Obstetrics

HONOLULU — The diagnosis of herpes simplex hepatitis in pregnancy is one that simply can't afford to be missed, Dr. Eileen Hay said at the annual meeting of the American College of Gastroenterology.

That's because treatment with acyclovir or vidarabine is lifesaving—and without it, one-half of affected mothers will die of fulminant hepatitis, stressed Dr. Hay, professor of medicine at the Mayo Medical School, Rochester, Minn.

Herpes hepatitis is a rare disorder. In pregnancy, it occurs in the third trimester. It is usually but not always preceded by a flulike viral prodrome. The typical mucocutaneous herpetic lesions aren't always present.

The characteristic features of this infection are the third-trimester presentation, marked elevation of transaminases (with levels often in the thousands) along with coagulopathy, and encephalopathy, but no jaundice.

Liver biopsy shows hepatocytes with the classic viral inclusion bodies of herpes simplex virus.

It's necessary to consider delivery only in the very rare instance where the patient shows no response to antiviral therapy, Dr. Hay said.

HONOLULU — The diagnosis of herpes simplex hepatitis in pregnancy is one that simply can't afford to be missed, Dr. Eileen Hay said at the annual meeting of the American College of Gastroenterology.

That's because treatment with acyclovir or vidarabine is lifesaving—and without it, one-half of affected mothers will die of fulminant hepatitis, stressed Dr. Hay, professor of medicine at the Mayo Medical School, Rochester, Minn.

Herpes hepatitis is a rare disorder. In pregnancy, it occurs in the third trimester. It is usually but not always preceded by a flulike viral prodrome. The typical mucocutaneous herpetic lesions aren't always present.

The characteristic features of this infection are the third-trimester presentation, marked elevation of transaminases (with levels often in the thousands) along with coagulopathy, and encephalopathy, but no jaundice.

Liver biopsy shows hepatocytes with the classic viral inclusion bodies of herpes simplex virus.

It's necessary to consider delivery only in the very rare instance where the patient shows no response to antiviral therapy, Dr. Hay said.

HONOLULU — The diagnosis of herpes simplex hepatitis in pregnancy is one that simply can't afford to be missed, Dr. Eileen Hay said at the annual meeting of the American College of Gastroenterology.

That's because treatment with acyclovir or vidarabine is lifesaving—and without it, one-half of affected mothers will die of fulminant hepatitis, stressed Dr. Hay, professor of medicine at the Mayo Medical School, Rochester, Minn.

Herpes hepatitis is a rare disorder. In pregnancy, it occurs in the third trimester. It is usually but not always preceded by a flulike viral prodrome. The typical mucocutaneous herpetic lesions aren't always present.

The characteristic features of this infection are the third-trimester presentation, marked elevation of transaminases (with levels often in the thousands) along with coagulopathy, and encephalopathy, but no jaundice.

Liver biopsy shows hepatocytes with the classic viral inclusion bodies of herpes simplex virus.

It's necessary to consider delivery only in the very rare instance where the patient shows no response to antiviral therapy, Dr. Hay said.

MIAMI BEACH — Maternal serum α-fetoprotein is no longer an effective or cost-effective second-trimester screen for neural tube defects in an era when women routinely undergo first-trimester Down syndrome screening and subsequent ultrasound, Dr. Todd J. Rosen said at the annual meeting of the Society for Maternal-Fetal Medicine.

Before ultrasound was commonplace—back in the 1970s and 1980s—women got an α-fetoprotein (AFP) test for spina bifida and anencephaly. “Now more and more women are screening for Down syndrome in the first trimester, and it is routine for women to do an ultrasound screen as well,” said Dr. Rosen of the division of maternal-fetal medicine, Columbia University, New York. Dr. Rosen and his associates assessed clinical and cost effectiveness of AFP testing for U.S. women who had a first-trimester Down syndrome risk assessment and second-trimester ultrasound examination. They used a decision analysis model that assumed ultrasound provides 100% detection of anencephaly and 92% detection of spina bifida (the lowest percentage reported in the literature). To put AFP testing in the most favorable light, the model assumed a 92% detection rate for spina bifida (the highest in the literature) with a 3% false-positive rate.

The model predicted an estimated 4,000 neural tube defects among the approximate 4 million births in the United States in 2003. Screening of all these women with ultrasound would detect 2,208 of the 2,400 cases of spina bifida. AFP testing would yield 120,000 positive results and detect 176 of the 192 cases of spina bifida missed by ultrasound.

“The AFP test induces anxiety—for every 10,000 women who screen positive, only 3 will have a baby with spina bifida,” Dr. Rosen said. AFP screening in women who undergo first- and second-trimester ultrasound examinations has a poor predictive value and causes more pregnancy losses from amniocentesis than cases of spina bifida it detects, he added.

In addition, “by continuing to do AFP, we are spending all this money,” Dr. Rosen said. For example, universal screening in the study cohort would cost $184 million. Because about 40% of women terminate a pregnancy because of spina bifida (in this model, 70 of 176 women), the cost becomes $2.6 million for each case prevented. With the assumption that 50% of women with an elevated AFP result have amniocentesis, and the procedure's loss rate is 1 fetus per 250, 245 women would lose their pregnancies, he estimated.

“As doctors we are really caught. We want to do what is right for patients, but we have a high risk of malpractice [suits],” he said. “Because we are so wary of missing anything, we err on the side of overtesting and this can do more harm than good.”

MIAMI BEACH — Maternal serum α-fetoprotein is no longer an effective or cost-effective second-trimester screen for neural tube defects in an era when women routinely undergo first-trimester Down syndrome screening and subsequent ultrasound, Dr. Todd J. Rosen said at the annual meeting of the Society for Maternal-Fetal Medicine.

Before ultrasound was commonplace—back in the 1970s and 1980s—women got an α-fetoprotein (AFP) test for spina bifida and anencephaly. “Now more and more women are screening for Down syndrome in the first trimester, and it is routine for women to do an ultrasound screen as well,” said Dr. Rosen of the division of maternal-fetal medicine, Columbia University, New York. Dr. Rosen and his associates assessed clinical and cost effectiveness of AFP testing for U.S. women who had a first-trimester Down syndrome risk assessment and second-trimester ultrasound examination. They used a decision analysis model that assumed ultrasound provides 100% detection of anencephaly and 92% detection of spina bifida (the lowest percentage reported in the literature). To put AFP testing in the most favorable light, the model assumed a 92% detection rate for spina bifida (the highest in the literature) with a 3% false-positive rate.

The model predicted an estimated 4,000 neural tube defects among the approximate 4 million births in the United States in 2003. Screening of all these women with ultrasound would detect 2,208 of the 2,400 cases of spina bifida. AFP testing would yield 120,000 positive results and detect 176 of the 192 cases of spina bifida missed by ultrasound.

“The AFP test induces anxiety—for every 10,000 women who screen positive, only 3 will have a baby with spina bifida,” Dr. Rosen said. AFP screening in women who undergo first- and second-trimester ultrasound examinations has a poor predictive value and causes more pregnancy losses from amniocentesis than cases of spina bifida it detects, he added.

In addition, “by continuing to do AFP, we are spending all this money,” Dr. Rosen said. For example, universal screening in the study cohort would cost $184 million. Because about 40% of women terminate a pregnancy because of spina bifida (in this model, 70 of 176 women), the cost becomes $2.6 million for each case prevented. With the assumption that 50% of women with an elevated AFP result have amniocentesis, and the procedure's loss rate is 1 fetus per 250, 245 women would lose their pregnancies, he estimated.

“As doctors we are really caught. We want to do what is right for patients, but we have a high risk of malpractice [suits],” he said. “Because we are so wary of missing anything, we err on the side of overtesting and this can do more harm than good.”

MIAMI BEACH — Maternal serum α-fetoprotein is no longer an effective or cost-effective second-trimester screen for neural tube defects in an era when women routinely undergo first-trimester Down syndrome screening and subsequent ultrasound, Dr. Todd J. Rosen said at the annual meeting of the Society for Maternal-Fetal Medicine.

Before ultrasound was commonplace—back in the 1970s and 1980s—women got an α-fetoprotein (AFP) test for spina bifida and anencephaly. “Now more and more women are screening for Down syndrome in the first trimester, and it is routine for women to do an ultrasound screen as well,” said Dr. Rosen of the division of maternal-fetal medicine, Columbia University, New York. Dr. Rosen and his associates assessed clinical and cost effectiveness of AFP testing for U.S. women who had a first-trimester Down syndrome risk assessment and second-trimester ultrasound examination. They used a decision analysis model that assumed ultrasound provides 100% detection of anencephaly and 92% detection of spina bifida (the lowest percentage reported in the literature). To put AFP testing in the most favorable light, the model assumed a 92% detection rate for spina bifida (the highest in the literature) with a 3% false-positive rate.

The model predicted an estimated 4,000 neural tube defects among the approximate 4 million births in the United States in 2003. Screening of all these women with ultrasound would detect 2,208 of the 2,400 cases of spina bifida. AFP testing would yield 120,000 positive results and detect 176 of the 192 cases of spina bifida missed by ultrasound.

“The AFP test induces anxiety—for every 10,000 women who screen positive, only 3 will have a baby with spina bifida,” Dr. Rosen said. AFP screening in women who undergo first- and second-trimester ultrasound examinations has a poor predictive value and causes more pregnancy losses from amniocentesis than cases of spina bifida it detects, he added.

In addition, “by continuing to do AFP, we are spending all this money,” Dr. Rosen said. For example, universal screening in the study cohort would cost $184 million. Because about 40% of women terminate a pregnancy because of spina bifida (in this model, 70 of 176 women), the cost becomes $2.6 million for each case prevented. With the assumption that 50% of women with an elevated AFP result have amniocentesis, and the procedure's loss rate is 1 fetus per 250, 245 women would lose their pregnancies, he estimated.

