Obstetrics

Preexisting glaucoma behaves unpredictably during pregnancy, according to findings from a small retrospective study.

The results underscore the need for close monitoring and physician-patient communication, reported Dr. Stacey C. Brauner and colleagues at the Massachusetts Eye and Ear Infirmary at Harvard Medical School in Boston.

Although medication is often necessary to control intraocular pressure, pregnant women may be reluctant to take it because of the potential teratogenic effects.

“This reinforces the need for good communication between physician and patient to minimize the risk to the fetus while preserving vision in the patient,” the authors wrote (Arch. Ophthalmol. 2006;124:1089–94).

Whenever possible, physicians should address glaucoma management options in all women of childbearing age before they become pregnant. “With proper planning, surgical treatments such as laser trabeculoplasty can be offered in anticipation of decreasing or stopping medication use during pregnancy,” Dr. Brauner said.

The retrospective case series of 28 eyes in 15 pregnant women with preexisting glaucoma found that while the condition remained stable in most women, 36% of eyes demonstrated either an increase in intraocular pressure (IOP) or a progression of visual field loss that required an increase in medication.

Most glaucoma medications such as β-blockers, carbonic anhydrase inhibitors (topical and systemic), prostaglandin analogues, cholinergic agents, anticholinesterases, and apraclonidine hydrochloride are classified by the Food and Drug Administration as pregnancy category C, noted the authors.

“This designation indicates that studies in animals have shown adverse effects on the fetus and there are no controlled studies in women, or that studies in women and animals are unavailable,” the investigators wrote. Thus, they advise that medication should be given “only if the potential benefit to the pregnant woman justifies the potential risk to the fetus,” and should be “prescribed in collaboration with obstetricians to ensure the safety of the mother and the fetus.”

Of the 28 eyes studied, IOP remained stable in 16 (57%), with no change in the visual fields. “Many of these eyes were maintained on fewer IOP-lowering medications during pregnancy compared with before pregnancy.”

In another 5 (18%) of the 28 eyes IOP increased but with no progression in visual field loss. However, in another five eyes IOP remained stable or increased, and there was also a progression in visual field loss. (Data were inconclusive in the remaining two eyes).

Although 13 of the 15 women required medication to control their IOP during pregnancy, there was a general trend toward medication noncompliance once they became pregnant, according to the authors. Two women discontinued all medication, resulting in an increase in IOP. “There were no adverse effects of medication use during pregnancy observed in the patients or their offspring,” the authors reported.

They advise that ophthalmologists work closely with obstetricians when selecting IOP-lowering medications during pregnancy. “In our experience, obstetricians are most comfortable with the use of β-blockers,” they said.

Preexisting glaucoma behaves unpredictably during pregnancy, according to findings from a small retrospective study.

The results underscore the need for close monitoring and physician-patient communication, reported Dr. Stacey C. Brauner and colleagues at the Massachusetts Eye and Ear Infirmary at Harvard Medical School in Boston.

Although medication is often necessary to control intraocular pressure, pregnant women may be reluctant to take it because of the potential teratogenic effects.

“This reinforces the need for good communication between physician and patient to minimize the risk to the fetus while preserving vision in the patient,” the authors wrote (Arch. Ophthalmol. 2006;124:1089–94).

Whenever possible, physicians should address glaucoma management options in all women of childbearing age before they become pregnant. “With proper planning, surgical treatments such as laser trabeculoplasty can be offered in anticipation of decreasing or stopping medication use during pregnancy,” Dr. Brauner said.

The retrospective case series of 28 eyes in 15 pregnant women with preexisting glaucoma found that while the condition remained stable in most women, 36% of eyes demonstrated either an increase in intraocular pressure (IOP) or a progression of visual field loss that required an increase in medication.

Most glaucoma medications such as β-blockers, carbonic anhydrase inhibitors (topical and systemic), prostaglandin analogues, cholinergic agents, anticholinesterases, and apraclonidine hydrochloride are classified by the Food and Drug Administration as pregnancy category C, noted the authors.

“This designation indicates that studies in animals have shown adverse effects on the fetus and there are no controlled studies in women, or that studies in women and animals are unavailable,” the investigators wrote. Thus, they advise that medication should be given “only if the potential benefit to the pregnant woman justifies the potential risk to the fetus,” and should be “prescribed in collaboration with obstetricians to ensure the safety of the mother and the fetus.”

Of the 28 eyes studied, IOP remained stable in 16 (57%), with no change in the visual fields. “Many of these eyes were maintained on fewer IOP-lowering medications during pregnancy compared with before pregnancy.”

In another 5 (18%) of the 28 eyes IOP increased but with no progression in visual field loss. However, in another five eyes IOP remained stable or increased, and there was also a progression in visual field loss. (Data were inconclusive in the remaining two eyes).

Although 13 of the 15 women required medication to control their IOP during pregnancy, there was a general trend toward medication noncompliance once they became pregnant, according to the authors. Two women discontinued all medication, resulting in an increase in IOP. “There were no adverse effects of medication use during pregnancy observed in the patients or their offspring,” the authors reported.

They advise that ophthalmologists work closely with obstetricians when selecting IOP-lowering medications during pregnancy. “In our experience, obstetricians are most comfortable with the use of β-blockers,” they said.

Preexisting glaucoma behaves unpredictably during pregnancy, according to findings from a small retrospective study.

The results underscore the need for close monitoring and physician-patient communication, reported Dr. Stacey C. Brauner and colleagues at the Massachusetts Eye and Ear Infirmary at Harvard Medical School in Boston.

Although medication is often necessary to control intraocular pressure, pregnant women may be reluctant to take it because of the potential teratogenic effects.

“This reinforces the need for good communication between physician and patient to minimize the risk to the fetus while preserving vision in the patient,” the authors wrote (Arch. Ophthalmol. 2006;124:1089–94).

Whenever possible, physicians should address glaucoma management options in all women of childbearing age before they become pregnant. “With proper planning, surgical treatments such as laser trabeculoplasty can be offered in anticipation of decreasing or stopping medication use during pregnancy,” Dr. Brauner said.

The retrospective case series of 28 eyes in 15 pregnant women with preexisting glaucoma found that while the condition remained stable in most women, 36% of eyes demonstrated either an increase in intraocular pressure (IOP) or a progression of visual field loss that required an increase in medication.

Most glaucoma medications such as β-blockers, carbonic anhydrase inhibitors (topical and systemic), prostaglandin analogues, cholinergic agents, anticholinesterases, and apraclonidine hydrochloride are classified by the Food and Drug Administration as pregnancy category C, noted the authors.

“This designation indicates that studies in animals have shown adverse effects on the fetus and there are no controlled studies in women, or that studies in women and animals are unavailable,” the investigators wrote. Thus, they advise that medication should be given “only if the potential benefit to the pregnant woman justifies the potential risk to the fetus,” and should be “prescribed in collaboration with obstetricians to ensure the safety of the mother and the fetus.”

Of the 28 eyes studied, IOP remained stable in 16 (57%), with no change in the visual fields. “Many of these eyes were maintained on fewer IOP-lowering medications during pregnancy compared with before pregnancy.”

In another 5 (18%) of the 28 eyes IOP increased but with no progression in visual field loss. However, in another five eyes IOP remained stable or increased, and there was also a progression in visual field loss. (Data were inconclusive in the remaining two eyes).

Although 13 of the 15 women required medication to control their IOP during pregnancy, there was a general trend toward medication noncompliance once they became pregnant, according to the authors. Two women discontinued all medication, resulting in an increase in IOP. “There were no adverse effects of medication use during pregnancy observed in the patients or their offspring,” the authors reported.

They advise that ophthalmologists work closely with obstetricians when selecting IOP-lowering medications during pregnancy. “In our experience, obstetricians are most comfortable with the use of β-blockers,” they said.

TUCSON, ARIZ. — Although only 49 cases of lymphocytic choriomeningitis virus have been reported in the medical literature worldwide, Dr. Marilyn Baird Mets has a hunch that the prevalence could be much higher.

Since 1997, she has seen seven children with the condition present to Children's Memorial Hospital, Chicago, where she is head of ophthalmology.

Subsequently, three other clinicians have called her with reports of positive cases: one from the western suburbs of Chicago, one from Los Angeles, and one from Fort Collins, Colo.

“This virus is out there,” Dr. Mets said at the annual meeting of the Teratology Society. “Obstetricians should be telling their patients not to work around rats in medical labs during their pregnancy [and] not to get a hamster for their 4-year-old if they're going to have other children. It's a preventable disease, but people need to know about it.”

Discovered in 1933 and classified in the 1960s as a prototype for the arena virus, lymphocytic choriomeningitis virus (LCMV) is harbored in mice and transferred vertically by uterine infection. “There is documented infection to humans from wild mice, lab mice, rats, and hamsters,” said Dr. Mets, also professor of ophthalmology and surgery at Northwestern University, Chicago. “Transmission is thought to be airborne or contamination of food by infected mouse urine. There has also been experimental transmission demonstrated by ticks, fleas, mosquitos, and bedbugs.”

About one-third of adults who acquire LCMV are asymptomatic. Of the remaining two-thirds, about half have central nervous system disease. Illness occurs in a biphasic pattern. “First there's an acute febrile illness with myalgias and headache,” she said. “Later on, meningeal signs may develop, and rarely encephalitis, myocarditis, parotitis, orchitis, and pneumonia. Very rarely, fatal systemic disease is reported.”

It's the causative agent in about 10% of aseptic meningitis cases.

LCMV was first described as a fetal pathogen in Great Britain in 1955. The first case of congenital LCMV in the United States was reported in 1993. The baby was born with a birth weight of 2,898 grams. During pregnancy the mother lived in a well-maintained inner-city apartment. At 5 months' gestation, she had a febrile illness that lasted a week. The child was born with hydrocephalus and microphthalmos of the right eye. The right eye had leukocoria, a cloudy vitreous, and exudative retinitis.

A review of 26 infants with LCMV published in 1997 revealed that 88% had chorioretinopathy, 45% had hydrocephalus, and 13% had microcephaly. Diagnosis is made by IgG indirect fluorescent antibody, which is commercially available. “Or you can get an IgG ELISA at the [Centers for Disease Control and Prevention],” Dr. Mets said. “Complement fixation testing lacks the sensitivity” of the other two tests.

