Obstetrics

SAN FRANCISCO — Babies conceived via assisted reproductive technology are significantly more likely to have birth defects than those conceived naturally, a large Canadian study has shown.

Despite the observed increase, however, the incidence of birth defects in this population “is still relatively uncommon and should not discourage infertile couples from considering this reproductive option,” said lead investigator Dr. Darine El-Chaar at the annual meeting of the Society for Maternal-Fetal Medicine. Rather, “the risk information should become part of counseling for couples that are infertile in order to clarify the risk picture,” she noted.

In a retrospective study of 2005 birth data obtained from the Ontario Niday perinatal database, Dr. El-Chaar and colleagues observed a 1.58-fold increased risk of birth defects overall in babies conceived with assisted reproductive technology (ART), compared with babies conceived naturally.

Of the 61,208 births identified in the database for which information about reproductive assistance was available, 1,394 resulted from fertility treatments. For purposes of this study, “we lost some subjects in the ART [group] due to missing variables and other factors, and were left with 870 subjects, including 320 who used ovulation induction medications, 180 who underwent intrauterine insemination, and 370 who underwent in vitro fertilization,” said Dr. El-Chaar of the University of Ottawa.

In terms of patient and clinical characteristics, mothers in the ART group tended to be older, were less likely to have had a previous child, and were less likely to smoke than mothers in the non-ART group, said Dr. El-Chaar. Also, the ART mothers had a higher rate of cesarean sections and preterm births, and a higher number of multiple births—a factor that likely contributed to the higher preterm birth rate.

After adjustment for these factors using logistic regression, the statistical model showed an overall incidence of birth defects in the ART population of 2.62%, compared with 1.87% in the non-ART population, reported Dr. El-Chaar, noting that increased values fall within the 2%–3% rate of birth defects seen in the general population.

When analyzed by type of ART intervention, babies conceived via in vitro fertilization had the greatest increased risk of birth defects, at 2.97%, compared with 2.66% for intrauterine insemination and 2.19% for ovulation induction—a finding that suggests an association with the degree to which the various techniques manipulate egg and sperm, Dr. El-Chaar said.

“The highest increase in the ART group was seen in gastrointestinal birth defects, with an adjusted odds ratio of 8.86, followed by cardiovascular defects with an odds ratio of 2.27 and musculoskeletal defects with an odds ratio of 1.51,” said Dr. El-Chaar. There were no significant increases in the risks of neural tube or facial defects between the groups.

Some factors that may contribute to the increased risk of birth defects in the study population are the relatively advanced age of infertile couples, the medications used to stimulate ovulation or to maintain the luteal phase, and factors associated with the procedures themselves, such as the freezing and thawing of embryos or delayed oocyte fertilization, said Dr. El-Chaar. “Further studies are needed to clarify the contributions of these factors, infertility itself, and ART to the development of birth defects.”

SAN FRANCISCO — Babies conceived via assisted reproductive technology are significantly more likely to have birth defects than those conceived naturally, a large Canadian study has shown.

Despite the observed increase, however, the incidence of birth defects in this population “is still relatively uncommon and should not discourage infertile couples from considering this reproductive option,” said lead investigator Dr. Darine El-Chaar at the annual meeting of the Society for Maternal-Fetal Medicine. Rather, “the risk information should become part of counseling for couples that are infertile in order to clarify the risk picture,” she noted.

In a retrospective study of 2005 birth data obtained from the Ontario Niday perinatal database, Dr. El-Chaar and colleagues observed a 1.58-fold increased risk of birth defects overall in babies conceived with assisted reproductive technology (ART), compared with babies conceived naturally.

Of the 61,208 births identified in the database for which information about reproductive assistance was available, 1,394 resulted from fertility treatments. For purposes of this study, “we lost some subjects in the ART [group] due to missing variables and other factors, and were left with 870 subjects, including 320 who used ovulation induction medications, 180 who underwent intrauterine insemination, and 370 who underwent in vitro fertilization,” said Dr. El-Chaar of the University of Ottawa.

In terms of patient and clinical characteristics, mothers in the ART group tended to be older, were less likely to have had a previous child, and were less likely to smoke than mothers in the non-ART group, said Dr. El-Chaar. Also, the ART mothers had a higher rate of cesarean sections and preterm births, and a higher number of multiple births—a factor that likely contributed to the higher preterm birth rate.

After adjustment for these factors using logistic regression, the statistical model showed an overall incidence of birth defects in the ART population of 2.62%, compared with 1.87% in the non-ART population, reported Dr. El-Chaar, noting that increased values fall within the 2%–3% rate of birth defects seen in the general population.

When analyzed by type of ART intervention, babies conceived via in vitro fertilization had the greatest increased risk of birth defects, at 2.97%, compared with 2.66% for intrauterine insemination and 2.19% for ovulation induction—a finding that suggests an association with the degree to which the various techniques manipulate egg and sperm, Dr. El-Chaar said.

“The highest increase in the ART group was seen in gastrointestinal birth defects, with an adjusted odds ratio of 8.86, followed by cardiovascular defects with an odds ratio of 2.27 and musculoskeletal defects with an odds ratio of 1.51,” said Dr. El-Chaar. There were no significant increases in the risks of neural tube or facial defects between the groups.

Some factors that may contribute to the increased risk of birth defects in the study population are the relatively advanced age of infertile couples, the medications used to stimulate ovulation or to maintain the luteal phase, and factors associated with the procedures themselves, such as the freezing and thawing of embryos or delayed oocyte fertilization, said Dr. El-Chaar. “Further studies are needed to clarify the contributions of these factors, infertility itself, and ART to the development of birth defects.”

SAN FRANCISCO — Babies conceived via assisted reproductive technology are significantly more likely to have birth defects than those conceived naturally, a large Canadian study has shown.

Despite the observed increase, however, the incidence of birth defects in this population “is still relatively uncommon and should not discourage infertile couples from considering this reproductive option,” said lead investigator Dr. Darine El-Chaar at the annual meeting of the Society for Maternal-Fetal Medicine. Rather, “the risk information should become part of counseling for couples that are infertile in order to clarify the risk picture,” she noted.

In a retrospective study of 2005 birth data obtained from the Ontario Niday perinatal database, Dr. El-Chaar and colleagues observed a 1.58-fold increased risk of birth defects overall in babies conceived with assisted reproductive technology (ART), compared with babies conceived naturally.

Of the 61,208 births identified in the database for which information about reproductive assistance was available, 1,394 resulted from fertility treatments. For purposes of this study, “we lost some subjects in the ART [group] due to missing variables and other factors, and were left with 870 subjects, including 320 who used ovulation induction medications, 180 who underwent intrauterine insemination, and 370 who underwent in vitro fertilization,” said Dr. El-Chaar of the University of Ottawa.

In terms of patient and clinical characteristics, mothers in the ART group tended to be older, were less likely to have had a previous child, and were less likely to smoke than mothers in the non-ART group, said Dr. El-Chaar. Also, the ART mothers had a higher rate of cesarean sections and preterm births, and a higher number of multiple births—a factor that likely contributed to the higher preterm birth rate.

After adjustment for these factors using logistic regression, the statistical model showed an overall incidence of birth defects in the ART population of 2.62%, compared with 1.87% in the non-ART population, reported Dr. El-Chaar, noting that increased values fall within the 2%–3% rate of birth defects seen in the general population.

When analyzed by type of ART intervention, babies conceived via in vitro fertilization had the greatest increased risk of birth defects, at 2.97%, compared with 2.66% for intrauterine insemination and 2.19% for ovulation induction—a finding that suggests an association with the degree to which the various techniques manipulate egg and sperm, Dr. El-Chaar said.

“The highest increase in the ART group was seen in gastrointestinal birth defects, with an adjusted odds ratio of 8.86, followed by cardiovascular defects with an odds ratio of 2.27 and musculoskeletal defects with an odds ratio of 1.51,” said Dr. El-Chaar. There were no significant increases in the risks of neural tube or facial defects between the groups.

Some factors that may contribute to the increased risk of birth defects in the study population are the relatively advanced age of infertile couples, the medications used to stimulate ovulation or to maintain the luteal phase, and factors associated with the procedures themselves, such as the freezing and thawing of embryos or delayed oocyte fertilization, said Dr. El-Chaar. “Further studies are needed to clarify the contributions of these factors, infertility itself, and ART to the development of birth defects.”

SAN FRANCISCO — Getting a protein-to-creatinine ratio was more helpful than using a urine dipstick to measure proteinuria in patients with suspected preeclampsia, according to a retrospective cohort study.

The protein to creatinine (P/C) ratio correlated strongly with a 24-hour urine protein measurement, which is the standard for quantifying protein. The P/C ratio had a 90% correlation with 24-hour urine protein measurements, compared with only a 58% correlation between the urine dipstick and 24-hour urine protein measurements, Jasmine Lai and associates reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Investigators analyzed data on 140 women with suspected preeclampsia who had both a dipstick and 24-hour protein measurement, 177 who had both a P/C ratio and 24-hour protein measurement, and 244 who had both a dipstick and P/C ratio. The different assays were performed within 48 hours of each other for each patient.

The P/C ratio was a more sensitive marker for proteinuria, with a sensitivity of 75%, compared with dipstick's sensitivity of 44%, reported Ms. Lai, a student at the University of California, San Francisco, who conducted the study while a summer fellow at the University of California, San Diego.

Now that getting a dipstick measurement has been encumbered by the Clinical Laboratory Improvement Amendments law, it's just as fast and efficient to get a P/C ratio, Dr. Douglas Woelkers, the primary investigator in the study, said in an interview.

“Nurses now can't do dipsticks in the [labor and delivery] setting. Our hospital requires that all dipsticks go down to the laboratory to be read by machine. Why not get the more accurate P/C ratio, because it takes the same time to get a result back, and it's the same expense compared with the dipstick?” said Dr. Woelkers of the University of California, San Diego.

The dipstick underestimated proteinuria 44%–48% of the time, he added. Patients with a false-negative dipstick and mild hypertension would be sent home “only to find out later on that they truly had the disease and we weren't intervening soon enough,” he said.

Dipstick measurements were significantly confounded by the method of collection and the presence of blood, squamous cells, white blood cells, or leukocyte esterase, the investigators found.

To confirm the superiority of the P/C ratio, the investigators analyzed adverse maternal or fetal outcomes from delivery records of 209 patients who had both a urine dipstick and a P/C ratio. They used a composite of three or more markers for severe disease, including thrombocytopenia, elevated liver function tests, high creatinine level, low Apgar score, low birth weight, and maternal hospitalization longer than 3 days.

The P/C ratio was more accurate than the dipstick in predicting adverse outcomes because it more accurately measured proteinuria, Dr. Woelkers said. The P/C ratio had a sensitivity of 50% for composite adverse outcomes and a specificity of 72%. Taking one or more dipstick measurements was 35% sensitive and 81% specific for predicting adverse outcomes. Taking two or more dipstick measurements was 24% sensitive and 83% specific for adverse outcomes. Dr. Woelkers' hospital has converted entirely to doing P/C ratios instead of dipsticks for patients with suspected preeclampsia.

Further research will be needed to see if it makes sense to switch from dipsticks to P/C ratios for patients with suspected preeclampsia in office settings, not just in hospitals, he added.

SAN FRANCISCO — Getting a protein-to-creatinine ratio was more helpful than using a urine dipstick to measure proteinuria in patients with suspected preeclampsia, according to a retrospective cohort study.

