Obstetrics

HOLLYWOOD, FLA. — Remifentanil was found to be effective and safe for labor analgesia in a small randomized controlled study, Dr. Mrinalini Balki reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A total of 15 women were randomized to receive either a fixed bolus/increasing infusion regimen, or a fixed infusion/increasing bolus regimen of the short-acting opioid analgesic.

The groups had similar overall median satisfaction scores (9 and 9 on a 0–10 scale), and pain scores (6 and 7 on a 0–10 scale), but maternal side effects were more common in the fixed infusion group, and pain control appeared to be less effective in that group, said Dr. Balki of the University of Toronto.

For example, 38% in the fixed bolus group, compared with 100% in the fixed infusion group, experienced drowsiness. Desaturation was noted in 13% in the fixed bolus group, compared with 57% in the fixed infusion group. And effective pain control, as measured by successful patient-controlled analgesia attempts (74% vs. 56%) and drug consumption (407 ng vs. 532 ng), was more common in the fixed bolus group.

Patients in both groups were treated with remifentanil infusion at 0.025 mcg/kg per minute, and patients were offered a patient-controlled analgesia bolus of 0.25 mcg/kg, with a lockout interval of 2 minutes.

The fixed-bolus group had infusions increased in a stepwise manner from 0.025 to 0.05, 0.075, and 0.1 mcg/kg minute as needed, and the bolus was fixed at 0.25 mcg/kg.

In the fixed infusion group, the infusion was fixed at 0.025 mcg/kg per minute and the bolus was increased from 0.25 to 0.5, 0.75, and 1 mcg/kg as needed.

Patient satisfaction in both groups was high, despite high pain scores.

This could reflect patient motivation or altered pain perception among those who choose remifentanil, Dr. Balki explained.

Since those in the fixed bolus group had better pain scores and required less drug, this regimen appears superior.

Neonatal safety was also similar in the two groups. A nonreassuring fetal heart rate was noted in one fetus in the fixed-bolus and in none of those in the fixed-infusion group, and Apgar scores were greater than 7 in all babies in both groups, Dr. Balki noted.

HOLLYWOOD, FLA. — Remifentanil was found to be effective and safe for labor analgesia in a small randomized controlled study, Dr. Mrinalini Balki reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A total of 15 women were randomized to receive either a fixed bolus/increasing infusion regimen, or a fixed infusion/increasing bolus regimen of the short-acting opioid analgesic.

The groups had similar overall median satisfaction scores (9 and 9 on a 0–10 scale), and pain scores (6 and 7 on a 0–10 scale), but maternal side effects were more common in the fixed infusion group, and pain control appeared to be less effective in that group, said Dr. Balki of the University of Toronto.

For example, 38% in the fixed bolus group, compared with 100% in the fixed infusion group, experienced drowsiness. Desaturation was noted in 13% in the fixed bolus group, compared with 57% in the fixed infusion group. And effective pain control, as measured by successful patient-controlled analgesia attempts (74% vs. 56%) and drug consumption (407 ng vs. 532 ng), was more common in the fixed bolus group.

Patients in both groups were treated with remifentanil infusion at 0.025 mcg/kg per minute, and patients were offered a patient-controlled analgesia bolus of 0.25 mcg/kg, with a lockout interval of 2 minutes.

The fixed-bolus group had infusions increased in a stepwise manner from 0.025 to 0.05, 0.075, and 0.1 mcg/kg minute as needed, and the bolus was fixed at 0.25 mcg/kg.

In the fixed infusion group, the infusion was fixed at 0.025 mcg/kg per minute and the bolus was increased from 0.25 to 0.5, 0.75, and 1 mcg/kg as needed.

Patient satisfaction in both groups was high, despite high pain scores.

This could reflect patient motivation or altered pain perception among those who choose remifentanil, Dr. Balki explained.

Since those in the fixed bolus group had better pain scores and required less drug, this regimen appears superior.

Neonatal safety was also similar in the two groups. A nonreassuring fetal heart rate was noted in one fetus in the fixed-bolus and in none of those in the fixed-infusion group, and Apgar scores were greater than 7 in all babies in both groups, Dr. Balki noted.

HOLLYWOOD, FLA. — Remifentanil was found to be effective and safe for labor analgesia in a small randomized controlled study, Dr. Mrinalini Balki reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A total of 15 women were randomized to receive either a fixed bolus/increasing infusion regimen, or a fixed infusion/increasing bolus regimen of the short-acting opioid analgesic.

The groups had similar overall median satisfaction scores (9 and 9 on a 0–10 scale), and pain scores (6 and 7 on a 0–10 scale), but maternal side effects were more common in the fixed infusion group, and pain control appeared to be less effective in that group, said Dr. Balki of the University of Toronto.

For example, 38% in the fixed bolus group, compared with 100% in the fixed infusion group, experienced drowsiness. Desaturation was noted in 13% in the fixed bolus group, compared with 57% in the fixed infusion group. And effective pain control, as measured by successful patient-controlled analgesia attempts (74% vs. 56%) and drug consumption (407 ng vs. 532 ng), was more common in the fixed bolus group.

Patients in both groups were treated with remifentanil infusion at 0.025 mcg/kg per minute, and patients were offered a patient-controlled analgesia bolus of 0.25 mcg/kg, with a lockout interval of 2 minutes.

The fixed-bolus group had infusions increased in a stepwise manner from 0.025 to 0.05, 0.075, and 0.1 mcg/kg minute as needed, and the bolus was fixed at 0.25 mcg/kg.

In the fixed infusion group, the infusion was fixed at 0.025 mcg/kg per minute and the bolus was increased from 0.25 to 0.5, 0.75, and 1 mcg/kg as needed.

Patient satisfaction in both groups was high, despite high pain scores.

This could reflect patient motivation or altered pain perception among those who choose remifentanil, Dr. Balki explained.

Since those in the fixed bolus group had better pain scores and required less drug, this regimen appears superior.

Neonatal safety was also similar in the two groups. A nonreassuring fetal heart rate was noted in one fetus in the fixed-bolus and in none of those in the fixed-infusion group, and Apgar scores were greater than 7 in all babies in both groups, Dr. Balki noted.

PRAGUE — New insights into the pathophysiologic changes of preeclampsia that occur in the placenta are helping researchers to develop potential early screening tests for the disease using biomarkers in maternal blood, Dr. Wolfgang Holzgreve said at the 20th European Congress of Perinatal Medicine.

The current line of research into the cause of preeclampsia originates from observations that associated the long-term presence of fetal cells and DNA in maternal blood with autoimmune diseases such as scleroderma and conditions such as polymorphic eruptions of pregnancy (Lancet 1998;352:1898–901). About 8 years ago, Dr. Holzgreve and his colleagues at the University of Basel (Switzerland) began to recognize that the association between microchimerism and maternal disease might extend to preeclampsia and play a role in its pathophysiology.

In Dr. Holzgreve's lab, researchers found many more fetal cells and DNA in the blood of women with preeclampsia than in women with normal pregnancies. Reports from his lab indicated that the elevated levels of free fetal DNA in maternal blood positively correlated with the presence and severity of preeclampsia in mothers in a dose-response-like effect (Am. J. Obstet. Gynecol. 2001;184:414–9).

Similar observations were made regarding the effect of the total amount of free maternal DNA in a pregnant woman's plasma. The total free maternal DNA seemed to be a marker for the amount of damage that preeclampsia causes to the endothelial cells that line the liver and kidneys, as well as the circulatory system, he said.

The first insult to occur in preeclampsia is an invasion of trophoblasts that causes impairment of the spiral arteries and placental changes. The investigators hypothesized that the excess fetal cells and DNA going into the maternal circulation cause leukocyte activation and an “inflammatory-like reaction” in the peripheral endothelial system (Placenta 2005;26:515–26).

Anatomists working with Dr. Holzgreve's group have calculated that about 3 billion mitoses occur in the placenta each day—no cancer in humans has such a high rate of division—and this activity produces about 3.6 g of new syncytium each day from all of the placental cell divisions. But only 0.6 g of new syncytium is incorporated into the placenta each day. Thus, about 3 g of syncytial tissue travels into the intervillous space and into the maternal circulation each day.