The differential diagnosis includes toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, enteroviruses, syphilis, parvovirus B19, and West Nile virus.

'Obstetricians should be telling their patients not to work around rats in a medical lab during their pregnancy.' DR. METS

An optical scan shows the eye of a 22-month-old with congenital LCMV who was referred for visual delay. Courtesy Dr. Marilyn Baird Mets

TUCSON, ARIZ. — Although only 49 cases of lymphocytic choriomeningitis virus have been reported in the medical literature worldwide, Dr. Marilyn Baird Mets has a hunch that the prevalence could be much higher.

Since 1997, she has seen seven children with the condition present to Children's Memorial Hospital, Chicago, where she is head of ophthalmology.

Subsequently, three other clinicians have called her with reports of positive cases: one from the western suburbs of Chicago, one from Los Angeles, and one from Fort Collins, Colo.

“This virus is out there,” Dr. Mets said at the annual meeting of the Teratology Society. “Obstetricians should be telling their patients not to work around rats in medical labs during their pregnancy [and] not to get a hamster for their 4-year-old if they're going to have other children. It's a preventable disease, but people need to know about it.”

Discovered in 1933 and classified in the 1960s as a prototype for the arena virus, lymphocytic choriomeningitis virus (LCMV) is harbored in mice and transferred vertically by uterine infection. “There is documented infection to humans from wild mice, lab mice, rats, and hamsters,” said Dr. Mets, also professor of ophthalmology and surgery at Northwestern University, Chicago. “Transmission is thought to be airborne or contamination of food by infected mouse urine. There has also been experimental transmission demonstrated by ticks, fleas, mosquitos, and bedbugs.”

About one-third of adults who acquire LCMV are asymptomatic. Of the remaining two-thirds, about half have central nervous system disease. Illness occurs in a biphasic pattern. “First there's an acute febrile illness with myalgias and headache,” she said. “Later on, meningeal signs may develop, and rarely encephalitis, myocarditis, parotitis, orchitis, and pneumonia. Very rarely, fatal systemic disease is reported.”

It's the causative agent in about 10% of aseptic meningitis cases.

LCMV was first described as a fetal pathogen in Great Britain in 1955. The first case of congenital LCMV in the United States was reported in 1993. The baby was born with a birth weight of 2,898 grams. During pregnancy the mother lived in a well-maintained inner-city apartment. At 5 months' gestation, she had a febrile illness that lasted a week. The child was born with hydrocephalus and microphthalmos of the right eye. The right eye had leukocoria, a cloudy vitreous, and exudative retinitis.

A review of 26 infants with LCMV published in 1997 revealed that 88% had chorioretinopathy, 45% had hydrocephalus, and 13% had microcephaly. Diagnosis is made by IgG indirect fluorescent antibody, which is commercially available. “Or you can get an IgG ELISA at the [Centers for Disease Control and Prevention],” Dr. Mets said. “Complement fixation testing lacks the sensitivity” of the other two tests.

The differential diagnosis includes toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, enteroviruses, syphilis, parvovirus B19, and West Nile virus.

'Obstetricians should be telling their patients not to work around rats in a medical lab during their pregnancy.' DR. METS

An optical scan shows the eye of a 22-month-old with congenital LCMV who was referred for visual delay. Courtesy Dr. Marilyn Baird Mets

TUCSON, ARIZ. — Although only 49 cases of lymphocytic choriomeningitis virus have been reported in the medical literature worldwide, Dr. Marilyn Baird Mets has a hunch that the prevalence could be much higher.

Since 1997, she has seen seven children with the condition present to Children's Memorial Hospital, Chicago, where she is head of ophthalmology.

Subsequently, three other clinicians have called her with reports of positive cases: one from the western suburbs of Chicago, one from Los Angeles, and one from Fort Collins, Colo.

“This virus is out there,” Dr. Mets said at the annual meeting of the Teratology Society. “Obstetricians should be telling their patients not to work around rats in medical labs during their pregnancy [and] not to get a hamster for their 4-year-old if they're going to have other children. It's a preventable disease, but people need to know about it.”

Discovered in 1933 and classified in the 1960s as a prototype for the arena virus, lymphocytic choriomeningitis virus (LCMV) is harbored in mice and transferred vertically by uterine infection. “There is documented infection to humans from wild mice, lab mice, rats, and hamsters,” said Dr. Mets, also professor of ophthalmology and surgery at Northwestern University, Chicago. “Transmission is thought to be airborne or contamination of food by infected mouse urine. There has also been experimental transmission demonstrated by ticks, fleas, mosquitos, and bedbugs.”

About one-third of adults who acquire LCMV are asymptomatic. Of the remaining two-thirds, about half have central nervous system disease. Illness occurs in a biphasic pattern. “First there's an acute febrile illness with myalgias and headache,” she said. “Later on, meningeal signs may develop, and rarely encephalitis, myocarditis, parotitis, orchitis, and pneumonia. Very rarely, fatal systemic disease is reported.”

It's the causative agent in about 10% of aseptic meningitis cases.

LCMV was first described as a fetal pathogen in Great Britain in 1955. The first case of congenital LCMV in the United States was reported in 1993. The baby was born with a birth weight of 2,898 grams. During pregnancy the mother lived in a well-maintained inner-city apartment. At 5 months' gestation, she had a febrile illness that lasted a week. The child was born with hydrocephalus and microphthalmos of the right eye. The right eye had leukocoria, a cloudy vitreous, and exudative retinitis.

A review of 26 infants with LCMV published in 1997 revealed that 88% had chorioretinopathy, 45% had hydrocephalus, and 13% had microcephaly. Diagnosis is made by IgG indirect fluorescent antibody, which is commercially available. “Or you can get an IgG ELISA at the [Centers for Disease Control and Prevention],” Dr. Mets said. “Complement fixation testing lacks the sensitivity” of the other two tests.

The differential diagnosis includes toxoplasmosis, rubella, cytomegalovirus, herpes simplex virus, enteroviruses, syphilis, parvovirus B19, and West Nile virus.

'Obstetricians should be telling their patients not to work around rats in a medical lab during their pregnancy.' DR. METS

An optical scan shows the eye of a 22-month-old with congenital LCMV who was referred for visual delay. Courtesy Dr. Marilyn Baird Mets

CHICAGO — Measures of soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein secreted in excess by the placentas of women with preeclampsia, may prove to be a screening test for preeclampsia.

“Looking to the future, I have a lot of faith in blocking sFlt-1” as a possible treatment for preeclampsia, Dr. Sharon Maynard said in an interview after her presentation at a meeting on clinical nephrology sponsored by the National Kidney Foundation. The first phase I trial of an agent that blocks sFlt-1 will begin next year. If shown to be safe and effective, a potential treatment could be available within 3–4 years.

The ability to prevent and treat preeclampsia has long eluded medicine, said Dr. Maynard, a nephrologist at George Washington University. Most studies have addressed preventive therapies for preeclampsia: calcium, antioxidants, aspirin, magnesium, and blood pressure control.

Several small studies initially suggested that calcium supplementation could help prevent preeclampsia, but the findings did not hold up in later studies. Outcomes were comparable in one large trial that randomized more than 4,500 healthy nulliparous women to calcium or placebo (N. Engl. J. Med.1997;337:69–76). A subgroup analysis of these data indicated women with low baseline calcium levels may derive some benefit from supplements. A World Health Organization-sponsored trial of 5,000 women with low baseline calcium levels also revealed a lower risk of preeclampsia and neonatal death.

Antioxidants similarly failed to hold up to the rigors of a controlled trial in 2,395 women. In fact, the gravid women taking antioxidant supplements had a greater risk of low-birth-weight babies and stillbirths.

The data on aspirin in this population are “the most confusing of all,” noted Dr. Maynard. Although three large randomized controlled trials of 12,000 high-risk women found no differences with aspirin versus placebo, results were mixed in a subsequent metaanalysis of 51 trials involving 36,500 women. A Cochrane analysis showed that benefits were seen in small studies, but not in large ones. “I am really concerned that there may be no benefit at all,” she said.

Although magnesium has not been shown to prevent preeclampsia, it should be used “across the board. [It] clearly cuts the risk of seizures in half,” said Dr. Maynard.

CHICAGO — Measures of soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein secreted in excess by the placentas of women with preeclampsia, may prove to be a screening test for preeclampsia.

“Looking to the future, I have a lot of faith in blocking sFlt-1” as a possible treatment for preeclampsia, Dr. Sharon Maynard said in an interview after her presentation at a meeting on clinical nephrology sponsored by the National Kidney Foundation. The first phase I trial of an agent that blocks sFlt-1 will begin next year. If shown to be safe and effective, a potential treatment could be available within 3–4 years.

The ability to prevent and treat preeclampsia has long eluded medicine, said Dr. Maynard, a nephrologist at George Washington University. Most studies have addressed preventive therapies for preeclampsia: calcium, antioxidants, aspirin, magnesium, and blood pressure control.

Several small studies initially suggested that calcium supplementation could help prevent preeclampsia, but the findings did not hold up in later studies. Outcomes were comparable in one large trial that randomized more than 4,500 healthy nulliparous women to calcium or placebo (N. Engl. J. Med.1997;337:69–76). A subgroup analysis of these data indicated women with low baseline calcium levels may derive some benefit from supplements. A World Health Organization-sponsored trial of 5,000 women with low baseline calcium levels also revealed a lower risk of preeclampsia and neonatal death.

Antioxidants similarly failed to hold up to the rigors of a controlled trial in 2,395 women. In fact, the gravid women taking antioxidant supplements had a greater risk of low-birth-weight babies and stillbirths.

The data on aspirin in this population are “the most confusing of all,” noted Dr. Maynard. Although three large randomized controlled trials of 12,000 high-risk women found no differences with aspirin versus placebo, results were mixed in a subsequent metaanalysis of 51 trials involving 36,500 women. A Cochrane analysis showed that benefits were seen in small studies, but not in large ones. “I am really concerned that there may be no benefit at all,” she said.

Although magnesium has not been shown to prevent preeclampsia, it should be used “across the board. [It] clearly cuts the risk of seizures in half,” said Dr. Maynard.