The protein to creatinine (P/C) ratio correlated strongly with a 24-hour urine protein measurement, which is the standard for quantifying protein. The P/C ratio had a 90% correlation with 24-hour urine protein measurements, compared with only a 58% correlation between the urine dipstick and 24-hour urine protein measurements, Jasmine Lai and associates reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Investigators analyzed data on 140 women with suspected preeclampsia who had both a dipstick and 24-hour protein measurement, 177 who had both a P/C ratio and 24-hour protein measurement, and 244 who had both a dipstick and P/C ratio. The different assays were performed within 48 hours of each other for each patient.

The P/C ratio was a more sensitive marker for proteinuria, with a sensitivity of 75%, compared with dipstick's sensitivity of 44%, reported Ms. Lai, a student at the University of California, San Francisco, who conducted the study while a summer fellow at the University of California, San Diego.

Now that getting a dipstick measurement has been encumbered by the Clinical Laboratory Improvement Amendments law, it's just as fast and efficient to get a P/C ratio, Dr. Douglas Woelkers, the primary investigator in the study, said in an interview.

“Nurses now can't do dipsticks in the [labor and delivery] setting. Our hospital requires that all dipsticks go down to the laboratory to be read by machine. Why not get the more accurate P/C ratio, because it takes the same time to get a result back, and it's the same expense compared with the dipstick?” said Dr. Woelkers of the University of California, San Diego.

The dipstick underestimated proteinuria 44%–48% of the time, he added. Patients with a false-negative dipstick and mild hypertension would be sent home “only to find out later on that they truly had the disease and we weren't intervening soon enough,” he said.

Dipstick measurements were significantly confounded by the method of collection and the presence of blood, squamous cells, white blood cells, or leukocyte esterase, the investigators found.

To confirm the superiority of the P/C ratio, the investigators analyzed adverse maternal or fetal outcomes from delivery records of 209 patients who had both a urine dipstick and a P/C ratio. They used a composite of three or more markers for severe disease, including thrombocytopenia, elevated liver function tests, high creatinine level, low Apgar score, low birth weight, and maternal hospitalization longer than 3 days.

The P/C ratio was more accurate than the dipstick in predicting adverse outcomes because it more accurately measured proteinuria, Dr. Woelkers said. The P/C ratio had a sensitivity of 50% for composite adverse outcomes and a specificity of 72%. Taking one or more dipstick measurements was 35% sensitive and 81% specific for predicting adverse outcomes. Taking two or more dipstick measurements was 24% sensitive and 83% specific for adverse outcomes. Dr. Woelkers' hospital has converted entirely to doing P/C ratios instead of dipsticks for patients with suspected preeclampsia.

Further research will be needed to see if it makes sense to switch from dipsticks to P/C ratios for patients with suspected preeclampsia in office settings, not just in hospitals, he added.

SAN FRANCISCO — Getting a protein-to-creatinine ratio was more helpful than using a urine dipstick to measure proteinuria in patients with suspected preeclampsia, according to a retrospective cohort study.

The protein to creatinine (P/C) ratio correlated strongly with a 24-hour urine protein measurement, which is the standard for quantifying protein. The P/C ratio had a 90% correlation with 24-hour urine protein measurements, compared with only a 58% correlation between the urine dipstick and 24-hour urine protein measurements, Jasmine Lai and associates reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Investigators analyzed data on 140 women with suspected preeclampsia who had both a dipstick and 24-hour protein measurement, 177 who had both a P/C ratio and 24-hour protein measurement, and 244 who had both a dipstick and P/C ratio. The different assays were performed within 48 hours of each other for each patient.

The P/C ratio was a more sensitive marker for proteinuria, with a sensitivity of 75%, compared with dipstick's sensitivity of 44%, reported Ms. Lai, a student at the University of California, San Francisco, who conducted the study while a summer fellow at the University of California, San Diego.

Now that getting a dipstick measurement has been encumbered by the Clinical Laboratory Improvement Amendments law, it's just as fast and efficient to get a P/C ratio, Dr. Douglas Woelkers, the primary investigator in the study, said in an interview.

“Nurses now can't do dipsticks in the [labor and delivery] setting. Our hospital requires that all dipsticks go down to the laboratory to be read by machine. Why not get the more accurate P/C ratio, because it takes the same time to get a result back, and it's the same expense compared with the dipstick?” said Dr. Woelkers of the University of California, San Diego.

The dipstick underestimated proteinuria 44%–48% of the time, he added. Patients with a false-negative dipstick and mild hypertension would be sent home “only to find out later on that they truly had the disease and we weren't intervening soon enough,” he said.

Dipstick measurements were significantly confounded by the method of collection and the presence of blood, squamous cells, white blood cells, or leukocyte esterase, the investigators found.

To confirm the superiority of the P/C ratio, the investigators analyzed adverse maternal or fetal outcomes from delivery records of 209 patients who had both a urine dipstick and a P/C ratio. They used a composite of three or more markers for severe disease, including thrombocytopenia, elevated liver function tests, high creatinine level, low Apgar score, low birth weight, and maternal hospitalization longer than 3 days.

The P/C ratio was more accurate than the dipstick in predicting adverse outcomes because it more accurately measured proteinuria, Dr. Woelkers said. The P/C ratio had a sensitivity of 50% for composite adverse outcomes and a specificity of 72%. Taking one or more dipstick measurements was 35% sensitive and 81% specific for predicting adverse outcomes. Taking two or more dipstick measurements was 24% sensitive and 83% specific for adverse outcomes. Dr. Woelkers' hospital has converted entirely to doing P/C ratios instead of dipsticks for patients with suspected preeclampsia.

Further research will be needed to see if it makes sense to switch from dipsticks to P/C ratios for patients with suspected preeclampsia in office settings, not just in hospitals, he added.

SAN FRANCISCO — Evaluating persistent headache that presents more than 24 hours after delivery requires a stepwise, multidisciplinary approach, Dr. Caroline Stella said at the annual meeting of the Society for Maternal-Fetal Medicine.

Postpartum headache affects 11%–80% of women after delivery, and usually is benign. Little has been known about headaches that start more than a day after delivery.

Dr. Stella of the University of Cincinnati and her associates retrospectively studied records for 95 women with severe headaches that started 25 hours to 32 days post partum and were unresponsive to usual doses of analgesics.

Approximately half of the women (47 patients) ultimately were diagnosed with tension-type or migraine headaches, and all responded to higher doses of analgesics or narcotics.

Twenty-three women (24%) with headaches caused by preeclampsia or eclampsia were treated with magnesium sulfate or antihypertensives; one had a cerebral venous thrombosis, and one had a subarachnoid hemorrhage.

Fifteen women (16%) had a final diagnosis of spinal headache. All received an anesthesiology consultation and initially were treated with analgesics. Twelve patients (13%) eventually required a blood patch. Headaches caused by other abnormalities in 10 women (11%) were treated with anticonvulsants, anticoagulants, or a dopamine antagonist.

Some patients had overlapping diagnoses. In 78 women, the headaches started while they were in the hospital; the other 17 were readmitted after postpartum discharge. Cesarean deliveries had been performed in 28 women.

Of the 95 women, 22 (23%) underwent cerebral imaging studies. Indications for imaging included persistent visual changes in 14 patients, focal neurologic deficits in 8, refractory headache in 8, and other reasons.

Neurologic symptoms other than headache resolved in 20 of the 22 women. Two patients were left with residual facial droop. No patients died.

On the basis of the study's findings, Dr. Stella and her associates recommended the following algorithm for work-up of postpartum headache presenting after 24 hours.

If neurologic deficits are present, perform cerebral imaging right away. If no neurologic deficits are present in a normotensive patient without proteinuria, treat for presumed migraine or tension-type headache.

If that therapy doesn't work and the patient has a history of regional anesthesia placement, consider the diagnosis of postdural puncture headache. Give intravenous fluids and analgesia, and consider administering a blood patch. If the headache still doesn't respond to therapy, perform cerebral imaging.

Presume a diagnosis of preeclampsia or eclampsia in women with hypertension or proteinuria and administer magnesium sulfate and antihypertensive agents. If the headache is unresponsive, perform cerebral imaging.

Eclampsia increased the risk for cognitive dysfunction years later in a separate case-control study of 87 women presented in a poster session by Annet M. Aukes, a medical student at the University of Groningen (the Netherlands).

From 6 to 8 years after their eclampsia episodes, 29 women were matched by age and year of pregnancy with formerly preeclamptic women and normotensive controls. All completed a validated Cognitive Failures Questionnaire designed to assess the likelihood of committing a cognitive error in an everyday task.

The women with a history of eclampsia scored significantly worse, compared with preeclamptic women or controls. The paradigm that eclamptic women can expect a full recovery should be reevaluated, she said in an interview.

“It's very important that these women are treated adequately right away when they come in with headaches so we can prevent more eclamptic seizures,” Ms. Aukes said.

These women need support months and years later to understand that their dysfunction is not psychological but caused by white matter lesions, she added.

MRIs of a patient's brain show cerebral edema (red arrows, left) in the occipital lobes and, on follow-up, complete resolution of the edema (red arrows, right). Photos courtesy Dr. Caroline Stella

SAN FRANCISCO — Evaluating persistent headache that presents more than 24 hours after delivery requires a stepwise, multidisciplinary approach, Dr. Caroline Stella said at the annual meeting of the Society for Maternal-Fetal Medicine.

Postpartum headache affects 11%–80% of women after delivery, and usually is benign. Little has been known about headaches that start more than a day after delivery.

Dr. Stella of the University of Cincinnati and her associates retrospectively studied records for 95 women with severe headaches that started 25 hours to 32 days post partum and were unresponsive to usual doses of analgesics.

Approximately half of the women (47 patients) ultimately were diagnosed with tension-type or migraine headaches, and all responded to higher doses of analgesics or narcotics.

Twenty-three women (24%) with headaches caused by preeclampsia or eclampsia were treated with magnesium sulfate or antihypertensives; one had a cerebral venous thrombosis, and one had a subarachnoid hemorrhage.

Fifteen women (16%) had a final diagnosis of spinal headache. All received an anesthesiology consultation and initially were treated with analgesics. Twelve patients (13%) eventually required a blood patch. Headaches caused by other abnormalities in 10 women (11%) were treated with anticonvulsants, anticoagulants, or a dopamine antagonist.

Some patients had overlapping diagnoses. In 78 women, the headaches started while they were in the hospital; the other 17 were readmitted after postpartum discharge. Cesarean deliveries had been performed in 28 women.

Of the 95 women, 22 (23%) underwent cerebral imaging studies. Indications for imaging included persistent visual changes in 14 patients, focal neurologic deficits in 8, refractory headache in 8, and other reasons.

Neurologic symptoms other than headache resolved in 20 of the 22 women. Two patients were left with residual facial droop. No patients died.

On the basis of the study's findings, Dr. Stella and her associates recommended the following algorithm for work-up of postpartum headache presenting after 24 hours.

If neurologic deficits are present, perform cerebral imaging right away. If no neurologic deficits are present in a normotensive patient without proteinuria, treat for presumed migraine or tension-type headache.

If that therapy doesn't work and the patient has a history of regional anesthesia placement, consider the diagnosis of postdural puncture headache. Give intravenous fluids and analgesia, and consider administering a blood patch. If the headache still doesn't respond to therapy, perform cerebral imaging.

Presume a diagnosis of preeclampsia or eclampsia in women with hypertension or proteinuria and administer magnesium sulfate and antihypertensive agents. If the headache is unresponsive, perform cerebral imaging.

Eclampsia increased the risk for cognitive dysfunction years later in a separate case-control study of 87 women presented in a poster session by Annet M. Aukes, a medical student at the University of Groningen (the Netherlands).