Normally the multinucleated cells and membrane-bound particles of syncytium undergo controlled apoptosis. But if the placenta is hypoxic from trophoblast invasion, a separate pathway of aponecrotic shedding occurs, releasing materials that are toxic to the maternal epithelial system. In vitro tests in Dr. Holzgreve's lab have shown that cultures of endothelial cells from umbilical veins break down after exposure to particles of placental syncytium.

Recent evidence has shown that the body traps the materials shed from the placenta by an extracellular filamentous network produced by neutrophils, which is the same as the defensive mechanism described for neutrophils that trap pathogenic bacteria (Science 2004;303:1532–5). These networks are present in higher abundance in preeclamptic women than in pregnant control women, Dr. Holzgreve said.

The model of excess fetal cells and free DNA also fits with the knowledge that the highest risk for preeclampsia occurs in first pregnancies (in which the mother has not been exposed to her partner's genes), in women who have a new pregnancy from a different man, and in cases of ovum donation in which all of the fetal material is foreign.

Because clinical signs and symptoms are so poor at predicting who will have preeclampsia, Dr. Holzgreve and his colleagues have tried, using the increase in free fetal DNA in the maternal circulation, to predict preeclampsia as early in pregnancy as possible. Recent studies have indicated that women with preeclampsia have significantly increased levels of free fetal DNA in their blood beginning at a gestational age of 20 weeks, which could have potential as an early test for the disease, he said.

“What needs to be done now is a big, multicenter study to see what the predictive tests are,” he said. “Then the vision would be that there is first-trimester screening of nuchal translucency and second-trimester screening including free fetal DNA” in maternal blood.

PRAGUE — New insights into the pathophysiologic changes of preeclampsia that occur in the placenta are helping researchers to develop potential early screening tests for the disease using biomarkers in maternal blood, Dr. Wolfgang Holzgreve said at the 20th European Congress of Perinatal Medicine.

The current line of research into the cause of preeclampsia originates from observations that associated the long-term presence of fetal cells and DNA in maternal blood with autoimmune diseases such as scleroderma and conditions such as polymorphic eruptions of pregnancy (Lancet 1998;352:1898–901). About 8 years ago, Dr. Holzgreve and his colleagues at the University of Basel (Switzerland) began to recognize that the association between microchimerism and maternal disease might extend to preeclampsia and play a role in its pathophysiology.

In Dr. Holzgreve's lab, researchers found many more fetal cells and DNA in the blood of women with preeclampsia than in women with normal pregnancies. Reports from his lab indicated that the elevated levels of free fetal DNA in maternal blood positively correlated with the presence and severity of preeclampsia in mothers in a dose-response-like effect (Am. J. Obstet. Gynecol. 2001;184:414–9).

Similar observations were made regarding the effect of the total amount of free maternal DNA in a pregnant woman's plasma. The total free maternal DNA seemed to be a marker for the amount of damage that preeclampsia causes to the endothelial cells that line the liver and kidneys, as well as the circulatory system, he said.

The first insult to occur in preeclampsia is an invasion of trophoblasts that causes impairment of the spiral arteries and placental changes. The investigators hypothesized that the excess fetal cells and DNA going into the maternal circulation cause leukocyte activation and an “inflammatory-like reaction” in the peripheral endothelial system (Placenta 2005;26:515–26).

Anatomists working with Dr. Holzgreve's group have calculated that about 3 billion mitoses occur in the placenta each day—no cancer in humans has such a high rate of division—and this activity produces about 3.6 g of new syncytium each day from all of the placental cell divisions. But only 0.6 g of new syncytium is incorporated into the placenta each day. Thus, about 3 g of syncytial tissue travels into the intervillous space and into the maternal circulation each day.

Normally the multinucleated cells and membrane-bound particles of syncytium undergo controlled apoptosis. But if the placenta is hypoxic from trophoblast invasion, a separate pathway of aponecrotic shedding occurs, releasing materials that are toxic to the maternal epithelial system. In vitro tests in Dr. Holzgreve's lab have shown that cultures of endothelial cells from umbilical veins break down after exposure to particles of placental syncytium.

Recent evidence has shown that the body traps the materials shed from the placenta by an extracellular filamentous network produced by neutrophils, which is the same as the defensive mechanism described for neutrophils that trap pathogenic bacteria (Science 2004;303:1532–5). These networks are present in higher abundance in preeclamptic women than in pregnant control women, Dr. Holzgreve said.

The model of excess fetal cells and free DNA also fits with the knowledge that the highest risk for preeclampsia occurs in first pregnancies (in which the mother has not been exposed to her partner's genes), in women who have a new pregnancy from a different man, and in cases of ovum donation in which all of the fetal material is foreign.

Because clinical signs and symptoms are so poor at predicting who will have preeclampsia, Dr. Holzgreve and his colleagues have tried, using the increase in free fetal DNA in the maternal circulation, to predict preeclampsia as early in pregnancy as possible. Recent studies have indicated that women with preeclampsia have significantly increased levels of free fetal DNA in their blood beginning at a gestational age of 20 weeks, which could have potential as an early test for the disease, he said.

“What needs to be done now is a big, multicenter study to see what the predictive tests are,” he said. “Then the vision would be that there is first-trimester screening of nuchal translucency and second-trimester screening including free fetal DNA” in maternal blood.

PRAGUE — New insights into the pathophysiologic changes of preeclampsia that occur in the placenta are helping researchers to develop potential early screening tests for the disease using biomarkers in maternal blood, Dr. Wolfgang Holzgreve said at the 20th European Congress of Perinatal Medicine.

The current line of research into the cause of preeclampsia originates from observations that associated the long-term presence of fetal cells and DNA in maternal blood with autoimmune diseases such as scleroderma and conditions such as polymorphic eruptions of pregnancy (Lancet 1998;352:1898–901). About 8 years ago, Dr. Holzgreve and his colleagues at the University of Basel (Switzerland) began to recognize that the association between microchimerism and maternal disease might extend to preeclampsia and play a role in its pathophysiology.

In Dr. Holzgreve's lab, researchers found many more fetal cells and DNA in the blood of women with preeclampsia than in women with normal pregnancies. Reports from his lab indicated that the elevated levels of free fetal DNA in maternal blood positively correlated with the presence and severity of preeclampsia in mothers in a dose-response-like effect (Am. J. Obstet. Gynecol. 2001;184:414–9).

Similar observations were made regarding the effect of the total amount of free maternal DNA in a pregnant woman's plasma. The total free maternal DNA seemed to be a marker for the amount of damage that preeclampsia causes to the endothelial cells that line the liver and kidneys, as well as the circulatory system, he said.

The first insult to occur in preeclampsia is an invasion of trophoblasts that causes impairment of the spiral arteries and placental changes. The investigators hypothesized that the excess fetal cells and DNA going into the maternal circulation cause leukocyte activation and an “inflammatory-like reaction” in the peripheral endothelial system (Placenta 2005;26:515–26).

Anatomists working with Dr. Holzgreve's group have calculated that about 3 billion mitoses occur in the placenta each day—no cancer in humans has such a high rate of division—and this activity produces about 3.6 g of new syncytium each day from all of the placental cell divisions. But only 0.6 g of new syncytium is incorporated into the placenta each day. Thus, about 3 g of syncytial tissue travels into the intervillous space and into the maternal circulation each day.

Normally the multinucleated cells and membrane-bound particles of syncytium undergo controlled apoptosis. But if the placenta is hypoxic from trophoblast invasion, a separate pathway of aponecrotic shedding occurs, releasing materials that are toxic to the maternal epithelial system. In vitro tests in Dr. Holzgreve's lab have shown that cultures of endothelial cells from umbilical veins break down after exposure to particles of placental syncytium.

Recent evidence has shown that the body traps the materials shed from the placenta by an extracellular filamentous network produced by neutrophils, which is the same as the defensive mechanism described for neutrophils that trap pathogenic bacteria (Science 2004;303:1532–5). These networks are present in higher abundance in preeclamptic women than in pregnant control women, Dr. Holzgreve said.

The model of excess fetal cells and free DNA also fits with the knowledge that the highest risk for preeclampsia occurs in first pregnancies (in which the mother has not been exposed to her partner's genes), in women who have a new pregnancy from a different man, and in cases of ovum donation in which all of the fetal material is foreign.