CHICAGO — Measures of soluble fms-like tyrosine kinase 1 (sFlt-1), a circulating antiangiogenic protein secreted in excess by the placentas of women with preeclampsia, may prove to be a screening test for preeclampsia.

“Looking to the future, I have a lot of faith in blocking sFlt-1” as a possible treatment for preeclampsia, Dr. Sharon Maynard said in an interview after her presentation at a meeting on clinical nephrology sponsored by the National Kidney Foundation. The first phase I trial of an agent that blocks sFlt-1 will begin next year. If shown to be safe and effective, a potential treatment could be available within 3–4 years.

The ability to prevent and treat preeclampsia has long eluded medicine, said Dr. Maynard, a nephrologist at George Washington University. Most studies have addressed preventive therapies for preeclampsia: calcium, antioxidants, aspirin, magnesium, and blood pressure control.

Several small studies initially suggested that calcium supplementation could help prevent preeclampsia, but the findings did not hold up in later studies. Outcomes were comparable in one large trial that randomized more than 4,500 healthy nulliparous women to calcium or placebo (N. Engl. J. Med.1997;337:69–76). A subgroup analysis of these data indicated women with low baseline calcium levels may derive some benefit from supplements. A World Health Organization-sponsored trial of 5,000 women with low baseline calcium levels also revealed a lower risk of preeclampsia and neonatal death.

Antioxidants similarly failed to hold up to the rigors of a controlled trial in 2,395 women. In fact, the gravid women taking antioxidant supplements had a greater risk of low-birth-weight babies and stillbirths.

The data on aspirin in this population are “the most confusing of all,” noted Dr. Maynard. Although three large randomized controlled trials of 12,000 high-risk women found no differences with aspirin versus placebo, results were mixed in a subsequent metaanalysis of 51 trials involving 36,500 women. A Cochrane analysis showed that benefits were seen in small studies, but not in large ones. “I am really concerned that there may be no benefit at all,” she said.

Although magnesium has not been shown to prevent preeclampsia, it should be used “across the board. [It] clearly cuts the risk of seizures in half,” said Dr. Maynard.

ASHEVILLE, N.C. — When looking for causes of stillbirth, obstetricians and pediatricians should not overlook infection, Dr. Sean Blackwell said at the Southern Obstetric and Gynecologic Seminar.

Though the fetal death rate has declined, about half of stillbirths are due to unexplained causes, said Dr. Blackwell of the maternal fetal medicine division at William Beaumont Hospital in Royal Oak, Mich.

A recent paper (Sem. Perinatol. 2006;30:20–3) hypothesized that at least 10% of stillbirths result from infection, a rate equal to the number of deaths caused by fetal anomalies but slightly less than those caused by fetal growth restriction (14%), abruption (14%), or cord- or placenta-related problems (18%). The same study estimated that 27% of stillbirths have unexplained causes.

The number of unexplained stillbirths increases with rising gestational age, said Dr. Blackwell, adding that some of these cases may be undiagnosed or undetected infection.

A variety of pathogens have been associated with stillbirth, including spirochetes, protozoans, viruses, and bacteria, he said. There are three potential ways a fetus can acquire an infection: through systemic maternal illness; through the cervicovaginal compartment; or via a transplacental route. Maternal illness may result in a proinflammatory response that redistributes blood flow, leading to uteroplacental insufficiency.

An ascending infection will infect fetal and placental tissue, leading to sepsis. Group B streptococci, Escherichia coli, Ureaplasma, and Candida are known to use the ascending route, said Dr. Blackwell.

Similarly, a pathogen that crosses the placental barrier will infect fetal and placental tissue, leading to sepsis and anomalies. Malaria, syphilis, coxsackievirus, cytomegalovirus, and parvovirus are known to cross the placenta.

Dr. Blackwell said that several papers have shown that parvovirus may lead to fetal death by previously unknown mechanisms. In testing tissue from stillbirths with unexplained causes, Dr. Blackwell and colleagues found that though 43 of the 44 had negative cultures, there were changes in the tissue consistent with exposure to an infectious agent (J. Matern. Fetal Neonatal Med. 2003;14:151–7 and 241–6).

Recent findings show that genetics may also play a role in susceptibility to stillbirth. Some women have a polymorphism that appears to cause hyperresponsiveness to infections like bacterial vaginosis, resulting in a proinflammatory cascade that could harm the fetus. There is growing evidence also that fetal response to infection may be partly governed by phenotypes. Several papers have postulated that there may be a normal response in which the fetal immune response results in the triggering of labor, which helps the fetus escape a hostile environment, Dr. Blackwell said. He urged clinicians to conduct full work-ups on stillbirths, including taking cultures of the placenta and blood and organs of the fetus in order to get some answers.

ASHEVILLE, N.C. — When looking for causes of stillbirth, obstetricians and pediatricians should not overlook infection, Dr. Sean Blackwell said at the Southern Obstetric and Gynecologic Seminar.

Though the fetal death rate has declined, about half of stillbirths are due to unexplained causes, said Dr. Blackwell of the maternal fetal medicine division at William Beaumont Hospital in Royal Oak, Mich.

A recent paper (Sem. Perinatol. 2006;30:20–3) hypothesized that at least 10% of stillbirths result from infection, a rate equal to the number of deaths caused by fetal anomalies but slightly less than those caused by fetal growth restriction (14%), abruption (14%), or cord- or placenta-related problems (18%). The same study estimated that 27% of stillbirths have unexplained causes.

The number of unexplained stillbirths increases with rising gestational age, said Dr. Blackwell, adding that some of these cases may be undiagnosed or undetected infection.

A variety of pathogens have been associated with stillbirth, including spirochetes, protozoans, viruses, and bacteria, he said. There are three potential ways a fetus can acquire an infection: through systemic maternal illness; through the cervicovaginal compartment; or via a transplacental route. Maternal illness may result in a proinflammatory response that redistributes blood flow, leading to uteroplacental insufficiency.

An ascending infection will infect fetal and placental tissue, leading to sepsis. Group B streptococci, Escherichia coli, Ureaplasma, and Candida are known to use the ascending route, said Dr. Blackwell.

Similarly, a pathogen that crosses the placental barrier will infect fetal and placental tissue, leading to sepsis and anomalies. Malaria, syphilis, coxsackievirus, cytomegalovirus, and parvovirus are known to cross the placenta.

Dr. Blackwell said that several papers have shown that parvovirus may lead to fetal death by previously unknown mechanisms. In testing tissue from stillbirths with unexplained causes, Dr. Blackwell and colleagues found that though 43 of the 44 had negative cultures, there were changes in the tissue consistent with exposure to an infectious agent (J. Matern. Fetal Neonatal Med. 2003;14:151–7 and 241–6).

Recent findings show that genetics may also play a role in susceptibility to stillbirth. Some women have a polymorphism that appears to cause hyperresponsiveness to infections like bacterial vaginosis, resulting in a proinflammatory cascade that could harm the fetus. There is growing evidence also that fetal response to infection may be partly governed by phenotypes. Several papers have postulated that there may be a normal response in which the fetal immune response results in the triggering of labor, which helps the fetus escape a hostile environment, Dr. Blackwell said. He urged clinicians to conduct full work-ups on stillbirths, including taking cultures of the placenta and blood and organs of the fetus in order to get some answers.

ASHEVILLE, N.C. — When looking for causes of stillbirth, obstetricians and pediatricians should not overlook infection, Dr. Sean Blackwell said at the Southern Obstetric and Gynecologic Seminar.

Though the fetal death rate has declined, about half of stillbirths are due to unexplained causes, said Dr. Blackwell of the maternal fetal medicine division at William Beaumont Hospital in Royal Oak, Mich.

A recent paper (Sem. Perinatol. 2006;30:20–3) hypothesized that at least 10% of stillbirths result from infection, a rate equal to the number of deaths caused by fetal anomalies but slightly less than those caused by fetal growth restriction (14%), abruption (14%), or cord- or placenta-related problems (18%). The same study estimated that 27% of stillbirths have unexplained causes.

The number of unexplained stillbirths increases with rising gestational age, said Dr. Blackwell, adding that some of these cases may be undiagnosed or undetected infection.

A variety of pathogens have been associated with stillbirth, including spirochetes, protozoans, viruses, and bacteria, he said. There are three potential ways a fetus can acquire an infection: through systemic maternal illness; through the cervicovaginal compartment; or via a transplacental route. Maternal illness may result in a proinflammatory response that redistributes blood flow, leading to uteroplacental insufficiency.

An ascending infection will infect fetal and placental tissue, leading to sepsis. Group B streptococci, Escherichia coli, Ureaplasma, and Candida are known to use the ascending route, said Dr. Blackwell.

Similarly, a pathogen that crosses the placental barrier will infect fetal and placental tissue, leading to sepsis and anomalies. Malaria, syphilis, coxsackievirus, cytomegalovirus, and parvovirus are known to cross the placenta.

Dr. Blackwell said that several papers have shown that parvovirus may lead to fetal death by previously unknown mechanisms. In testing tissue from stillbirths with unexplained causes, Dr. Blackwell and colleagues found that though 43 of the 44 had negative cultures, there were changes in the tissue consistent with exposure to an infectious agent (J. Matern. Fetal Neonatal Med. 2003;14:151–7 and 241–6).

Recent findings show that genetics may also play a role in susceptibility to stillbirth. Some women have a polymorphism that appears to cause hyperresponsiveness to infections like bacterial vaginosis, resulting in a proinflammatory cascade that could harm the fetus. There is growing evidence also that fetal response to infection may be partly governed by phenotypes. Several papers have postulated that there may be a normal response in which the fetal immune response results in the triggering of labor, which helps the fetus escape a hostile environment, Dr. Blackwell said. He urged clinicians to conduct full work-ups on stillbirths, including taking cultures of the placenta and blood and organs of the fetus in order to get some answers.

SAN FRANCISCO — Pregnancy soon after bariatric surgery does not appear to pose safety concerns for the mother or newborn, Dr. Tuoc N. Dao reported at the annual meeting of the American Society for Bariatric Surgery.

Surgeons have generally recommended that bariatric surgery patients should not become pregnant until 12–18 months after the procedure because of a perceived risk to the fetus or the woman during the period of large weight loss and limited calorie and nutrient intake following the surgery, said Dr. Dao, a surgical resident at Baylor University Medical Center at Dallas.