“As doctors we are really caught. We want to do what is right for patients, but we have a high risk of malpractice [suits],” he said. “Because we are so wary of missing anything, we err on the side of overtesting and this can do more harm than good.”

SAN DIEGO — Female gender in extremely-low-birth-weight infants has a positive influence on the neurodevelopmental outcome at 18–22 months, increasing the Bayley-II Mental Developmental Index scores by 8–10 points, Dr. Regina A. Gargus reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“The persistence of this effect over time will need to be reassessed in longer-term studies,” said Dr. Gargus, medical director of the Dennis Developmental Center at Arkansas Children's Hospital, Little Rock.

The finding is important because the influence of gender alone on the outcome of extremely-low-birth-weight (ELBW) infants has not been described.

In a study Dr. Gargus conducted during her fellowship at Brown University, Providence, R.I., she and her associates reviewed prospectively collected data from the neonatal intensive care unit (NICU) course and follow-up visits of 71 female and 53 male ELBW infant survivors who were admitted to Women and Infants Hospital of Rhode Island in Providence from January 1, 2000 to December 31, 2001. The infants had a gestational age of less than 32 weeks and a birth weight of less than 1,000 g, and they participated in developmental assessments at 18–22 months. Infants who were born with chromosomal or major congenital anomalies were excluded from the study.

The investigators analyzed the data for demographic characteristics, Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE II) scores, neonatal course, perinatal morbidities, and 18-month outcome.

Most of the medical characteristics did not differ between the two groups, but the mean number of days on oxygen was significantly greater in the male population (65.9 days vs. 50.6 days). The incidence of chronic lung disease was 1.5 times greater in males compared with females, but other comorbidities were not different between the two groups.

Bivariate analysis revealed that female gender was associated with decreased neurodevelopmental impairment and increased Bayley-II Mental Developmental Index scores.

Multivariate regression analysis, adjusted for gestation, chronic lung disease, SNAP-PE II, and level of maternal education, revealed that Bayley-II MDI scores were associated with female gender. Overall, the MDI scores of females were 8–10 points higher than the scores of their male counterparts.

SAN DIEGO — Female gender in extremely-low-birth-weight infants has a positive influence on the neurodevelopmental outcome at 18–22 months, increasing the Bayley-II Mental Developmental Index scores by 8–10 points, Dr. Regina A. Gargus reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“The persistence of this effect over time will need to be reassessed in longer-term studies,” said Dr. Gargus, medical director of the Dennis Developmental Center at Arkansas Children's Hospital, Little Rock.

The finding is important because the influence of gender alone on the outcome of extremely-low-birth-weight (ELBW) infants has not been described.

In a study Dr. Gargus conducted during her fellowship at Brown University, Providence, R.I., she and her associates reviewed prospectively collected data from the neonatal intensive care unit (NICU) course and follow-up visits of 71 female and 53 male ELBW infant survivors who were admitted to Women and Infants Hospital of Rhode Island in Providence from January 1, 2000 to December 31, 2001. The infants had a gestational age of less than 32 weeks and a birth weight of less than 1,000 g, and they participated in developmental assessments at 18–22 months. Infants who were born with chromosomal or major congenital anomalies were excluded from the study.

The investigators analyzed the data for demographic characteristics, Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE II) scores, neonatal course, perinatal morbidities, and 18-month outcome.

Most of the medical characteristics did not differ between the two groups, but the mean number of days on oxygen was significantly greater in the male population (65.9 days vs. 50.6 days). The incidence of chronic lung disease was 1.5 times greater in males compared with females, but other comorbidities were not different between the two groups.

Bivariate analysis revealed that female gender was associated with decreased neurodevelopmental impairment and increased Bayley-II Mental Developmental Index scores.

Multivariate regression analysis, adjusted for gestation, chronic lung disease, SNAP-PE II, and level of maternal education, revealed that Bayley-II MDI scores were associated with female gender. Overall, the MDI scores of females were 8–10 points higher than the scores of their male counterparts.

SAN DIEGO — Female gender in extremely-low-birth-weight infants has a positive influence on the neurodevelopmental outcome at 18–22 months, increasing the Bayley-II Mental Developmental Index scores by 8–10 points, Dr. Regina A. Gargus reported at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

“The persistence of this effect over time will need to be reassessed in longer-term studies,” said Dr. Gargus, medical director of the Dennis Developmental Center at Arkansas Children's Hospital, Little Rock.

The finding is important because the influence of gender alone on the outcome of extremely-low-birth-weight (ELBW) infants has not been described.

In a study Dr. Gargus conducted during her fellowship at Brown University, Providence, R.I., she and her associates reviewed prospectively collected data from the neonatal intensive care unit (NICU) course and follow-up visits of 71 female and 53 male ELBW infant survivors who were admitted to Women and Infants Hospital of Rhode Island in Providence from January 1, 2000 to December 31, 2001. The infants had a gestational age of less than 32 weeks and a birth weight of less than 1,000 g, and they participated in developmental assessments at 18–22 months. Infants who were born with chromosomal or major congenital anomalies were excluded from the study.

The investigators analyzed the data for demographic characteristics, Score for Neonatal Acute Physiology-Perinatal Extension II (SNAP-PE II) scores, neonatal course, perinatal morbidities, and 18-month outcome.

Most of the medical characteristics did not differ between the two groups, but the mean number of days on oxygen was significantly greater in the male population (65.9 days vs. 50.6 days). The incidence of chronic lung disease was 1.5 times greater in males compared with females, but other comorbidities were not different between the two groups.

Bivariate analysis revealed that female gender was associated with decreased neurodevelopmental impairment and increased Bayley-II Mental Developmental Index scores.

Multivariate regression analysis, adjusted for gestation, chronic lung disease, SNAP-PE II, and level of maternal education, revealed that Bayley-II MDI scores were associated with female gender. Overall, the MDI scores of females were 8–10 points higher than the scores of their male counterparts.

WASHINGTON — Decreased use of valproate to manage epilepsy during pregnancy in Australia has produced a corresponding drop in fetal malformations associated with the drug, Dr. Frank Vajda said at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

Dr. Vajda, a neurologist at the Victorian Epilepsy Centre in Victoria, Australia, presented the most recent data from the Australian Pregnancy Registry for Women on Antiepileptic Medication. The registry, established in 1999, has enrolled 810 women—77% of all Australian women who had taken antiepilepsy drugs (AEDs) for any reason. The 64-month data contained outcome information on 715 births.

Of the women in the registry, most who were currently taking AEDs (692) were taking the drugs for epilepsy. Other indications were bipolar disorder (11), pain (4), sleep (1), and unspecified (14). The majority of the women (504) were on AED monotherapy.

Most of the births (640) were of live infants without congenital malformations. There were 44 births with fetal malformations: 27 live births with defects, 9 live births with defects that emerged by 1 year, and 8 induced abortions of malformed fetuses. The malformations included spina bifida, anencephaly, holoprosencephaly, Dandy-Walker syndrome, and a variety of cardiac defects.

There were also 23 spontaneous abortions, one induced abortion for maternal indications, and seven stillbirths; no malformations were noted in these fetuses.

The only significant drug/defect associations occurred in women taking high doses of valproate, either as monotherapy or polytherapy. Women taking more than 1,100 mg/day of valproate as monotherapy had a 13-fold increased risk of fetal malformations, compared with women not taking any AEDs. Women taking similar doses of the drug as polytherapy had a sixfold increased risk of fetal malformations.

The rate of malformation among women taking less than 1,100 mg/day was higher than the 2%–3% that occurs in the general population, but the difference was not statistically significant.

Australian physicians appear to be heeding the data linking valproate to birth defects, Dr. Vajda said. The rate of valproate prescribing and dosages prescribed has decreased over the length of the registry, as have the rates of fetal malformation. In 1999, 26% of women on the registry were on the drug. The rate increased to 33% by 2001 and has since dropped to 21%. The average daily dose has decreased from 1,780 mg in 1999 to 936 mg in 2004.

The rate of malformation associated with valproate monotherapy was 16% before 2004, compared with 7% in 2004; the rate associated with polytherapy was 10% before 2004 and 0% in 2004.

However, he noted, the rates of malformation among women on carbamazepine or lamotrigine monotherapy have increased. For carbamazepine, the pre-2004 rate was 4.8%; it rose to 6.5% in 2004. The rate associated with lamotrigine monotherapy was 4.5% before 2004 and rose to 8.6% in 2004. The average dosages of these drugs increased from 1999–2004 as well.

“These are not regarded as significant as the numbers are,” Dr. Vajda said in an interview. “It's possible that the increases in dosing may play a part, but there are no significant data available as yet.”

WASHINGTON — Decreased use of valproate to manage epilepsy during pregnancy in Australia has produced a corresponding drop in fetal malformations associated with the drug, Dr. Frank Vajda said at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

Dr. Vajda, a neurologist at the Victorian Epilepsy Centre in Victoria, Australia, presented the most recent data from the Australian Pregnancy Registry for Women on Antiepileptic Medication. The registry, established in 1999, has enrolled 810 women—77% of all Australian women who had taken antiepilepsy drugs (AEDs) for any reason. The 64-month data contained outcome information on 715 births.

Of the women in the registry, most who were currently taking AEDs (692) were taking the drugs for epilepsy. Other indications were bipolar disorder (11), pain (4), sleep (1), and unspecified (14). The majority of the women (504) were on AED monotherapy.

Most of the births (640) were of live infants without congenital malformations. There were 44 births with fetal malformations: 27 live births with defects, 9 live births with defects that emerged by 1 year, and 8 induced abortions of malformed fetuses. The malformations included spina bifida, anencephaly, holoprosencephaly, Dandy-Walker syndrome, and a variety of cardiac defects.

There were also 23 spontaneous abortions, one induced abortion for maternal indications, and seven stillbirths; no malformations were noted in these fetuses.