Because clinical signs and symptoms are so poor at predicting who will have preeclampsia, Dr. Holzgreve and his colleagues have tried, using the increase in free fetal DNA in the maternal circulation, to predict preeclampsia as early in pregnancy as possible. Recent studies have indicated that women with preeclampsia have significantly increased levels of free fetal DNA in their blood beginning at a gestational age of 20 weeks, which could have potential as an early test for the disease, he said.

“What needs to be done now is a big, multicenter study to see what the predictive tests are,” he said. “Then the vision would be that there is first-trimester screening of nuchal translucency and second-trimester screening including free fetal DNA” in maternal blood.

PRAGUE — Very few women in their first pregnancy appear to request an elective cesarean section but when they do, few would do it again, according to a study of nearly 400 German and U.S. women presented at the 20th European Congress of Perinatal Medicine.

In a prospective study of maternal preferences for birth, questionnaires were completed by 55 of 64 American and 342 of 366 German women.

All of the women were primigravid with singleton pregnancies and in good health when they completed questionnaires in the third trimester and 8–12 weeks after their pregnancy, Dr. Beate Schücking reported.

In 2005, the 29% rate of cesarean section in Germany closely mirrored that of the United States, said Dr. Schücking of the University of Osnabrück (Germany).

In the third trimester, nearly all U.S. (95%) and German (96%) women said that they preferred vaginal delivery. The women reported that they believed a vaginal birth would offer more security, an easier recovery, and less pain and injury than would a cesarean section.

Three of the 55 women in the United States were indecisive about which method they preferred. The 13 German women who preferred a C-section said they wanted the surgical procedure because of anxiety, and they wanted to avoid pain and injuries, to have security for their baby, and to deliver a breech-positioned fetus safely.

Unlike the women who decided that they wanted a vaginal delivery early in their pregnancy, the women who preferred a C-section were indecisive about which method they preferred until the end of their pregnancy.

Those who preferred a C-section were younger, had lower scores of well-being, and were more likely to be unmarried.

These results were “quite consistent” with a Swedish study of 3,061 pregnant women that found that 8% would opt for a C-section and that that same 8% had more anxiety and depression than those who desired a vaginal delivery (BJOG 2002;109:618–23).

Although the women in that study were not all first-time mothers, they, too, were more likely to be single, younger, and have already had a negative birth experience. “The women got quite a different birth experience from what they had wished to have,” Dr. Schücking noted.

In reality, spontaneous vaginal births occurred at lower rates among the U.S. (64%) and German (61%) women than they would have liked. The actual C-section rates were higher among the U.S. (20%) and German (26%) women than their stated preference. Vaginal operative births occurred in 16% of U.S. and 13% of German women

Spontaneous vaginal birth was more satisfying to the women than elective C-section, followed by vaginal operative birth and C-section after the onset of labor.

In the German sample, 89% of the women who had a spontaneous vaginal delivery indicated that they would like to repeat that method if they had a second child.

But only 18% of those who received an elective C-section said that they would like to repeat it with a second baby. Few women who had an unplanned C-section (14%) or vaginal operative delivery (9%) wanted to repeat those methods.

The well-being of both U.S. and German women was significantly lower in the postpartum than antenatal period, although this did not correlate with the method of birth, Dr. Schücking said.

The fact that very few women in the two groups requested a cesarean section may indicate that “rising [C-section] rates are not really due to maternal request” but are most likely to occur among “vulnerable, anxious women,” she said.

“For me, the question is if surgery is really the best way to answer a mental problem.”

PRAGUE — Very few women in their first pregnancy appear to request an elective cesarean section but when they do, few would do it again, according to a study of nearly 400 German and U.S. women presented at the 20th European Congress of Perinatal Medicine.

In a prospective study of maternal preferences for birth, questionnaires were completed by 55 of 64 American and 342 of 366 German women.

All of the women were primigravid with singleton pregnancies and in good health when they completed questionnaires in the third trimester and 8–12 weeks after their pregnancy, Dr. Beate Schücking reported.

In 2005, the 29% rate of cesarean section in Germany closely mirrored that of the United States, said Dr. Schücking of the University of Osnabrück (Germany).

In the third trimester, nearly all U.S. (95%) and German (96%) women said that they preferred vaginal delivery. The women reported that they believed a vaginal birth would offer more security, an easier recovery, and less pain and injury than would a cesarean section.

Three of the 55 women in the United States were indecisive about which method they preferred. The 13 German women who preferred a C-section said they wanted the surgical procedure because of anxiety, and they wanted to avoid pain and injuries, to have security for their baby, and to deliver a breech-positioned fetus safely.

Unlike the women who decided that they wanted a vaginal delivery early in their pregnancy, the women who preferred a C-section were indecisive about which method they preferred until the end of their pregnancy.

Those who preferred a C-section were younger, had lower scores of well-being, and were more likely to be unmarried.

These results were “quite consistent” with a Swedish study of 3,061 pregnant women that found that 8% would opt for a C-section and that that same 8% had more anxiety and depression than those who desired a vaginal delivery (BJOG 2002;109:618–23).

Although the women in that study were not all first-time mothers, they, too, were more likely to be single, younger, and have already had a negative birth experience. “The women got quite a different birth experience from what they had wished to have,” Dr. Schücking noted.

In reality, spontaneous vaginal births occurred at lower rates among the U.S. (64%) and German (61%) women than they would have liked. The actual C-section rates were higher among the U.S. (20%) and German (26%) women than their stated preference. Vaginal operative births occurred in 16% of U.S. and 13% of German women

Spontaneous vaginal birth was more satisfying to the women than elective C-section, followed by vaginal operative birth and C-section after the onset of labor.

In the German sample, 89% of the women who had a spontaneous vaginal delivery indicated that they would like to repeat that method if they had a second child.

But only 18% of those who received an elective C-section said that they would like to repeat it with a second baby. Few women who had an unplanned C-section (14%) or vaginal operative delivery (9%) wanted to repeat those methods.

The well-being of both U.S. and German women was significantly lower in the postpartum than antenatal period, although this did not correlate with the method of birth, Dr. Schücking said.

The fact that very few women in the two groups requested a cesarean section may indicate that “rising [C-section] rates are not really due to maternal request” but are most likely to occur among “vulnerable, anxious women,” she said.

“For me, the question is if surgery is really the best way to answer a mental problem.”

PRAGUE — Very few women in their first pregnancy appear to request an elective cesarean section but when they do, few would do it again, according to a study of nearly 400 German and U.S. women presented at the 20th European Congress of Perinatal Medicine.

In a prospective study of maternal preferences for birth, questionnaires were completed by 55 of 64 American and 342 of 366 German women.

All of the women were primigravid with singleton pregnancies and in good health when they completed questionnaires in the third trimester and 8–12 weeks after their pregnancy, Dr. Beate Schücking reported.

In 2005, the 29% rate of cesarean section in Germany closely mirrored that of the United States, said Dr. Schücking of the University of Osnabrück (Germany).

In the third trimester, nearly all U.S. (95%) and German (96%) women said that they preferred vaginal delivery. The women reported that they believed a vaginal birth would offer more security, an easier recovery, and less pain and injury than would a cesarean section.

Three of the 55 women in the United States were indecisive about which method they preferred. The 13 German women who preferred a C-section said they wanted the surgical procedure because of anxiety, and they wanted to avoid pain and injuries, to have security for their baby, and to deliver a breech-positioned fetus safely.

Unlike the women who decided that they wanted a vaginal delivery early in their pregnancy, the women who preferred a C-section were indecisive about which method they preferred until the end of their pregnancy.

Those who preferred a C-section were younger, had lower scores of well-being, and were more likely to be unmarried.

These results were “quite consistent” with a Swedish study of 3,061 pregnant women that found that 8% would opt for a C-section and that that same 8% had more anxiety and depression than those who desired a vaginal delivery (BJOG 2002;109:618–23).

Although the women in that study were not all first-time mothers, they, too, were more likely to be single, younger, and have already had a negative birth experience. “The women got quite a different birth experience from what they had wished to have,” Dr. Schücking noted.