Although her review of 24 patients indicated that “the desire for pregnancy should not be a deterrent for Roux-en-Y gastric bypass as a weight-loss procedure,” Dr. Dao and her colleagues continue to recommend that most bariatric surgery patients wait 12–18 months before becoming pregnant “due to the psychological component of trying to undergo all of these changes at one time. Trying to lose weight and deal with a pregnancy at the same time, I think, would be too much for people.”

Several previous studies have not reported any major adverse events or outcomes in women who became pregnant after bariatric surgery.

In a study of 298 deliveries, no adverse perinatal outcomes were reported in women who had restrictive or malabsorptive surgery, although Roux-en-Y gastric bypass (RYGB) was associated with an increased risk of premature rupture of membranes, labor induction, and fetal macrosomia (Am. J. Obstet. Gynecol. 2004;190:1335–40).

A separate review of 18 pregnancies after gastric bypass showed few metabolic problems or deficiencies in vitamin B₁₂ or iron (South. Med. J. 1989;82:1319–20).

In another group of 46 deliveries, four of seven preterm infants were born to mothers who became pregnant within 16 months of their surgery. Pregnancy was safe outside of that time period (Am. Surg. 1982;48:363–5).

Pregnancy during the period of rapid weight loss immediately after surgery can cause deficiencies in iron, folate, calcium, and vitamin B₁₂.

It also has been questioned whether women will be able to lose additional weight post partum during the early postoperative phase.

Fetal and maternal deaths have been reported in a few cases of postoperative small bowel herniations and ischemia, but other reports have recorded good outcomes with early detection and treatment of this complication, Dr. Dao said.

In her review of 2,532 patients who underwent RYGB at Baylor during 2001–2005, 24 became pregnant within 1 year after the surgery.

These patients were 32 years old with a body mass index of 49 kg/m

At the time of delivery, the women were 34 years old and had gained a mean of 0.3 pounds during pregnancy, although this varied widely from losing 70 pounds to gaining 45 pounds.

The patients' mean body mass index dropped from 34 kg/m

Only one patient failed to sustain their excess weight loss.

The 24 women had 26 pregnancies, 2 of which were early miscarriages in women who soon became pregnant again and carried to term. Of three other miscarriages, two occurred in the first trimester and one at a gestational age of 20 weeks.

Another patient had an ectopic pregnancy.

One patient had mild iron deficiency during pregnancy that resolved with iron supplementation.

One patient had symptomatic cholelithiasis and underwent laparoscopic cholecystectomy after the delivery of her baby.

An internal hernia in one patient was detected early and repaired without any incident.

Another patient with a gastrogastric fistula was treated conservatively until her delivery.

Two patients had preterm labor. One patient had preeclampsia and one had mild hypertension that was much improved since her last pregnancy before bariatric surgery.

The 21 babies (including one set of twins) had an average birth weight of 2,874 g. Three neonates, including the twins, had a low birth weight (less than 2,500 g). One infant had intrauterine growth restriction (born to the mother with an internal hernia).

Another infant had intrauterine growth restriction plus a low birth weight (born to the mother with a gastrogastric fistula).

No infants had any congenital or developmental defects.

In five of the women who had pregnancies before their RYGB surgery, there were fewer instances of diabetes, hypertension, and complications during postsurgery pregnancies than in those that occurred before the operation.

Dr. Dao did not know how many of the other patients who received RYGB in the cohort were lost to follow-up, but she said that patients who report pregnancy at clinical visits or on follow-up surveys are interviewed to gather information.

SAN FRANCISCO — Pregnancy soon after bariatric surgery does not appear to pose safety concerns for the mother or newborn, Dr. Tuoc N. Dao reported at the annual meeting of the American Society for Bariatric Surgery.

Surgeons have generally recommended that bariatric surgery patients should not become pregnant until 12–18 months after the procedure because of a perceived risk to the fetus or the woman during the period of large weight loss and limited calorie and nutrient intake following the surgery, said Dr. Dao, a surgical resident at Baylor University Medical Center at Dallas.

Although her review of 24 patients indicated that “the desire for pregnancy should not be a deterrent for Roux-en-Y gastric bypass as a weight-loss procedure,” Dr. Dao and her colleagues continue to recommend that most bariatric surgery patients wait 12–18 months before becoming pregnant “due to the psychological component of trying to undergo all of these changes at one time. Trying to lose weight and deal with a pregnancy at the same time, I think, would be too much for people.”

Several previous studies have not reported any major adverse events or outcomes in women who became pregnant after bariatric surgery.

In a study of 298 deliveries, no adverse perinatal outcomes were reported in women who had restrictive or malabsorptive surgery, although Roux-en-Y gastric bypass (RYGB) was associated with an increased risk of premature rupture of membranes, labor induction, and fetal macrosomia (Am. J. Obstet. Gynecol. 2004;190:1335–40).

A separate review of 18 pregnancies after gastric bypass showed few metabolic problems or deficiencies in vitamin B₁₂ or iron (South. Med. J. 1989;82:1319–20).

In another group of 46 deliveries, four of seven preterm infants were born to mothers who became pregnant within 16 months of their surgery. Pregnancy was safe outside of that time period (Am. Surg. 1982;48:363–5).

Pregnancy during the period of rapid weight loss immediately after surgery can cause deficiencies in iron, folate, calcium, and vitamin B₁₂.

It also has been questioned whether women will be able to lose additional weight post partum during the early postoperative phase.

Fetal and maternal deaths have been reported in a few cases of postoperative small bowel herniations and ischemia, but other reports have recorded good outcomes with early detection and treatment of this complication, Dr. Dao said.

In her review of 2,532 patients who underwent RYGB at Baylor during 2001–2005, 24 became pregnant within 1 year after the surgery.

These patients were 32 years old with a body mass index of 49 kg/m

At the time of delivery, the women were 34 years old and had gained a mean of 0.3 pounds during pregnancy, although this varied widely from losing 70 pounds to gaining 45 pounds.

The patients' mean body mass index dropped from 34 kg/m

Only one patient failed to sustain their excess weight loss.

The 24 women had 26 pregnancies, 2 of which were early miscarriages in women who soon became pregnant again and carried to term. Of three other miscarriages, two occurred in the first trimester and one at a gestational age of 20 weeks.

Another patient had an ectopic pregnancy.

One patient had mild iron deficiency during pregnancy that resolved with iron supplementation.

One patient had symptomatic cholelithiasis and underwent laparoscopic cholecystectomy after the delivery of her baby.

An internal hernia in one patient was detected early and repaired without any incident.

Another patient with a gastrogastric fistula was treated conservatively until her delivery.

Two patients had preterm labor. One patient had preeclampsia and one had mild hypertension that was much improved since her last pregnancy before bariatric surgery.

The 21 babies (including one set of twins) had an average birth weight of 2,874 g. Three neonates, including the twins, had a low birth weight (less than 2,500 g). One infant had intrauterine growth restriction (born to the mother with an internal hernia).

Another infant had intrauterine growth restriction plus a low birth weight (born to the mother with a gastrogastric fistula).

No infants had any congenital or developmental defects.

In five of the women who had pregnancies before their RYGB surgery, there were fewer instances of diabetes, hypertension, and complications during postsurgery pregnancies than in those that occurred before the operation.

Dr. Dao did not know how many of the other patients who received RYGB in the cohort were lost to follow-up, but she said that patients who report pregnancy at clinical visits or on follow-up surveys are interviewed to gather information.

SAN FRANCISCO — Pregnancy soon after bariatric surgery does not appear to pose safety concerns for the mother or newborn, Dr. Tuoc N. Dao reported at the annual meeting of the American Society for Bariatric Surgery.

Surgeons have generally recommended that bariatric surgery patients should not become pregnant until 12–18 months after the procedure because of a perceived risk to the fetus or the woman during the period of large weight loss and limited calorie and nutrient intake following the surgery, said Dr. Dao, a surgical resident at Baylor University Medical Center at Dallas.

Although her review of 24 patients indicated that “the desire for pregnancy should not be a deterrent for Roux-en-Y gastric bypass as a weight-loss procedure,” Dr. Dao and her colleagues continue to recommend that most bariatric surgery patients wait 12–18 months before becoming pregnant “due to the psychological component of trying to undergo all of these changes at one time. Trying to lose weight and deal with a pregnancy at the same time, I think, would be too much for people.”

Several previous studies have not reported any major adverse events or outcomes in women who became pregnant after bariatric surgery.

In a study of 298 deliveries, no adverse perinatal outcomes were reported in women who had restrictive or malabsorptive surgery, although Roux-en-Y gastric bypass (RYGB) was associated with an increased risk of premature rupture of membranes, labor induction, and fetal macrosomia (Am. J. Obstet. Gynecol. 2004;190:1335–40).

A separate review of 18 pregnancies after gastric bypass showed few metabolic problems or deficiencies in vitamin B₁₂ or iron (South. Med. J. 1989;82:1319–20).

In another group of 46 deliveries, four of seven preterm infants were born to mothers who became pregnant within 16 months of their surgery. Pregnancy was safe outside of that time period (Am. Surg. 1982;48:363–5).

Pregnancy during the period of rapid weight loss immediately after surgery can cause deficiencies in iron, folate, calcium, and vitamin B₁₂.

It also has been questioned whether women will be able to lose additional weight post partum during the early postoperative phase.

Fetal and maternal deaths have been reported in a few cases of postoperative small bowel herniations and ischemia, but other reports have recorded good outcomes with early detection and treatment of this complication, Dr. Dao said.

In her review of 2,532 patients who underwent RYGB at Baylor during 2001–2005, 24 became pregnant within 1 year after the surgery.

These patients were 32 years old with a body mass index of 49 kg/m

At the time of delivery, the women were 34 years old and had gained a mean of 0.3 pounds during pregnancy, although this varied widely from losing 70 pounds to gaining 45 pounds.

The patients' mean body mass index dropped from 34 kg/m

Only one patient failed to sustain their excess weight loss.

The 24 women had 26 pregnancies, 2 of which were early miscarriages in women who soon became pregnant again and carried to term. Of three other miscarriages, two occurred in the first trimester and one at a gestational age of 20 weeks.

Another patient had an ectopic pregnancy.

One patient had mild iron deficiency during pregnancy that resolved with iron supplementation.