The only significant drug/defect associations occurred in women taking high doses of valproate, either as monotherapy or polytherapy. Women taking more than 1,100 mg/day of valproate as monotherapy had a 13-fold increased risk of fetal malformations, compared with women not taking any AEDs. Women taking similar doses of the drug as polytherapy had a sixfold increased risk of fetal malformations.

The rate of malformation among women taking less than 1,100 mg/day was higher than the 2%–3% that occurs in the general population, but the difference was not statistically significant.

Australian physicians appear to be heeding the data linking valproate to birth defects, Dr. Vajda said. The rate of valproate prescribing and dosages prescribed has decreased over the length of the registry, as have the rates of fetal malformation. In 1999, 26% of women on the registry were on the drug. The rate increased to 33% by 2001 and has since dropped to 21%. The average daily dose has decreased from 1,780 mg in 1999 to 936 mg in 2004.

The rate of malformation associated with valproate monotherapy was 16% before 2004, compared with 7% in 2004; the rate associated with polytherapy was 10% before 2004 and 0% in 2004.

However, he noted, the rates of malformation among women on carbamazepine or lamotrigine monotherapy have increased. For carbamazepine, the pre-2004 rate was 4.8%; it rose to 6.5% in 2004. The rate associated with lamotrigine monotherapy was 4.5% before 2004 and rose to 8.6% in 2004. The average dosages of these drugs increased from 1999–2004 as well.

“These are not regarded as significant as the numbers are,” Dr. Vajda said in an interview. “It's possible that the increases in dosing may play a part, but there are no significant data available as yet.”

WASHINGTON — Decreased use of valproate to manage epilepsy during pregnancy in Australia has produced a corresponding drop in fetal malformations associated with the drug, Dr. Frank Vajda said at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

Dr. Vajda, a neurologist at the Victorian Epilepsy Centre in Victoria, Australia, presented the most recent data from the Australian Pregnancy Registry for Women on Antiepileptic Medication. The registry, established in 1999, has enrolled 810 women—77% of all Australian women who had taken antiepilepsy drugs (AEDs) for any reason. The 64-month data contained outcome information on 715 births.

Of the women in the registry, most who were currently taking AEDs (692) were taking the drugs for epilepsy. Other indications were bipolar disorder (11), pain (4), sleep (1), and unspecified (14). The majority of the women (504) were on AED monotherapy.

Most of the births (640) were of live infants without congenital malformations. There were 44 births with fetal malformations: 27 live births with defects, 9 live births with defects that emerged by 1 year, and 8 induced abortions of malformed fetuses. The malformations included spina bifida, anencephaly, holoprosencephaly, Dandy-Walker syndrome, and a variety of cardiac defects.

There were also 23 spontaneous abortions, one induced abortion for maternal indications, and seven stillbirths; no malformations were noted in these fetuses.

The only significant drug/defect associations occurred in women taking high doses of valproate, either as monotherapy or polytherapy. Women taking more than 1,100 mg/day of valproate as monotherapy had a 13-fold increased risk of fetal malformations, compared with women not taking any AEDs. Women taking similar doses of the drug as polytherapy had a sixfold increased risk of fetal malformations.

The rate of malformation among women taking less than 1,100 mg/day was higher than the 2%–3% that occurs in the general population, but the difference was not statistically significant.

Australian physicians appear to be heeding the data linking valproate to birth defects, Dr. Vajda said. The rate of valproate prescribing and dosages prescribed has decreased over the length of the registry, as have the rates of fetal malformation. In 1999, 26% of women on the registry were on the drug. The rate increased to 33% by 2001 and has since dropped to 21%. The average daily dose has decreased from 1,780 mg in 1999 to 936 mg in 2004.

The rate of malformation associated with valproate monotherapy was 16% before 2004, compared with 7% in 2004; the rate associated with polytherapy was 10% before 2004 and 0% in 2004.

However, he noted, the rates of malformation among women on carbamazepine or lamotrigine monotherapy have increased. For carbamazepine, the pre-2004 rate was 4.8%; it rose to 6.5% in 2004. The rate associated with lamotrigine monotherapy was 4.5% before 2004 and rose to 8.6% in 2004. The average dosages of these drugs increased from 1999–2004 as well.

“These are not regarded as significant as the numbers are,” Dr. Vajda said in an interview. “It's possible that the increases in dosing may play a part, but there are no significant data available as yet.”

KAILUA KONA, HAWAII — Insignificant trauma to the mother may not be insignificant to the fetus, Dr. William G. Barsan said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Severe maternal injury is likely to lead to fetal loss in 40%–50% of cases, but severe maternal injuries are relatively rare. Minor injuries to the mother result from 88% of trauma in pregnancy; 60%–70% of fetal losses resulting from maternal trauma follow relatively minor maternal injuries, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

Placental abruption is the cause of fetal death in 50%–70% of losses after maternal trauma. “This is the one that may occur with relatively minor trauma” and can be hard to detect, he said.

In one study of nine fetal deaths after 25-mph motor vehicle crashes in which the mothers were not wearing seat belts, six of the women sustained only “insignificant” injures, such as bruising or abrasions, Dr. Barsan noted.

A separate study of 22 fetal deaths resulting from motor vehicle crashes found that six mothers sustained no injuries at all, and nine had bruised abdomens. Other maternal injuries included three ruptured uteri, two chest injuries, one extremity fracture, and one head injury with shock.

Perform electronic fetal monitoring for 4 hours on any pregnant woman with a viable fetus who sustains a significant impact to the torso from falling, crashing, or other causes, Dr. Barsan advised. In one study, all patients with placental abruption after trauma developed uterine contractions every 2–5 minutes at some point during a 4-hour monitoring period.

Many women will have uterine contractions after trauma, and most will not have placental abruption. At Dr. Barsan's institution, women with frequent uterine contractions after trauma receive an additional 24 hours of electronic fetal monitoring.

“This seems to be a protocol that works pretty well” to identify patients at risk of placental abruption, he said at the conference sponsored by Boston University.

Even if the patient says that she fell yesterday, or last night, do 4 hours of monitoring, he added. Traumas unrelated to the torso—such as hammering a finger—do not call for monitoring.

If there are no adverse outcomes within the first few days after trauma, pregnancy outcomes can be expected to be similar to cases without trauma, he said.

Besides placental abruption, maternal hypovolemic shock kills less than 5% of fetuses after maternal trauma; direct fetal injury causes less than 10% of deaths, and about 10% of fetuses die because the mother died after trauma.

No cause is recognized in more than 10% of fetal deaths after maternal trauma, he said.

The cause of placental abruption in motor vehicle accidents was demonstrated in crash testing using “pregnant” dummy-within-a-dummy models and computer modeling.

A frontal impact first throws the uterus forward against the abdominal wall, increasing anterior intrauterine pressure up to 550 mm/Hg. Then the torso gets thrown forward and the body flexes forward, crushing the uterus between the torso and the knees and causing a second increase in intrauterine pressure, which may become as great as 600 mm/Hg.

All this creates a high degree of negative pressure in the back of the uterus that can pull the placenta off the uterine wall, Dr. Barsan explained.

'[Placental abruption] is the one that may occur with relatively minor trauma' and can be hard to detect. DR. BARSAN

Fetal Loss From Maternal Trauma

U.S. deliveries per year 4 million

Pregnancies complicated by trauma 6%–7%

Fetal loss in pregnancies with trauma 1%–2%

Number of fetuses lost from trauma 2,600–5,200

Source: Dr. Barsan

KAILUA KONA, HAWAII — Insignificant trauma to the mother may not be insignificant to the fetus, Dr. William G. Barsan said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Severe maternal injury is likely to lead to fetal loss in 40%–50% of cases, but severe maternal injuries are relatively rare. Minor injuries to the mother result from 88% of trauma in pregnancy; 60%–70% of fetal losses resulting from maternal trauma follow relatively minor maternal injuries, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

Placental abruption is the cause of fetal death in 50%–70% of losses after maternal trauma. “This is the one that may occur with relatively minor trauma” and can be hard to detect, he said.

In one study of nine fetal deaths after 25-mph motor vehicle crashes in which the mothers were not wearing seat belts, six of the women sustained only “insignificant” injures, such as bruising or abrasions, Dr. Barsan noted.

A separate study of 22 fetal deaths resulting from motor vehicle crashes found that six mothers sustained no injuries at all, and nine had bruised abdomens. Other maternal injuries included three ruptured uteri, two chest injuries, one extremity fracture, and one head injury with shock.

Perform electronic fetal monitoring for 4 hours on any pregnant woman with a viable fetus who sustains a significant impact to the torso from falling, crashing, or other causes, Dr. Barsan advised. In one study, all patients with placental abruption after trauma developed uterine contractions every 2–5 minutes at some point during a 4-hour monitoring period.

Many women will have uterine contractions after trauma, and most will not have placental abruption. At Dr. Barsan's institution, women with frequent uterine contractions after trauma receive an additional 24 hours of electronic fetal monitoring.

“This seems to be a protocol that works pretty well” to identify patients at risk of placental abruption, he said at the conference sponsored by Boston University.

Even if the patient says that she fell yesterday, or last night, do 4 hours of monitoring, he added. Traumas unrelated to the torso—such as hammering a finger—do not call for monitoring.

If there are no adverse outcomes within the first few days after trauma, pregnancy outcomes can be expected to be similar to cases without trauma, he said.

Besides placental abruption, maternal hypovolemic shock kills less than 5% of fetuses after maternal trauma; direct fetal injury causes less than 10% of deaths, and about 10% of fetuses die because the mother died after trauma.

No cause is recognized in more than 10% of fetal deaths after maternal trauma, he said.

The cause of placental abruption in motor vehicle accidents was demonstrated in crash testing using “pregnant” dummy-within-a-dummy models and computer modeling.

A frontal impact first throws the uterus forward against the abdominal wall, increasing anterior intrauterine pressure up to 550 mm/Hg. Then the torso gets thrown forward and the body flexes forward, crushing the uterus between the torso and the knees and causing a second increase in intrauterine pressure, which may become as great as 600 mm/Hg.

