women (30%) would have been missed, the investigators said (J. Clin. Endocrinol. Metab. 2007;92:203-7).

Chronic thyroiditis has an incidence in women of child-bearing age of between 5% and 20%, Dr. Mestman said. Subclinical hypothyroidism—a normal thyroxine (T4) level but an elevated TSH—may have an incidence of 2%.

Many studies have shown that hypothyroidism, even subclinical hypothyroidism, is associated with greater risk of miscarriage and premature delivery, anywhere from a two- to fivefold higher risk.

One study that looked at the children of mothers who were hypothyroid during pregnancy found that at age 7-9 years those children had a mean IQ that was 4 points lower than that of a group of control children. The mean IQ of children of women who were hypothyroid during pregnancy and not treated was 7 points lower (N. Engl. J. Med. 1999;341:549-55).

The detrimental effects of hypothyroidism presumably occur because the mother produces all the thyroid hormone for her fetus during the first trimester at least, and fetal brains have been shown to have thyroid hormone receptors.

During the first trimester, T4 levels need to increase by 50%, which is why women who may be subclinical before conception can run into trouble. They cannot compensate for the increased demand.

By the second and third trimester, T4 levels return to normal; however, some women who become hypothyroid during the first trimester will become hypothyroid again after delivery. Those women will become hyperthyroid for the first 3 months after delivery, and then hypothyroid for approximately another 6 months. Of those, about 30% will become clinically hypothyroid within 5 years. All of these women should be followed for thyroid function after their pregnancy, Dr. Mestman said. The pattern can occur even after spontaneous abortion.

The good news is that treatment prevents pregnancy complications, Dr. Mestman said. In a series of 88 hypothyroid women seen at his institution, the pregnancy complication rate of those who never became euthyroid during their pregnancy was 32% (6 of 19 patients), compared with a rate of 17% in those women who became euthyroid but only after 20 weeks' gestation (7 of 42), and 5% in those who became euthyroid before 20 weeks (1 of 21).

One of the tragedies they observed in that series of women concerned the 30% who were already on levothyroxine prior to their pregnancy, Dr. Mestman said. Some of them were told to stop all medications when they became pregnant and they stopped their thyroid medication.

Another, more recent study also looked at the pregnancy complication rate in women who were euthyroid but who had thyroid peroxidase antibodies. They treated half of a group of 115 antibody-positive women with levothyroxine, and compared those women with 869 pregnant women who were antibody negative.

The treated antibody-positive women had a miscarriage rate of 3%, similar to the rate in the control group, 2%. But the untreated antibody-positive women had a rate of 14%. The treated women had a premature delivery rate of 7%, similar to the 8% for the control group. That compared with a rate of 22% for the untreated women.

Given those findings, Dr. Mestman recommended that antibody-positive euthyroid women who are pregnant should be treated. The treatment should include a prenatal vitamin with 150 mcg of iodine, because there is some suggestion that many Americans may no longer get adequate iodine in their diet. And they should have their TSH and T4 levels monitored every 4-6 weeks during the first 20 weeks of pregnancy.

After 20 weeks, they should have their TSH and T4 measured once at 28 weeks. In addition, they should be treated with 50-75 mcg a day of levothyroxine. If the patient is already on levothyroxine at the time, the dose should be increased by 25 mcg.

“Early treatment prevents all the known complications,” Dr. Mestman said.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis.

In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before the mother's diagnosis (Diabetes 2000;49:2208-11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m2 heavier than were their nonexposed siblings.

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth.

They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546-47).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, when he manages maternal diabetes in pregnancy, he is mindful that it can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” he said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth or nutrient restricted, it shunts nutrients to the most essential organs.

One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis.

In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before the mother's diagnosis (Diabetes 2000;49:2208-11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m2 heavier than were their nonexposed siblings.

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth.

They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546-47).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, when he manages maternal diabetes in pregnancy, he is mindful that it can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” he said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth or nutrient restricted, it shunts nutrients to the most essential organs.

One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

LOS ANGELES — Obesity, like cardiovascular disease risk, can originate in the womb, a phenomenon that could have important implications in managing the current obesity epidemic, Dr. Thomas R. Moore said at a meeting of the Obstetrical and Gynecological Assembly of Southern California.

Much evidence now indicates that infants born to mothers with diabetes are likely to become overweight children and adults. They are also more likely to develop gestational diabetes and possibly diabetes as adults.

However, the evidence also seems to suggest that infants born underweight may face a similar risk of obesity and are more likely to experience cardiovascular disease, said Dr. Moore, the chairman of the department of reproductive medicine at the University of California, San Diego.

With regard to the association between a diabetic mother and later obesity in the child, Dr. Moore cited a study of the Pima Indians of Arizona, who have been followed closely in a study since 1965 and among whom there is a high rate of obesity and diabetes.

In that study, the investigators looked at siblings in families with a mother who was diabetic. They compared siblings born before the mother was diagnosed as diabetic with siblings born after her diagnosis.

In 19 families in which one sibling had diabetes and the other did not, 15 of the diabetic children were born after their mother's diagnosis, and only 4 were born before the mother's diagnosis (Diabetes 2000;49:2208-11).

There was no difference in the number of siblings with diabetes in those families born before or after a father's diabetes diagnosis.

The siblings who were exposed to intrauterine diabetes also were a mean 2.6 kg/m2 heavier than were their nonexposed siblings.