In reality, spontaneous vaginal births occurred at lower rates among the U.S. (64%) and German (61%) women than they would have liked. The actual C-section rates were higher among the U.S. (20%) and German (26%) women than their stated preference. Vaginal operative births occurred in 16% of U.S. and 13% of German women

Spontaneous vaginal birth was more satisfying to the women than elective C-section, followed by vaginal operative birth and C-section after the onset of labor.

In the German sample, 89% of the women who had a spontaneous vaginal delivery indicated that they would like to repeat that method if they had a second child.

But only 18% of those who received an elective C-section said that they would like to repeat it with a second baby. Few women who had an unplanned C-section (14%) or vaginal operative delivery (9%) wanted to repeat those methods.

The well-being of both U.S. and German women was significantly lower in the postpartum than antenatal period, although this did not correlate with the method of birth, Dr. Schücking said.

The fact that very few women in the two groups requested a cesarean section may indicate that “rising [C-section] rates are not really due to maternal request” but are most likely to occur among “vulnerable, anxious women,” she said.

“For me, the question is if surgery is really the best way to answer a mental problem.”

WASHINGTON — The use of forceps and vacuum did not increase the risk for cervical laceration among patients who had vaginal deliveries performed at a large community hospital, according to a poster presented at the annual meeting of the American College of Obstetricians and Gynecologists.

However, cervical cerclage and induction of labor appeared to be risk factors for cervical laceration in these deliveries, wrote Dr. Reshma Parikh and his colleagues at St. Luke's Hospital and Health Network in Bethlehem, Pa. The researchers performed a retrospective analysis of all vaginal deliveries at their large community hospital over a 5-year period.

They analyzed a number of suspected risk factors for cervical laceration including parity, body mass index, cervical cerclage, prior cervical procedures, induction of labor, duration of second stage, mode of delivery, and infant weight. Of the 16,931 vaginal deliveries performed at the hospital, 32 cervical lacerations were reported. Cervical cerclage was associated with an 11.5-fold increase in relative risk in cervical laceration, and induction of labor was associated with a threefold increase in relative risk, the researchers reported.

However, the researchers noted that they were surprised to find that operative delivery, using either forceps or vacuum, did not appear to be a risk factor for cervical laceration in the study population. In addition, none of the other factors examined were found to significantly increase risk for cervical laceration.

WASHINGTON — The use of forceps and vacuum did not increase the risk for cervical laceration among patients who had vaginal deliveries performed at a large community hospital, according to a poster presented at the annual meeting of the American College of Obstetricians and Gynecologists.

However, cervical cerclage and induction of labor appeared to be risk factors for cervical laceration in these deliveries, wrote Dr. Reshma Parikh and his colleagues at St. Luke's Hospital and Health Network in Bethlehem, Pa. The researchers performed a retrospective analysis of all vaginal deliveries at their large community hospital over a 5-year period.

They analyzed a number of suspected risk factors for cervical laceration including parity, body mass index, cervical cerclage, prior cervical procedures, induction of labor, duration of second stage, mode of delivery, and infant weight. Of the 16,931 vaginal deliveries performed at the hospital, 32 cervical lacerations were reported. Cervical cerclage was associated with an 11.5-fold increase in relative risk in cervical laceration, and induction of labor was associated with a threefold increase in relative risk, the researchers reported.

However, the researchers noted that they were surprised to find that operative delivery, using either forceps or vacuum, did not appear to be a risk factor for cervical laceration in the study population. In addition, none of the other factors examined were found to significantly increase risk for cervical laceration.

WASHINGTON — The use of forceps and vacuum did not increase the risk for cervical laceration among patients who had vaginal deliveries performed at a large community hospital, according to a poster presented at the annual meeting of the American College of Obstetricians and Gynecologists.

However, cervical cerclage and induction of labor appeared to be risk factors for cervical laceration in these deliveries, wrote Dr. Reshma Parikh and his colleagues at St. Luke's Hospital and Health Network in Bethlehem, Pa. The researchers performed a retrospective analysis of all vaginal deliveries at their large community hospital over a 5-year period.

They analyzed a number of suspected risk factors for cervical laceration including parity, body mass index, cervical cerclage, prior cervical procedures, induction of labor, duration of second stage, mode of delivery, and infant weight. Of the 16,931 vaginal deliveries performed at the hospital, 32 cervical lacerations were reported. Cervical cerclage was associated with an 11.5-fold increase in relative risk in cervical laceration, and induction of labor was associated with a threefold increase in relative risk, the researchers reported.

However, the researchers noted that they were surprised to find that operative delivery, using either forceps or vacuum, did not appear to be a risk factor for cervical laceration in the study population. In addition, none of the other factors examined were found to significantly increase risk for cervical laceration.

PRAGUE — Preeclampsia may significantly worsen some perinatal outcomes in growth-restricted infants, according to a review of infants born to mothers with and without preeclampsia.

In a study of growth-restricted neonates born at a gestational age older than 24 weeks, 25 infants whose mothers had preeclampsia had significantly worse psychomotor development on the Ages and Stages Questionnaire than did 46 infants born to mothers who did not have preeclampsia, Dr. Elisenda Eixarch reported in a poster session at the 20th European Congress of Perinatal Medicine.

In those neurologic evaluations, which were prospectively evaluated at 24 months, the children born to preeclamptic mothers scored at a significantly lower centile on the fine motor and problem-solving dimensions than did children of nonpreeclamptic mothers. The other three dimensions of the questionnaire (communication, gross motor, and personal-social) were worse in children of mothers with preeclampsia than in those of mothers without preeclampsia but not significantly so, according to Dr. Eixarch of the department of obstetrics and gynecology at the Hospital Clinic, Barcelona.

All of the infants in the study were estimated to have a birth weight below the 10th percentile.

Dr. Eixarch and her colleagues adjusted the analysis of each dimension of the questionnaire for birth weight and gestational age, because those two variables were significantly higher among infants born to mothers without preeclampsia than among those born to mothers with preeclampsia.

Compared with infants born to nonpreeclamptic mothers, the babies who had preeclamptic mothers had significantly higher rates of cesarean section (36% vs. 70%) and “significant neonatal neurological morbidity” (3% vs. 13%)—that is, seizures, grade 2 or 3 intraventricular hemorrhage, or hypoxic encephalopathy—and a significantly longer length of stay in the neonatal ICU (5.4 days vs. 18.3 days).

PRAGUE — Preeclampsia may significantly worsen some perinatal outcomes in growth-restricted infants, according to a review of infants born to mothers with and without preeclampsia.

In a study of growth-restricted neonates born at a gestational age older than 24 weeks, 25 infants whose mothers had preeclampsia had significantly worse psychomotor development on the Ages and Stages Questionnaire than did 46 infants born to mothers who did not have preeclampsia, Dr. Elisenda Eixarch reported in a poster session at the 20th European Congress of Perinatal Medicine.

In those neurologic evaluations, which were prospectively evaluated at 24 months, the children born to preeclamptic mothers scored at a significantly lower centile on the fine motor and problem-solving dimensions than did children of nonpreeclamptic mothers. The other three dimensions of the questionnaire (communication, gross motor, and personal-social) were worse in children of mothers with preeclampsia than in those of mothers without preeclampsia but not significantly so, according to Dr. Eixarch of the department of obstetrics and gynecology at the Hospital Clinic, Barcelona.

All of the infants in the study were estimated to have a birth weight below the 10th percentile.

Dr. Eixarch and her colleagues adjusted the analysis of each dimension of the questionnaire for birth weight and gestational age, because those two variables were significantly higher among infants born to mothers without preeclampsia than among those born to mothers with preeclampsia.

Compared with infants born to nonpreeclamptic mothers, the babies who had preeclamptic mothers had significantly higher rates of cesarean section (36% vs. 70%) and “significant neonatal neurological morbidity” (3% vs. 13%)—that is, seizures, grade 2 or 3 intraventricular hemorrhage, or hypoxic encephalopathy—and a significantly longer length of stay in the neonatal ICU (5.4 days vs. 18.3 days).

PRAGUE — Preeclampsia may significantly worsen some perinatal outcomes in growth-restricted infants, according to a review of infants born to mothers with and without preeclampsia.