From 6 to 8 years after their eclampsia episodes, 29 women were matched by age and year of pregnancy with formerly preeclamptic women and normotensive controls. All completed a validated Cognitive Failures Questionnaire designed to assess the likelihood of committing a cognitive error in an everyday task.

The women with a history of eclampsia scored significantly worse, compared with preeclamptic women or controls. The paradigm that eclamptic women can expect a full recovery should be reevaluated, she said in an interview.

“It's very important that these women are treated adequately right away when they come in with headaches so we can prevent more eclamptic seizures,” Ms. Aukes said.

These women need support months and years later to understand that their dysfunction is not psychological but caused by white matter lesions, she added.

MRIs of a patient's brain show cerebral edema (red arrows, left) in the occipital lobes and, on follow-up, complete resolution of the edema (red arrows, right). Photos courtesy Dr. Caroline Stella

SAN FRANCISCO — Evaluating persistent headache that presents more than 24 hours after delivery requires a stepwise, multidisciplinary approach, Dr. Caroline Stella said at the annual meeting of the Society for Maternal-Fetal Medicine.

Postpartum headache affects 11%–80% of women after delivery, and usually is benign. Little has been known about headaches that start more than a day after delivery.

Dr. Stella of the University of Cincinnati and her associates retrospectively studied records for 95 women with severe headaches that started 25 hours to 32 days post partum and were unresponsive to usual doses of analgesics.

Approximately half of the women (47 patients) ultimately were diagnosed with tension-type or migraine headaches, and all responded to higher doses of analgesics or narcotics.

Twenty-three women (24%) with headaches caused by preeclampsia or eclampsia were treated with magnesium sulfate or antihypertensives; one had a cerebral venous thrombosis, and one had a subarachnoid hemorrhage.

Fifteen women (16%) had a final diagnosis of spinal headache. All received an anesthesiology consultation and initially were treated with analgesics. Twelve patients (13%) eventually required a blood patch. Headaches caused by other abnormalities in 10 women (11%) were treated with anticonvulsants, anticoagulants, or a dopamine antagonist.

Some patients had overlapping diagnoses. In 78 women, the headaches started while they were in the hospital; the other 17 were readmitted after postpartum discharge. Cesarean deliveries had been performed in 28 women.

Of the 95 women, 22 (23%) underwent cerebral imaging studies. Indications for imaging included persistent visual changes in 14 patients, focal neurologic deficits in 8, refractory headache in 8, and other reasons.

Neurologic symptoms other than headache resolved in 20 of the 22 women. Two patients were left with residual facial droop. No patients died.

On the basis of the study's findings, Dr. Stella and her associates recommended the following algorithm for work-up of postpartum headache presenting after 24 hours.

If neurologic deficits are present, perform cerebral imaging right away. If no neurologic deficits are present in a normotensive patient without proteinuria, treat for presumed migraine or tension-type headache.

If that therapy doesn't work and the patient has a history of regional anesthesia placement, consider the diagnosis of postdural puncture headache. Give intravenous fluids and analgesia, and consider administering a blood patch. If the headache still doesn't respond to therapy, perform cerebral imaging.

Presume a diagnosis of preeclampsia or eclampsia in women with hypertension or proteinuria and administer magnesium sulfate and antihypertensive agents. If the headache is unresponsive, perform cerebral imaging.

Eclampsia increased the risk for cognitive dysfunction years later in a separate case-control study of 87 women presented in a poster session by Annet M. Aukes, a medical student at the University of Groningen (the Netherlands).

From 6 to 8 years after their eclampsia episodes, 29 women were matched by age and year of pregnancy with formerly preeclamptic women and normotensive controls. All completed a validated Cognitive Failures Questionnaire designed to assess the likelihood of committing a cognitive error in an everyday task.

The women with a history of eclampsia scored significantly worse, compared with preeclamptic women or controls. The paradigm that eclamptic women can expect a full recovery should be reevaluated, she said in an interview.

“It's very important that these women are treated adequately right away when they come in with headaches so we can prevent more eclamptic seizures,” Ms. Aukes said.

These women need support months and years later to understand that their dysfunction is not psychological but caused by white matter lesions, she added.

MRIs of a patient's brain show cerebral edema (red arrows, left) in the occipital lobes and, on follow-up, complete resolution of the edema (red arrows, right). Photos courtesy Dr. Caroline Stella

RENO, NEV. — Cervical dilatation at presentation and over the 6 hours following admission was highly predictive of preterm birth in women admitted with preterm labor, but obstetric history also contributed important information about which mothers were likely to deliver before 34 weeks' or 37 weeks' gestation.

Dr. Jamie A. Bastek and associates in the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, reviewed the records of 400 women with singleton pregnancies who were admitted in preterm labor before 34 weeks' gestation.

The researchers sought to determine whether the risk of preterm birth could be stratified based on a number of easily identifiable variables, including cervical dilatation and a prior history of preterm or full-term birth.

Dr. Bastek presented their results at the annual meeting of the Society for Gynecologic Investigation.

“As tocolytics are not without harm, we felt it was important to see if we could identify women with a low likelihood of preterm birth who could be managed without admission and/or tocolytic agents” she said in an interview at the meeting, where the study was presented in poster form.

As expected, the total cohort had a significant risk of early delivery.

Nearly 45% delivered before 34 weeks, and 63% delivered before 37 weeks' gestation.

In trying to determine what distinguished the women who delivered after 37 weeks, Dr. Bastek and associates found a number of features conferring protection, including later gestational age at presentation, less cervical dilatation at presentation, smaller rates of change in cervical dilatation, and obstetric history.

Presentation at fewer than 25 weeks' gestation conferred more than a 15-fold increase in the odds of delivering before 34 weeks, compared with women who presented at 32 weeks' gestation. Presentation before 28 weeks was also a noteworthy risk, bestowing 3.5 times the risk of delivering before 34 weeks.

However, presenting at more than 30 weeks' gestation did not demonstrate elevated odds of delivering before 34 weeks or before 37 weeks, compared with presentation at 32 weeks' gestation.

Cervical dilatation—both on presentation and over the course of 6 hours following admission—was significantly predictive of preterm birth, even after controlling for multiple other variables such as maternal age, race, prenatal care, and gestational age on admission.

Each 1-cm increase in cervical dilatation on presentation more than doubled the odds of delivering before 37 weeks, a significant finding (P less than .0001). However, this risk was modified depending on obstetric history.

At a dilatation of 2 cm on admission, for example, the patients who were at highest risk of a preterm birth before 37 weeks were those with no previous births, followed by those with one or more prior preterm deliveries. Rates were lower for mothers who had a history of both preterm and full-term deliveries, and for those who previously had only had full-term deliveries.

The interaction between obstetric history and cervical dilatation was complex.

Patients with a previous preterm birth had the highest baseline risk of another preterm delivery before 37 weeks if cervical dilatation was not taken into consideration.

Within each obstetric history cohort, advancing cervical dilatation was significantly associated with preterm birth before 34 and 37 weeks. Advancing cervical dilatation had the greatest impact on patients with no prior preterm birth and the least impact on those with only a prior preterm birth.

Notably, more than 60% of women with a history of one or more full-term deliveries and no preterm deliveries carried their pregnancies beyond 34 weeks.

What happened after admission was also very relevant to the risk of preterm delivery.

Just 17.8% of the cohort (71 patients) delivered within 6 hours of admission.

Among the remaining 329 women, a 1- to 2-cm change in cervical dilatation after admission conferred almost a threefold risk of delivery before 34 weeks and a twofold risk of delivering before 37 weeks.

A 3-cm or greater change in cervical dilatation was associated with a nearly 12-fold increase in risk of a preterm birth before 34 weeks and a sevenfold increase in the odds of delivering before 37 weeks.

All eight women with more than a 4-cm change in dilatation over the first 6 hours post admission delivered at fewer than 34 weeks.

The research pointed to a number of factors that should be considered in the management of women with preterm labor, especially gestational age at presentation; cervical dilatation on presentation and cervical change over the 6 hours following admission; and obstetric history.

Further research is planned to randomize women with no previous preterm births and a low-risk cervical dilatation profile to tocolysis or expectant management.

“Our goal is to use this information to move into a trial that examines whether women with a low baseline risk can be managed without exposing them to magnesium or other tocolytics,” she said.

Dr. Bastek's coresearchers included principal investigator Dr. Michal A. Elovitz, Dr. Sindhu Srinivas, and biostatistician Mary D. Sammel.

RENO, NEV. — Cervical dilatation at presentation and over the 6 hours following admission was highly predictive of preterm birth in women admitted with preterm labor, but obstetric history also contributed important information about which mothers were likely to deliver before 34 weeks' or 37 weeks' gestation.

Dr. Jamie A. Bastek and associates in the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, reviewed the records of 400 women with singleton pregnancies who were admitted in preterm labor before 34 weeks' gestation.

The researchers sought to determine whether the risk of preterm birth could be stratified based on a number of easily identifiable variables, including cervical dilatation and a prior history of preterm or full-term birth.

Dr. Bastek presented their results at the annual meeting of the Society for Gynecologic Investigation.

“As tocolytics are not without harm, we felt it was important to see if we could identify women with a low likelihood of preterm birth who could be managed without admission and/or tocolytic agents” she said in an interview at the meeting, where the study was presented in poster form.

As expected, the total cohort had a significant risk of early delivery.

Nearly 45% delivered before 34 weeks, and 63% delivered before 37 weeks' gestation.

In trying to determine what distinguished the women who delivered after 37 weeks, Dr. Bastek and associates found a number of features conferring protection, including later gestational age at presentation, less cervical dilatation at presentation, smaller rates of change in cervical dilatation, and obstetric history.

Presentation at fewer than 25 weeks' gestation conferred more than a 15-fold increase in the odds of delivering before 34 weeks, compared with women who presented at 32 weeks' gestation. Presentation before 28 weeks was also a noteworthy risk, bestowing 3.5 times the risk of delivering before 34 weeks.

However, presenting at more than 30 weeks' gestation did not demonstrate elevated odds of delivering before 34 weeks or before 37 weeks, compared with presentation at 32 weeks' gestation.

Cervical dilatation—both on presentation and over the course of 6 hours following admission—was significantly predictive of preterm birth, even after controlling for multiple other variables such as maternal age, race, prenatal care, and gestational age on admission.

Each 1-cm increase in cervical dilatation on presentation more than doubled the odds of delivering before 37 weeks, a significant finding (P less than .0001). However, this risk was modified depending on obstetric history.

At a dilatation of 2 cm on admission, for example, the patients who were at highest risk of a preterm birth before 37 weeks were those with no previous births, followed by those with one or more prior preterm deliveries. Rates were lower for mothers who had a history of both preterm and full-term deliveries, and for those who previously had only had full-term deliveries.

The interaction between obstetric history and cervical dilatation was complex.

Patients with a previous preterm birth had the highest baseline risk of another preterm delivery before 37 weeks if cervical dilatation was not taken into consideration.

Within each obstetric history cohort, advancing cervical dilatation was significantly associated with preterm birth before 34 and 37 weeks. Advancing cervical dilatation had the greatest impact on patients with no prior preterm birth and the least impact on those with only a prior preterm birth.

Notably, more than 60% of women with a history of one or more full-term deliveries and no preterm deliveries carried their pregnancies beyond 34 weeks.

What happened after admission was also very relevant to the risk of preterm delivery.

Just 17.8% of the cohort (71 patients) delivered within 6 hours of admission.