In another study linking heaviness and diabetes in the child to that in the mother, Norwegian investigators looked at almost 140,000 women who had given birth.

They found that the rate of gestational diabetes among the women was 31/1,000 in those whose own mothers had diabetes when they were born, compared with a rate of 4/1,000 in those whose own mothers did not have diabetes (BMJ 2000;321:546-47).

Dr. Moore said that in his own practice, he is careful to measure and record body mass index, not just weight, and to help patients who want to lose weight before conception.

Moreover, when he manages maternal diabetes in pregnancy, he is mindful that it can have critical implications for the life of the infant.

“I actually believe I'm making a difference in the adult health of the fetus, who I am helping to treat through the mother by optimizing glucose control,” he said.

In reference to the risks facing underweight newborns, Dr. Moore said that most of the data come from epidemiologic studies that show those infants are more likely to develop high insulin levels, hypertension, diabetes, stroke, and heart disease.

He said that the theory explaining this phenomenon, the “thrifty phenotype,” asserts that when a fetus is growth or nutrient restricted, it shunts nutrients to the most essential organs.

One of the mechanisms the fetus body uses to prevent nutrients from going to less essential systems, such as the musculature, is by making those systems insulin resistant. This insulin resistance persists after birth and predisposes the individual to the conditions associated with metabolic syndrome.

The theory calls into question the common practice in neonatal nurseries of trying to get as many calories as possible into underweight infants in an effort to get them to gain weight quickly, said Dr. Moore.

PHILADELPHIA — Infections caused by methicillin-resistant Staphylococcus aureus occur in a bimodal pattern in the first year of life, with peaks in the first 5 months and again shortly before the first birthday. The peaks reflect two separate reservoirs of methicillin-resistant S. aureus (MRSA)—the first possibly from a maternal source and the latter from the community, Dr. Ana Krishnan and Dr. Karen Carpenter said in a poster presentation at a meeting of the Eastern Society for Pediatric Research.

The physicians conducted a 10-year retrospective review of MRSA among children less than age 12 months treated in a large Northern Virginia birthing center. The review identified 85 MRSA-positive cultures, which occurred with increasing frequency as the years progressed. Only two cases were identified in 1997, the first year of the study. Cases remained infrequent, between 1 and 8 per year, until 2004, when they doubled to 15. Infections have continued to rise each year since then, with 25 cases recorded by the end of 2006.

Most infections (64%) occurred in infants less than 5 months old, with 25% occurring in children less than 1 month old, said Dr. Krishnan, a pediatric resident at Inova Fairfax Hospital for Children, Falls Church, Va.

“In the first 30-60 days of life, there are more [hospital-acquired] than community-acquired MRSA infections,” she said in an interview. “This correlates with the greater number of babies in the neonatal intensive care unit. About 50% of the babies who had the infections in the first 60 days were in the [neonatal] ICU.”

The ratio of hospital-acquired (HA) and community-acquired (CA) infections began to change after the patients reached about 2 months of age, she said. “At this point, we found a shift toward more infections being acquired in the community. But this difference disappears toward the end of the first year.” In months 11 and 12, there are about equal numbers of community- and hospital-acquired infections.

She also noted that a second peak of infection occurred just before the first birthday, with the highest incidence (71%) during the fall and winter months. Additionally, most patients in this age group (73%) presented with a concurrent upper respiratory infection. “This apparent association needs further investigation,” Dr. Krishnan said at the meeting, which was cosponsored by Children's Hospital of Philadelphia.

CA-MRSA also was significantly more likely than HA-MRSA to cause pustulosis (28% vs. 13%) and abscesses requiring drainage (33% vs. 10%). Invasive infections were similar between the groups (22% and 26%), but among invasive infections, bacteremia was more common in HA-MRSA (18% vs. 7%) and nonbacteremic invasive infections more common in CA-MRSA (17% vs. 8%).

The two types of MRSA infections display distinct antibiotic susceptibilities, Dr. Krishnan said. Most CA-MRSA infections were susceptible to clindamycin (76%), with none of the tested cultures displaying inducible resistance. Only 37% of HA-MRSA cultures were sensitive to clindamycin, however, and 25% of those tested did display inducible resistance.

The researchers plan additional studies to explore the possible relationship between early-infancy infections and a maternal reservoir of MRSA, Dr. Krishnan said. “We plan a prospective study looking at mother-infant couplets. We want to culture mothers before delivery, identify those with MRSA, and follow the pairs for a year to assess MRSA colonization and disease.”

Most infections (64%) occurred in infants less than 5 months old, with 25% occurring in children less than 1 month old. DR. KRISHNAN

PHILADELPHIA — Infections caused by methicillin-resistant Staphylococcus aureus occur in a bimodal pattern in the first year of life, with peaks in the first 5 months and again shortly before the first birthday. The peaks reflect two separate reservoirs of methicillin-resistant S. aureus (MRSA)—the first possibly from a maternal source and the latter from the community, Dr. Ana Krishnan and Dr. Karen Carpenter said in a poster presentation at a meeting of the Eastern Society for Pediatric Research.