One patient had symptomatic cholelithiasis and underwent laparoscopic cholecystectomy after the delivery of her baby.

An internal hernia in one patient was detected early and repaired without any incident.

Another patient with a gastrogastric fistula was treated conservatively until her delivery.

Two patients had preterm labor. One patient had preeclampsia and one had mild hypertension that was much improved since her last pregnancy before bariatric surgery.

The 21 babies (including one set of twins) had an average birth weight of 2,874 g. Three neonates, including the twins, had a low birth weight (less than 2,500 g). One infant had intrauterine growth restriction (born to the mother with an internal hernia).

Another infant had intrauterine growth restriction plus a low birth weight (born to the mother with a gastrogastric fistula).

No infants had any congenital or developmental defects.

In five of the women who had pregnancies before their RYGB surgery, there were fewer instances of diabetes, hypertension, and complications during postsurgery pregnancies than in those that occurred before the operation.

Dr. Dao did not know how many of the other patients who received RYGB in the cohort were lost to follow-up, but she said that patients who report pregnancy at clinical visits or on follow-up surveys are interviewed to gather information.

STOCKHOLM — Psoriasis improves considerably for some women during pregnancy, and now there are data pointing to the ratio of estrogen to progesterone as a possible explanation for this improvement, according to the results of a study presented at an international conference on psoriasis and psoriatic arthritis.

For the study, 47 pregnant women with psoriasis had their psoriasis assessed and hormone levels measured at 10, 20, and 30 weeks' gestation and at 6 and 24 weeks post partum, said Stefani Kappel, a fourth-year medical student at the University of California, Irvine. Twenty-seven menstruating psoriasis patients were also recruited as controls. and were assessed at similar intervals over a 54-week period.

During pregnancy, just over half of the women (55%) reported improvement in their psoriasis: 21% reported no change and 23% reported worsening. “This was very similar to findings that were reported in the retrospective studies,” said Ms. Kappel, who collaborated with principal investigator Dr. Jenny E. Murase, a dermatology resident at the university.

In the postpartum period, 65% of the women reported a worsening of their psoriasis, 26% reported no change, and 9% reported an improvement.

Psoriatic body surface area decreased significantly among the pregnant women at 10–20 weeks' gestation, compared with the women in the control group. Psoriatic body surface area increased significantly by 6 weeks post partum among the new mothers, compared with the control women.

“Although two-thirds of the patients reported a worsening of psoriasis in the postpartum period … it was more of a return to baseline,” Ms. Kappel said.

The correlation between progesterone levels and improvement of psoriasis during pregnancy was not significant, nor was the correlation between estrone and improvement of psoriasis during pregnancy. There were moderate correlations between improvement in psoriasis and estriol and estradiol levels during pregnancy.

“Given that progesterone increases so much more than estradiol or estrone [during pregnancy], we hypothesized that it was the ratio of estrogen to progesterone that created an altered immunity,” Ms. Kappel said. The correlation between improvement of psoriasis during pregnancy and the ratio of estrogen to progesterone was the strongest.

One patient in particular had a progesterone level that was six standard deviations above the average of the general population during the pregnancy period but an estriol level that was within the normal range. Her psoriasis body surface area worsened from 52% to 65%. The researchers speculate that her ratio of progesterone to estrogen may have caused her worsening disease.

The study results illustrate that there is a shift from Th1 to Th2 immunity in pregnant patients. “This makes sense because Th1-mediated diseases, such as rheumatoid arthritis, psoriasis, and multiple sclerosis, tend to improve during pregnancy, whereas Th2-mediated diseases such as lupus tend to worsen,” Ms. Kappel explained.

In light of these findings, “estrogen, as a potential therapeutic option in conjunction with other treatment modalities, warrants further investigation,” she added.

Progesterone is the hormone that increases the most in pregnancy—about 200-fold—and is the key hormone in uterine suppression during pregnancy. Most of the pregnant women in this study had elevated progesterone levels within the normal range for the general population. Estrogen suppresses T-cell immunity but is also known to stimulate B-cell-mediated immunity in pregnancy.

Estradiol increases 24-fold during pregnancy and is the most potent estrogen; estrone increases about 6-fold during pregnancy. Estriol is the least potent and is only produced in significant amounts during pregnancy. Most of the pregnant study patients had normal-range levels of all three estrogens during their pregnancies.

STOCKHOLM — Psoriasis improves considerably for some women during pregnancy, and now there are data pointing to the ratio of estrogen to progesterone as a possible explanation for this improvement, according to the results of a study presented at an international conference on psoriasis and psoriatic arthritis.

For the study, 47 pregnant women with psoriasis had their psoriasis assessed and hormone levels measured at 10, 20, and 30 weeks' gestation and at 6 and 24 weeks post partum, said Stefani Kappel, a fourth-year medical student at the University of California, Irvine. Twenty-seven menstruating psoriasis patients were also recruited as controls. and were assessed at similar intervals over a 54-week period.

During pregnancy, just over half of the women (55%) reported improvement in their psoriasis: 21% reported no change and 23% reported worsening. “This was very similar to findings that were reported in the retrospective studies,” said Ms. Kappel, who collaborated with principal investigator Dr. Jenny E. Murase, a dermatology resident at the university.

In the postpartum period, 65% of the women reported a worsening of their psoriasis, 26% reported no change, and 9% reported an improvement.

Psoriatic body surface area decreased significantly among the pregnant women at 10–20 weeks' gestation, compared with the women in the control group. Psoriatic body surface area increased significantly by 6 weeks post partum among the new mothers, compared with the control women.

“Although two-thirds of the patients reported a worsening of psoriasis in the postpartum period … it was more of a return to baseline,” Ms. Kappel said.

The correlation between progesterone levels and improvement of psoriasis during pregnancy was not significant, nor was the correlation between estrone and improvement of psoriasis during pregnancy. There were moderate correlations between improvement in psoriasis and estriol and estradiol levels during pregnancy.

“Given that progesterone increases so much more than estradiol or estrone [during pregnancy], we hypothesized that it was the ratio of estrogen to progesterone that created an altered immunity,” Ms. Kappel said. The correlation between improvement of psoriasis during pregnancy and the ratio of estrogen to progesterone was the strongest.

One patient in particular had a progesterone level that was six standard deviations above the average of the general population during the pregnancy period but an estriol level that was within the normal range. Her psoriasis body surface area worsened from 52% to 65%. The researchers speculate that her ratio of progesterone to estrogen may have caused her worsening disease.

The study results illustrate that there is a shift from Th1 to Th2 immunity in pregnant patients. “This makes sense because Th1-mediated diseases, such as rheumatoid arthritis, psoriasis, and multiple sclerosis, tend to improve during pregnancy, whereas Th2-mediated diseases such as lupus tend to worsen,” Ms. Kappel explained.

In light of these findings, “estrogen, as a potential therapeutic option in conjunction with other treatment modalities, warrants further investigation,” she added.

Progesterone is the hormone that increases the most in pregnancy—about 200-fold—and is the key hormone in uterine suppression during pregnancy. Most of the pregnant women in this study had elevated progesterone levels within the normal range for the general population. Estrogen suppresses T-cell immunity but is also known to stimulate B-cell-mediated immunity in pregnancy.

Estradiol increases 24-fold during pregnancy and is the most potent estrogen; estrone increases about 6-fold during pregnancy. Estriol is the least potent and is only produced in significant amounts during pregnancy. Most of the pregnant study patients had normal-range levels of all three estrogens during their pregnancies.

STOCKHOLM — Psoriasis improves considerably for some women during pregnancy, and now there are data pointing to the ratio of estrogen to progesterone as a possible explanation for this improvement, according to the results of a study presented at an international conference on psoriasis and psoriatic arthritis.

For the study, 47 pregnant women with psoriasis had their psoriasis assessed and hormone levels measured at 10, 20, and 30 weeks' gestation and at 6 and 24 weeks post partum, said Stefani Kappel, a fourth-year medical student at the University of California, Irvine. Twenty-seven menstruating psoriasis patients were also recruited as controls. and were assessed at similar intervals over a 54-week period.

During pregnancy, just over half of the women (55%) reported improvement in their psoriasis: 21% reported no change and 23% reported worsening. “This was very similar to findings that were reported in the retrospective studies,” said Ms. Kappel, who collaborated with principal investigator Dr. Jenny E. Murase, a dermatology resident at the university.

In the postpartum period, 65% of the women reported a worsening of their psoriasis, 26% reported no change, and 9% reported an improvement.

Psoriatic body surface area decreased significantly among the pregnant women at 10–20 weeks' gestation, compared with the women in the control group. Psoriatic body surface area increased significantly by 6 weeks post partum among the new mothers, compared with the control women.

“Although two-thirds of the patients reported a worsening of psoriasis in the postpartum period … it was more of a return to baseline,” Ms. Kappel said.

The correlation between progesterone levels and improvement of psoriasis during pregnancy was not significant, nor was the correlation between estrone and improvement of psoriasis during pregnancy. There were moderate correlations between improvement in psoriasis and estriol and estradiol levels during pregnancy.

“Given that progesterone increases so much more than estradiol or estrone [during pregnancy], we hypothesized that it was the ratio of estrogen to progesterone that created an altered immunity,” Ms. Kappel said. The correlation between improvement of psoriasis during pregnancy and the ratio of estrogen to progesterone was the strongest.

One patient in particular had a progesterone level that was six standard deviations above the average of the general population during the pregnancy period but an estriol level that was within the normal range. Her psoriasis body surface area worsened from 52% to 65%. The researchers speculate that her ratio of progesterone to estrogen may have caused her worsening disease.

The study results illustrate that there is a shift from Th1 to Th2 immunity in pregnant patients. “This makes sense because Th1-mediated diseases, such as rheumatoid arthritis, psoriasis, and multiple sclerosis, tend to improve during pregnancy, whereas Th2-mediated diseases such as lupus tend to worsen,” Ms. Kappel explained.

In light of these findings, “estrogen, as a potential therapeutic option in conjunction with other treatment modalities, warrants further investigation,” she added.

Progesterone is the hormone that increases the most in pregnancy—about 200-fold—and is the key hormone in uterine suppression during pregnancy. Most of the pregnant women in this study had elevated progesterone levels within the normal range for the general population. Estrogen suppresses T-cell immunity but is also known to stimulate B-cell-mediated immunity in pregnancy.