Among the remaining 329 women, a 1- to 2-cm change in cervical dilatation after admission conferred almost a threefold risk of delivery before 34 weeks and a twofold risk of delivering before 37 weeks.

A 3-cm or greater change in cervical dilatation was associated with a nearly 12-fold increase in risk of a preterm birth before 34 weeks and a sevenfold increase in the odds of delivering before 37 weeks.

All eight women with more than a 4-cm change in dilatation over the first 6 hours post admission delivered at fewer than 34 weeks.

The research pointed to a number of factors that should be considered in the management of women with preterm labor, especially gestational age at presentation; cervical dilatation on presentation and cervical change over the 6 hours following admission; and obstetric history.

Further research is planned to randomize women with no previous preterm births and a low-risk cervical dilatation profile to tocolysis or expectant management.

“Our goal is to use this information to move into a trial that examines whether women with a low baseline risk can be managed without exposing them to magnesium or other tocolytics,” she said.

Dr. Bastek's coresearchers included principal investigator Dr. Michal A. Elovitz, Dr. Sindhu Srinivas, and biostatistician Mary D. Sammel.

RENO, NEV. — Cervical dilatation at presentation and over the 6 hours following admission was highly predictive of preterm birth in women admitted with preterm labor, but obstetric history also contributed important information about which mothers were likely to deliver before 34 weeks' or 37 weeks' gestation.

Dr. Jamie A. Bastek and associates in the department of obstetrics and gynecology at the University of Pennsylvania, Philadelphia, reviewed the records of 400 women with singleton pregnancies who were admitted in preterm labor before 34 weeks' gestation.

The researchers sought to determine whether the risk of preterm birth could be stratified based on a number of easily identifiable variables, including cervical dilatation and a prior history of preterm or full-term birth.

Dr. Bastek presented their results at the annual meeting of the Society for Gynecologic Investigation.

“As tocolytics are not without harm, we felt it was important to see if we could identify women with a low likelihood of preterm birth who could be managed without admission and/or tocolytic agents” she said in an interview at the meeting, where the study was presented in poster form.

As expected, the total cohort had a significant risk of early delivery.

Nearly 45% delivered before 34 weeks, and 63% delivered before 37 weeks' gestation.

In trying to determine what distinguished the women who delivered after 37 weeks, Dr. Bastek and associates found a number of features conferring protection, including later gestational age at presentation, less cervical dilatation at presentation, smaller rates of change in cervical dilatation, and obstetric history.

Presentation at fewer than 25 weeks' gestation conferred more than a 15-fold increase in the odds of delivering before 34 weeks, compared with women who presented at 32 weeks' gestation. Presentation before 28 weeks was also a noteworthy risk, bestowing 3.5 times the risk of delivering before 34 weeks.

However, presenting at more than 30 weeks' gestation did not demonstrate elevated odds of delivering before 34 weeks or before 37 weeks, compared with presentation at 32 weeks' gestation.

Cervical dilatation—both on presentation and over the course of 6 hours following admission—was significantly predictive of preterm birth, even after controlling for multiple other variables such as maternal age, race, prenatal care, and gestational age on admission.

Each 1-cm increase in cervical dilatation on presentation more than doubled the odds of delivering before 37 weeks, a significant finding (P less than .0001). However, this risk was modified depending on obstetric history.

At a dilatation of 2 cm on admission, for example, the patients who were at highest risk of a preterm birth before 37 weeks were those with no previous births, followed by those with one or more prior preterm deliveries. Rates were lower for mothers who had a history of both preterm and full-term deliveries, and for those who previously had only had full-term deliveries.

The interaction between obstetric history and cervical dilatation was complex.

Patients with a previous preterm birth had the highest baseline risk of another preterm delivery before 37 weeks if cervical dilatation was not taken into consideration.

Within each obstetric history cohort, advancing cervical dilatation was significantly associated with preterm birth before 34 and 37 weeks. Advancing cervical dilatation had the greatest impact on patients with no prior preterm birth and the least impact on those with only a prior preterm birth.

Notably, more than 60% of women with a history of one or more full-term deliveries and no preterm deliveries carried their pregnancies beyond 34 weeks.

What happened after admission was also very relevant to the risk of preterm delivery.

Just 17.8% of the cohort (71 patients) delivered within 6 hours of admission.

Among the remaining 329 women, a 1- to 2-cm change in cervical dilatation after admission conferred almost a threefold risk of delivery before 34 weeks and a twofold risk of delivering before 37 weeks.

A 3-cm or greater change in cervical dilatation was associated with a nearly 12-fold increase in risk of a preterm birth before 34 weeks and a sevenfold increase in the odds of delivering before 37 weeks.

All eight women with more than a 4-cm change in dilatation over the first 6 hours post admission delivered at fewer than 34 weeks.

The research pointed to a number of factors that should be considered in the management of women with preterm labor, especially gestational age at presentation; cervical dilatation on presentation and cervical change over the 6 hours following admission; and obstetric history.

Further research is planned to randomize women with no previous preterm births and a low-risk cervical dilatation profile to tocolysis or expectant management.

“Our goal is to use this information to move into a trial that examines whether women with a low baseline risk can be managed without exposing them to magnesium or other tocolytics,” she said.

Dr. Bastek's coresearchers included principal investigator Dr. Michal A. Elovitz, Dr. Sindhu Srinivas, and biostatistician Mary D. Sammel.

SAN FRANCISCO — Women with preterm premature rupture of membranes who request pain medication twice within a 3-hour time period for regular painful contractions should be offered epidural analgesia, inasmuch as they are highly likely to deliver with the ensuing 24 hours, a study of more than 1,600 patients has shown.

A retrospective review of 1,608 women with premature rupture of membranes (PROM) and 74 women with preterm PROM (PPROM) showed that the majority of the PPROM group delivered within 24 hours of their second request for analgesia, yet they were significantly less likely to receive an epidural, compared with women in the PROM group, reported Melanie Chichester, R.N., and colleagues in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Because digital examination is precluded in women with PPROM, onset of labor is difficult to determine and timely administration of epidural analgesia can be challenging, Ms. Chichester said.

For this reason, she and colleagues at Christiana Care Health Systems in Newark, Del., sought to assess whether contractions sufficient to cause a second maternal request for analgesia within a 3-hour time period could be substituted for contractions with cervical change as a maker of labor onset.

The investigators reviewed all admissions to their institution with confirmed PROM and PPROM from January 2004 through June 2005.

For analytical purposes, women with rupture of membranes after 24 weeks' and before 34 weeks' gestation were categorized as having PPROM and those with rupture of membranes at week 34 or later were classified as having PROM.

Among women with PPROM, the median time to delivery was 6.62 hours from the time of second request for analgesia, Ms. Chichester said.

Additionally, in the PPROM population, a total of 82% of the women delivered within 24 hours and 96% delivered within 48 hours of their second request for analgesia.

Compared with 79% of the PROM group who received an epidural following their second request for pain medication, only 42% of the PPROM group received an epidural, she said.

Although the study is limited by its retrospective design and small sample size, the findings suggest “it is incumbent upon the obstetrician to offer the same level of pain management to the laboring woman with PPROM as to any other parturient,” said Ms. Chichester.

For the relatively small percentage of women who do not deliver in the subsequent 48 hours, the epidural may be discontinued or active management of labor may be considered, depending on presence or absence of signs of infection, she said.

SAN FRANCISCO — Women with preterm premature rupture of membranes who request pain medication twice within a 3-hour time period for regular painful contractions should be offered epidural analgesia, inasmuch as they are highly likely to deliver with the ensuing 24 hours, a study of more than 1,600 patients has shown.

A retrospective review of 1,608 women with premature rupture of membranes (PROM) and 74 women with preterm PROM (PPROM) showed that the majority of the PPROM group delivered within 24 hours of their second request for analgesia, yet they were significantly less likely to receive an epidural, compared with women in the PROM group, reported Melanie Chichester, R.N., and colleagues in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Because digital examination is precluded in women with PPROM, onset of labor is difficult to determine and timely administration of epidural analgesia can be challenging, Ms. Chichester said.

For this reason, she and colleagues at Christiana Care Health Systems in Newark, Del., sought to assess whether contractions sufficient to cause a second maternal request for analgesia within a 3-hour time period could be substituted for contractions with cervical change as a maker of labor onset.

The investigators reviewed all admissions to their institution with confirmed PROM and PPROM from January 2004 through June 2005.

For analytical purposes, women with rupture of membranes after 24 weeks' and before 34 weeks' gestation were categorized as having PPROM and those with rupture of membranes at week 34 or later were classified as having PROM.

Among women with PPROM, the median time to delivery was 6.62 hours from the time of second request for analgesia, Ms. Chichester said.

Additionally, in the PPROM population, a total of 82% of the women delivered within 24 hours and 96% delivered within 48 hours of their second request for analgesia.

Compared with 79% of the PROM group who received an epidural following their second request for pain medication, only 42% of the PPROM group received an epidural, she said.

Although the study is limited by its retrospective design and small sample size, the findings suggest “it is incumbent upon the obstetrician to offer the same level of pain management to the laboring woman with PPROM as to any other parturient,” said Ms. Chichester.

For the relatively small percentage of women who do not deliver in the subsequent 48 hours, the epidural may be discontinued or active management of labor may be considered, depending on presence or absence of signs of infection, she said.

SAN FRANCISCO — Women with preterm premature rupture of membranes who request pain medication twice within a 3-hour time period for regular painful contractions should be offered epidural analgesia, inasmuch as they are highly likely to deliver with the ensuing 24 hours, a study of more than 1,600 patients has shown.

A retrospective review of 1,608 women with premature rupture of membranes (PROM) and 74 women with preterm PROM (PPROM) showed that the majority of the PPROM group delivered within 24 hours of their second request for analgesia, yet they were significantly less likely to receive an epidural, compared with women in the PROM group, reported Melanie Chichester, R.N., and colleagues in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Because digital examination is precluded in women with PPROM, onset of labor is difficult to determine and timely administration of epidural analgesia can be challenging, Ms. Chichester said.

For this reason, she and colleagues at Christiana Care Health Systems in Newark, Del., sought to assess whether contractions sufficient to cause a second maternal request for analgesia within a 3-hour time period could be substituted for contractions with cervical change as a maker of labor onset.

The investigators reviewed all admissions to their institution with confirmed PROM and PPROM from January 2004 through June 2005.

For analytical purposes, women with rupture of membranes after 24 weeks' and before 34 weeks' gestation were categorized as having PPROM and those with rupture of membranes at week 34 or later were classified as having PROM.

Among women with PPROM, the median time to delivery was 6.62 hours from the time of second request for analgesia, Ms. Chichester said.

Additionally, in the PPROM population, a total of 82% of the women delivered within 24 hours and 96% delivered within 48 hours of their second request for analgesia.

Compared with 79% of the PROM group who received an epidural following their second request for pain medication, only 42% of the PPROM group received an epidural, she said.

Although the study is limited by its retrospective design and small sample size, the findings suggest “it is incumbent upon the obstetrician to offer the same level of pain management to the laboring woman with PPROM as to any other parturient,” said Ms. Chichester.

For the relatively small percentage of women who do not deliver in the subsequent 48 hours, the epidural may be discontinued or active management of labor may be considered, depending on presence or absence of signs of infection, she said.

MIAMI BEACH — Treat the labor and delivery suite like an intensive care unit when a maternal intrapartum emergency arises, Dr. Baha Sibai said during a presentation at an ob.gyn. conference sponsored by the University of Miami.