The physicians conducted a 10-year retrospective review of MRSA among children less than age 12 months treated in a large Northern Virginia birthing center. The review identified 85 MRSA-positive cultures, which occurred with increasing frequency as the years progressed. Only two cases were identified in 1997, the first year of the study. Cases remained infrequent, between 1 and 8 per year, until 2004, when they doubled to 15. Infections have continued to rise each year since then, with 25 cases recorded by the end of 2006.

Most infections (64%) occurred in infants less than 5 months old, with 25% occurring in children less than 1 month old, said Dr. Krishnan, a pediatric resident at Inova Fairfax Hospital for Children, Falls Church, Va.

“In the first 30-60 days of life, there are more [hospital-acquired] than community-acquired MRSA infections,” she said in an interview. “This correlates with the greater number of babies in the neonatal intensive care unit. About 50% of the babies who had the infections in the first 60 days were in the [neonatal] ICU.”

The ratio of hospital-acquired (HA) and community-acquired (CA) infections began to change after the patients reached about 2 months of age, she said. “At this point, we found a shift toward more infections being acquired in the community. But this difference disappears toward the end of the first year.” In months 11 and 12, there are about equal numbers of community- and hospital-acquired infections.

She also noted that a second peak of infection occurred just before the first birthday, with the highest incidence (71%) during the fall and winter months. Additionally, most patients in this age group (73%) presented with a concurrent upper respiratory infection. “This apparent association needs further investigation,” Dr. Krishnan said at the meeting, which was cosponsored by Children's Hospital of Philadelphia.

CA-MRSA also was significantly more likely than HA-MRSA to cause pustulosis (28% vs. 13%) and abscesses requiring drainage (33% vs. 10%). Invasive infections were similar between the groups (22% and 26%), but among invasive infections, bacteremia was more common in HA-MRSA (18% vs. 7%) and nonbacteremic invasive infections more common in CA-MRSA (17% vs. 8%).

The two types of MRSA infections display distinct antibiotic susceptibilities, Dr. Krishnan said. Most CA-MRSA infections were susceptible to clindamycin (76%), with none of the tested cultures displaying inducible resistance. Only 37% of HA-MRSA cultures were sensitive to clindamycin, however, and 25% of those tested did display inducible resistance.

The researchers plan additional studies to explore the possible relationship between early-infancy infections and a maternal reservoir of MRSA, Dr. Krishnan said. “We plan a prospective study looking at mother-infant couplets. We want to culture mothers before delivery, identify those with MRSA, and follow the pairs for a year to assess MRSA colonization and disease.”

Most infections (64%) occurred in infants less than 5 months old, with 25% occurring in children less than 1 month old. DR. KRISHNAN

PHILADELPHIA — Infections caused by methicillin-resistant Staphylococcus aureus occur in a bimodal pattern in the first year of life, with peaks in the first 5 months and again shortly before the first birthday. The peaks reflect two separate reservoirs of methicillin-resistant S. aureus (MRSA)—the first possibly from a maternal source and the latter from the community, Dr. Ana Krishnan and Dr. Karen Carpenter said in a poster presentation at a meeting of the Eastern Society for Pediatric Research.

The physicians conducted a 10-year retrospective review of MRSA among children less than age 12 months treated in a large Northern Virginia birthing center. The review identified 85 MRSA-positive cultures, which occurred with increasing frequency as the years progressed. Only two cases were identified in 1997, the first year of the study. Cases remained infrequent, between 1 and 8 per year, until 2004, when they doubled to 15. Infections have continued to rise each year since then, with 25 cases recorded by the end of 2006.

Most infections (64%) occurred in infants less than 5 months old, with 25% occurring in children less than 1 month old, said Dr. Krishnan, a pediatric resident at Inova Fairfax Hospital for Children, Falls Church, Va.

“In the first 30-60 days of life, there are more [hospital-acquired] than community-acquired MRSA infections,” she said in an interview. “This correlates with the greater number of babies in the neonatal intensive care unit. About 50% of the babies who had the infections in the first 60 days were in the [neonatal] ICU.”

The ratio of hospital-acquired (HA) and community-acquired (CA) infections began to change after the patients reached about 2 months of age, she said. “At this point, we found a shift toward more infections being acquired in the community. But this difference disappears toward the end of the first year.” In months 11 and 12, there are about equal numbers of community- and hospital-acquired infections.

She also noted that a second peak of infection occurred just before the first birthday, with the highest incidence (71%) during the fall and winter months. Additionally, most patients in this age group (73%) presented with a concurrent upper respiratory infection. “This apparent association needs further investigation,” Dr. Krishnan said at the meeting, which was cosponsored by Children's Hospital of Philadelphia.

CA-MRSA also was significantly more likely than HA-MRSA to cause pustulosis (28% vs. 13%) and abscesses requiring drainage (33% vs. 10%). Invasive infections were similar between the groups (22% and 26%), but among invasive infections, bacteremia was more common in HA-MRSA (18% vs. 7%) and nonbacteremic invasive infections more common in CA-MRSA (17% vs. 8%).

The two types of MRSA infections display distinct antibiotic susceptibilities, Dr. Krishnan said. Most CA-MRSA infections were susceptible to clindamycin (76%), with none of the tested cultures displaying inducible resistance. Only 37% of HA-MRSA cultures were sensitive to clindamycin, however, and 25% of those tested did display inducible resistance.