Estradiol increases 24-fold during pregnancy and is the most potent estrogen; estrone increases about 6-fold during pregnancy. Estriol is the least potent and is only produced in significant amounts during pregnancy. Most of the pregnant study patients had normal-range levels of all three estrogens during their pregnancies.

PITTSBURGH — Pregnant women with anxiety or depression have higher levels of α-amylase, a measure of adrenergic system activity, and lower morning cortisol levels, preliminary results from a longitudinal study demonstrated.

The findings suggest that the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis may be affected in opposite directions by stress during pregnancy, Alison Shea, Ph.D. candidate, and her associates reported in a poster at the International Congress of Neuroendocrinology.

The analysis included 60 women who were among the first of 250 pregnant women to be recruited as part of the multicenter Maternal Adversity, Vulnerability, and Neurodevelopment (MAVAN) study led by Dr. Meir Steiner, of McMaster University, Hamilton, Ont.

The women were divided into three groups: those presenting with symptoms of depression or anxiety who chose psychotherapy only, those with symptoms who chose antidepressants, and a control group with no current or past psychiatric illness.

A battery of psychological tests was performed at baseline (gestational age 14–24 weeks), and morning salivary samples were collected daily to measure stress indicators such as cortisol, dehydroepiandrosterone (DHEA), and α-amylase. A follow-up assessment was performed at 24–30 weeks and included psychological testing, salivary samples, and a 24-hour Holter ECG.

Infants are being followed during the postpartum period until 3 years of age.

The results indicate that depression and anxiety scores during pregnancy are positively correlated with α-amylase levels and negatively correlated with morning cortisol levels.

Both associations were statistically significant, reported Ms. Shea, of the Women's Health Concerns Clinic, St. Joseph's Healthcare, Hamilton.

Compared with controls, both the cortisol response to awakening and the 24-hour heart rate variability were lower for mothers with anxiety and depression, particularly among those not taking antidepressants. Reduced heart rate variability indicates the body's inability to respond to stress in a changing environment, and is thought to improve with the use of antidepressants, Ms. Shea said in an interview. Interestingly, the study found that the greater the gravida's heart rate variability, the longer the gestation. “It makes sense, but it's never been looked at in pregnant women,” she said.

Head circumference at birth was strongly correlated with maternal 24-hour mean heart rate during pregnancy, even after controlling for birth weight and gestational age.

Among women with depression and anxiety, the higher the heart rate during pregnancy, the smaller the head circumference. Head circumference is purported to be a measure of brain volume and has been found to be smaller among babies born to women with posttraumatic stress disorder, she said.

Birth length was significantly smaller for babies born to women with anxiety or depression (49.64 cm), compared with those born to women treated with antidepressants (50.91 cm) and controls (53.01 cm).

Ponderal index, which is an indicator of infant body mass index, also was significantly higher among babies of women suffering from anxiety and depression (2.65 g/cm

The data provide some insights into the mechanisms by which stress, depression, and anxiety impact fetal development. But Ms. Shea cautioned that the data remain preliminary and the number of patients is small.

PITTSBURGH — Pregnant women with anxiety or depression have higher levels of α-amylase, a measure of adrenergic system activity, and lower morning cortisol levels, preliminary results from a longitudinal study demonstrated.

The findings suggest that the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis may be affected in opposite directions by stress during pregnancy, Alison Shea, Ph.D. candidate, and her associates reported in a poster at the International Congress of Neuroendocrinology.

The analysis included 60 women who were among the first of 250 pregnant women to be recruited as part of the multicenter Maternal Adversity, Vulnerability, and Neurodevelopment (MAVAN) study led by Dr. Meir Steiner, of McMaster University, Hamilton, Ont.

The women were divided into three groups: those presenting with symptoms of depression or anxiety who chose psychotherapy only, those with symptoms who chose antidepressants, and a control group with no current or past psychiatric illness.

A battery of psychological tests was performed at baseline (gestational age 14–24 weeks), and morning salivary samples were collected daily to measure stress indicators such as cortisol, dehydroepiandrosterone (DHEA), and α-amylase. A follow-up assessment was performed at 24–30 weeks and included psychological testing, salivary samples, and a 24-hour Holter ECG.

Infants are being followed during the postpartum period until 3 years of age.

The results indicate that depression and anxiety scores during pregnancy are positively correlated with α-amylase levels and negatively correlated with morning cortisol levels.

Both associations were statistically significant, reported Ms. Shea, of the Women's Health Concerns Clinic, St. Joseph's Healthcare, Hamilton.

Compared with controls, both the cortisol response to awakening and the 24-hour heart rate variability were lower for mothers with anxiety and depression, particularly among those not taking antidepressants. Reduced heart rate variability indicates the body's inability to respond to stress in a changing environment, and is thought to improve with the use of antidepressants, Ms. Shea said in an interview. Interestingly, the study found that the greater the gravida's heart rate variability, the longer the gestation. “It makes sense, but it's never been looked at in pregnant women,” she said.

Head circumference at birth was strongly correlated with maternal 24-hour mean heart rate during pregnancy, even after controlling for birth weight and gestational age.

Among women with depression and anxiety, the higher the heart rate during pregnancy, the smaller the head circumference. Head circumference is purported to be a measure of brain volume and has been found to be smaller among babies born to women with posttraumatic stress disorder, she said.

Birth length was significantly smaller for babies born to women with anxiety or depression (49.64 cm), compared with those born to women treated with antidepressants (50.91 cm) and controls (53.01 cm).

Ponderal index, which is an indicator of infant body mass index, also was significantly higher among babies of women suffering from anxiety and depression (2.65 g/cm

The data provide some insights into the mechanisms by which stress, depression, and anxiety impact fetal development. But Ms. Shea cautioned that the data remain preliminary and the number of patients is small.

PITTSBURGH — Pregnant women with anxiety or depression have higher levels of α-amylase, a measure of adrenergic system activity, and lower morning cortisol levels, preliminary results from a longitudinal study demonstrated.

The findings suggest that the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis may be affected in opposite directions by stress during pregnancy, Alison Shea, Ph.D. candidate, and her associates reported in a poster at the International Congress of Neuroendocrinology.

The analysis included 60 women who were among the first of 250 pregnant women to be recruited as part of the multicenter Maternal Adversity, Vulnerability, and Neurodevelopment (MAVAN) study led by Dr. Meir Steiner, of McMaster University, Hamilton, Ont.

The women were divided into three groups: those presenting with symptoms of depression or anxiety who chose psychotherapy only, those with symptoms who chose antidepressants, and a control group with no current or past psychiatric illness.

A battery of psychological tests was performed at baseline (gestational age 14–24 weeks), and morning salivary samples were collected daily to measure stress indicators such as cortisol, dehydroepiandrosterone (DHEA), and α-amylase. A follow-up assessment was performed at 24–30 weeks and included psychological testing, salivary samples, and a 24-hour Holter ECG.

Infants are being followed during the postpartum period until 3 years of age.

The results indicate that depression and anxiety scores during pregnancy are positively correlated with α-amylase levels and negatively correlated with morning cortisol levels.

Both associations were statistically significant, reported Ms. Shea, of the Women's Health Concerns Clinic, St. Joseph's Healthcare, Hamilton.

Compared with controls, both the cortisol response to awakening and the 24-hour heart rate variability were lower for mothers with anxiety and depression, particularly among those not taking antidepressants. Reduced heart rate variability indicates the body's inability to respond to stress in a changing environment, and is thought to improve with the use of antidepressants, Ms. Shea said in an interview. Interestingly, the study found that the greater the gravida's heart rate variability, the longer the gestation. “It makes sense, but it's never been looked at in pregnant women,” she said.

Head circumference at birth was strongly correlated with maternal 24-hour mean heart rate during pregnancy, even after controlling for birth weight and gestational age.

Among women with depression and anxiety, the higher the heart rate during pregnancy, the smaller the head circumference. Head circumference is purported to be a measure of brain volume and has been found to be smaller among babies born to women with posttraumatic stress disorder, she said.

Birth length was significantly smaller for babies born to women with anxiety or depression (49.64 cm), compared with those born to women treated with antidepressants (50.91 cm) and controls (53.01 cm).

Ponderal index, which is an indicator of infant body mass index, also was significantly higher among babies of women suffering from anxiety and depression (2.65 g/cm

The data provide some insights into the mechanisms by which stress, depression, and anxiety impact fetal development. But Ms. Shea cautioned that the data remain preliminary and the number of patients is small.

PRAGUE — Elective cesarean sections that are carried out near the end of term may be more likely to result in neonatal respiratory morbidity than planned vaginal births, Dr. Anne Kirkeby Hansen reported at the 20th European Congress of Perinatal Medicine.

Using data from the prospective Århus Birth Cohort, Dr. Hansen and her colleagues identified 2,438 singleton neonates born in 1998–2005 by elective cesarean section at a gestational age of greater than 36 weeks.

Overall, 403 (17%) of these infants had respiratory morbidity classified as respiratory distress syndrome, transient tachypnea of the newborn, or persistent pulmonary hypertension of the newborn, said Dr. Hansen of the Perinatal Epidemiology Research Unit at Århus (Denmark) University Hospital.

Respiratory morbidity occurred significantly more often among infants who were delivered by elective C-section at 37 weeks (4.5%) or 38 weeks (3.4%) than among those who were born via an intended vaginal delivery (1.4% and 1%, respectively). The relative risk of respiratory morbidity was 3.2 and 3.6 times higher if an elective C-section was performed at those gestational ages instead of an intended vaginal delivery, which included deliveries by vacuum, forceps, and emergency C-section.

Elective C-section at 37 weeks was associated with a significant, nearly sixfold higher relative risk of respiratory morbidity than among infants born by intended vaginal delivery at a gestational age of 40 weeks, 0.8% of whom had respiratory morbidity. The relative risk of respiratory morbidity for those born by C-section at 38 weeks was 4.4 times higher than that of neonates who were intended to be born vaginally.

Infants born by elective C-section at 37 weeks were 3.6 times more likely and those born at 38 weeks were 2.7 times more likely to have respiratory morbidity than infants born by elective C-section at 39 weeks.

The incidence of respiratory morbidity did not differ significantly between neonates in either category at a gestational age of 39 or 40 weeks.