All this creates a high degree of negative pressure in the back of the uterus that can pull the placenta off the uterine wall, Dr. Barsan explained.

'[Placental abruption] is the one that may occur with relatively minor trauma' and can be hard to detect. DR. BARSAN

Fetal Loss From Maternal Trauma

U.S. deliveries per year 4 million

Pregnancies complicated by trauma 6%–7%

Fetal loss in pregnancies with trauma 1%–2%

Number of fetuses lost from trauma 2,600–5,200

Source: Dr. Barsan

KAILUA KONA, HAWAII — Insignificant trauma to the mother may not be insignificant to the fetus, Dr. William G. Barsan said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Severe maternal injury is likely to lead to fetal loss in 40%–50% of cases, but severe maternal injuries are relatively rare. Minor injuries to the mother result from 88% of trauma in pregnancy; 60%–70% of fetal losses resulting from maternal trauma follow relatively minor maternal injuries, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

Placental abruption is the cause of fetal death in 50%–70% of losses after maternal trauma. “This is the one that may occur with relatively minor trauma” and can be hard to detect, he said.

In one study of nine fetal deaths after 25-mph motor vehicle crashes in which the mothers were not wearing seat belts, six of the women sustained only “insignificant” injures, such as bruising or abrasions, Dr. Barsan noted.

A separate study of 22 fetal deaths resulting from motor vehicle crashes found that six mothers sustained no injuries at all, and nine had bruised abdomens. Other maternal injuries included three ruptured uteri, two chest injuries, one extremity fracture, and one head injury with shock.

Perform electronic fetal monitoring for 4 hours on any pregnant woman with a viable fetus who sustains a significant impact to the torso from falling, crashing, or other causes, Dr. Barsan advised. In one study, all patients with placental abruption after trauma developed uterine contractions every 2–5 minutes at some point during a 4-hour monitoring period.

Many women will have uterine contractions after trauma, and most will not have placental abruption. At Dr. Barsan's institution, women with frequent uterine contractions after trauma receive an additional 24 hours of electronic fetal monitoring.

“This seems to be a protocol that works pretty well” to identify patients at risk of placental abruption, he said at the conference sponsored by Boston University.

Even if the patient says that she fell yesterday, or last night, do 4 hours of monitoring, he added. Traumas unrelated to the torso—such as hammering a finger—do not call for monitoring.

If there are no adverse outcomes within the first few days after trauma, pregnancy outcomes can be expected to be similar to cases without trauma, he said.

Besides placental abruption, maternal hypovolemic shock kills less than 5% of fetuses after maternal trauma; direct fetal injury causes less than 10% of deaths, and about 10% of fetuses die because the mother died after trauma.

No cause is recognized in more than 10% of fetal deaths after maternal trauma, he said.

The cause of placental abruption in motor vehicle accidents was demonstrated in crash testing using “pregnant” dummy-within-a-dummy models and computer modeling.

A frontal impact first throws the uterus forward against the abdominal wall, increasing anterior intrauterine pressure up to 550 mm/Hg. Then the torso gets thrown forward and the body flexes forward, crushing the uterus between the torso and the knees and causing a second increase in intrauterine pressure, which may become as great as 600 mm/Hg.

All this creates a high degree of negative pressure in the back of the uterus that can pull the placenta off the uterine wall, Dr. Barsan explained.

'[Placental abruption] is the one that may occur with relatively minor trauma' and can be hard to detect. DR. BARSAN

Fetal Loss From Maternal Trauma

U.S. deliveries per year 4 million

Pregnancies complicated by trauma 6%–7%

Fetal loss in pregnancies with trauma 1%–2%

Number of fetuses lost from trauma 2,600–5,200

Source: Dr. Barsan

KAILUA KONA, HAWAII — Three-dimensional ultrasound is less helpful for diagnosing fetal abnormalities than for counseling patients, Dr. Dolores H. Pretorius said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always performed as an adjunct to two-dimensional prenatal ultrasound, never as a replacement for it, 3-D ultrasound can help visualize and evaluate certain fetal abnormalities, give clinicians more confidence about what they're identifying, and help explain the problem to patients, she said.

Rarely does 3-D ultrasound identify additional abnormalities, said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The most helpful medical use of 3-D ultrasound may be for imaging facial anomalies, especially small cleft lips and cleft palates that are difficult to see with 2-D ultrasound, according to a 2005 consensus panel convened by the American Institute of Ultrasound in Medicine.

Because 3-D ultrasound can provide consistent symmetrical views, unlike 2-D ultrasound, it may help diagnose micrognathia (small chin), but further research is needed to confirm that, she said at the conference, which was sponsored by Boston University. It also may be helpful for imaging brain and spinal anomalies, identifying sutures on the fetal skull, and for research studies of cardiac anomalies, the consensus panel suggested.

Anomalies of the ear or the extremities can be seen with 3-D ultrasound. A diagnosis of club feet by 3-D ultrasound is false 12%–22% of the time, however, so patients must be warned of the false-positive rate, she cautioned. “We've had patients terminate the pregnancy for club feet and then have normal feet at autopsy.”

Referrals to check for central nervous system anomalies include cases of craniosynostosis or of mild ventriculomegaly, to look for the corpus callosum. A 3-D ultrasound of a neural tube defect can localize the level of the defect. “Most of the time this does not impact patient care” except when surgical treatment is planned, she said. Scoliosis is much more apparent on 3-D than on 2-D ultrasound to the parents and clinicians.

Trying to get parents to understand a fetal movement disorder can be difficult with just a 2-D image of an outstretched arm. Show them a 3-D image, however, “and all of a sudden the light bulb goes off in their head and they can understand it. Sometimes for patients the visual appearance of these can be very helpful,” Dr. Pretorius said.

Parents love to see 3-D images of the fetal face, which has led some nonmedical businesses to offer controversial “entertainment” 3-D ultrasound services in shopping malls and elsewhere. “I've already seen several lawsuits coming through related to 3-D ultrasounds that missed anomalies. The key question is, did the patient know that this was for entertainment, not diagnosis?” said Dr. Pretorius, who has studied 3-D ultrasound for 17 years.

A 3-D exam can be a frustrating experience for sonographers. Even experts only manage to image the face in 80% of midtrimester fetuses and 50% of third-trimester fetuses. The fetus must be in the right position without anything obscuring the face, and with plenty of amniotic fluid around it. The results are affected by gestational age and other factors.

At the start of a 3-D exam, “there's no predicting whether I'm going to make a good picture or not. If the parents don't get a good picture, they think that I'm not a good doctor,” Dr. Pretorius said.

As 3-D ultrasound gets used more and more, clinicians must become familiar with a slew of new imaging artifacts. To the untrained eye, a 3-D ultrasound may seem to show a fetus with a single nostril, or a black eye. Motion artifacts can simulate a cleft lip. Rendering artifacts can look like terrible ventriculomegaly. What seems to be a missing arm bone may be a shadow artifact.

KAILUA KONA, HAWAII — Three-dimensional ultrasound is less helpful for diagnosing fetal abnormalities than for counseling patients, Dr. Dolores H. Pretorius said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always performed as an adjunct to two-dimensional prenatal ultrasound, never as a replacement for it, 3-D ultrasound can help visualize and evaluate certain fetal abnormalities, give clinicians more confidence about what they're identifying, and help explain the problem to patients, she said.

Rarely does 3-D ultrasound identify additional abnormalities, said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The most helpful medical use of 3-D ultrasound may be for imaging facial anomalies, especially small cleft lips and cleft palates that are difficult to see with 2-D ultrasound, according to a 2005 consensus panel convened by the American Institute of Ultrasound in Medicine.

Because 3-D ultrasound can provide consistent symmetrical views, unlike 2-D ultrasound, it may help diagnose micrognathia (small chin), but further research is needed to confirm that, she said at the conference, which was sponsored by Boston University. It also may be helpful for imaging brain and spinal anomalies, identifying sutures on the fetal skull, and for research studies of cardiac anomalies, the consensus panel suggested.

Anomalies of the ear or the extremities can be seen with 3-D ultrasound. A diagnosis of club feet by 3-D ultrasound is false 12%–22% of the time, however, so patients must be warned of the false-positive rate, she cautioned. “We've had patients terminate the pregnancy for club feet and then have normal feet at autopsy.”

Referrals to check for central nervous system anomalies include cases of craniosynostosis or of mild ventriculomegaly, to look for the corpus callosum. A 3-D ultrasound of a neural tube defect can localize the level of the defect. “Most of the time this does not impact patient care” except when surgical treatment is planned, she said. Scoliosis is much more apparent on 3-D than on 2-D ultrasound to the parents and clinicians.

Trying to get parents to understand a fetal movement disorder can be difficult with just a 2-D image of an outstretched arm. Show them a 3-D image, however, “and all of a sudden the light bulb goes off in their head and they can understand it. Sometimes for patients the visual appearance of these can be very helpful,” Dr. Pretorius said.

Parents love to see 3-D images of the fetal face, which has led some nonmedical businesses to offer controversial “entertainment” 3-D ultrasound services in shopping malls and elsewhere. “I've already seen several lawsuits coming through related to 3-D ultrasounds that missed anomalies. The key question is, did the patient know that this was for entertainment, not diagnosis?” said Dr. Pretorius, who has studied 3-D ultrasound for 17 years.

A 3-D exam can be a frustrating experience for sonographers. Even experts only manage to image the face in 80% of midtrimester fetuses and 50% of third-trimester fetuses. The fetus must be in the right position without anything obscuring the face, and with plenty of amniotic fluid around it. The results are affected by gestational age and other factors.

At the start of a 3-D exam, “there's no predicting whether I'm going to make a good picture or not. If the parents don't get a good picture, they think that I'm not a good doctor,” Dr. Pretorius said.