An obstetric emergency response team is vital. This team needs mandatory training in obstetric emergencies, including advanced life support, Dr. Sibai said.

In addition, there should be “fire drills” for common emergencies such as pulmonary edema, abruptio placentae, disseminated intravascular coagulation (DIC), and complications from acute fatty liver of pregnancy.

Increases in maternal age, obesity, nulliparity, and multifetal gestations are spurring a higher incidence of these intrapartum emergencies.

“We are also seeing more women with severe, preexisting conditions, such as cystic fibrosis. I also have two women on dialysis now,” said Dr. Sibai, professor and chairman of obstetrics and gynecology at the University of Cincinnati.

Mandatory policies and procedures for physicians responding to maternal intrapartum emergencies should be required, as they are for nurses, Dr. Sibai said. “Some of you will not like this, but you cannot let every physician do what they want.”

Immediate resuscitation and support of the cardiovascular, respiratory, central nervous, and renal systems are important. Also check and continuously monitor hemostasis, electrolytes, and vital signs, he said.

Act quickly. “You cannot delay things 1 or 2 hours—it may be too late to do anything,” Dr. Sibai said.

Consider crystalloids, colloids, blood and blood products, inotropic agents, and vasopressors for maternal cardiovascular support, Dr. Sibai suggested.

Options for respiratory support include mechanical ventilation, placement of an oro- or nasopharyngeal airway, or administering oxygen by continuous positive airway pressure (CPAP). “A CPAP mask avoids intubation, but if respiratory distress is severe, intubate and ventilate,” he advised.

“You need to know how much oxygen you can deliver by different modalities,” Dr. Sibai said. “If you don't know, ask an anesthesiologist. And remember that none of this matters if you don't have adequate circulation,” Dr. Sibai said.

Some of the more common maternal intrapartum emergencies include the following:

▸ Pulmonary edema. Preeclampsia and eclampsia are the leading causes, but the condition also can be caused by tocolytics, cardiac disease, and infections such as pyelonephritis or varicella pneumonia. Pulmonary edema in preeclampsia is associated with capillary endothelial damage, Dr. Sibai said, which can cause increased permeability, increased interstitial oncotic pressure, and sepsis.

Tocolytics can cause increased capillary wedge pressure, fluid overload, and a need for blood transfusion, Dr. Sibai said, particularly in women with underlying risk factors.

There can also be high output failure caused by multifetal pregnancy, anemia, infection, thyroid disease, or tachycardia.

Treatment of pulmonary edema includes stopping tocolytics, placing the patient in a 45-degree position, giving morphine sulfate 10–15 mg IV, or giving furosemide 20–40 mg IV.

▸ Abruptio placentae. Risk factors for abruptio placentae include preterm premature rupture of the membranes, preeclampsia/hypertension, major abdominal trauma, and substance abuse.

“If the abruptio is occult—you don't see blood—these are the highest risk [cases] for the baby.” By the time you perform a cesarean section, the baby will be dead, Dr. Sibai said.

If a patient presents with abruptio placentae and DIC, give four units of packed red blood cells right away, Dr. Sibai said. “Don't use your brain or think. Just administer, and don't give just one or two units.”

Also give four units of fresh frozen plasma, administer platelets if levels are below 40,000, and monitor coagulation studies. Maintain renal perfusion and deliver the baby.

▸ Disseminated intravascular coagulation. There are three types of disseminated intravascular coagulation. DIC of consumption is very easy to correct, Dr. Sibai said. Once you remove the placenta, the patient will be back to normal within 24 hours. DIC as the result of production (for example, from a fatty liver) can be very difficult and take a week or more to correct. Dilutional DIC occurs when a patient is losing coagulation factor through blood loss while an anesthesiologist is giving fluid. “This is when you have to start calling for fresh frozen plasma,” Dr. Sibai said.

Other treatment options include packed red blood cells, platelets, cryoprecipitate, and recombinant factor VII. “You need these things handy, along with people who know how to use them,” Dr. Sibai said. “A lot of anesthesiologists are familiar with these things, so make use of them.”

▸ Acute fatty liver of pregnancy. “Women with fatty liver are among the sickest women you will see,” Dr. Sibai said, and a differential diagnosis from HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome is important because of overlapping symptoms and laboratory findings.

The urine of women with acute fatty liver is tea colored—very different from the urine of women with HELLP, Dr. Sibai said. A low fibrinogen level (below 300 mg/dL) is almost always only acute fatty liver, he added.

The altered texture of a fatty liver on CT image can also help distinguish these patients from those with HELLP syndrome, Dr. Sibai said.

Acute renal failure is common in women with acute fatty liver but not very common in HELLP. These women can also develop pulmonary edema, metabolic acidosis, and pancreatitis, Dr. Sibai said. “Acute fatty liver is a metabolic disorder; preeclampsia and HELLP are ischemic disorders. The problem with the baby is acidosis, not hypoxia, with acute fatty liver.”

HELLP syndrome (above) has ovelapping symptoms and laboratory findings similar to acute fatty liver.

The altered texture of a fatty liver on CT image can help distinguish these patients from those with HELLP. Photos courtesy Dr. Baha Sibai

MIAMI BEACH — Treat the labor and delivery suite like an intensive care unit when a maternal intrapartum emergency arises, Dr. Baha Sibai said during a presentation at an ob.gyn. conference sponsored by the University of Miami.

An obstetric emergency response team is vital. This team needs mandatory training in obstetric emergencies, including advanced life support, Dr. Sibai said.

In addition, there should be “fire drills” for common emergencies such as pulmonary edema, abruptio placentae, disseminated intravascular coagulation (DIC), and complications from acute fatty liver of pregnancy.

Increases in maternal age, obesity, nulliparity, and multifetal gestations are spurring a higher incidence of these intrapartum emergencies.

“We are also seeing more women with severe, preexisting conditions, such as cystic fibrosis. I also have two women on dialysis now,” said Dr. Sibai, professor and chairman of obstetrics and gynecology at the University of Cincinnati.

Mandatory policies and procedures for physicians responding to maternal intrapartum emergencies should be required, as they are for nurses, Dr. Sibai said. “Some of you will not like this, but you cannot let every physician do what they want.”

Immediate resuscitation and support of the cardiovascular, respiratory, central nervous, and renal systems are important. Also check and continuously monitor hemostasis, electrolytes, and vital signs, he said.

Act quickly. “You cannot delay things 1 or 2 hours—it may be too late to do anything,” Dr. Sibai said.

Consider crystalloids, colloids, blood and blood products, inotropic agents, and vasopressors for maternal cardiovascular support, Dr. Sibai suggested.

Options for respiratory support include mechanical ventilation, placement of an oro- or nasopharyngeal airway, or administering oxygen by continuous positive airway pressure (CPAP). “A CPAP mask avoids intubation, but if respiratory distress is severe, intubate and ventilate,” he advised.

“You need to know how much oxygen you can deliver by different modalities,” Dr. Sibai said. “If you don't know, ask an anesthesiologist. And remember that none of this matters if you don't have adequate circulation,” Dr. Sibai said.

Some of the more common maternal intrapartum emergencies include the following:

▸ Pulmonary edema. Preeclampsia and eclampsia are the leading causes, but the condition also can be caused by tocolytics, cardiac disease, and infections such as pyelonephritis or varicella pneumonia. Pulmonary edema in preeclampsia is associated with capillary endothelial damage, Dr. Sibai said, which can cause increased permeability, increased interstitial oncotic pressure, and sepsis.

Tocolytics can cause increased capillary wedge pressure, fluid overload, and a need for blood transfusion, Dr. Sibai said, particularly in women with underlying risk factors.

There can also be high output failure caused by multifetal pregnancy, anemia, infection, thyroid disease, or tachycardia.

Treatment of pulmonary edema includes stopping tocolytics, placing the patient in a 45-degree position, giving morphine sulfate 10–15 mg IV, or giving furosemide 20–40 mg IV.

▸ Abruptio placentae. Risk factors for abruptio placentae include preterm premature rupture of the membranes, preeclampsia/hypertension, major abdominal trauma, and substance abuse.

“If the abruptio is occult—you don't see blood—these are the highest risk [cases] for the baby.” By the time you perform a cesarean section, the baby will be dead, Dr. Sibai said.

If a patient presents with abruptio placentae and DIC, give four units of packed red blood cells right away, Dr. Sibai said. “Don't use your brain or think. Just administer, and don't give just one or two units.”

Also give four units of fresh frozen plasma, administer platelets if levels are below 40,000, and monitor coagulation studies. Maintain renal perfusion and deliver the baby.

▸ Disseminated intravascular coagulation. There are three types of disseminated intravascular coagulation. DIC of consumption is very easy to correct, Dr. Sibai said. Once you remove the placenta, the patient will be back to normal within 24 hours. DIC as the result of production (for example, from a fatty liver) can be very difficult and take a week or more to correct. Dilutional DIC occurs when a patient is losing coagulation factor through blood loss while an anesthesiologist is giving fluid. “This is when you have to start calling for fresh frozen plasma,” Dr. Sibai said.

Other treatment options include packed red blood cells, platelets, cryoprecipitate, and recombinant factor VII. “You need these things handy, along with people who know how to use them,” Dr. Sibai said. “A lot of anesthesiologists are familiar with these things, so make use of them.”

▸ Acute fatty liver of pregnancy. “Women with fatty liver are among the sickest women you will see,” Dr. Sibai said, and a differential diagnosis from HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome is important because of overlapping symptoms and laboratory findings.

The urine of women with acute fatty liver is tea colored—very different from the urine of women with HELLP, Dr. Sibai said. A low fibrinogen level (below 300 mg/dL) is almost always only acute fatty liver, he added.

The altered texture of a fatty liver on CT image can also help distinguish these patients from those with HELLP syndrome, Dr. Sibai said.

Acute renal failure is common in women with acute fatty liver but not very common in HELLP. These women can also develop pulmonary edema, metabolic acidosis, and pancreatitis, Dr. Sibai said. “Acute fatty liver is a metabolic disorder; preeclampsia and HELLP are ischemic disorders. The problem with the baby is acidosis, not hypoxia, with acute fatty liver.”

HELLP syndrome (above) has ovelapping symptoms and laboratory findings similar to acute fatty liver.

The altered texture of a fatty liver on CT image can help distinguish these patients from those with HELLP. Photos courtesy Dr. Baha Sibai

MIAMI BEACH — Treat the labor and delivery suite like an intensive care unit when a maternal intrapartum emergency arises, Dr. Baha Sibai said during a presentation at an ob.gyn. conference sponsored by the University of Miami.

An obstetric emergency response team is vital. This team needs mandatory training in obstetric emergencies, including advanced life support, Dr. Sibai said.

In addition, there should be “fire drills” for common emergencies such as pulmonary edema, abruptio placentae, disseminated intravascular coagulation (DIC), and complications from acute fatty liver of pregnancy.

Increases in maternal age, obesity, nulliparity, and multifetal gestations are spurring a higher incidence of these intrapartum emergencies.

“We are also seeing more women with severe, preexisting conditions, such as cystic fibrosis. I also have two women on dialysis now,” said Dr. Sibai, professor and chairman of obstetrics and gynecology at the University of Cincinnati.

Mandatory policies and procedures for physicians responding to maternal intrapartum emergencies should be required, as they are for nurses, Dr. Sibai said. “Some of you will not like this, but you cannot let every physician do what they want.”

Immediate resuscitation and support of the cardiovascular, respiratory, central nervous, and renal systems are important. Also check and continuously monitor hemostasis, electrolytes, and vital signs, he said.