In a study of growth-restricted neonates born at a gestational age older than 24 weeks, 25 infants whose mothers had preeclampsia had significantly worse psychomotor development on the Ages and Stages Questionnaire than did 46 infants born to mothers who did not have preeclampsia, Dr. Elisenda Eixarch reported in a poster session at the 20th European Congress of Perinatal Medicine.

In those neurologic evaluations, which were prospectively evaluated at 24 months, the children born to preeclamptic mothers scored at a significantly lower centile on the fine motor and problem-solving dimensions than did children of nonpreeclamptic mothers. The other three dimensions of the questionnaire (communication, gross motor, and personal-social) were worse in children of mothers with preeclampsia than in those of mothers without preeclampsia but not significantly so, according to Dr. Eixarch of the department of obstetrics and gynecology at the Hospital Clinic, Barcelona.

All of the infants in the study were estimated to have a birth weight below the 10th percentile.

Dr. Eixarch and her colleagues adjusted the analysis of each dimension of the questionnaire for birth weight and gestational age, because those two variables were significantly higher among infants born to mothers without preeclampsia than among those born to mothers with preeclampsia.

Compared with infants born to nonpreeclamptic mothers, the babies who had preeclamptic mothers had significantly higher rates of cesarean section (36% vs. 70%) and “significant neonatal neurological morbidity” (3% vs. 13%)—that is, seizures, grade 2 or 3 intraventricular hemorrhage, or hypoxic encephalopathy—and a significantly longer length of stay in the neonatal ICU (5.4 days vs. 18.3 days).

HOLLYWOOD, FLA. — Maintaining hemodynamic stability is particularly important in the anesthetic management of parturients with aortic stenosis, and the use of a slowly titrated epidural or combined spinal-epidural with a reduced spinal anesthesia dose appears to provide this stability in most patients, findings from a case series suggest.

The cases, including six patients with moderate aortic stenosis and six with severe aortic stenosis, also suggest that invasive monitoring facilitates anesthetic management in some patients, and that special attention to postoperative analgesia, monitoring, and volume status can prevent hemodynamic instability and complications, Dr. Alexander Ioscovich reported in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The 12 patients were treated at two university hospitals, and compose all the cases of aortic stenosis in parturients seen at those hospitals from 1990 to 2005. Five of six patients with moderate aortic stenosis, and three of six with severe aortic stenosis had regional anesthesia; two with moderate aortic stenosis, and four with severe aortic stenosis had invasive monitoring; and one with critical symptomatic aortic stenosis had intraoperative transesophageal echocardiography under general anesthesia. There were no cases of hemodynamic instability or anesthetic complications, although one patient had a failed epidural, wrote Dr. Ioscovich of Sunnybrook Women's College Hospital, Toronto.

Although neuraxial anesthesia has traditionally been considered contraindicated in aortic stenosis patients, the findings suggest this approach is useful in all but the most severe cases, he concluded.

HOLLYWOOD, FLA. — Maintaining hemodynamic stability is particularly important in the anesthetic management of parturients with aortic stenosis, and the use of a slowly titrated epidural or combined spinal-epidural with a reduced spinal anesthesia dose appears to provide this stability in most patients, findings from a case series suggest.

The cases, including six patients with moderate aortic stenosis and six with severe aortic stenosis, also suggest that invasive monitoring facilitates anesthetic management in some patients, and that special attention to postoperative analgesia, monitoring, and volume status can prevent hemodynamic instability and complications, Dr. Alexander Ioscovich reported in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The 12 patients were treated at two university hospitals, and compose all the cases of aortic stenosis in parturients seen at those hospitals from 1990 to 2005. Five of six patients with moderate aortic stenosis, and three of six with severe aortic stenosis had regional anesthesia; two with moderate aortic stenosis, and four with severe aortic stenosis had invasive monitoring; and one with critical symptomatic aortic stenosis had intraoperative transesophageal echocardiography under general anesthesia. There were no cases of hemodynamic instability or anesthetic complications, although one patient had a failed epidural, wrote Dr. Ioscovich of Sunnybrook Women's College Hospital, Toronto.

Although neuraxial anesthesia has traditionally been considered contraindicated in aortic stenosis patients, the findings suggest this approach is useful in all but the most severe cases, he concluded.

HOLLYWOOD, FLA. — Maintaining hemodynamic stability is particularly important in the anesthetic management of parturients with aortic stenosis, and the use of a slowly titrated epidural or combined spinal-epidural with a reduced spinal anesthesia dose appears to provide this stability in most patients, findings from a case series suggest.

The cases, including six patients with moderate aortic stenosis and six with severe aortic stenosis, also suggest that invasive monitoring facilitates anesthetic management in some patients, and that special attention to postoperative analgesia, monitoring, and volume status can prevent hemodynamic instability and complications, Dr. Alexander Ioscovich reported in a poster at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

The 12 patients were treated at two university hospitals, and compose all the cases of aortic stenosis in parturients seen at those hospitals from 1990 to 2005. Five of six patients with moderate aortic stenosis, and three of six with severe aortic stenosis had regional anesthesia; two with moderate aortic stenosis, and four with severe aortic stenosis had invasive monitoring; and one with critical symptomatic aortic stenosis had intraoperative transesophageal echocardiography under general anesthesia. There were no cases of hemodynamic instability or anesthetic complications, although one patient had a failed epidural, wrote Dr. Ioscovich of Sunnybrook Women's College Hospital, Toronto.

Although neuraxial anesthesia has traditionally been considered contraindicated in aortic stenosis patients, the findings suggest this approach is useful in all but the most severe cases, he concluded.

WASHINGTON — Often, the best episiotomy may be no episiotomy, Dr. Lily A. Arya noted at the annual meeting of the American College of Obstetricians and Gynecologists.

That said, episiotomies are needed in some cases, and sometimes wound dehiscence requires additional repair, said Dr. Arya, a urogynecologist at the University of Pennsylvania Medical Center in Philadelphia.

The need for episiotomies remains a subject for debate. Dr. Arya cited a recent study that compared routine episiotomy, selective episiotomy, and no episiotomy, and found no significant difference in the incidence of minor lacerations or fecal incontinence (Acta Obstet. Gynecol. Scand. 2004;83:364–8).

“Sometimes, if you let nature take its course you will only end up with minor lacerations,” Dr. Arya said, although she added that she favors selective episiotomies. The surgeon's challenge lies in trying to deduce whether significant tearing might occur.

Mediolateral episiotomy has several advantages over median episiotomy if the surgeon decides to proceed, Dr. Arya said. Although the midline episiotomy involves less bleeding, pain, and dyspareunia, the median technique tends to cause more fecal incontinence and a greater risk of anal sphincter injury.

Mediolateral episiotomy, on the other hand, will not prevent tears, but it will not cause tearing, either.

The traditional strategy in dehiscence cases has been to reopen the wound and perform a secondary repair in 3–4 months.

However, the wound can be debrided and repaired almost immediately if there is no infection. “Infection from an episiotomy is extremely rare,” Dr. Arya noted. If infection is present, the wound can be debrided on an outpatient basis until all necrotic material is gone and pink, granulating tissue is achieved, and a repair can usually be performed within a week.

Closures for episiotomy dehiscence are similar to those for perineal tears, but Dr. Arya recommends incorporating some tissue from the sides of the wound to close with two layers. The repair will bring the transverse perineal muscles together.

“Make sure you don't leave gaps in the submucosa; that is what will cause a fistula,” she noted.

To minimize the patient's postoperative discomfort, Dr. Arya recommends stool softeners for 6 weeks, antibiotics for the first 48 hours, and a low-residue diet for the first 72 hours to postpone bowel movements and prevent the patient from becoming constipated.

Fecal incontinence remains a significant problem in women, and the majority of cases stem from obstetric trauma, said Dr. Najia N. Mahmoud, a colorectal surgeon at the University of Pennsylvania, Philadelphia.

Many women who present with fecal incontinence have managed for long periods of time by employing a range of coping strategies. Their tricks include avoiding travel, reducing food intake and exercise, wearing dark clothing and multiple absorbent products, and only visiting places with readily accessible bathrooms. Dr. Mahmoud's strategy for evaluating fecal incontinence starts with an examination of the patient.