As 3-D ultrasound gets used more and more, clinicians must become familiar with a slew of new imaging artifacts. To the untrained eye, a 3-D ultrasound may seem to show a fetus with a single nostril, or a black eye. Motion artifacts can simulate a cleft lip. Rendering artifacts can look like terrible ventriculomegaly. What seems to be a missing arm bone may be a shadow artifact.

KAILUA KONA, HAWAII — Three-dimensional ultrasound is less helpful for diagnosing fetal abnormalities than for counseling patients, Dr. Dolores H. Pretorius said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always performed as an adjunct to two-dimensional prenatal ultrasound, never as a replacement for it, 3-D ultrasound can help visualize and evaluate certain fetal abnormalities, give clinicians more confidence about what they're identifying, and help explain the problem to patients, she said.

Rarely does 3-D ultrasound identify additional abnormalities, said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The most helpful medical use of 3-D ultrasound may be for imaging facial anomalies, especially small cleft lips and cleft palates that are difficult to see with 2-D ultrasound, according to a 2005 consensus panel convened by the American Institute of Ultrasound in Medicine.

Because 3-D ultrasound can provide consistent symmetrical views, unlike 2-D ultrasound, it may help diagnose micrognathia (small chin), but further research is needed to confirm that, she said at the conference, which was sponsored by Boston University. It also may be helpful for imaging brain and spinal anomalies, identifying sutures on the fetal skull, and for research studies of cardiac anomalies, the consensus panel suggested.

Anomalies of the ear or the extremities can be seen with 3-D ultrasound. A diagnosis of club feet by 3-D ultrasound is false 12%–22% of the time, however, so patients must be warned of the false-positive rate, she cautioned. “We've had patients terminate the pregnancy for club feet and then have normal feet at autopsy.”

Referrals to check for central nervous system anomalies include cases of craniosynostosis or of mild ventriculomegaly, to look for the corpus callosum. A 3-D ultrasound of a neural tube defect can localize the level of the defect. “Most of the time this does not impact patient care” except when surgical treatment is planned, she said. Scoliosis is much more apparent on 3-D than on 2-D ultrasound to the parents and clinicians.

Trying to get parents to understand a fetal movement disorder can be difficult with just a 2-D image of an outstretched arm. Show them a 3-D image, however, “and all of a sudden the light bulb goes off in their head and they can understand it. Sometimes for patients the visual appearance of these can be very helpful,” Dr. Pretorius said.

Parents love to see 3-D images of the fetal face, which has led some nonmedical businesses to offer controversial “entertainment” 3-D ultrasound services in shopping malls and elsewhere. “I've already seen several lawsuits coming through related to 3-D ultrasounds that missed anomalies. The key question is, did the patient know that this was for entertainment, not diagnosis?” said Dr. Pretorius, who has studied 3-D ultrasound for 17 years.

A 3-D exam can be a frustrating experience for sonographers. Even experts only manage to image the face in 80% of midtrimester fetuses and 50% of third-trimester fetuses. The fetus must be in the right position without anything obscuring the face, and with plenty of amniotic fluid around it. The results are affected by gestational age and other factors.

At the start of a 3-D exam, “there's no predicting whether I'm going to make a good picture or not. If the parents don't get a good picture, they think that I'm not a good doctor,” Dr. Pretorius said.

As 3-D ultrasound gets used more and more, clinicians must become familiar with a slew of new imaging artifacts. To the untrained eye, a 3-D ultrasound may seem to show a fetus with a single nostril, or a black eye. Motion artifacts can simulate a cleft lip. Rendering artifacts can look like terrible ventriculomegaly. What seems to be a missing arm bone may be a shadow artifact.

KAILUA KONA, HAWAII — Clinicians who offer fetal ultrasounds in their offices should ensure that those performing the scans are properly trained and that they explain to patients the limitations of the technology, to reduce the risk of being sued over ultrasound results, several speakers said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

In recent years, sonographers and ultrasound technicians who used to work exclusively for radiologists have been hired by some obstetricians to do ultrasounds in their offices. Many malpractice suits arising from misinterpretation or mismanagement of fetal ultrasound derive from inadequate staffing, training, and education, said Kimberly D. Baker, J.D.

She said too many clinicians want to have a fully equipped office technologically but are unwilling to pay for the education and training needed to maximize use of the technology. Turf wars make it more common for radiologists and other experts to criticize obstetricians or general practitioners whose use of ultrasound contributes to a legal case, said Ms. Baker, a defense lawyer in Seattle who also holds a BS degree in nursing.

“If you are going to have someone in your office who does this, you need to make sure that they are adequately trained, that their status is updated, that they are educated, and that you have a quality review process for your staff,” she advised.

Dr. Dolores H. Pretorius noted during a question-and-answer session that the American Institute of Ultrasound in Medicine offers a voluntary set of credentialing mechanisms for physicians who perform ultrasound. “I think it is helpful to have that to defend yourself,” said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The expertise of the sonographer is especially important with multifetal pregnancies, Dr. Michael A. Belfort said in a separate presentation. “It's not easy to scan twins and exponentially more difficult with triplets” or quadruplets. I can't understand why some doctors, without specific experience in managing high-order multiples, will choose to follow quadruplets in their office with a small, low-tech ultrasound machine and no consultation with a maternal and fetal medicine specialist. I just don't think it's worth the risk,” said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

In particular, when scanning multifetal pregnancies, it's important to get an early and accurate estimation of gestational age, determine amnionicity and chorionicity, and advise the patient of their implications.

Later in a twin pregnancy, one should consider following cervical length by ultrasound, because a woman with a cervix shorter than 25 mm at 24 weeks is more likely to deliver before 32–37 weeks than a woman with a longer cervix, Dr. Belfort advised. And definitely consider following cervical length in higher-order multiples. An anatomic survey by a maternal-fetal medicine specialist is also advisable. It's easy to miss an anomaly or scan the same fetus or parts of the fetus three times and think all three triplets are normal, he said.

One should reduce one's legal risk by explaining the benefits and the limitations of ultrasound to patients, Ms. Baker said at the meeting, sponsored by Boston University. Document in the chart that you explained the technology's limitations as they apply to the particular patient instead of relying on one-size-fits-all consent forms, she advised.

Document that you explained the technology's limitations as they apply to the particular patient. MS. BAKER

A short cervix, such as this one, in a woman with a multifetal pregnancy connotes a higher risk for preterm delivery, which ultrasound could detect early on. Courtesy Dr. Michael A. Belfort

KAILUA KONA, HAWAII — Clinicians who offer fetal ultrasounds in their offices should ensure that those performing the scans are properly trained and that they explain to patients the limitations of the technology, to reduce the risk of being sued over ultrasound results, several speakers said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

In recent years, sonographers and ultrasound technicians who used to work exclusively for radiologists have been hired by some obstetricians to do ultrasounds in their offices. Many malpractice suits arising from misinterpretation or mismanagement of fetal ultrasound derive from inadequate staffing, training, and education, said Kimberly D. Baker, J.D.

She said too many clinicians want to have a fully equipped office technologically but are unwilling to pay for the education and training needed to maximize use of the technology. Turf wars make it more common for radiologists and other experts to criticize obstetricians or general practitioners whose use of ultrasound contributes to a legal case, said Ms. Baker, a defense lawyer in Seattle who also holds a BS degree in nursing.

“If you are going to have someone in your office who does this, you need to make sure that they are adequately trained, that their status is updated, that they are educated, and that you have a quality review process for your staff,” she advised.

Dr. Dolores H. Pretorius noted during a question-and-answer session that the American Institute of Ultrasound in Medicine offers a voluntary set of credentialing mechanisms for physicians who perform ultrasound. “I think it is helpful to have that to defend yourself,” said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The expertise of the sonographer is especially important with multifetal pregnancies, Dr. Michael A. Belfort said in a separate presentation. “It's not easy to scan twins and exponentially more difficult with triplets” or quadruplets. I can't understand why some doctors, without specific experience in managing high-order multiples, will choose to follow quadruplets in their office with a small, low-tech ultrasound machine and no consultation with a maternal and fetal medicine specialist. I just don't think it's worth the risk,” said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

In particular, when scanning multifetal pregnancies, it's important to get an early and accurate estimation of gestational age, determine amnionicity and chorionicity, and advise the patient of their implications.

Later in a twin pregnancy, one should consider following cervical length by ultrasound, because a woman with a cervix shorter than 25 mm at 24 weeks is more likely to deliver before 32–37 weeks than a woman with a longer cervix, Dr. Belfort advised. And definitely consider following cervical length in higher-order multiples. An anatomic survey by a maternal-fetal medicine specialist is also advisable. It's easy to miss an anomaly or scan the same fetus or parts of the fetus three times and think all three triplets are normal, he said.

One should reduce one's legal risk by explaining the benefits and the limitations of ultrasound to patients, Ms. Baker said at the meeting, sponsored by Boston University. Document in the chart that you explained the technology's limitations as they apply to the particular patient instead of relying on one-size-fits-all consent forms, she advised.

Document that you explained the technology's limitations as they apply to the particular patient. MS. BAKER

A short cervix, such as this one, in a woman with a multifetal pregnancy connotes a higher risk for preterm delivery, which ultrasound could detect early on. Courtesy Dr. Michael A. Belfort

KAILUA KONA, HAWAII — Clinicians who offer fetal ultrasounds in their offices should ensure that those performing the scans are properly trained and that they explain to patients the limitations of the technology, to reduce the risk of being sued over ultrasound results, several speakers said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

In recent years, sonographers and ultrasound technicians who used to work exclusively for radiologists have been hired by some obstetricians to do ultrasounds in their offices. Many malpractice suits arising from misinterpretation or mismanagement of fetal ultrasound derive from inadequate staffing, training, and education, said Kimberly D. Baker, J.D.