Act quickly. “You cannot delay things 1 or 2 hours—it may be too late to do anything,” Dr. Sibai said.

Consider crystalloids, colloids, blood and blood products, inotropic agents, and vasopressors for maternal cardiovascular support, Dr. Sibai suggested.

Options for respiratory support include mechanical ventilation, placement of an oro- or nasopharyngeal airway, or administering oxygen by continuous positive airway pressure (CPAP). “A CPAP mask avoids intubation, but if respiratory distress is severe, intubate and ventilate,” he advised.

“You need to know how much oxygen you can deliver by different modalities,” Dr. Sibai said. “If you don't know, ask an anesthesiologist. And remember that none of this matters if you don't have adequate circulation,” Dr. Sibai said.

Some of the more common maternal intrapartum emergencies include the following:

▸ Pulmonary edema. Preeclampsia and eclampsia are the leading causes, but the condition also can be caused by tocolytics, cardiac disease, and infections such as pyelonephritis or varicella pneumonia. Pulmonary edema in preeclampsia is associated with capillary endothelial damage, Dr. Sibai said, which can cause increased permeability, increased interstitial oncotic pressure, and sepsis.

Tocolytics can cause increased capillary wedge pressure, fluid overload, and a need for blood transfusion, Dr. Sibai said, particularly in women with underlying risk factors.

There can also be high output failure caused by multifetal pregnancy, anemia, infection, thyroid disease, or tachycardia.

Treatment of pulmonary edema includes stopping tocolytics, placing the patient in a 45-degree position, giving morphine sulfate 10–15 mg IV, or giving furosemide 20–40 mg IV.

▸ Abruptio placentae. Risk factors for abruptio placentae include preterm premature rupture of the membranes, preeclampsia/hypertension, major abdominal trauma, and substance abuse.

“If the abruptio is occult—you don't see blood—these are the highest risk [cases] for the baby.” By the time you perform a cesarean section, the baby will be dead, Dr. Sibai said.

If a patient presents with abruptio placentae and DIC, give four units of packed red blood cells right away, Dr. Sibai said. “Don't use your brain or think. Just administer, and don't give just one or two units.”

Also give four units of fresh frozen plasma, administer platelets if levels are below 40,000, and monitor coagulation studies. Maintain renal perfusion and deliver the baby.

▸ Disseminated intravascular coagulation. There are three types of disseminated intravascular coagulation. DIC of consumption is very easy to correct, Dr. Sibai said. Once you remove the placenta, the patient will be back to normal within 24 hours. DIC as the result of production (for example, from a fatty liver) can be very difficult and take a week or more to correct. Dilutional DIC occurs when a patient is losing coagulation factor through blood loss while an anesthesiologist is giving fluid. “This is when you have to start calling for fresh frozen plasma,” Dr. Sibai said.

Other treatment options include packed red blood cells, platelets, cryoprecipitate, and recombinant factor VII. “You need these things handy, along with people who know how to use them,” Dr. Sibai said. “A lot of anesthesiologists are familiar with these things, so make use of them.”

▸ Acute fatty liver of pregnancy. “Women with fatty liver are among the sickest women you will see,” Dr. Sibai said, and a differential diagnosis from HELLP [hemolysis, elevated liver enzymes, and low platelet count] syndrome is important because of overlapping symptoms and laboratory findings.

The urine of women with acute fatty liver is tea colored—very different from the urine of women with HELLP, Dr. Sibai said. A low fibrinogen level (below 300 mg/dL) is almost always only acute fatty liver, he added.

The altered texture of a fatty liver on CT image can also help distinguish these patients from those with HELLP syndrome, Dr. Sibai said.

Acute renal failure is common in women with acute fatty liver but not very common in HELLP. These women can also develop pulmonary edema, metabolic acidosis, and pancreatitis, Dr. Sibai said. “Acute fatty liver is a metabolic disorder; preeclampsia and HELLP are ischemic disorders. The problem with the baby is acidosis, not hypoxia, with acute fatty liver.”

HELLP syndrome (above) has ovelapping symptoms and laboratory findings similar to acute fatty liver.

The altered texture of a fatty liver on CT image can help distinguish these patients from those with HELLP. Photos courtesy Dr. Baha Sibai

SAN FRANCISCO — The use of high-dose progesterone in women at risk for preterm delivery following premature labor slows the progression of cervical changes linked to early delivery, Dr. Fabio Facchinetti said at the annual meeting of the Society for Maternal-Fetal Medicine.

In a randomized controlled trial, the use of 17 α-hydroxyprogesterone caproate (17-OHPC) was associated with reduced cervical shortening and local inflammation, which led to a significantly reduced incidence of preterm deliveries, said Dr. Facchinetti of Universita di Modena e Reggio Emilia in Modena, Italy.

To investigate the mechanism of action of 17-OHPC in the prevention of preterm delivery, Dr. Facchinetti and colleagues randomized 45 hospitalized women who remained undelivered after an episode of preterm labor between 25 and 33 weeks to observation only or to treatment with twice weekly intramuscular injections of 341 mg of 17-OHPC until 36 weeks.

The study dose of 17-OHPC is substantially higher than that which is typically used to prevent preterm births in women with a history of premature delivery, which generally consists of a single weekly injection

“Our reasoning for the high dose was twofold,” said Dr. Facchinetti. “The cervical inflammatory processes in these women were already activated, so we needed to challenge them. Also, treatment was started later in pregnancy [compared with prophylactic treatment to prevent repeat preterm birth], thus there was less time for efficacy.”

All of the women in the study had singleton pregnancies, intact membranes, and cervical dilatation less than 2 cm. Patients with chronic disease, gestational disease, large or multiple uterine myomas, or suspected intra-amniotic infection were excluded.

There were differences between the 23 women in the treatment group and the 22 controls in terms of maternal age or gestational age at time of preterm labor (mean 29 weeks), and the majority of patients had sonographic evidence of a short cervix at baseline, Dr. Facchinetti reported. Per hospital protocol, all of the women received two doses of intramuscular betamethasone 24 hours apart to promote fetal lung development, he said.

After randomization, which took place 4–6 days following hospital admission for preterm labor, each subject underwent a cervical swab and ultrasound measurement of cervical length at baseline, 1 week, and 3 weeks. With respect to the cervical swab, “we collected [cervical] fluid beyond the external os to avoid shear stress and blood, and the samples were weighted and stored for immunoassays to measure inflammatory markers,” said Dr. Facchinetti.

In terms of clinical outcome, 22% of the women in the treatment group had preterm delivery (prior to week 37) compared with 54% in the observation group, representing a statistically significant reduction, according to Dr. Facchinetti. Among women in the treatment group, the mean length of pregnancy was 9 days longer than in the control group. There were no between-group differences in the number of women who delivered prior to week 35 or in infant birth weight or rate of low-birth-weight infants, he said.

An analysis of the primary study outcome—change in cervical length—demonstrated significant differences between the treatment and observation groups. “After 3 weeks, women treated with 17-OHPC had a median 2-mm reduction in cervical length compared with 4 mm in untreated women,” said Dr. Facchinetti.

The investigators also observed “important” within-group and between-group changes in the level of cervical secretion of interleukin 1 (IL-1), Dr. Facchinetti noted. “In the untreated group, there was a trend toward increased IL-1 secretion over 3 weeks, while the treatment group showed a significant decrease.” No statistically significant changes were observed in the other proinflammatory markers that were measured, including IL-6, IL-8, tumor necrosis factor-α, or nitrates/nitrites—a finding that suggests 17-OHPC selectively inhibits IL-1, he said.

Based on the results, “our speculation is that preterm cervical ripening is the real driver of preterm delivery and can be blocked by [17-OHPC],” said Dr. Facchinetti.

SAN FRANCISCO — The use of high-dose progesterone in women at risk for preterm delivery following premature labor slows the progression of cervical changes linked to early delivery, Dr. Fabio Facchinetti said at the annual meeting of the Society for Maternal-Fetal Medicine.

In a randomized controlled trial, the use of 17 α-hydroxyprogesterone caproate (17-OHPC) was associated with reduced cervical shortening and local inflammation, which led to a significantly reduced incidence of preterm deliveries, said Dr. Facchinetti of Universita di Modena e Reggio Emilia in Modena, Italy.

To investigate the mechanism of action of 17-OHPC in the prevention of preterm delivery, Dr. Facchinetti and colleagues randomized 45 hospitalized women who remained undelivered after an episode of preterm labor between 25 and 33 weeks to observation only or to treatment with twice weekly intramuscular injections of 341 mg of 17-OHPC until 36 weeks.

The study dose of 17-OHPC is substantially higher than that which is typically used to prevent preterm births in women with a history of premature delivery, which generally consists of a single weekly injection

“Our reasoning for the high dose was twofold,” said Dr. Facchinetti. “The cervical inflammatory processes in these women were already activated, so we needed to challenge them. Also, treatment was started later in pregnancy [compared with prophylactic treatment to prevent repeat preterm birth], thus there was less time for efficacy.”

All of the women in the study had singleton pregnancies, intact membranes, and cervical dilatation less than 2 cm. Patients with chronic disease, gestational disease, large or multiple uterine myomas, or suspected intra-amniotic infection were excluded.

There were differences between the 23 women in the treatment group and the 22 controls in terms of maternal age or gestational age at time of preterm labor (mean 29 weeks), and the majority of patients had sonographic evidence of a short cervix at baseline, Dr. Facchinetti reported. Per hospital protocol, all of the women received two doses of intramuscular betamethasone 24 hours apart to promote fetal lung development, he said.

After randomization, which took place 4–6 days following hospital admission for preterm labor, each subject underwent a cervical swab and ultrasound measurement of cervical length at baseline, 1 week, and 3 weeks. With respect to the cervical swab, “we collected [cervical] fluid beyond the external os to avoid shear stress and blood, and the samples were weighted and stored for immunoassays to measure inflammatory markers,” said Dr. Facchinetti.

In terms of clinical outcome, 22% of the women in the treatment group had preterm delivery (prior to week 37) compared with 54% in the observation group, representing a statistically significant reduction, according to Dr. Facchinetti. Among women in the treatment group, the mean length of pregnancy was 9 days longer than in the control group. There were no between-group differences in the number of women who delivered prior to week 35 or in infant birth weight or rate of low-birth-weight infants, he said.

An analysis of the primary study outcome—change in cervical length—demonstrated significant differences between the treatment and observation groups. “After 3 weeks, women treated with 17-OHPC had a median 2-mm reduction in cervical length compared with 4 mm in untreated women,” said Dr. Facchinetti.

The investigators also observed “important” within-group and between-group changes in the level of cervical secretion of interleukin 1 (IL-1), Dr. Facchinetti noted. “In the untreated group, there was a trend toward increased IL-1 secretion over 3 weeks, while the treatment group showed a significant decrease.” No statistically significant changes were observed in the other proinflammatory markers that were measured, including IL-6, IL-8, tumor necrosis factor-α, or nitrates/nitrites—a finding that suggests 17-OHPC selectively inhibits IL-1, he said.

Based on the results, “our speculation is that preterm cervical ripening is the real driver of preterm delivery and can be blocked by [17-OHPC],” said Dr. Facchinetti.

SAN FRANCISCO — The use of high-dose progesterone in women at risk for preterm delivery following premature labor slows the progression of cervical changes linked to early delivery, Dr. Fabio Facchinetti said at the annual meeting of the Society for Maternal-Fetal Medicine.

In a randomized controlled trial, the use of 17 α-hydroxyprogesterone caproate (17-OHPC) was associated with reduced cervical shortening and local inflammation, which led to a significantly reduced incidence of preterm deliveries, said Dr. Facchinetti of Universita di Modena e Reggio Emilia in Modena, Italy.