“A lot of what you learn about the patient's incontinence comes from the physical exam,” she said. Unless the physical exam is confusing in some way, anal manometry and pudendal nerve testing do not add much to the diagnosis. “I don't think these are necessary for people with obvious signs of fecal incontinence.” However, endoanal ultrasound allows for an anatomic description of the injury and helps with surgical planning for patients who are good surgical candidates. Incontinence to solid stool constitutes the most common indication for surgery.

Biofeedback with a trained physical therapist can be helpful both pre- and postoperatively for patients with mild or moderate fecal incontinence (incontinence to gas or urgency), as well as for patients who aren't immediate candidates for surgery, she said.

In addition, Dr. Mahmoud said that she makes an effort to modify the patient's diet. “It's imperative that you investigate the underlying causes of diarrhea and modify the bowel movements,” she said. In many cases, the incontinence will resolve once diarrhea is under control.

Most people don't consume as much fiber as they think they do, so Dr. Mahmoud prescribes a daily dose of fiber wafers with 6 ounces of water for incontinent patients or those with soft or loose bowel movements. The consistent fiber consumption seems to result in a better-formed stool and improved continence, and provides a good adjuvant therapy to either conservative strategies like biofeedback or surgical solutions such as sphincter reconstruction.

Surgery is rarely necessary for patients with incontinence to liquid stool and flatulence, she emphasized.

An overlapping sphincteroplasty is an appropriate surgical plan for patients with sphincter defects who are consistently incontinent to solid stool. The technique is generally successful; data from a 2000 study of 40 patients showed an 81% success rate immediately following surgery, and a 51% success rate after 40 months.

To optimize outcomes, be sure to address patient expectations, and remind them that the return to normal muscle and sphincter function is slow, and can take up to 3 months. Kegel exercises can help strengthen the muscles during recovery, she said. Infection rates are low—less than 8%-in overlapping sphincteroplasty patients, but the presence of infection increases the failure rate.

The most significant factor in a successful sphincter repair is its durability, and constipation must be prevented to preserve the intactness of the repair in the immediate postoperative period.

“Constipation is the enemy of a sphincter repair in the first week or two,” Dr. Mahmoud said. She uses a combination of treatments including milk of magnesia, fiber, and stool softeners, and mineral oil, to help steer patients through recovery.

WASHINGTON — Often, the best episiotomy may be no episiotomy, Dr. Lily A. Arya noted at the annual meeting of the American College of Obstetricians and Gynecologists.

That said, episiotomies are needed in some cases, and sometimes wound dehiscence requires additional repair, said Dr. Arya, a urogynecologist at the University of Pennsylvania Medical Center in Philadelphia.

The need for episiotomies remains a subject for debate. Dr. Arya cited a recent study that compared routine episiotomy, selective episiotomy, and no episiotomy, and found no significant difference in the incidence of minor lacerations or fecal incontinence (Acta Obstet. Gynecol. Scand. 2004;83:364–8).

“Sometimes, if you let nature take its course you will only end up with minor lacerations,” Dr. Arya said, although she added that she favors selective episiotomies. The surgeon's challenge lies in trying to deduce whether significant tearing might occur.

Mediolateral episiotomy has several advantages over median episiotomy if the surgeon decides to proceed, Dr. Arya said. Although the midline episiotomy involves less bleeding, pain, and dyspareunia, the median technique tends to cause more fecal incontinence and a greater risk of anal sphincter injury.

Mediolateral episiotomy, on the other hand, will not prevent tears, but it will not cause tearing, either.

The traditional strategy in dehiscence cases has been to reopen the wound and perform a secondary repair in 3–4 months.

However, the wound can be debrided and repaired almost immediately if there is no infection. “Infection from an episiotomy is extremely rare,” Dr. Arya noted. If infection is present, the wound can be debrided on an outpatient basis until all necrotic material is gone and pink, granulating tissue is achieved, and a repair can usually be performed within a week.

Closures for episiotomy dehiscence are similar to those for perineal tears, but Dr. Arya recommends incorporating some tissue from the sides of the wound to close with two layers. The repair will bring the transverse perineal muscles together.

“Make sure you don't leave gaps in the submucosa; that is what will cause a fistula,” she noted.

To minimize the patient's postoperative discomfort, Dr. Arya recommends stool softeners for 6 weeks, antibiotics for the first 48 hours, and a low-residue diet for the first 72 hours to postpone bowel movements and prevent the patient from becoming constipated.

Fecal incontinence remains a significant problem in women, and the majority of cases stem from obstetric trauma, said Dr. Najia N. Mahmoud, a colorectal surgeon at the University of Pennsylvania, Philadelphia.

Many women who present with fecal incontinence have managed for long periods of time by employing a range of coping strategies. Their tricks include avoiding travel, reducing food intake and exercise, wearing dark clothing and multiple absorbent products, and only visiting places with readily accessible bathrooms. Dr. Mahmoud's strategy for evaluating fecal incontinence starts with an examination of the patient.

“A lot of what you learn about the patient's incontinence comes from the physical exam,” she said. Unless the physical exam is confusing in some way, anal manometry and pudendal nerve testing do not add much to the diagnosis. “I don't think these are necessary for people with obvious signs of fecal incontinence.” However, endoanal ultrasound allows for an anatomic description of the injury and helps with surgical planning for patients who are good surgical candidates. Incontinence to solid stool constitutes the most common indication for surgery.

Biofeedback with a trained physical therapist can be helpful both pre- and postoperatively for patients with mild or moderate fecal incontinence (incontinence to gas or urgency), as well as for patients who aren't immediate candidates for surgery, she said.

In addition, Dr. Mahmoud said that she makes an effort to modify the patient's diet. “It's imperative that you investigate the underlying causes of diarrhea and modify the bowel movements,” she said. In many cases, the incontinence will resolve once diarrhea is under control.

Most people don't consume as much fiber as they think they do, so Dr. Mahmoud prescribes a daily dose of fiber wafers with 6 ounces of water for incontinent patients or those with soft or loose bowel movements. The consistent fiber consumption seems to result in a better-formed stool and improved continence, and provides a good adjuvant therapy to either conservative strategies like biofeedback or surgical solutions such as sphincter reconstruction.

Surgery is rarely necessary for patients with incontinence to liquid stool and flatulence, she emphasized.

An overlapping sphincteroplasty is an appropriate surgical plan for patients with sphincter defects who are consistently incontinent to solid stool. The technique is generally successful; data from a 2000 study of 40 patients showed an 81% success rate immediately following surgery, and a 51% success rate after 40 months.

To optimize outcomes, be sure to address patient expectations, and remind them that the return to normal muscle and sphincter function is slow, and can take up to 3 months. Kegel exercises can help strengthen the muscles during recovery, she said. Infection rates are low—less than 8%-in overlapping sphincteroplasty patients, but the presence of infection increases the failure rate.

The most significant factor in a successful sphincter repair is its durability, and constipation must be prevented to preserve the intactness of the repair in the immediate postoperative period.

“Constipation is the enemy of a sphincter repair in the first week or two,” Dr. Mahmoud said. She uses a combination of treatments including milk of magnesia, fiber, and stool softeners, and mineral oil, to help steer patients through recovery.

WASHINGTON — Often, the best episiotomy may be no episiotomy, Dr. Lily A. Arya noted at the annual meeting of the American College of Obstetricians and Gynecologists.

That said, episiotomies are needed in some cases, and sometimes wound dehiscence requires additional repair, said Dr. Arya, a urogynecologist at the University of Pennsylvania Medical Center in Philadelphia.

The need for episiotomies remains a subject for debate. Dr. Arya cited a recent study that compared routine episiotomy, selective episiotomy, and no episiotomy, and found no significant difference in the incidence of minor lacerations or fecal incontinence (Acta Obstet. Gynecol. Scand. 2004;83:364–8).

“Sometimes, if you let nature take its course you will only end up with minor lacerations,” Dr. Arya said, although she added that she favors selective episiotomies. The surgeon's challenge lies in trying to deduce whether significant tearing might occur.