The researchers plan additional studies to explore the possible relationship between early-infancy infections and a maternal reservoir of MRSA, Dr. Krishnan said. “We plan a prospective study looking at mother-infant couplets. We want to culture mothers before delivery, identify those with MRSA, and follow the pairs for a year to assess MRSA colonization and disease.”

Most infections (64%) occurred in infants less than 5 months old, with 25% occurring in children less than 1 month old. DR. KRISHNAN

MIAMI BEACH — Eclamptic seizures are a rare but serious complication best treated according to a preestablished protocol, Dr. Baha Sibai said at an ob.gyn. conference sponsored by the University of Miami.

“Don't look for fetal heart rate first or think of the seizure. Don't stop to give meds to stop the seizure, and cover the fetal heart rate monitor,” he said. Instead, take care of the mother first, and “treat the patient according to her vital signs,” said Dr. Sibai, professor of obstetrics and gynecology at the University of Cincinnati.

He suggested the following seven steps for managing eclamptic seizure:

1. Prevent hypoxia by supporting maternal respiratory and cardiovascular functions.

2. Prevent maternal injury and aspiration.

3. Avoid the temptation to try to arrest the first seizure.

4. Prevent convulsions from recurring. This is accomplished chiefly with intravenous magnesium sulfate, administered slowly and never as an intravenous push, Dr. Sibai said. He suggested 6 g administered IV over 20 minutes, with 2 g IV per hour for maintenance. “When you give the loading dose, they feel terrible,” Dr. Sibai said. “I know this feels bad. I gave it to myself when I developed these protocols.” Talk to the patient to prevent magnesium toxicity. “If they are disoriented, they are approaching toxic levels,” Dr. Sibai said. “If a patient on magnesium shows abnormal behavior for any reason, for heaven's sake, stop it. No one has ever died from a lack of magnesium.”

5. Control severe hypertension to prevent cerebrovascular injury. “Most people don't know how to give antihypertension meds,” he said. “Call someone if you don't know, but not someone more ignorant than you. An IV bolus of 5 mg hydralazine, with another 10 mg IV bolus given 20-30 minutes later, can help control severe hypertension, he added. “Notice I haven't mentioned the fetal heart rate or baby yet,” Dr. Sibai said.

6. Manage complications such as disseminated intravascular coagulation and pulmonary edema.

7. Begin induction/delivery within 24 hours. “The worst thing you can do is everyone panics and rushes the woman to a C-section,” Dr. Sibai said. “Assess neurologic status. This is extremely important—do not take her for a C-section if unconscious.” Ask the patient to state her name, where she is, and the time of year.

Taking care of the mother first is important because “the baby will not do well if the mother is not doing well,” Dr. Sibai concluded.

MIAMI BEACH — Eclamptic seizures are a rare but serious complication best treated according to a preestablished protocol, Dr. Baha Sibai said at an ob.gyn. conference sponsored by the University of Miami.

“Don't look for fetal heart rate first or think of the seizure. Don't stop to give meds to stop the seizure, and cover the fetal heart rate monitor,” he said. Instead, take care of the mother first, and “treat the patient according to her vital signs,” said Dr. Sibai, professor of obstetrics and gynecology at the University of Cincinnati.

He suggested the following seven steps for managing eclamptic seizure:

1. Prevent hypoxia by supporting maternal respiratory and cardiovascular functions.

2. Prevent maternal injury and aspiration.

3. Avoid the temptation to try to arrest the first seizure.

4. Prevent convulsions from recurring. This is accomplished chiefly with intravenous magnesium sulfate, administered slowly and never as an intravenous push, Dr. Sibai said. He suggested 6 g administered IV over 20 minutes, with 2 g IV per hour for maintenance. “When you give the loading dose, they feel terrible,” Dr. Sibai said. “I know this feels bad. I gave it to myself when I developed these protocols.” Talk to the patient to prevent magnesium toxicity. “If they are disoriented, they are approaching toxic levels,” Dr. Sibai said. “If a patient on magnesium shows abnormal behavior for any reason, for heaven's sake, stop it. No one has ever died from a lack of magnesium.”

5. Control severe hypertension to prevent cerebrovascular injury. “Most people don't know how to give antihypertension meds,” he said. “Call someone if you don't know, but not someone more ignorant than you. An IV bolus of 5 mg hydralazine, with another 10 mg IV bolus given 20-30 minutes later, can help control severe hypertension, he added. “Notice I haven't mentioned the fetal heart rate or baby yet,” Dr. Sibai said.

6. Manage complications such as disseminated intravascular coagulation and pulmonary edema.

7. Begin induction/delivery within 24 hours. “The worst thing you can do is everyone panics and rushes the woman to a C-section,” Dr. Sibai said. “Assess neurologic status. This is extremely important—do not take her for a C-section if unconscious.” Ask the patient to state her name, where she is, and the time of year.

Taking care of the mother first is important because “the baby will not do well if the mother is not doing well,” Dr. Sibai concluded.

MIAMI BEACH — Eclamptic seizures are a rare but serious complication best treated according to a preestablished protocol, Dr. Baha Sibai said at an ob.gyn. conference sponsored by the University of Miami.

“Don't look for fetal heart rate first or think of the seizure. Don't stop to give meds to stop the seizure, and cover the fetal heart rate monitor,” he said. Instead, take care of the mother first, and “treat the patient according to her vital signs,” said Dr. Sibai, professor of obstetrics and gynecology at the University of Cincinnati.