“Both way of delivery and timing of elective cesarean section influence the risk of respiratory morbidity,” Dr. Hansen said.

“These results indicate that elective cesarean section is associated with an increased risk of respiratory morbidity regardless of gestational age. Timing of elective C-section is crucial as the risk of respiratory morbidity increases with decreasing gestational age,” she said.

PRAGUE — Elective cesarean sections that are carried out near the end of term may be more likely to result in neonatal respiratory morbidity than planned vaginal births, Dr. Anne Kirkeby Hansen reported at the 20th European Congress of Perinatal Medicine.

Using data from the prospective Århus Birth Cohort, Dr. Hansen and her colleagues identified 2,438 singleton neonates born in 1998–2005 by elective cesarean section at a gestational age of greater than 36 weeks.

Overall, 403 (17%) of these infants had respiratory morbidity classified as respiratory distress syndrome, transient tachypnea of the newborn, or persistent pulmonary hypertension of the newborn, said Dr. Hansen of the Perinatal Epidemiology Research Unit at Århus (Denmark) University Hospital.

Respiratory morbidity occurred significantly more often among infants who were delivered by elective C-section at 37 weeks (4.5%) or 38 weeks (3.4%) than among those who were born via an intended vaginal delivery (1.4% and 1%, respectively). The relative risk of respiratory morbidity was 3.2 and 3.6 times higher if an elective C-section was performed at those gestational ages instead of an intended vaginal delivery, which included deliveries by vacuum, forceps, and emergency C-section.

Elective C-section at 37 weeks was associated with a significant, nearly sixfold higher relative risk of respiratory morbidity than among infants born by intended vaginal delivery at a gestational age of 40 weeks, 0.8% of whom had respiratory morbidity. The relative risk of respiratory morbidity for those born by C-section at 38 weeks was 4.4 times higher than that of neonates who were intended to be born vaginally.

Infants born by elective C-section at 37 weeks were 3.6 times more likely and those born at 38 weeks were 2.7 times more likely to have respiratory morbidity than infants born by elective C-section at 39 weeks.

The incidence of respiratory morbidity did not differ significantly between neonates in either category at a gestational age of 39 or 40 weeks.

“Both way of delivery and timing of elective cesarean section influence the risk of respiratory morbidity,” Dr. Hansen said.

“These results indicate that elective cesarean section is associated with an increased risk of respiratory morbidity regardless of gestational age. Timing of elective C-section is crucial as the risk of respiratory morbidity increases with decreasing gestational age,” she said.

PRAGUE — Elective cesarean sections that are carried out near the end of term may be more likely to result in neonatal respiratory morbidity than planned vaginal births, Dr. Anne Kirkeby Hansen reported at the 20th European Congress of Perinatal Medicine.

Using data from the prospective Århus Birth Cohort, Dr. Hansen and her colleagues identified 2,438 singleton neonates born in 1998–2005 by elective cesarean section at a gestational age of greater than 36 weeks.

Overall, 403 (17%) of these infants had respiratory morbidity classified as respiratory distress syndrome, transient tachypnea of the newborn, or persistent pulmonary hypertension of the newborn, said Dr. Hansen of the Perinatal Epidemiology Research Unit at Århus (Denmark) University Hospital.

Respiratory morbidity occurred significantly more often among infants who were delivered by elective C-section at 37 weeks (4.5%) or 38 weeks (3.4%) than among those who were born via an intended vaginal delivery (1.4% and 1%, respectively). The relative risk of respiratory morbidity was 3.2 and 3.6 times higher if an elective C-section was performed at those gestational ages instead of an intended vaginal delivery, which included deliveries by vacuum, forceps, and emergency C-section.

Elective C-section at 37 weeks was associated with a significant, nearly sixfold higher relative risk of respiratory morbidity than among infants born by intended vaginal delivery at a gestational age of 40 weeks, 0.8% of whom had respiratory morbidity. The relative risk of respiratory morbidity for those born by C-section at 38 weeks was 4.4 times higher than that of neonates who were intended to be born vaginally.

Infants born by elective C-section at 37 weeks were 3.6 times more likely and those born at 38 weeks were 2.7 times more likely to have respiratory morbidity than infants born by elective C-section at 39 weeks.

The incidence of respiratory morbidity did not differ significantly between neonates in either category at a gestational age of 39 or 40 weeks.

“Both way of delivery and timing of elective cesarean section influence the risk of respiratory morbidity,” Dr. Hansen said.

“These results indicate that elective cesarean section is associated with an increased risk of respiratory morbidity regardless of gestational age. Timing of elective C-section is crucial as the risk of respiratory morbidity increases with decreasing gestational age,” she said.

LISBON — Recombinant factor VIIa is potentially lifesaving for women undergoing massive hemorrhage after delivery, Dr. Claire McLintock said at the annual meeting of the International Society of Obstetric Medicine.

Although little information is available on the benefits and risks of treatment with recombinant factor VIIa in postpartum women, it's an option when all other treatments have failed to stop bleeding, said Dr. McLintock, an obstetric physician and hematologist at National Women's Health at Auckland City Hospital, New Zealand.

“I'm not sure that a randomized trial will ever be done” to test the drug's safety and efficacy, so for the time being, registry reviews provide the only data, she said.

A registry of factor VIIa recipients in Australia and New Zealand with a total of 289 patients includes eight cases of obstetric use. Each of the eight women received a single dose. In two women, the bleeding stopped immediately after treatment, and in the other six, bleeding slowed. Treatment also led to reduced transfusions with red cells, platelets, cryoprecipitate, and fresh frozen plasma.

The registry is sponsored by Novo Nordisk, which markets recombinant factor VIIa (NovoSeven). Novo Nordisk also provided travel funds for Dr. McLintock.

Another registry for obstetric patients receiving recombinant factor VIIa is kept by 475 hospitals in several northern European countries. This registry recently included 77 women who received the drug for bleeding, and bleeding improved in 82%. Three of the women (4%) had a thromboembolism after treatment.

“There is no doubt that treatment with factor VIIa has a thromboembolism risk that may be as high as 2%–4%, but this risk may be outweighed by benefits,” said Dr. McLintock. “In addition, the risks from massive blood transfusion cannot be underestimated.”

Cost is an issue. In the United States, the average wholesale cost for the drug is $1.48/mcg, according to the 2005 Red Book. The effective dose in hemorrhage has not been established, but 100 mcg/kg is recommended when factor VIIa is used for hemophilia patients. Dr. McLintock recommended a dose of 100 mcg/kg that is rounded off to the nearest vial size. For a 60-kg woman, the dose would be 6,000 mcg, which would cost almost $9,000. Factor VIIa works quickly; if the patient doesn't respond to the first dose within 20 minutes, consider giving a second dose, she said.

Once a patient has received a massive transfusion with red cells, platelets, cryoprecipitate, and fresh frozen plasma, dilution of clotting factors worsens the coagulopathy and makes it harder to stop bleeding. Such cases are “hard to rescue without a dramatic treatment” such as factor VIIa, Dr. McLintock said.

If the patient doesn't respond to the first dose within 20 minutes, consider giving a second dose. DR. MCLINTOCK

LISBON — Recombinant factor VIIa is potentially lifesaving for women undergoing massive hemorrhage after delivery, Dr. Claire McLintock said at the annual meeting of the International Society of Obstetric Medicine.

Although little information is available on the benefits and risks of treatment with recombinant factor VIIa in postpartum women, it's an option when all other treatments have failed to stop bleeding, said Dr. McLintock, an obstetric physician and hematologist at National Women's Health at Auckland City Hospital, New Zealand.

“I'm not sure that a randomized trial will ever be done” to test the drug's safety and efficacy, so for the time being, registry reviews provide the only data, she said.

A registry of factor VIIa recipients in Australia and New Zealand with a total of 289 patients includes eight cases of obstetric use. Each of the eight women received a single dose. In two women, the bleeding stopped immediately after treatment, and in the other six, bleeding slowed. Treatment also led to reduced transfusions with red cells, platelets, cryoprecipitate, and fresh frozen plasma.

The registry is sponsored by Novo Nordisk, which markets recombinant factor VIIa (NovoSeven). Novo Nordisk also provided travel funds for Dr. McLintock.

Another registry for obstetric patients receiving recombinant factor VIIa is kept by 475 hospitals in several northern European countries. This registry recently included 77 women who received the drug for bleeding, and bleeding improved in 82%. Three of the women (4%) had a thromboembolism after treatment.

“There is no doubt that treatment with factor VIIa has a thromboembolism risk that may be as high as 2%–4%, but this risk may be outweighed by benefits,” said Dr. McLintock. “In addition, the risks from massive blood transfusion cannot be underestimated.”

Cost is an issue. In the United States, the average wholesale cost for the drug is $1.48/mcg, according to the 2005 Red Book. The effective dose in hemorrhage has not been established, but 100 mcg/kg is recommended when factor VIIa is used for hemophilia patients. Dr. McLintock recommended a dose of 100 mcg/kg that is rounded off to the nearest vial size. For a 60-kg woman, the dose would be 6,000 mcg, which would cost almost $9,000. Factor VIIa works quickly; if the patient doesn't respond to the first dose within 20 minutes, consider giving a second dose, she said.

Once a patient has received a massive transfusion with red cells, platelets, cryoprecipitate, and fresh frozen plasma, dilution of clotting factors worsens the coagulopathy and makes it harder to stop bleeding. Such cases are “hard to rescue without a dramatic treatment” such as factor VIIa, Dr. McLintock said.

If the patient doesn't respond to the first dose within 20 minutes, consider giving a second dose. DR. MCLINTOCK

LISBON — Recombinant factor VIIa is potentially lifesaving for women undergoing massive hemorrhage after delivery, Dr. Claire McLintock said at the annual meeting of the International Society of Obstetric Medicine.

Although little information is available on the benefits and risks of treatment with recombinant factor VIIa in postpartum women, it's an option when all other treatments have failed to stop bleeding, said Dr. McLintock, an obstetric physician and hematologist at National Women's Health at Auckland City Hospital, New Zealand.

“I'm not sure that a randomized trial will ever be done” to test the drug's safety and efficacy, so for the time being, registry reviews provide the only data, she said.