Mediolateral episiotomy has several advantages over median episiotomy if the surgeon decides to proceed, Dr. Arya said. Although the midline episiotomy involves less bleeding, pain, and dyspareunia, the median technique tends to cause more fecal incontinence and a greater risk of anal sphincter injury.

Mediolateral episiotomy, on the other hand, will not prevent tears, but it will not cause tearing, either.

The traditional strategy in dehiscence cases has been to reopen the wound and perform a secondary repair in 3–4 months.

However, the wound can be debrided and repaired almost immediately if there is no infection. “Infection from an episiotomy is extremely rare,” Dr. Arya noted. If infection is present, the wound can be debrided on an outpatient basis until all necrotic material is gone and pink, granulating tissue is achieved, and a repair can usually be performed within a week.

Closures for episiotomy dehiscence are similar to those for perineal tears, but Dr. Arya recommends incorporating some tissue from the sides of the wound to close with two layers. The repair will bring the transverse perineal muscles together.

“Make sure you don't leave gaps in the submucosa; that is what will cause a fistula,” she noted.

To minimize the patient's postoperative discomfort, Dr. Arya recommends stool softeners for 6 weeks, antibiotics for the first 48 hours, and a low-residue diet for the first 72 hours to postpone bowel movements and prevent the patient from becoming constipated.

Fecal incontinence remains a significant problem in women, and the majority of cases stem from obstetric trauma, said Dr. Najia N. Mahmoud, a colorectal surgeon at the University of Pennsylvania, Philadelphia.

Many women who present with fecal incontinence have managed for long periods of time by employing a range of coping strategies. Their tricks include avoiding travel, reducing food intake and exercise, wearing dark clothing and multiple absorbent products, and only visiting places with readily accessible bathrooms. Dr. Mahmoud's strategy for evaluating fecal incontinence starts with an examination of the patient.

“A lot of what you learn about the patient's incontinence comes from the physical exam,” she said. Unless the physical exam is confusing in some way, anal manometry and pudendal nerve testing do not add much to the diagnosis. “I don't think these are necessary for people with obvious signs of fecal incontinence.” However, endoanal ultrasound allows for an anatomic description of the injury and helps with surgical planning for patients who are good surgical candidates. Incontinence to solid stool constitutes the most common indication for surgery.

Biofeedback with a trained physical therapist can be helpful both pre- and postoperatively for patients with mild or moderate fecal incontinence (incontinence to gas or urgency), as well as for patients who aren't immediate candidates for surgery, she said.

In addition, Dr. Mahmoud said that she makes an effort to modify the patient's diet. “It's imperative that you investigate the underlying causes of diarrhea and modify the bowel movements,” she said. In many cases, the incontinence will resolve once diarrhea is under control.

Most people don't consume as much fiber as they think they do, so Dr. Mahmoud prescribes a daily dose of fiber wafers with 6 ounces of water for incontinent patients or those with soft or loose bowel movements. The consistent fiber consumption seems to result in a better-formed stool and improved continence, and provides a good adjuvant therapy to either conservative strategies like biofeedback or surgical solutions such as sphincter reconstruction.

Surgery is rarely necessary for patients with incontinence to liquid stool and flatulence, she emphasized.

An overlapping sphincteroplasty is an appropriate surgical plan for patients with sphincter defects who are consistently incontinent to solid stool. The technique is generally successful; data from a 2000 study of 40 patients showed an 81% success rate immediately following surgery, and a 51% success rate after 40 months.

To optimize outcomes, be sure to address patient expectations, and remind them that the return to normal muscle and sphincter function is slow, and can take up to 3 months. Kegel exercises can help strengthen the muscles during recovery, she said. Infection rates are low—less than 8%-in overlapping sphincteroplasty patients, but the presence of infection increases the failure rate.

The most significant factor in a successful sphincter repair is its durability, and constipation must be prevented to preserve the intactness of the repair in the immediate postoperative period.

“Constipation is the enemy of a sphincter repair in the first week or two,” Dr. Mahmoud said. She uses a combination of treatments including milk of magnesia, fiber, and stool softeners, and mineral oil, to help steer patients through recovery.

WASHINGTON — Data from 597 cesarean sections suggest that smoking may slow wound healing, Dr. Cecilia Avila reported in a poster presented at the annual meeting of the American College of Obstetricians and Gynecologists.

Both smoking and chorioamnionitis were significantly associated with wound complications in 20 cases of infection and 10 cases of hematoma that were identified in a case-control review of patients who had cesarean sections during a 7-year period.

Overall, wound complications were about three times more likely in smokers, wrote Dr. Avila of Stony Brook (N.Y.) University Hospital.

About 47% of the patients with wound complications were smokers, compared with 28% of the patients without wound complications.

In addition, chorioamnionitis was about five times more common in patients with wound complications, compared with patients without wound complications (28% vs. 7%).

The independent associations between smoking and wound complications and between chorioamnionitis and wound complications remained significant in a logistic regression analysis, the investigators noted.

Younger maternal age, premature membrane rupture, primary cesarean delivery, and earlier gestational age showed trends toward an association with wound complications, but these associations did not reach statistical significance. No associations were found between wound complications and several other clinical variables including body mass index, diabetes, and substance use.

WASHINGTON — Data from 597 cesarean sections suggest that smoking may slow wound healing, Dr. Cecilia Avila reported in a poster presented at the annual meeting of the American College of Obstetricians and Gynecologists.

Both smoking and chorioamnionitis were significantly associated with wound complications in 20 cases of infection and 10 cases of hematoma that were identified in a case-control review of patients who had cesarean sections during a 7-year period.

Overall, wound complications were about three times more likely in smokers, wrote Dr. Avila of Stony Brook (N.Y.) University Hospital.

About 47% of the patients with wound complications were smokers, compared with 28% of the patients without wound complications.

In addition, chorioamnionitis was about five times more common in patients with wound complications, compared with patients without wound complications (28% vs. 7%).

The independent associations between smoking and wound complications and between chorioamnionitis and wound complications remained significant in a logistic regression analysis, the investigators noted.

Younger maternal age, premature membrane rupture, primary cesarean delivery, and earlier gestational age showed trends toward an association with wound complications, but these associations did not reach statistical significance. No associations were found between wound complications and several other clinical variables including body mass index, diabetes, and substance use.

WASHINGTON — Data from 597 cesarean sections suggest that smoking may slow wound healing, Dr. Cecilia Avila reported in a poster presented at the annual meeting of the American College of Obstetricians and Gynecologists.

Both smoking and chorioamnionitis were significantly associated with wound complications in 20 cases of infection and 10 cases of hematoma that were identified in a case-control review of patients who had cesarean sections during a 7-year period.

Overall, wound complications were about three times more likely in smokers, wrote Dr. Avila of Stony Brook (N.Y.) University Hospital.

About 47% of the patients with wound complications were smokers, compared with 28% of the patients without wound complications.

In addition, chorioamnionitis was about five times more common in patients with wound complications, compared with patients without wound complications (28% vs. 7%).

The independent associations between smoking and wound complications and between chorioamnionitis and wound complications remained significant in a logistic regression analysis, the investigators noted.

Younger maternal age, premature membrane rupture, primary cesarean delivery, and earlier gestational age showed trends toward an association with wound complications, but these associations did not reach statistical significance. No associations were found between wound complications and several other clinical variables including body mass index, diabetes, and substance use.

HOLLYWOOD, FLA. — Women need to be better educated about the risks of type 2 diabetes in pregnancy, Dr. Erin Keely said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“Type 2 diabetes is at least as dangerous in pregnancy as type 1 diabetes,” said Dr. Keely of the University of Ottawa.

The incidence of type 2 diabetes is on the rise—largely due to the increasing prevalence of obesity. Since 1991, there has been more than a 60% increase in the prevalence of obesity.

Currently, about 6% of women of childbearing age are morbidly obese (body mass index over 40), and obesity is associated with substantially increased risk of gestational diabetes and type 2 diabetes.

In fact, 90% of women with type 2 diabetes are overweight, Dr. Keely noted.

The problem of increasing type 2 diabetes in pregnancy is compounded by the fact that the age of onset of type 2 diabetes is decreasing, and maternal age is increasing, she said.

Research suggests that type 2 diabetes is associated with double the risk of stillbirth, 2.5 times the risk of perinatal mortality, and 11 times the risk of congenital anomalies as healthy pregnancies.