To investigate the mechanism of action of 17-OHPC in the prevention of preterm delivery, Dr. Facchinetti and colleagues randomized 45 hospitalized women who remained undelivered after an episode of preterm labor between 25 and 33 weeks to observation only or to treatment with twice weekly intramuscular injections of 341 mg of 17-OHPC until 36 weeks.

The study dose of 17-OHPC is substantially higher than that which is typically used to prevent preterm births in women with a history of premature delivery, which generally consists of a single weekly injection

“Our reasoning for the high dose was twofold,” said Dr. Facchinetti. “The cervical inflammatory processes in these women were already activated, so we needed to challenge them. Also, treatment was started later in pregnancy [compared with prophylactic treatment to prevent repeat preterm birth], thus there was less time for efficacy.”

All of the women in the study had singleton pregnancies, intact membranes, and cervical dilatation less than 2 cm. Patients with chronic disease, gestational disease, large or multiple uterine myomas, or suspected intra-amniotic infection were excluded.

There were differences between the 23 women in the treatment group and the 22 controls in terms of maternal age or gestational age at time of preterm labor (mean 29 weeks), and the majority of patients had sonographic evidence of a short cervix at baseline, Dr. Facchinetti reported. Per hospital protocol, all of the women received two doses of intramuscular betamethasone 24 hours apart to promote fetal lung development, he said.

After randomization, which took place 4–6 days following hospital admission for preterm labor, each subject underwent a cervical swab and ultrasound measurement of cervical length at baseline, 1 week, and 3 weeks. With respect to the cervical swab, “we collected [cervical] fluid beyond the external os to avoid shear stress and blood, and the samples were weighted and stored for immunoassays to measure inflammatory markers,” said Dr. Facchinetti.

In terms of clinical outcome, 22% of the women in the treatment group had preterm delivery (prior to week 37) compared with 54% in the observation group, representing a statistically significant reduction, according to Dr. Facchinetti. Among women in the treatment group, the mean length of pregnancy was 9 days longer than in the control group. There were no between-group differences in the number of women who delivered prior to week 35 or in infant birth weight or rate of low-birth-weight infants, he said.

An analysis of the primary study outcome—change in cervical length—demonstrated significant differences between the treatment and observation groups. “After 3 weeks, women treated with 17-OHPC had a median 2-mm reduction in cervical length compared with 4 mm in untreated women,” said Dr. Facchinetti.

The investigators also observed “important” within-group and between-group changes in the level of cervical secretion of interleukin 1 (IL-1), Dr. Facchinetti noted. “In the untreated group, there was a trend toward increased IL-1 secretion over 3 weeks, while the treatment group showed a significant decrease.” No statistically significant changes were observed in the other proinflammatory markers that were measured, including IL-6, IL-8, tumor necrosis factor-α, or nitrates/nitrites—a finding that suggests 17-OHPC selectively inhibits IL-1, he said.

Based on the results, “our speculation is that preterm cervical ripening is the real driver of preterm delivery and can be blocked by [17-OHPC],” said Dr. Facchinetti.

SAN FRANCISCO — Repeating one of the assays used in serum-integrated screening for Down syndrome could halve the false-positive rate, Dr. Fergal D. Malone said at the annual meeting of the Society for Maternal-Fetal Medicine.

Adding another repeat assay could reduce the false-positive rate by a further 25%, said Dr. Malone, professor and chairman of ob.gyn. at the Royal College of Surgeons, Dublin.

Conventional serum-integrated screening entails collecting first- and second-trimester blood samples. The first-trimester sample is assayed for pregnancy-associated plasma protein A (PAPP-A) and assays are performed on the second-trimester sample for several other markers of Down syndrome risk: alpha-fetoprotein, total HCG, unconjugated estriol, and inhibin A. The marker results are combined in a single assessment of risk for trisomy 21.

Serum-integrated screening detects 90% of Down syndrome cases with a 4.9% false-positive rate. If the PAPP-A assay is simply repeated on the second-trimester serum sample, the false-positive rate would drop to 1.9%, according to a modeling study that Dr. Malone and associates conducted using data from the First and Second Trimester Evaluation of Risk trial.

Doing an HCG assay on the first-trimester sample in addition to repeating the PAPP-A assay on the second-trimester sample should further reduce the false-positive rate to 1.4%, he added.

Repeating the PAPP-A assay would improve the Down syndrome detection rate to about 92%. Doing the PAPP-A and the HCG assays on first- and second-trimester samples would increase detection to nearly 100%, he calculated.

A similar benefit is seen when repeating PAPP-A measures in fully integrated screening for Down syndrome, which combines first-trimester imaging of nuchal translucency with serum-integrated screening. Fully integrated screening detects 90% of Down syndrome cases with a 1.3% false-positive rate. Repeating the PAPP-A assay on the second-trimester serum sample would decrease the false-positive rate to 0.5%, Dr. Malone said.

Reducing false positives could reduce the use of invasive tests for Down syndrome and terminations of some pregnancies, and improve the cost-effectiveness of screening.

These preliminary modeling results must be supported by prospective studies before repeat-measures screening is adopted in clinical practice, he cautioned.

The concept of repeat-measures screening expands screening strategies beyond conventional notions of evaluating each marker individually and measuring it at the one time point where it provides the best information. Measuring PAPP-A alone at 10 weeks' gestation, for example, detects 85% of Down syndrome cases with a 17% false-positive rate. Measuring PAPP-A alone only in the second trimester produces a massive 60% false-positive rate.

“Conventional wisdom says that PAPP-A in the first but not the second trimester is the way to proceed,” Dr. Malone noted. “However, things are not that simple.”

Measuring PAPP-A at 10 weeks and again between 14 and 22 weeks has not been recommended because the marker is highly correlated across gestation ages and is a poor marker for detection in the second trimester alone.

“It may surprise you, therefore, to see that PAPP-A in the first and second trimester has been estimated to provide a huge improvement in performance, for an 85% detection rate and only a 2% screen positive rate,” he said.

A low PAPP-A at 10 weeks accurately identifies trisomy 21 but falsely identifies quite a few unaffected infants. PAPP-A levels tend to be higher in Down syndrome cases in the second trimester.

“Having the added knowledge of what the second-trimester PAPP-A value is allows us to almost completely discriminate Down syndrome from normal pregnancies,” Dr. Malone said.

SAN FRANCISCO — Repeating one of the assays used in serum-integrated screening for Down syndrome could halve the false-positive rate, Dr. Fergal D. Malone said at the annual meeting of the Society for Maternal-Fetal Medicine.

Adding another repeat assay could reduce the false-positive rate by a further 25%, said Dr. Malone, professor and chairman of ob.gyn. at the Royal College of Surgeons, Dublin.

Conventional serum-integrated screening entails collecting first- and second-trimester blood samples. The first-trimester sample is assayed for pregnancy-associated plasma protein A (PAPP-A) and assays are performed on the second-trimester sample for several other markers of Down syndrome risk: alpha-fetoprotein, total HCG, unconjugated estriol, and inhibin A. The marker results are combined in a single assessment of risk for trisomy 21.

Serum-integrated screening detects 90% of Down syndrome cases with a 4.9% false-positive rate. If the PAPP-A assay is simply repeated on the second-trimester serum sample, the false-positive rate would drop to 1.9%, according to a modeling study that Dr. Malone and associates conducted using data from the First and Second Trimester Evaluation of Risk trial.

Doing an HCG assay on the first-trimester sample in addition to repeating the PAPP-A assay on the second-trimester sample should further reduce the false-positive rate to 1.4%, he added.

Repeating the PAPP-A assay would improve the Down syndrome detection rate to about 92%. Doing the PAPP-A and the HCG assays on first- and second-trimester samples would increase detection to nearly 100%, he calculated.

A similar benefit is seen when repeating PAPP-A measures in fully integrated screening for Down syndrome, which combines first-trimester imaging of nuchal translucency with serum-integrated screening. Fully integrated screening detects 90% of Down syndrome cases with a 1.3% false-positive rate. Repeating the PAPP-A assay on the second-trimester serum sample would decrease the false-positive rate to 0.5%, Dr. Malone said.

Reducing false positives could reduce the use of invasive tests for Down syndrome and terminations of some pregnancies, and improve the cost-effectiveness of screening.

These preliminary modeling results must be supported by prospective studies before repeat-measures screening is adopted in clinical practice, he cautioned.

The concept of repeat-measures screening expands screening strategies beyond conventional notions of evaluating each marker individually and measuring it at the one time point where it provides the best information. Measuring PAPP-A alone at 10 weeks' gestation, for example, detects 85% of Down syndrome cases with a 17% false-positive rate. Measuring PAPP-A alone only in the second trimester produces a massive 60% false-positive rate.

“Conventional wisdom says that PAPP-A in the first but not the second trimester is the way to proceed,” Dr. Malone noted. “However, things are not that simple.”

Measuring PAPP-A at 10 weeks and again between 14 and 22 weeks has not been recommended because the marker is highly correlated across gestation ages and is a poor marker for detection in the second trimester alone.

“It may surprise you, therefore, to see that PAPP-A in the first and second trimester has been estimated to provide a huge improvement in performance, for an 85% detection rate and only a 2% screen positive rate,” he said.

A low PAPP-A at 10 weeks accurately identifies trisomy 21 but falsely identifies quite a few unaffected infants. PAPP-A levels tend to be higher in Down syndrome cases in the second trimester.

“Having the added knowledge of what the second-trimester PAPP-A value is allows us to almost completely discriminate Down syndrome from normal pregnancies,” Dr. Malone said.

SAN FRANCISCO — Repeating one of the assays used in serum-integrated screening for Down syndrome could halve the false-positive rate, Dr. Fergal D. Malone said at the annual meeting of the Society for Maternal-Fetal Medicine.

Adding another repeat assay could reduce the false-positive rate by a further 25%, said Dr. Malone, professor and chairman of ob.gyn. at the Royal College of Surgeons, Dublin.

Conventional serum-integrated screening entails collecting first- and second-trimester blood samples. The first-trimester sample is assayed for pregnancy-associated plasma protein A (PAPP-A) and assays are performed on the second-trimester sample for several other markers of Down syndrome risk: alpha-fetoprotein, total HCG, unconjugated estriol, and inhibin A. The marker results are combined in a single assessment of risk for trisomy 21.

Serum-integrated screening detects 90% of Down syndrome cases with a 4.9% false-positive rate. If the PAPP-A assay is simply repeated on the second-trimester serum sample, the false-positive rate would drop to 1.9%, according to a modeling study that Dr. Malone and associates conducted using data from the First and Second Trimester Evaluation of Risk trial.

Doing an HCG assay on the first-trimester sample in addition to repeating the PAPP-A assay on the second-trimester sample should further reduce the false-positive rate to 1.4%, he added.

Repeating the PAPP-A assay would improve the Down syndrome detection rate to about 92%. Doing the PAPP-A and the HCG assays on first- and second-trimester samples would increase detection to nearly 100%, he calculated.

A similar benefit is seen when repeating PAPP-A measures in fully integrated screening for Down syndrome, which combines first-trimester imaging of nuchal translucency with serum-integrated screening. Fully integrated screening detects 90% of Down syndrome cases with a 1.3% false-positive rate. Repeating the PAPP-A assay on the second-trimester serum sample would decrease the false-positive rate to 0.5%, Dr. Malone said.