A registry of factor VIIa recipients in Australia and New Zealand with a total of 289 patients includes eight cases of obstetric use. Each of the eight women received a single dose. In two women, the bleeding stopped immediately after treatment, and in the other six, bleeding slowed. Treatment also led to reduced transfusions with red cells, platelets, cryoprecipitate, and fresh frozen plasma.

The registry is sponsored by Novo Nordisk, which markets recombinant factor VIIa (NovoSeven). Novo Nordisk also provided travel funds for Dr. McLintock.

Another registry for obstetric patients receiving recombinant factor VIIa is kept by 475 hospitals in several northern European countries. This registry recently included 77 women who received the drug for bleeding, and bleeding improved in 82%. Three of the women (4%) had a thromboembolism after treatment.

“There is no doubt that treatment with factor VIIa has a thromboembolism risk that may be as high as 2%–4%, but this risk may be outweighed by benefits,” said Dr. McLintock. “In addition, the risks from massive blood transfusion cannot be underestimated.”

Cost is an issue. In the United States, the average wholesale cost for the drug is $1.48/mcg, according to the 2005 Red Book. The effective dose in hemorrhage has not been established, but 100 mcg/kg is recommended when factor VIIa is used for hemophilia patients. Dr. McLintock recommended a dose of 100 mcg/kg that is rounded off to the nearest vial size. For a 60-kg woman, the dose would be 6,000 mcg, which would cost almost $9,000. Factor VIIa works quickly; if the patient doesn't respond to the first dose within 20 minutes, consider giving a second dose, she said.

Once a patient has received a massive transfusion with red cells, platelets, cryoprecipitate, and fresh frozen plasma, dilution of clotting factors worsens the coagulopathy and makes it harder to stop bleeding. Such cases are “hard to rescue without a dramatic treatment” such as factor VIIa, Dr. McLintock said.

If the patient doesn't respond to the first dose within 20 minutes, consider giving a second dose. DR. MCLINTOCK

TUCSON, ARIZ. — Recent published data suggest a risk of birth defects among live-born infants of mothers infected with West Nile virus, but much more work is needed to confirm the association, Dr. Dawn M. Wesson said at the annual meeting of the Teratology Society.

“There appears to be a slightly higher frequency of major birth defects in the West Nile-infected group as compared to the general population, but … even though this is suggestive it's certainly not proof,” cautioned Dr. Wesson, of the department of tropical medicine at Tulane University School of Public Health and Tropical Medicine in New Orleans.

She based her remarks on a clinical study of 77 women infected with West Nile virus (WNV) during pregnancy in 2003 and 2004 who were followed in 16 states. Of the 77 women, 71 delivered 72 live infants. Four women had miscarriages and two had abortions (Pediatrics 2006;117:e537–45).

Of the 72 live infants, 67 were born at term, 4 were born preterm, and the gestational age of 1 infant was unknown.

The researchers, led by Daniel R. O'Leary, D.V.M., of the division of vector-borne infectious diseases at the Centers for Disease Control and Prevention, found that nearly 11% of infants born to mothers infected with West Nile virus during pregnancy had major birth defects, compared with almost 6% of infants born to uninfected mothers in the general population.

The researchers cautioned that of the 72 infants followed to date, nearly all appeared to be normal, and none had conclusive laboratory evidence of congenital WNV infection.

Seven infants had major malformations, but “only three had defects that could have been caused by maternal WNV infection based on the timing of the infections and the sensitive developmental period for the specific malformations, and none had any conclusive evidence of WNV etiology,” Dr. O'Leary and his associates wrote.

At the meeting, Dr. Wesson said one of the key reasons researchers are unable to determine with certainty whether WNV is a teratogen is that the sensitivity and specificity of IgM testing of cord blood to detect WNV is really unknown.

“Also, congenital WNV infection among newborns with IgM-negative serology cannot be ruled out,” she said. “We need more studies.”

In a partnership between the Centers for Disease Control and Prevention and Tulane University, researchers are studying the effect of WNV on pregnancy outcomes in two groups of women: retrospectively in those infected while pregnant during 2003 and 2004, and prospectively in those infected while pregnant between 2005 and 2008.

In addition to performing all recommended tests during and after pregnancy, the researchers plan to follow case and control infants with ophthalmologic and developmental exams as well as a CT scan if indicated, and a dysmorphology exam in infected infants.

The final part of the effort is to perform morphologic, endocrine, and molecular assessments of the villous placenta, trophoblast, conceptus membranes, and maternal decidua.

“We don't know the answer to the question [about WNV's possible role as a teratogen], but I think the pieces that we have in place and the collaborators we have in line should help us to answer those questions in the future,” Dr. Wesson concluded.

The capacity of IgM testing of cord blood to detect West Nile virus (shown in electron micrograph) is still unknown. CDC

TUCSON, ARIZ. — Recent published data suggest a risk of birth defects among live-born infants of mothers infected with West Nile virus, but much more work is needed to confirm the association, Dr. Dawn M. Wesson said at the annual meeting of the Teratology Society.

“There appears to be a slightly higher frequency of major birth defects in the West Nile-infected group as compared to the general population, but … even though this is suggestive it's certainly not proof,” cautioned Dr. Wesson, of the department of tropical medicine at Tulane University School of Public Health and Tropical Medicine in New Orleans.

She based her remarks on a clinical study of 77 women infected with West Nile virus (WNV) during pregnancy in 2003 and 2004 who were followed in 16 states. Of the 77 women, 71 delivered 72 live infants. Four women had miscarriages and two had abortions (Pediatrics 2006;117:e537–45).

Of the 72 live infants, 67 were born at term, 4 were born preterm, and the gestational age of 1 infant was unknown.

The researchers, led by Daniel R. O'Leary, D.V.M., of the division of vector-borne infectious diseases at the Centers for Disease Control and Prevention, found that nearly 11% of infants born to mothers infected with West Nile virus during pregnancy had major birth defects, compared with almost 6% of infants born to uninfected mothers in the general population.

The researchers cautioned that of the 72 infants followed to date, nearly all appeared to be normal, and none had conclusive laboratory evidence of congenital WNV infection.

Seven infants had major malformations, but “only three had defects that could have been caused by maternal WNV infection based on the timing of the infections and the sensitive developmental period for the specific malformations, and none had any conclusive evidence of WNV etiology,” Dr. O'Leary and his associates wrote.

At the meeting, Dr. Wesson said one of the key reasons researchers are unable to determine with certainty whether WNV is a teratogen is that the sensitivity and specificity of IgM testing of cord blood to detect WNV is really unknown.

“Also, congenital WNV infection among newborns with IgM-negative serology cannot be ruled out,” she said. “We need more studies.”

In a partnership between the Centers for Disease Control and Prevention and Tulane University, researchers are studying the effect of WNV on pregnancy outcomes in two groups of women: retrospectively in those infected while pregnant during 2003 and 2004, and prospectively in those infected while pregnant between 2005 and 2008.

In addition to performing all recommended tests during and after pregnancy, the researchers plan to follow case and control infants with ophthalmologic and developmental exams as well as a CT scan if indicated, and a dysmorphology exam in infected infants.

The final part of the effort is to perform morphologic, endocrine, and molecular assessments of the villous placenta, trophoblast, conceptus membranes, and maternal decidua.

“We don't know the answer to the question [about WNV's possible role as a teratogen], but I think the pieces that we have in place and the collaborators we have in line should help us to answer those questions in the future,” Dr. Wesson concluded.

The capacity of IgM testing of cord blood to detect West Nile virus (shown in electron micrograph) is still unknown. CDC

TUCSON, ARIZ. — Recent published data suggest a risk of birth defects among live-born infants of mothers infected with West Nile virus, but much more work is needed to confirm the association, Dr. Dawn M. Wesson said at the annual meeting of the Teratology Society.

“There appears to be a slightly higher frequency of major birth defects in the West Nile-infected group as compared to the general population, but … even though this is suggestive it's certainly not proof,” cautioned Dr. Wesson, of the department of tropical medicine at Tulane University School of Public Health and Tropical Medicine in New Orleans.

She based her remarks on a clinical study of 77 women infected with West Nile virus (WNV) during pregnancy in 2003 and 2004 who were followed in 16 states. Of the 77 women, 71 delivered 72 live infants. Four women had miscarriages and two had abortions (Pediatrics 2006;117:e537–45).

Of the 72 live infants, 67 were born at term, 4 were born preterm, and the gestational age of 1 infant was unknown.

The researchers, led by Daniel R. O'Leary, D.V.M., of the division of vector-borne infectious diseases at the Centers for Disease Control and Prevention, found that nearly 11% of infants born to mothers infected with West Nile virus during pregnancy had major birth defects, compared with almost 6% of infants born to uninfected mothers in the general population.

The researchers cautioned that of the 72 infants followed to date, nearly all appeared to be normal, and none had conclusive laboratory evidence of congenital WNV infection.

Seven infants had major malformations, but “only three had defects that could have been caused by maternal WNV infection based on the timing of the infections and the sensitive developmental period for the specific malformations, and none had any conclusive evidence of WNV etiology,” Dr. O'Leary and his associates wrote.

At the meeting, Dr. Wesson said one of the key reasons researchers are unable to determine with certainty whether WNV is a teratogen is that the sensitivity and specificity of IgM testing of cord blood to detect WNV is really unknown.

“Also, congenital WNV infection among newborns with IgM-negative serology cannot be ruled out,” she said. “We need more studies.”

In a partnership between the Centers for Disease Control and Prevention and Tulane University, researchers are studying the effect of WNV on pregnancy outcomes in two groups of women: retrospectively in those infected while pregnant during 2003 and 2004, and prospectively in those infected while pregnant between 2005 and 2008.

In addition to performing all recommended tests during and after pregnancy, the researchers plan to follow case and control infants with ophthalmologic and developmental exams as well as a CT scan if indicated, and a dysmorphology exam in infected infants.

The final part of the effort is to perform morphologic, endocrine, and molecular assessments of the villous placenta, trophoblast, conceptus membranes, and maternal decidua.

“We don't know the answer to the question [about WNV's possible role as a teratogen], but I think the pieces that we have in place and the collaborators we have in line should help us to answer those questions in the future,” Dr. Wesson concluded.

The capacity of IgM testing of cord blood to detect West Nile virus (shown in electron micrograph) is still unknown. CDC