He suggested the following seven steps for managing eclamptic seizure:

1. Prevent hypoxia by supporting maternal respiratory and cardiovascular functions.

2. Prevent maternal injury and aspiration.

3. Avoid the temptation to try to arrest the first seizure.

4. Prevent convulsions from recurring. This is accomplished chiefly with intravenous magnesium sulfate, administered slowly and never as an intravenous push, Dr. Sibai said. He suggested 6 g administered IV over 20 minutes, with 2 g IV per hour for maintenance. “When you give the loading dose, they feel terrible,” Dr. Sibai said. “I know this feels bad. I gave it to myself when I developed these protocols.” Talk to the patient to prevent magnesium toxicity. “If they are disoriented, they are approaching toxic levels,” Dr. Sibai said. “If a patient on magnesium shows abnormal behavior for any reason, for heaven's sake, stop it. No one has ever died from a lack of magnesium.”

5. Control severe hypertension to prevent cerebrovascular injury. “Most people don't know how to give antihypertension meds,” he said. “Call someone if you don't know, but not someone more ignorant than you. An IV bolus of 5 mg hydralazine, with another 10 mg IV bolus given 20-30 minutes later, can help control severe hypertension, he added. “Notice I haven't mentioned the fetal heart rate or baby yet,” Dr. Sibai said.

6. Manage complications such as disseminated intravascular coagulation and pulmonary edema.

7. Begin induction/delivery within 24 hours. “The worst thing you can do is everyone panics and rushes the woman to a C-section,” Dr. Sibai said. “Assess neurologic status. This is extremely important—do not take her for a C-section if unconscious.” Ask the patient to state her name, where she is, and the time of year.

Taking care of the mother first is important because “the baby will not do well if the mother is not doing well,” Dr. Sibai concluded.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that patients could easily do well. But that is not really so, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases in Los Angeles.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819-23). Another recent study, of pregnant women with diabetes in Canada, found much the same thing; moreover, these researchers compared pregnancy outcomes from 1988 to 2002 and saw almost no improvement over that time (Obstet. Gynecol. 2006;108:644-50).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women who had gestational diabetes at between 24 weeks' and 33 weeks' gestation to routine diabetes care and education or to routine care and insulin therapy. The researchers found that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477-86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467-70). Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

“These authors showed that the higher the fasting glucose, the more complications,” Dr. Mestman noted.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134-8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman said he uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin. It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

“I will tell you that there are very few endocrinologists who are using oral agents during pregnancy; but I am one of them,” he said.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that patients could easily do well. But that is not really so, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases in Los Angeles.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819-23). Another recent study, of pregnant women with diabetes in Canada, found much the same thing; moreover, these researchers compared pregnancy outcomes from 1988 to 2002 and saw almost no improvement over that time (Obstet. Gynecol. 2006;108:644-50).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women who had gestational diabetes at between 24 weeks' and 33 weeks' gestation to routine diabetes care and education or to routine care and insulin therapy. The researchers found that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477-86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467-70). Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

“These authors showed that the higher the fasting glucose, the more complications,” Dr. Mestman noted.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134-8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman said he uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin. It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

“I will tell you that there are very few endocrinologists who are using oral agents during pregnancy; but I am one of them,” he said.

LOS ANGELES — Recent research shows that even relatively minor elevations in blood glucose in pregnancy can have severe effects, and that diabetes in pregnant women is not being controlled as well as it should be, Dr. Jorge H. Mestman said at the Obstetrical and Gynecological Assembly of Southern California.

A short time ago, many experts believed that the problems of diabetes in pregnancy had been addressed and that patients could easily do well. But that is not really so, said Dr. Mestman, director of the University of Southern California Center for Diabetes and Metabolic Diseases in Los Angeles.

One study looked at a Danish registry of pregnant women with diabetes and found that this group of patients had elevated rates of stillbirth and congenital malformation relative to the general population, largely because their blood glucose was not under control (Diabetes Care 2004;27:2819-23). Another recent study, of pregnant women with diabetes in Canada, found much the same thing; moreover, these researchers compared pregnancy outcomes from 1988 to 2002 and saw almost no improvement over that time (Obstet. Gynecol. 2006;108:644-50).

Two other studies published within the last 2 years have shown that good glucose control could improve those outcomes, Dr. Mestman said.

One of those studies randomly assigned 1,000 women who had gestational diabetes at between 24 weeks' and 33 weeks' gestation to routine diabetes care and education or to routine care and insulin therapy. The researchers found that care and insulin therapy reduced the perinatal complication rate to 1% vs. 4% for care and education (N. Engl. J. Med. 2005;352:2477-86).

The second study looked at women in a gestational diabetes program who delivered at term, and compared the outcomes of those who had good glucose control and suboptimal glucose control. Good glucose control had a very rigorous definition in the study—an average fasting glucose level below 95 mg/dL, an average 1-hour postprandial level below 140 mg/dL, and an average 2-hour postprandial level of below 120 mg/dL.

More than one-third of the women with poor control (1,118 subjects) had poor pregnancy outcomes—which included macrosomia, large-for-gestational-age infants, hypoglycemia, jaundice, or stillbirth—compared with only 24% of those with optimal control (2,030 subjects; Diabetes Care 2007;30:467-70). Treatment of the infants in the intensive care unit and cesarean deliveries was also more common in the poorly controlled women.