Hypertension, anesthesia-related mortality, and preeclampsia are also increased.

Furthermore, maternal diabetes appears to have long-term health consequences for offspring, who have a dramatically increased risk of diabetes and other health problems throughout life.

The perception that type 2 diabetes is not as dangerous as type 1 diabetes leaves many pregnant women with the condition with less “prepregnancy optimization,” Dr. Keely noted.

Many of these women do not have specialized care, she explained, and as a result they receive less education about the seriousness of the illness.

HOLLYWOOD, FLA. — Women need to be better educated about the risks of type 2 diabetes in pregnancy, Dr. Erin Keely said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“Type 2 diabetes is at least as dangerous in pregnancy as type 1 diabetes,” said Dr. Keely of the University of Ottawa.

The incidence of type 2 diabetes is on the rise—largely due to the increasing prevalence of obesity. Since 1991, there has been more than a 60% increase in the prevalence of obesity.

Currently, about 6% of women of childbearing age are morbidly obese (body mass index over 40), and obesity is associated with substantially increased risk of gestational diabetes and type 2 diabetes.

In fact, 90% of women with type 2 diabetes are overweight, Dr. Keely noted.

The problem of increasing type 2 diabetes in pregnancy is compounded by the fact that the age of onset of type 2 diabetes is decreasing, and maternal age is increasing, she said.

Research suggests that type 2 diabetes is associated with double the risk of stillbirth, 2.5 times the risk of perinatal mortality, and 11 times the risk of congenital anomalies as healthy pregnancies.

Hypertension, anesthesia-related mortality, and preeclampsia are also increased.

Furthermore, maternal diabetes appears to have long-term health consequences for offspring, who have a dramatically increased risk of diabetes and other health problems throughout life.

The perception that type 2 diabetes is not as dangerous as type 1 diabetes leaves many pregnant women with the condition with less “prepregnancy optimization,” Dr. Keely noted.

Many of these women do not have specialized care, she explained, and as a result they receive less education about the seriousness of the illness.

HOLLYWOOD, FLA. — Women need to be better educated about the risks of type 2 diabetes in pregnancy, Dr. Erin Keely said at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

“Type 2 diabetes is at least as dangerous in pregnancy as type 1 diabetes,” said Dr. Keely of the University of Ottawa.

The incidence of type 2 diabetes is on the rise—largely due to the increasing prevalence of obesity. Since 1991, there has been more than a 60% increase in the prevalence of obesity.

Currently, about 6% of women of childbearing age are morbidly obese (body mass index over 40), and obesity is associated with substantially increased risk of gestational diabetes and type 2 diabetes.

In fact, 90% of women with type 2 diabetes are overweight, Dr. Keely noted.

The problem of increasing type 2 diabetes in pregnancy is compounded by the fact that the age of onset of type 2 diabetes is decreasing, and maternal age is increasing, she said.

Research suggests that type 2 diabetes is associated with double the risk of stillbirth, 2.5 times the risk of perinatal mortality, and 11 times the risk of congenital anomalies as healthy pregnancies.

Hypertension, anesthesia-related mortality, and preeclampsia are also increased.

Furthermore, maternal diabetes appears to have long-term health consequences for offspring, who have a dramatically increased risk of diabetes and other health problems throughout life.

The perception that type 2 diabetes is not as dangerous as type 1 diabetes leaves many pregnant women with the condition with less “prepregnancy optimization,” Dr. Keely noted.

Many of these women do not have specialized care, she explained, and as a result they receive less education about the seriousness of the illness.

HOLLYWOOD, FLA. — Combined spinal-epidural analgesia did not significantly improve the rate of successful external cephalic version, compared with systemic opioid analgesia for breech presentation, but it did improve maternal pain and satisfaction, Dr. John T. Sullivan reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A total of 86 women with singleton breech presentation were randomized to receive combined spinal-epidural (CSE)analgesia (2.5-mg intrathecal bupivacaine) plus 15-mcg fentanyl, followed by a 45-mg lidocaine and 15-mcg epinephrine epidural test dose, or 50 mcg of IV fentanyl.

Patients received analgesic intervention and terbutaline timed to provide peak analgesic and uterine relaxant effect at the time of external cephalic version, said Dr. Sullivan of Northwestern University, Chicago.

The success rate of external cephalic version was 43% in the CSE group and 33% in the systemic analgesia group. Vaginal deliveries occurred in 36% of those in the CSE group and 24% of those in the systemic analgesia group. The differences were not statistically significant.

However, pain scores were significantly lower in the CSE group (mean visual analog scale score of 11 vs. 36), and patient satisfaction with analgesic technique was higher in that group (median verbal rating of satisfaction score of 10 vs. 7).

Higher parity, greater estimated gestational age, and shorter procedure duration were significantly associated with version success, Dr. Sullivan noted.

Data regarding the impact of neuraxial anesthesia on the success rate of external cephalic version have been conflicting, and because improved success with external cephalic version has been suggested as a means for lowering cesarean section rates, further study is warranted, he said, noting that additional cases will be randomized for this study in an attempt to improve its power.

HOLLYWOOD, FLA. — Combined spinal-epidural analgesia did not significantly improve the rate of successful external cephalic version, compared with systemic opioid analgesia for breech presentation, but it did improve maternal pain and satisfaction, Dr. John T. Sullivan reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A total of 86 women with singleton breech presentation were randomized to receive combined spinal-epidural (CSE)analgesia (2.5-mg intrathecal bupivacaine) plus 15-mcg fentanyl, followed by a 45-mg lidocaine and 15-mcg epinephrine epidural test dose, or 50 mcg of IV fentanyl.

Patients received analgesic intervention and terbutaline timed to provide peak analgesic and uterine relaxant effect at the time of external cephalic version, said Dr. Sullivan of Northwestern University, Chicago.

The success rate of external cephalic version was 43% in the CSE group and 33% in the systemic analgesia group. Vaginal deliveries occurred in 36% of those in the CSE group and 24% of those in the systemic analgesia group. The differences were not statistically significant.

However, pain scores were significantly lower in the CSE group (mean visual analog scale score of 11 vs. 36), and patient satisfaction with analgesic technique was higher in that group (median verbal rating of satisfaction score of 10 vs. 7).

Higher parity, greater estimated gestational age, and shorter procedure duration were significantly associated with version success, Dr. Sullivan noted.

Data regarding the impact of neuraxial anesthesia on the success rate of external cephalic version have been conflicting, and because improved success with external cephalic version has been suggested as a means for lowering cesarean section rates, further study is warranted, he said, noting that additional cases will be randomized for this study in an attempt to improve its power.

HOLLYWOOD, FLA. — Combined spinal-epidural analgesia did not significantly improve the rate of successful external cephalic version, compared with systemic opioid analgesia for breech presentation, but it did improve maternal pain and satisfaction, Dr. John T. Sullivan reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A total of 86 women with singleton breech presentation were randomized to receive combined spinal-epidural (CSE)analgesia (2.5-mg intrathecal bupivacaine) plus 15-mcg fentanyl, followed by a 45-mg lidocaine and 15-mcg epinephrine epidural test dose, or 50 mcg of IV fentanyl.

Patients received analgesic intervention and terbutaline timed to provide peak analgesic and uterine relaxant effect at the time of external cephalic version, said Dr. Sullivan of Northwestern University, Chicago.

The success rate of external cephalic version was 43% in the CSE group and 33% in the systemic analgesia group. Vaginal deliveries occurred in 36% of those in the CSE group and 24% of those in the systemic analgesia group. The differences were not statistically significant.

However, pain scores were significantly lower in the CSE group (mean visual analog scale score of 11 vs. 36), and patient satisfaction with analgesic technique was higher in that group (median verbal rating of satisfaction score of 10 vs. 7).

Higher parity, greater estimated gestational age, and shorter procedure duration were significantly associated with version success, Dr. Sullivan noted.

Data regarding the impact of neuraxial anesthesia on the success rate of external cephalic version have been conflicting, and because improved success with external cephalic version has been suggested as a means for lowering cesarean section rates, further study is warranted, he said, noting that additional cases will be randomized for this study in an attempt to improve its power.