Reducing false positives could reduce the use of invasive tests for Down syndrome and terminations of some pregnancies, and improve the cost-effectiveness of screening.

These preliminary modeling results must be supported by prospective studies before repeat-measures screening is adopted in clinical practice, he cautioned.

The concept of repeat-measures screening expands screening strategies beyond conventional notions of evaluating each marker individually and measuring it at the one time point where it provides the best information. Measuring PAPP-A alone at 10 weeks' gestation, for example, detects 85% of Down syndrome cases with a 17% false-positive rate. Measuring PAPP-A alone only in the second trimester produces a massive 60% false-positive rate.

“Conventional wisdom says that PAPP-A in the first but not the second trimester is the way to proceed,” Dr. Malone noted. “However, things are not that simple.”

Measuring PAPP-A at 10 weeks and again between 14 and 22 weeks has not been recommended because the marker is highly correlated across gestation ages and is a poor marker for detection in the second trimester alone.

“It may surprise you, therefore, to see that PAPP-A in the first and second trimester has been estimated to provide a huge improvement in performance, for an 85% detection rate and only a 2% screen positive rate,” he said.

A low PAPP-A at 10 weeks accurately identifies trisomy 21 but falsely identifies quite a few unaffected infants. PAPP-A levels tend to be higher in Down syndrome cases in the second trimester.

“Having the added knowledge of what the second-trimester PAPP-A value is allows us to almost completely discriminate Down syndrome from normal pregnancies,” Dr. Malone said.

RIVIERA MAYA, MEXICO — Aspirate or biopsy any breast mass discovered in a pregnant or lactating woman, because breast cancer in these patients is associated with higher mortality—probably because of delay in diagnosis, Dr. Carol Scott-Conner said at a meeting on medical negligence and risk management.

Studies show that women who are pregnant within 2 years of a breast cancer diagnosis are at a much higher risk of poor outcomes, with 50% having locally advanced or regional disease at diagnosis, compared with 39% of nonpregnant patients, said Dr. Scott-Conner, professor of surgery at the University of Iowa, Iowa City.

Reasons for diagnostic delay may include the fact that masses are more difficult to detect in engorged breasts; patient denial and physician procrastination also probably play a role. “These masses also may be confused with mastitis or other benign entities, like fibroadenoma, lactating adenoma, galactocele, or breast abscess,” she said.

Although it has not been proven, there are concerns that pregnancy-associated breast cancer may be a more aggressive form of the disease. “Many patients I see have experienced no delay in diagnosis but still have a fairly advanced tumor. We just don't know,” she said.

Most patients come in with a self-identified palpable mass. Fine-needle aspiration cytology will give valuable information for these lesions. “I'm a great believer in liberal use of FNAC,” said Dr. Scott-Conner, previous chair of surgery at the university.

“It's a benign test that's easy to do and is very helpful.” Make sure to inform the lab that the patient is pregnant or lactating, though, because normal proliferative changes can mimic neoplastic changes, she noted at the meeting, which was sponsored by Boston University.

RIVIERA MAYA, MEXICO — Aspirate or biopsy any breast mass discovered in a pregnant or lactating woman, because breast cancer in these patients is associated with higher mortality—probably because of delay in diagnosis, Dr. Carol Scott-Conner said at a meeting on medical negligence and risk management.

Studies show that women who are pregnant within 2 years of a breast cancer diagnosis are at a much higher risk of poor outcomes, with 50% having locally advanced or regional disease at diagnosis, compared with 39% of nonpregnant patients, said Dr. Scott-Conner, professor of surgery at the University of Iowa, Iowa City.

Reasons for diagnostic delay may include the fact that masses are more difficult to detect in engorged breasts; patient denial and physician procrastination also probably play a role. “These masses also may be confused with mastitis or other benign entities, like fibroadenoma, lactating adenoma, galactocele, or breast abscess,” she said.

Although it has not been proven, there are concerns that pregnancy-associated breast cancer may be a more aggressive form of the disease. “Many patients I see have experienced no delay in diagnosis but still have a fairly advanced tumor. We just don't know,” she said.

Most patients come in with a self-identified palpable mass. Fine-needle aspiration cytology will give valuable information for these lesions. “I'm a great believer in liberal use of FNAC,” said Dr. Scott-Conner, previous chair of surgery at the university.

“It's a benign test that's easy to do and is very helpful.” Make sure to inform the lab that the patient is pregnant or lactating, though, because normal proliferative changes can mimic neoplastic changes, she noted at the meeting, which was sponsored by Boston University.

RIVIERA MAYA, MEXICO — Aspirate or biopsy any breast mass discovered in a pregnant or lactating woman, because breast cancer in these patients is associated with higher mortality—probably because of delay in diagnosis, Dr. Carol Scott-Conner said at a meeting on medical negligence and risk management.

Studies show that women who are pregnant within 2 years of a breast cancer diagnosis are at a much higher risk of poor outcomes, with 50% having locally advanced or regional disease at diagnosis, compared with 39% of nonpregnant patients, said Dr. Scott-Conner, professor of surgery at the University of Iowa, Iowa City.

Reasons for diagnostic delay may include the fact that masses are more difficult to detect in engorged breasts; patient denial and physician procrastination also probably play a role. “These masses also may be confused with mastitis or other benign entities, like fibroadenoma, lactating adenoma, galactocele, or breast abscess,” she said.

Although it has not been proven, there are concerns that pregnancy-associated breast cancer may be a more aggressive form of the disease. “Many patients I see have experienced no delay in diagnosis but still have a fairly advanced tumor. We just don't know,” she said.

Most patients come in with a self-identified palpable mass. Fine-needle aspiration cytology will give valuable information for these lesions. “I'm a great believer in liberal use of FNAC,” said Dr. Scott-Conner, previous chair of surgery at the university.

“It's a benign test that's easy to do and is very helpful.” Make sure to inform the lab that the patient is pregnant or lactating, though, because normal proliferative changes can mimic neoplastic changes, she noted at the meeting, which was sponsored by Boston University.

SAN FRANCISCO — After the onset of labor, using a classical incision for C-section delivery of a very-low-birth-weight neonate in nonvertex position reduced the risk of intraventricular hemorrhage, compared with a transverse incision or transverse incision with extension, a study of 148 deliveries found.

The decrease in risk was more pronounced for more severe intraventricular hemorrhage (IVH), Dr. Kai Ling Tan and associates reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Previous studies have shown that vaginal delivery is safe for infants in vertex position weighing less than 1,000 g, but data are sparse on rates of IVH after delivery of very-low-birth-weight (VLBW) infants in breech, transverse, or oblique positions.

“It is a constant debate among ob.gyns. in the [morbidity and mortality] conferences in my institution whether to do a classical or a low transverse incision” in these cases, said Dr. Tan of the Medical College of Wisconsin Affiliated Hospitals, Wauwatosa, Wis., in an interview at the poster session.

The current retrospective review found no significant difference in IVH rates between the 93 neonates delivered by classical C-section (27% with IVH) and 58 delivered using one of the two low transverse incisions (34% with IVH). For 94 women who went to C-section after the onset of labor, however, 27% of neonates in the classical incision group had IVH, compared with 54% in the low transverse incisions group, a significant difference.

In the laboring group, severe IVH (grade 3–4) or death occurred in 18% of neonates after a classical incision, and in 50% after a low transverse incision, which also was significant. The lead author of the poster was Dr. Jeffery Garland of Wheaton Franciscan Healthcare-St. Joseph, Milwaukee.

In general, physicians who encounter difficulty delivering an infant through a low transverse incision sometimes use a J or T extension of the incision. VLBW infants may be more vulnerable in these situations, Dr. Tan said. The most common reason for extending uterine incisions is to deliver a nonvertex infant, some reports suggest.

The association between classical incision and decreased risk for IVH in nonvertex, VLBW infants after labor remained significant after controlling for potential confounders, the investigators said.

SAN FRANCISCO — After the onset of labor, using a classical incision for C-section delivery of a very-low-birth-weight neonate in nonvertex position reduced the risk of intraventricular hemorrhage, compared with a transverse incision or transverse incision with extension, a study of 148 deliveries found.

The decrease in risk was more pronounced for more severe intraventricular hemorrhage (IVH), Dr. Kai Ling Tan and associates reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Previous studies have shown that vaginal delivery is safe for infants in vertex position weighing less than 1,000 g, but data are sparse on rates of IVH after delivery of very-low-birth-weight (VLBW) infants in breech, transverse, or oblique positions.

“It is a constant debate among ob.gyns. in the [morbidity and mortality] conferences in my institution whether to do a classical or a low transverse incision” in these cases, said Dr. Tan of the Medical College of Wisconsin Affiliated Hospitals, Wauwatosa, Wis., in an interview at the poster session.

The current retrospective review found no significant difference in IVH rates between the 93 neonates delivered by classical C-section (27% with IVH) and 58 delivered using one of the two low transverse incisions (34% with IVH). For 94 women who went to C-section after the onset of labor, however, 27% of neonates in the classical incision group had IVH, compared with 54% in the low transverse incisions group, a significant difference.

In the laboring group, severe IVH (grade 3–4) or death occurred in 18% of neonates after a classical incision, and in 50% after a low transverse incision, which also was significant. The lead author of the poster was Dr. Jeffery Garland of Wheaton Franciscan Healthcare-St. Joseph, Milwaukee.

In general, physicians who encounter difficulty delivering an infant through a low transverse incision sometimes use a J or T extension of the incision. VLBW infants may be more vulnerable in these situations, Dr. Tan said. The most common reason for extending uterine incisions is to deliver a nonvertex infant, some reports suggest.

The association between classical incision and decreased risk for IVH in nonvertex, VLBW infants after labor remained significant after controlling for potential confounders, the investigators said.

SAN FRANCISCO — After the onset of labor, using a classical incision for C-section delivery of a very-low-birth-weight neonate in nonvertex position reduced the risk of intraventricular hemorrhage, compared with a transverse incision or transverse incision with extension, a study of 148 deliveries found.

The decrease in risk was more pronounced for more severe intraventricular hemorrhage (IVH), Dr. Kai Ling Tan and associates reported in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Previous studies have shown that vaginal delivery is safe for infants in vertex position weighing less than 1,000 g, but data are sparse on rates of IVH after delivery of very-low-birth-weight (VLBW) infants in breech, transverse, or oblique positions.

“It is a constant debate among ob.gyns. in the [morbidity and mortality] conferences in my institution whether to do a classical or a low transverse incision” in these cases, said Dr. Tan of the Medical College of Wisconsin Affiliated Hospitals, Wauwatosa, Wis., in an interview at the poster session.

The current retrospective review found no significant difference in IVH rates between the 93 neonates delivered by classical C-section (27% with IVH) and 58 delivered using one of the two low transverse incisions (34% with IVH). For 94 women who went to C-section after the onset of labor, however, 27% of neonates in the classical incision group had IVH, compared with 54% in the low transverse incisions group, a significant difference.

In the laboring group, severe IVH (grade 3–4) or death occurred in 18% of neonates after a classical incision, and in 50% after a low transverse incision, which also was significant. The lead author of the poster was Dr. Jeffery Garland of Wheaton Franciscan Healthcare-St. Joseph, Milwaukee.

In general, physicians who encounter difficulty delivering an infant through a low transverse incision sometimes use a J or T extension of the incision. VLBW infants may be more vulnerable in these situations, Dr. Tan said. The most common reason for extending uterine incisions is to deliver a nonvertex infant, some reports suggest.

The association between classical incision and decreased risk for IVH in nonvertex, VLBW infants after labor remained significant after controlling for potential confounders, the investigators said.