“These authors showed that the higher the fasting glucose, the more complications,” Dr. Mestman noted.

Although there has been some concern about the use of oral diabetes drugs in pregnancy being associated with congenital abnormalities and neonatal hypoglycemia, Dr. Mestman said he has reviewed the literature and the experience at his own institution, and concluded that the evidence suggests there is no risk and that what differences have been seen are probably result from glycemic control.

Moreover, a study that compared glyburide with insulin treatment in patients with gestational diabetes reported that the two treatments produced equivalent glucose control and improved outcomes equally (N. Engl. J. Med. 2000;343:1134-8).

The advantage of glyburide was that there was much less maternal hypoglycemia, Dr. Mestman added.

Therefore, Dr. Mestman said he uses glyburide in pregnancy. The key to using this oral agent, he said, is knowing which patients respond well and which will need insulin. It has been shown that the patients who are not likely to respond to glyburide well enough are those who have a 1-hour glucose challenge test with a blood glucose level above 200 mg/dL, or who have a fasting glucose level above 95 mg/dL, he said.

“I will tell you that there are very few endocrinologists who are using oral agents during pregnancy; but I am one of them,” he said.

PHILADELPHIA — Universal prenatal screening of maternal blood lead levels significantly increases the identification rate of women with abnormal levels, allowing earlier identification of infants born at risk, Dr. Tatyana Gabinsky said at the annual meeting of the Eastern Society for Pediatric Research.

Dr. Gabinsky of Elmhurst (N.Y.) Hospital Center, presented a 4-year retrospective study (2002–2006) of more than 20,000 women who received blood lead screenings during their first prenatal visits.

Before 2002, her institution followed the Centers for Disease Control and Prevention recommendation for screening only women identified by questionnaire as being at increased risk for elevated lead levels. Beginning in 2004, the hospital began screening all women as part of routine care.

In all, 20,263 women were screened. The blood lead level was at least 5 mcg/dL in 6% and 7–10 mcg/dL in 5%.

About 1% of the women had extremely high levels (median 17 mcg/dL; range 11–56 mcg/dL).

With the selective screen, the identification rate of women with levels in the 5- to 10-mcg/dL range was 2.2%, and only 0.28% in those with a level greater than 10 mcg/dL.

With universal screening, those identification rates increased to 7% in women in the 5- to 10-mcg/dL range and 1.6% in women with a level greater than 10 mcg/dL.

Universal screening also allowed staff to increase their identification rate of infants born with elevated blood lead levels (2%–11%), Dr. Gabinsky said.

Most (91%) of the women with elevated blood lead levels were foreign born, she added. The most common nationalities were Mexican (35%), Bangladeshi (21%), and Pakistani (16%).

She is conducting a follow-up study of infants born to mothers with a blood lead level greater than 10 mcg/dL. Infants with a newborn level greater than 10 mcg/dL are retested on a monthly basis, while those with a newborn level of 5- to 10-mcg/dL are tested every 2–3 months. Most of them are able to clear the lead by 1 year of age, she said.

“By the time they are 12 months old, the majority are almost normal. Even in babies with a level as high as 42 mcg/dL, by 12 months they are only at 5 mcg/dL,” said Dr. Gabinsky.

PHILADELPHIA — Universal prenatal screening of maternal blood lead levels significantly increases the identification rate of women with abnormal levels, allowing earlier identification of infants born at risk, Dr. Tatyana Gabinsky said at the annual meeting of the Eastern Society for Pediatric Research.

Dr. Gabinsky of Elmhurst (N.Y.) Hospital Center, presented a 4-year retrospective study (2002–2006) of more than 20,000 women who received blood lead screenings during their first prenatal visits.

Before 2002, her institution followed the Centers for Disease Control and Prevention recommendation for screening only women identified by questionnaire as being at increased risk for elevated lead levels. Beginning in 2004, the hospital began screening all women as part of routine care.

In all, 20,263 women were screened. The blood lead level was at least 5 mcg/dL in 6% and 7–10 mcg/dL in 5%.

About 1% of the women had extremely high levels (median 17 mcg/dL; range 11–56 mcg/dL).

With the selective screen, the identification rate of women with levels in the 5- to 10-mcg/dL range was 2.2%, and only 0.28% in those with a level greater than 10 mcg/dL.

With universal screening, those identification rates increased to 7% in women in the 5- to 10-mcg/dL range and 1.6% in women with a level greater than 10 mcg/dL.

Universal screening also allowed staff to increase their identification rate of infants born with elevated blood lead levels (2%–11%), Dr. Gabinsky said.

Most (91%) of the women with elevated blood lead levels were foreign born, she added. The most common nationalities were Mexican (35%), Bangladeshi (21%), and Pakistani (16%).

She is conducting a follow-up study of infants born to mothers with a blood lead level greater than 10 mcg/dL. Infants with a newborn level greater than 10 mcg/dL are retested on a monthly basis, while those with a newborn level of 5- to 10-mcg/dL are tested every 2–3 months. Most of them are able to clear the lead by 1 year of age, she said.

“By the time they are 12 months old, the majority are almost normal. Even in babies with a level as high as 42 mcg/dL, by 12 months they are only at 5 mcg/dL,” said Dr. Gabinsky.