She said too many clinicians want to have a fully equipped office technologically but are unwilling to pay for the education and training needed to maximize use of the technology. Turf wars make it more common for radiologists and other experts to criticize obstetricians or general practitioners whose use of ultrasound contributes to a legal case, said Ms. Baker, a defense lawyer in Seattle who also holds a BS degree in nursing.

“If you are going to have someone in your office who does this, you need to make sure that they are adequately trained, that their status is updated, that they are educated, and that you have a quality review process for your staff,” she advised.

Dr. Dolores H. Pretorius noted during a question-and-answer session that the American Institute of Ultrasound in Medicine offers a voluntary set of credentialing mechanisms for physicians who perform ultrasound. “I think it is helpful to have that to defend yourself,” said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The expertise of the sonographer is especially important with multifetal pregnancies, Dr. Michael A. Belfort said in a separate presentation. “It's not easy to scan twins and exponentially more difficult with triplets” or quadruplets. I can't understand why some doctors, without specific experience in managing high-order multiples, will choose to follow quadruplets in their office with a small, low-tech ultrasound machine and no consultation with a maternal and fetal medicine specialist. I just don't think it's worth the risk,” said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

In particular, when scanning multifetal pregnancies, it's important to get an early and accurate estimation of gestational age, determine amnionicity and chorionicity, and advise the patient of their implications.

Later in a twin pregnancy, one should consider following cervical length by ultrasound, because a woman with a cervix shorter than 25 mm at 24 weeks is more likely to deliver before 32–37 weeks than a woman with a longer cervix, Dr. Belfort advised. And definitely consider following cervical length in higher-order multiples. An anatomic survey by a maternal-fetal medicine specialist is also advisable. It's easy to miss an anomaly or scan the same fetus or parts of the fetus three times and think all three triplets are normal, he said.

One should reduce one's legal risk by explaining the benefits and the limitations of ultrasound to patients, Ms. Baker said at the meeting, sponsored by Boston University. Document in the chart that you explained the technology's limitations as they apply to the particular patient instead of relying on one-size-fits-all consent forms, she advised.

Document that you explained the technology's limitations as they apply to the particular patient. MS. BAKER

A short cervix, such as this one, in a woman with a multifetal pregnancy connotes a higher risk for preterm delivery, which ultrasound could detect early on. Courtesy Dr. Michael A. Belfort

MIAMI BEACH — Contrary to prior reports, very-low-birth-weight multiples have significantly greater morbidity and mortality than weight-matched singleton fetuses, according to a study presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Researchers assessed outcomes for 1,779 infants born between July 1993 and July 2004 who weighed less than 1,500 g at birth.

They compared risk of death and severe intraventricular hemorrhage (IVH) among 475 infants from multiple gestations and 1,304 singletons.

When the researchers examined the data for multiple fetuses, “we saw increased neonatal death and/or severe IVH,” Dr. Edward Hayes, of Thomas Jefferson University Hospital in Philadelphia, said during a poster presentation. The risk of death for a VLBW infant born as part of a multiple pregnancy was higher than that of a VLBW singleton (odds ratio 1.3).

The risk increased as birth weights decreased, Dr. Hayes said. The multiples group included 206 infants born weighing less than 1,000 g and 86 weighing less than 750 g.

Mortality risk among multiples below 1,000 g carried an odds ratio of 1.5, and below 750 g the odds ratio was 1.9, compared with weight-matched singletons. “The risk was twice as high when you're a multiple [below 750 g],” Dr. Hayes said. The singletons group included 578 born weighing less than 1,000 g and 262 weighing less than 750 g.

The mean gestational age at birth was 28 weeks in both groups; the mean birth weight was 1,039 g in the multiple group and 1,035 g among singletons. There were no significant differences between the groups in mean gestational age or mean birth weight.

However, significant differences existed between mothers in the two groups. For example, the percentage who were white differed (68% of mothers of multiples vs. 43% of mothers of singletons); as did mean maternal age (29 years vs. 26 years); birth at the facility (95% vs. 86%); use of prenatal steroids (74% vs. 58%); preeclampsia (14% vs. 24%), and preterm labor (74% vs. 62%). The investigators used a multivariate analysis to control for these differences and then compared groups for neonatal morbidity and mortality.

The risk of severe, grade 3–4 intraventricular hemorrhage was higher among VLBW infants born as part of a multiple pregnancy (odds ratio 1.2) versus similar singletons. The risk of this outcome was similar for neonates in the multiple groups below 1,000 g or 750 g (odds ratio 1.1 for both).

The etiology of the higher risk among multiple gestation VLBW infants remains unknown, Dr. Hayes said. Researchers have theorized that multiples are more stressed than singletons because they share the same space in utero. “But I don't agree,” he said. He instead proposed that prenatal steroids play a role. “More data are coming out showing it's just the number of fetuses—you're giving the same dose of medicine to more. It's 12 mg of betamethasone whether you have one or more fetuses.”

The practice of giving the same dosage of prenatal steroids despite the number of fetuses is not likely to change soon, Dr. Hayes said. “There is no evidence in the literature for giving multiples a higher dose of steroids.”

MIAMI BEACH — Contrary to prior reports, very-low-birth-weight multiples have significantly greater morbidity and mortality than weight-matched singleton fetuses, according to a study presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Researchers assessed outcomes for 1,779 infants born between July 1993 and July 2004 who weighed less than 1,500 g at birth.

They compared risk of death and severe intraventricular hemorrhage (IVH) among 475 infants from multiple gestations and 1,304 singletons.

When the researchers examined the data for multiple fetuses, “we saw increased neonatal death and/or severe IVH,” Dr. Edward Hayes, of Thomas Jefferson University Hospital in Philadelphia, said during a poster presentation. The risk of death for a VLBW infant born as part of a multiple pregnancy was higher than that of a VLBW singleton (odds ratio 1.3).

The risk increased as birth weights decreased, Dr. Hayes said. The multiples group included 206 infants born weighing less than 1,000 g and 86 weighing less than 750 g.

Mortality risk among multiples below 1,000 g carried an odds ratio of 1.5, and below 750 g the odds ratio was 1.9, compared with weight-matched singletons. “The risk was twice as high when you're a multiple [below 750 g],” Dr. Hayes said. The singletons group included 578 born weighing less than 1,000 g and 262 weighing less than 750 g.

The mean gestational age at birth was 28 weeks in both groups; the mean birth weight was 1,039 g in the multiple group and 1,035 g among singletons. There were no significant differences between the groups in mean gestational age or mean birth weight.

However, significant differences existed between mothers in the two groups. For example, the percentage who were white differed (68% of mothers of multiples vs. 43% of mothers of singletons); as did mean maternal age (29 years vs. 26 years); birth at the facility (95% vs. 86%); use of prenatal steroids (74% vs. 58%); preeclampsia (14% vs. 24%), and preterm labor (74% vs. 62%). The investigators used a multivariate analysis to control for these differences and then compared groups for neonatal morbidity and mortality.

The risk of severe, grade 3–4 intraventricular hemorrhage was higher among VLBW infants born as part of a multiple pregnancy (odds ratio 1.2) versus similar singletons. The risk of this outcome was similar for neonates in the multiple groups below 1,000 g or 750 g (odds ratio 1.1 for both).

The etiology of the higher risk among multiple gestation VLBW infants remains unknown, Dr. Hayes said. Researchers have theorized that multiples are more stressed than singletons because they share the same space in utero. “But I don't agree,” he said. He instead proposed that prenatal steroids play a role. “More data are coming out showing it's just the number of fetuses—you're giving the same dose of medicine to more. It's 12 mg of betamethasone whether you have one or more fetuses.”

The practice of giving the same dosage of prenatal steroids despite the number of fetuses is not likely to change soon, Dr. Hayes said. “There is no evidence in the literature for giving multiples a higher dose of steroids.”

MIAMI BEACH — Contrary to prior reports, very-low-birth-weight multiples have significantly greater morbidity and mortality than weight-matched singleton fetuses, according to a study presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Researchers assessed outcomes for 1,779 infants born between July 1993 and July 2004 who weighed less than 1,500 g at birth.

They compared risk of death and severe intraventricular hemorrhage (IVH) among 475 infants from multiple gestations and 1,304 singletons.

When the researchers examined the data for multiple fetuses, “we saw increased neonatal death and/or severe IVH,” Dr. Edward Hayes, of Thomas Jefferson University Hospital in Philadelphia, said during a poster presentation. The risk of death for a VLBW infant born as part of a multiple pregnancy was higher than that of a VLBW singleton (odds ratio 1.3).

The risk increased as birth weights decreased, Dr. Hayes said. The multiples group included 206 infants born weighing less than 1,000 g and 86 weighing less than 750 g.

Mortality risk among multiples below 1,000 g carried an odds ratio of 1.5, and below 750 g the odds ratio was 1.9, compared with weight-matched singletons. “The risk was twice as high when you're a multiple [below 750 g],” Dr. Hayes said. The singletons group included 578 born weighing less than 1,000 g and 262 weighing less than 750 g.

The mean gestational age at birth was 28 weeks in both groups; the mean birth weight was 1,039 g in the multiple group and 1,035 g among singletons. There were no significant differences between the groups in mean gestational age or mean birth weight.

However, significant differences existed between mothers in the two groups. For example, the percentage who were white differed (68% of mothers of multiples vs. 43% of mothers of singletons); as did mean maternal age (29 years vs. 26 years); birth at the facility (95% vs. 86%); use of prenatal steroids (74% vs. 58%); preeclampsia (14% vs. 24%), and preterm labor (74% vs. 62%). The investigators used a multivariate analysis to control for these differences and then compared groups for neonatal morbidity and mortality.

The risk of severe, grade 3–4 intraventricular hemorrhage was higher among VLBW infants born as part of a multiple pregnancy (odds ratio 1.2) versus similar singletons. The risk of this outcome was similar for neonates in the multiple groups below 1,000 g or 750 g (odds ratio 1.1 for both).