PHILADELPHIA — Universal prenatal screening of maternal blood lead levels significantly increases the identification rate of women with abnormal levels, allowing earlier identification of infants born at risk, Dr. Tatyana Gabinsky said at the annual meeting of the Eastern Society for Pediatric Research.

Dr. Gabinsky of Elmhurst (N.Y.) Hospital Center, presented a 4-year retrospective study (2002–2006) of more than 20,000 women who received blood lead screenings during their first prenatal visits.

Before 2002, her institution followed the Centers for Disease Control and Prevention recommendation for screening only women identified by questionnaire as being at increased risk for elevated lead levels. Beginning in 2004, the hospital began screening all women as part of routine care.

In all, 20,263 women were screened. The blood lead level was at least 5 mcg/dL in 6% and 7–10 mcg/dL in 5%.

About 1% of the women had extremely high levels (median 17 mcg/dL; range 11–56 mcg/dL).

With the selective screen, the identification rate of women with levels in the 5- to 10-mcg/dL range was 2.2%, and only 0.28% in those with a level greater than 10 mcg/dL.

With universal screening, those identification rates increased to 7% in women in the 5- to 10-mcg/dL range and 1.6% in women with a level greater than 10 mcg/dL.

Universal screening also allowed staff to increase their identification rate of infants born with elevated blood lead levels (2%–11%), Dr. Gabinsky said.

Most (91%) of the women with elevated blood lead levels were foreign born, she added. The most common nationalities were Mexican (35%), Bangladeshi (21%), and Pakistani (16%).

She is conducting a follow-up study of infants born to mothers with a blood lead level greater than 10 mcg/dL. Infants with a newborn level greater than 10 mcg/dL are retested on a monthly basis, while those with a newborn level of 5- to 10-mcg/dL are tested every 2–3 months. Most of them are able to clear the lead by 1 year of age, she said.

“By the time they are 12 months old, the majority are almost normal. Even in babies with a level as high as 42 mcg/dL, by 12 months they are only at 5 mcg/dL,” said Dr. Gabinsky.

High maternal beef consumption in pregnancy was associated with significantly decreased sperm concentration in adult male offspring, investigators reported in Human Reproduction.

The study, which included 387 fertile men born between 1949 and 1983 and living in the United States, found that sons of women who ate at least seven servings of beef weekly had a mean sperm count that was 24% lower than did sons of mothers who ate less.

Investigators raised the possibility that the presence of anabolic steroids and other xenobiotics in beef—may have affected the men's testicular development in utero, resulting in lowered sperm counts.

They noted that diethylstilbestrol (DES), the first synthetic hormone, was used in cattle from 1954 to 1979 in the United States. After DES was banned, other anabolic hormones continued to be used legally (Human Reprod. 2007 [Epub DOI:10.1093/humrep/dem068]).

Of the offspring of high beef consumers, almost 18% met the World Health Organization threshold of subfertility (20 million sperm/mL of seminal fluid), compared with 5.7% of the sons of mothers who ate seven or fewer servings of beef per week. This was a statistically significant difference, Shanna Swan, Ph.D., director of the Center for Reproductive Epidemiology at the University of Rochester and her associates wrote.

Between 1999 and 2005, the researchers recruited 773 men born 1949–1983 from five U.S. cities. The men provided semen samples.

Mothers of 387 of the men provided diet information by completing a questionnaire. A total of 26% reported they ate more than seven servings per week of any type of red meat. Thirteen percent said they consumed more than seven servings of beef weekly.

Sons of women who ate more than seven servings of beef per week had sperm concentrations of 43.1 million/mL, compared with 56.9 million/mL in those sons whose mothers ate less beef. This 24% difference was statistically significant. Mothers' consumption of other red meat, fish, chicken, and vegetables were unrelated to their sons' sperm concentrations.

In addition to the higher proportion of men meeting the WHO definition of subfertility, the sons of the high beef consumers also were significantly more likely to self-report previous subfertility (9.8% vs. 5.7%), after adjustment for age.

The researchers noted that self-reporting of beef consumption is likely to be subject to error. In addition, they noted that the steroids in animal feeds might have affected the men as children or adults, and persistent pesticides and industrial chemicals in meat also might play a role. To clarify the role of steroids, the researchers suggested a study of men born in Europe after 1988, when steroids were banned in beef sold and produced there.

In an editorial accompanying the report, Frederick S. vom Saal, Ph.D., of the University of Missouri, Columbia, noted that although DES was banned in the United States in 1979, “administration of combinations of other hormonally active drugs to beef cattle has continued to be a common practice in the [United States].”

He added that, “if xenobiotics are causally involved, the finding of reduced semen quality should be the 'tip of the iceberg,' and other reproductive pathologies should also be observed.”

Dr. Saal urged regulatory bodies to revisit the risks associated with exposure during development to hormonal residues in beef (Human Reprod. 2007 [Epub DOI:10.1093/humrep/dem092]).

High maternal beef consumption in pregnancy was associated with significantly decreased sperm concentration in adult male offspring, investigators reported in Human Reproduction.

The study, which included 387 fertile men born between 1949 and 1983 and living in the United States, found that sons of women who ate at least seven servings of beef weekly had a mean sperm count that was 24% lower than did sons of mothers who ate less.

Investigators raised the possibility that the presence of anabolic steroids and other xenobiotics in beef—may have affected the men's testicular development in utero, resulting in lowered sperm counts.