The etiology of the higher risk among multiple gestation VLBW infants remains unknown, Dr. Hayes said. Researchers have theorized that multiples are more stressed than singletons because they share the same space in utero. “But I don't agree,” he said. He instead proposed that prenatal steroids play a role. “More data are coming out showing it's just the number of fetuses—you're giving the same dose of medicine to more. It's 12 mg of betamethasone whether you have one or more fetuses.”

The practice of giving the same dosage of prenatal steroids despite the number of fetuses is not likely to change soon, Dr. Hayes said. “There is no evidence in the literature for giving multiples a higher dose of steroids.”

KAILUA KONA, HAWAII — An important step in detecting preterm labor in a multifetal pregnancy is to increase the patient's awareness of contractions and pelvic pressure and the need to report these symptoms, Dr. Michael A. Belfort said.

Most women who are pregnant for the first time don't know what contractions feel like or what to do if they get them. Spend time describing the sensations and instruct the patient about who to call, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City, said medicolegal issues related to preterm birth in multifetal pregnancies tend to fall in the following categories:

▸ Prevention and diagnosis. There is little benefit from routine bed rest or hospitalization to prevent preterm labor in a multifetal pregnancy, the published evidence shows. It may make sense to hospitalize a woman with a high-risk pregnancy if there is a reason to continuously monitor contractions or fetal heart rate, but admitting someone with only occasional contractions just to have that person in the hospital generally is not helpful, he said. For patients with regular contractions, admission for a full evaluation may be the safest initial step.

Home uterine monitoring has not been shown to help improve outcomes in preterm birth, and the American College of Obstetricians and Gynecologists does not recommend its use. If you plan to follow cervical length measurements by ultrasound, consider also obtaining fetal fibronectin measurements. Some data are available that combine the two measures to estimate the risk of preterm birth, Dr. Belfort said at the meeting, which was sponsored by Boston University.

▸ Steroids. For singletons, it's the standard of care to give a single course of antenatal steroids when there's a high risk of preterm birth between 24 and 34 weeks' gestation if the membranes are intact or between 24 and 32 weeks when the membranes are ruptured and there is no infection. Although no prospective studies specifically recommend the same course of action for twins or higher-order multiples, it makes sense to give steroids in multifetal pregnancies at high risk of preterm birth in those time periods, and most physicians do, he said. Do not give more than one course of steroids, he added. Repeat courses may have harmful effects on fetal brain growth, according to emerging data.

▸ Tocolytics. At least seven prospective studies show there is no clear benefit to giving prophylactic tocolytic therapy to try to stop contractions. This strategy will not prevent preterm birth, improve birth weight, or reduce the risk of neonatal mortality. Probably the best one can hope for is to slow down labor for 48 hours, he said. The terbutaline pump has been associated with maternal cardiac arrhythmia, and ACOG does not support its use.

▸ Cerclage. Two prospective trials in twins found no benefit from prophylactic cerclage in preventing preterm birth. No prospective, randomized, controlled trials have been conducted with triplets.

▸ Follow-up. A multifetal pregnancy in preterm labor should be followed closely, whether in or out of the hospital. Giving hydration or antibiotics is not helpful in preventing preterm labor, although antibiotics should not be withheld if there is an infection. Studies are underway on the use of progesterone to reduce the risk of preterm birth in multifetal pregnancies, but this is not yet the standard of care. For singletons, two studies suggest that a weekly intramuscular injection of progesterone may be helpful when given to a pregnant woman with a history of preterm delivery that did not involve cervical incompetence or an abruption.

▸ Experience. Do not delay transferring a patient with a multifetal pregnancy at high risk for preterm delivery to a level 3 facility. Continue to manage only the pregnancies that you're equipped to handle to avoid a postbirth injury that might have been avoided with specialized neonatal care.

KAILUA KONA, HAWAII — An important step in detecting preterm labor in a multifetal pregnancy is to increase the patient's awareness of contractions and pelvic pressure and the need to report these symptoms, Dr. Michael A. Belfort said.

Most women who are pregnant for the first time don't know what contractions feel like or what to do if they get them. Spend time describing the sensations and instruct the patient about who to call, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City, said medicolegal issues related to preterm birth in multifetal pregnancies tend to fall in the following categories:

▸ Prevention and diagnosis. There is little benefit from routine bed rest or hospitalization to prevent preterm labor in a multifetal pregnancy, the published evidence shows. It may make sense to hospitalize a woman with a high-risk pregnancy if there is a reason to continuously monitor contractions or fetal heart rate, but admitting someone with only occasional contractions just to have that person in the hospital generally is not helpful, he said. For patients with regular contractions, admission for a full evaluation may be the safest initial step.

Home uterine monitoring has not been shown to help improve outcomes in preterm birth, and the American College of Obstetricians and Gynecologists does not recommend its use. If you plan to follow cervical length measurements by ultrasound, consider also obtaining fetal fibronectin measurements. Some data are available that combine the two measures to estimate the risk of preterm birth, Dr. Belfort said at the meeting, which was sponsored by Boston University.

▸ Steroids. For singletons, it's the standard of care to give a single course of antenatal steroids when there's a high risk of preterm birth between 24 and 34 weeks' gestation if the membranes are intact or between 24 and 32 weeks when the membranes are ruptured and there is no infection. Although no prospective studies specifically recommend the same course of action for twins or higher-order multiples, it makes sense to give steroids in multifetal pregnancies at high risk of preterm birth in those time periods, and most physicians do, he said. Do not give more than one course of steroids, he added. Repeat courses may have harmful effects on fetal brain growth, according to emerging data.

▸ Tocolytics. At least seven prospective studies show there is no clear benefit to giving prophylactic tocolytic therapy to try to stop contractions. This strategy will not prevent preterm birth, improve birth weight, or reduce the risk of neonatal mortality. Probably the best one can hope for is to slow down labor for 48 hours, he said. The terbutaline pump has been associated with maternal cardiac arrhythmia, and ACOG does not support its use.

▸ Cerclage. Two prospective trials in twins found no benefit from prophylactic cerclage in preventing preterm birth. No prospective, randomized, controlled trials have been conducted with triplets.

▸ Follow-up. A multifetal pregnancy in preterm labor should be followed closely, whether in or out of the hospital. Giving hydration or antibiotics is not helpful in preventing preterm labor, although antibiotics should not be withheld if there is an infection. Studies are underway on the use of progesterone to reduce the risk of preterm birth in multifetal pregnancies, but this is not yet the standard of care. For singletons, two studies suggest that a weekly intramuscular injection of progesterone may be helpful when given to a pregnant woman with a history of preterm delivery that did not involve cervical incompetence or an abruption.

▸ Experience. Do not delay transferring a patient with a multifetal pregnancy at high risk for preterm delivery to a level 3 facility. Continue to manage only the pregnancies that you're equipped to handle to avoid a postbirth injury that might have been avoided with specialized neonatal care.

KAILUA KONA, HAWAII — An important step in detecting preterm labor in a multifetal pregnancy is to increase the patient's awareness of contractions and pelvic pressure and the need to report these symptoms, Dr. Michael A. Belfort said.

Most women who are pregnant for the first time don't know what contractions feel like or what to do if they get them. Spend time describing the sensations and instruct the patient about who to call, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City, said medicolegal issues related to preterm birth in multifetal pregnancies tend to fall in the following categories:

▸ Prevention and diagnosis. There is little benefit from routine bed rest or hospitalization to prevent preterm labor in a multifetal pregnancy, the published evidence shows. It may make sense to hospitalize a woman with a high-risk pregnancy if there is a reason to continuously monitor contractions or fetal heart rate, but admitting someone with only occasional contractions just to have that person in the hospital generally is not helpful, he said. For patients with regular contractions, admission for a full evaluation may be the safest initial step.

Home uterine monitoring has not been shown to help improve outcomes in preterm birth, and the American College of Obstetricians and Gynecologists does not recommend its use. If you plan to follow cervical length measurements by ultrasound, consider also obtaining fetal fibronectin measurements. Some data are available that combine the two measures to estimate the risk of preterm birth, Dr. Belfort said at the meeting, which was sponsored by Boston University.

▸ Steroids. For singletons, it's the standard of care to give a single course of antenatal steroids when there's a high risk of preterm birth between 24 and 34 weeks' gestation if the membranes are intact or between 24 and 32 weeks when the membranes are ruptured and there is no infection. Although no prospective studies specifically recommend the same course of action for twins or higher-order multiples, it makes sense to give steroids in multifetal pregnancies at high risk of preterm birth in those time periods, and most physicians do, he said. Do not give more than one course of steroids, he added. Repeat courses may have harmful effects on fetal brain growth, according to emerging data.

▸ Tocolytics. At least seven prospective studies show there is no clear benefit to giving prophylactic tocolytic therapy to try to stop contractions. This strategy will not prevent preterm birth, improve birth weight, or reduce the risk of neonatal mortality. Probably the best one can hope for is to slow down labor for 48 hours, he said. The terbutaline pump has been associated with maternal cardiac arrhythmia, and ACOG does not support its use.

▸ Cerclage. Two prospective trials in twins found no benefit from prophylactic cerclage in preventing preterm birth. No prospective, randomized, controlled trials have been conducted with triplets.

▸ Follow-up. A multifetal pregnancy in preterm labor should be followed closely, whether in or out of the hospital. Giving hydration or antibiotics is not helpful in preventing preterm labor, although antibiotics should not be withheld if there is an infection. Studies are underway on the use of progesterone to reduce the risk of preterm birth in multifetal pregnancies, but this is not yet the standard of care. For singletons, two studies suggest that a weekly intramuscular injection of progesterone may be helpful when given to a pregnant woman with a history of preterm delivery that did not involve cervical incompetence or an abruption.

▸ Experience. Do not delay transferring a patient with a multifetal pregnancy at high risk for preterm delivery to a level 3 facility. Continue to manage only the pregnancies that you're equipped to handle to avoid a postbirth injury that might have been avoided with specialized neonatal care.

KAILUA KONA, HAWAII — Consider the worst thing that can happen when managing preeclampsia and then do the logical thing to avoid that outcome, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He highlighted some confusing aspects in current practice and gave his “logical” alternatives for managing mild and severe preeclampsia.

▸ Mild preeclampsia. Dr. Belfort challenged those who say that it is appropriate to delay delivery in a mildly preeclamptic patient with a preterm fetus (35–37 weeks' gestation). “We've got to get out of the mind-set that it's terrible to deliver somebody earlier than 37 weeks” in the face of a potentially disastrous disease process, he said at the conference sponsored by Boston University. At 35–37 weeks' gestation, deliver the baby if the benefits outweigh the risks to both mother and baby, he said.

He reminded the audience of the American College of Obstetricians and Gynecologists' recommendation to manage mild preeclampsia in the hospital initially, and he supported subsequent outpatient management under certain conditions. Ideally, patients managed on an outpatient basis should have a blood pressure monitor at home so that they can take measurements up to four times daily. The patient also needs clearly defined, written instructions for when to call the physician, he said. The frequency and type of prenatal surveillance in preeclamptic patients are areas open to clinical judgment. Weekly nonstress tests, biophysical profiles, or both, are recommended by ACOG, said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

He suggested increasing the frequency of these tests in hospitalized patients. Dr. Belfort orders a nonstress test, amniotic fluid index, and lab tests every 3–4 days or more often depending on the clinical circumstances. If intrauterine growth restriction (IUGR) is identified in someone with preeclampsia beyond 32 weeks, ACOG guidelines say that the baby should be delivered because the mother is now in the realm of severe preeclampsia. He recommends doing daily fetal movement counting in these patients; fetal movement counting is important not only in preeclampsia, but also in every pregnancy, he added.

When managing mild preeclampsia on an outpatient basis, Dr. Belfort prefers to do twice weekly nonstress testing with amniotic fluid index, the so-called modified biophysical profile. This gives him frequent opportunities not only to check the fetus but also to question patients about headache, abdominal pain, visual disturbances, or other complications.

In women with mild preeclampsia and the potential for developing IUGR, a growth ultrasound should be done every 2–3 weeks. Consider getting a weekly Doppler ultrasound, he added. Dr. Belfort repeats lab tests weekly as long as there's no progression and admits the patient if he suspects progression of disease.

▸ Severe preeclampsia. Beyond 32 weeks' gestation, delivery of the baby, as recommended by ACOG, is usually the safest option, Dr. Belfort said. ACOG guidelines say it's reasonable to deliver the babies of women with hemolysis, elevated liver enzymes, and low platelet count (HELPP) syndrome regardless of gestational age.

“The outcomes for 32-week babies are good in the average level 2 or level 3 neonatal unit. The outcomes for women with progressive, severe HELPP syndrome who have delayed delivery are usually not good,” he explained.

Do an elective cesarean if the cervix is unripe because 80% of women with severe preeclampsia and an unripe cervix will end up having a C-section anyway, he added. Attempting a vaginal delivery may deplete the baby's reserves and result in an emergency C-section. In women with severe preeclampsia, Dr. Belfort orders continuous electronic fetal monitoring and gets lab tests every 6–8 hours to watch for worsening condition.

Outcomes for women with HELPP syndrome who have delayed delivery are usually not good. DR. BELFORT

KAILUA KONA, HAWAII — Consider the worst thing that can happen when managing preeclampsia and then do the logical thing to avoid that outcome, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He highlighted some confusing aspects in current practice and gave his “logical” alternatives for managing mild and severe preeclampsia.

▸ Mild preeclampsia. Dr. Belfort challenged those who say that it is appropriate to delay delivery in a mildly preeclamptic patient with a preterm fetus (35–37 weeks' gestation). “We've got to get out of the mind-set that it's terrible to deliver somebody earlier than 37 weeks” in the face of a potentially disastrous disease process, he said at the conference sponsored by Boston University. At 35–37 weeks' gestation, deliver the baby if the benefits outweigh the risks to both mother and baby, he said.

He reminded the audience of the American College of Obstetricians and Gynecologists' recommendation to manage mild preeclampsia in the hospital initially, and he supported subsequent outpatient management under certain conditions. Ideally, patients managed on an outpatient basis should have a blood pressure monitor at home so that they can take measurements up to four times daily. The patient also needs clearly defined, written instructions for when to call the physician, he said. The frequency and type of prenatal surveillance in preeclamptic patients are areas open to clinical judgment. Weekly nonstress tests, biophysical profiles, or both, are recommended by ACOG, said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

He suggested increasing the frequency of these tests in hospitalized patients. Dr. Belfort orders a nonstress test, amniotic fluid index, and lab tests every 3–4 days or more often depending on the clinical circumstances. If intrauterine growth restriction (IUGR) is identified in someone with preeclampsia beyond 32 weeks, ACOG guidelines say that the baby should be delivered because the mother is now in the realm of severe preeclampsia. He recommends doing daily fetal movement counting in these patients; fetal movement counting is important not only in preeclampsia, but also in every pregnancy, he added.

When managing mild preeclampsia on an outpatient basis, Dr. Belfort prefers to do twice weekly nonstress testing with amniotic fluid index, the so-called modified biophysical profile. This gives him frequent opportunities not only to check the fetus but also to question patients about headache, abdominal pain, visual disturbances, or other complications.

In women with mild preeclampsia and the potential for developing IUGR, a growth ultrasound should be done every 2–3 weeks. Consider getting a weekly Doppler ultrasound, he added. Dr. Belfort repeats lab tests weekly as long as there's no progression and admits the patient if he suspects progression of disease.

▸ Severe preeclampsia. Beyond 32 weeks' gestation, delivery of the baby, as recommended by ACOG, is usually the safest option, Dr. Belfort said. ACOG guidelines say it's reasonable to deliver the babies of women with hemolysis, elevated liver enzymes, and low platelet count (HELPP) syndrome regardless of gestational age.

“The outcomes for 32-week babies are good in the average level 2 or level 3 neonatal unit. The outcomes for women with progressive, severe HELPP syndrome who have delayed delivery are usually not good,” he explained.

Do an elective cesarean if the cervix is unripe because 80% of women with severe preeclampsia and an unripe cervix will end up having a C-section anyway, he added. Attempting a vaginal delivery may deplete the baby's reserves and result in an emergency C-section. In women with severe preeclampsia, Dr. Belfort orders continuous electronic fetal monitoring and gets lab tests every 6–8 hours to watch for worsening condition.

Outcomes for women with HELPP syndrome who have delayed delivery are usually not good. DR. BELFORT

KAILUA KONA, HAWAII — Consider the worst thing that can happen when managing preeclampsia and then do the logical thing to avoid that outcome, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He highlighted some confusing aspects in current practice and gave his “logical” alternatives for managing mild and severe preeclampsia.

▸ Mild preeclampsia. Dr. Belfort challenged those who say that it is appropriate to delay delivery in a mildly preeclamptic patient with a preterm fetus (35–37 weeks' gestation). “We've got to get out of the mind-set that it's terrible to deliver somebody earlier than 37 weeks” in the face of a potentially disastrous disease process, he said at the conference sponsored by Boston University. At 35–37 weeks' gestation, deliver the baby if the benefits outweigh the risks to both mother and baby, he said.

He reminded the audience of the American College of Obstetricians and Gynecologists' recommendation to manage mild preeclampsia in the hospital initially, and he supported subsequent outpatient management under certain conditions. Ideally, patients managed on an outpatient basis should have a blood pressure monitor at home so that they can take measurements up to four times daily. The patient also needs clearly defined, written instructions for when to call the physician, he said. The frequency and type of prenatal surveillance in preeclamptic patients are areas open to clinical judgment. Weekly nonstress tests, biophysical profiles, or both, are recommended by ACOG, said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

He suggested increasing the frequency of these tests in hospitalized patients. Dr. Belfort orders a nonstress test, amniotic fluid index, and lab tests every 3–4 days or more often depending on the clinical circumstances. If intrauterine growth restriction (IUGR) is identified in someone with preeclampsia beyond 32 weeks, ACOG guidelines say that the baby should be delivered because the mother is now in the realm of severe preeclampsia. He recommends doing daily fetal movement counting in these patients; fetal movement counting is important not only in preeclampsia, but also in every pregnancy, he added.

When managing mild preeclampsia on an outpatient basis, Dr. Belfort prefers to do twice weekly nonstress testing with amniotic fluid index, the so-called modified biophysical profile. This gives him frequent opportunities not only to check the fetus but also to question patients about headache, abdominal pain, visual disturbances, or other complications.

In women with mild preeclampsia and the potential for developing IUGR, a growth ultrasound should be done every 2–3 weeks. Consider getting a weekly Doppler ultrasound, he added. Dr. Belfort repeats lab tests weekly as long as there's no progression and admits the patient if he suspects progression of disease.

▸ Severe preeclampsia. Beyond 32 weeks' gestation, delivery of the baby, as recommended by ACOG, is usually the safest option, Dr. Belfort said. ACOG guidelines say it's reasonable to deliver the babies of women with hemolysis, elevated liver enzymes, and low platelet count (HELPP) syndrome regardless of gestational age.

“The outcomes for 32-week babies are good in the average level 2 or level 3 neonatal unit. The outcomes for women with progressive, severe HELPP syndrome who have delayed delivery are usually not good,” he explained.

Do an elective cesarean if the cervix is unripe because 80% of women with severe preeclampsia and an unripe cervix will end up having a C-section anyway, he added. Attempting a vaginal delivery may deplete the baby's reserves and result in an emergency C-section. In women with severe preeclampsia, Dr. Belfort orders continuous electronic fetal monitoring and gets lab tests every 6–8 hours to watch for worsening condition.

Outcomes for women with HELPP syndrome who have delayed delivery are usually not good. DR. BELFORT