They noted that diethylstilbestrol (DES), the first synthetic hormone, was used in cattle from 1954 to 1979 in the United States. After DES was banned, other anabolic hormones continued to be used legally (Human Reprod. 2007 [Epub DOI:10.1093/humrep/dem068]).

Of the offspring of high beef consumers, almost 18% met the World Health Organization threshold of subfertility (20 million sperm/mL of seminal fluid), compared with 5.7% of the sons of mothers who ate seven or fewer servings of beef per week. This was a statistically significant difference, Shanna Swan, Ph.D., director of the Center for Reproductive Epidemiology at the University of Rochester and her associates wrote.

Between 1999 and 2005, the researchers recruited 773 men born 1949–1983 from five U.S. cities. The men provided semen samples.

Mothers of 387 of the men provided diet information by completing a questionnaire. A total of 26% reported they ate more than seven servings per week of any type of red meat. Thirteen percent said they consumed more than seven servings of beef weekly.

Sons of women who ate more than seven servings of beef per week had sperm concentrations of 43.1 million/mL, compared with 56.9 million/mL in those sons whose mothers ate less beef. This 24% difference was statistically significant. Mothers' consumption of other red meat, fish, chicken, and vegetables were unrelated to their sons' sperm concentrations.

In addition to the higher proportion of men meeting the WHO definition of subfertility, the sons of the high beef consumers also were significantly more likely to self-report previous subfertility (9.8% vs. 5.7%), after adjustment for age.

The researchers noted that self-reporting of beef consumption is likely to be subject to error. In addition, they noted that the steroids in animal feeds might have affected the men as children or adults, and persistent pesticides and industrial chemicals in meat also might play a role. To clarify the role of steroids, the researchers suggested a study of men born in Europe after 1988, when steroids were banned in beef sold and produced there.

In an editorial accompanying the report, Frederick S. vom Saal, Ph.D., of the University of Missouri, Columbia, noted that although DES was banned in the United States in 1979, “administration of combinations of other hormonally active drugs to beef cattle has continued to be a common practice in the [United States].”

He added that, “if xenobiotics are causally involved, the finding of reduced semen quality should be the 'tip of the iceberg,' and other reproductive pathologies should also be observed.”

Dr. Saal urged regulatory bodies to revisit the risks associated with exposure during development to hormonal residues in beef (Human Reprod. 2007 [Epub DOI:10.1093/humrep/dem092]).

High maternal beef consumption in pregnancy was associated with significantly decreased sperm concentration in adult male offspring, investigators reported in Human Reproduction.

The study, which included 387 fertile men born between 1949 and 1983 and living in the United States, found that sons of women who ate at least seven servings of beef weekly had a mean sperm count that was 24% lower than did sons of mothers who ate less.

Investigators raised the possibility that the presence of anabolic steroids and other xenobiotics in beef—may have affected the men's testicular development in utero, resulting in lowered sperm counts.

They noted that diethylstilbestrol (DES), the first synthetic hormone, was used in cattle from 1954 to 1979 in the United States. After DES was banned, other anabolic hormones continued to be used legally (Human Reprod. 2007 [Epub DOI:10.1093/humrep/dem068]).

Of the offspring of high beef consumers, almost 18% met the World Health Organization threshold of subfertility (20 million sperm/mL of seminal fluid), compared with 5.7% of the sons of mothers who ate seven or fewer servings of beef per week. This was a statistically significant difference, Shanna Swan, Ph.D., director of the Center for Reproductive Epidemiology at the University of Rochester and her associates wrote.

Between 1999 and 2005, the researchers recruited 773 men born 1949–1983 from five U.S. cities. The men provided semen samples.

Mothers of 387 of the men provided diet information by completing a questionnaire. A total of 26% reported they ate more than seven servings per week of any type of red meat. Thirteen percent said they consumed more than seven servings of beef weekly.

Sons of women who ate more than seven servings of beef per week had sperm concentrations of 43.1 million/mL, compared with 56.9 million/mL in those sons whose mothers ate less beef. This 24% difference was statistically significant. Mothers' consumption of other red meat, fish, chicken, and vegetables were unrelated to their sons' sperm concentrations.

In addition to the higher proportion of men meeting the WHO definition of subfertility, the sons of the high beef consumers also were significantly more likely to self-report previous subfertility (9.8% vs. 5.7%), after adjustment for age.

The researchers noted that self-reporting of beef consumption is likely to be subject to error. In addition, they noted that the steroids in animal feeds might have affected the men as children or adults, and persistent pesticides and industrial chemicals in meat also might play a role. To clarify the role of steroids, the researchers suggested a study of men born in Europe after 1988, when steroids were banned in beef sold and produced there.

In an editorial accompanying the report, Frederick S. vom Saal, Ph.D., of the University of Missouri, Columbia, noted that although DES was banned in the United States in 1979, “administration of combinations of other hormonally active drugs to beef cattle has continued to be a common practice in the [United States].”

He added that, “if xenobiotics are causally involved, the finding of reduced semen quality should be the 'tip of the iceberg,' and other reproductive pathologies should also be observed.”

Dr. Saal urged regulatory bodies to revisit the risks associated with exposure during development to hormonal residues in beef (Human Reprod. 2007 [Epub DOI:10.1093/humrep/dem092]).