Obstetrics

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be significantly underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview. Indeed, heartburn is so common, the researchers posited, that many patients and physicians think it is normal in pregnancy.

Conservative management, as prescribed in the study, consists of lifestyle changes such as not lying down after meals, not eating certain foods, raising the head of a person's bed, and taking antacids. Physicians know this does not work, and prescribe medication as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio. “Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have already begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes as well as reflux symptoms in patients treated with conservative management, pregnancy category B drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were described as being in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded from the study.

Women were defined as GERD positive if they had a score of at least 4 on Gastrointestinal Symptom Rating Scale questions specific to reflux. The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be significantly underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview. Indeed, heartburn is so common, the researchers posited, that many patients and physicians think it is normal in pregnancy.

Conservative management, as prescribed in the study, consists of lifestyle changes such as not lying down after meals, not eating certain foods, raising the head of a person's bed, and taking antacids. Physicians know this does not work, and prescribe medication as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio. “Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have already begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes as well as reflux symptoms in patients treated with conservative management, pregnancy category B drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were described as being in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded from the study.

Women were defined as GERD positive if they had a score of at least 4 on Gastrointestinal Symptom Rating Scale questions specific to reflux. The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

SCOTTSDALE, ARIZ. — Gastroesophageal reflux disease may be significantly underreported and undertreated in pregnant women, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Houmam Al-Hakeem and his coinvestigators at Southern Illinois University in Springfield diagnosed the condition in 72 of 111 pregnant women screened with the Gastrointestinal Symptom Rating Scale Questionnaire, a measure validated in published studies.

The poster reported that a 2-week trial of conservative management, described as “the first line of treatment in pregnant women,” failed to improve the cumulative scores of the women who had symptoms of gastroesophageal reflux disease (GERD).

GERD “is very common in pregnancy but at the same time it is very overlooked,” Dr. Al-Hakeem said in an interview. Indeed, heartburn is so common, the researchers posited, that many patients and physicians think it is normal in pregnancy.

Conservative management, as prescribed in the study, consists of lifestyle changes such as not lying down after meals, not eating certain foods, raising the head of a person's bed, and taking antacids. Physicians know this does not work, and prescribe medication as a first-line treatment in GERD patients who are not pregnant, according to Dr. Al-Hakeem, who now practices in San Antonio. “Why are we waiting during pregnancy?” he asked. “Because we are afraid to give medicine.”

He said the investigators have already begun the second phase of the study: a double-blind crossover trial of GERD treatments in a pregnant population. The study will look at fetal outcomes as well as reflux symptoms in patients treated with conservative management, pregnancy category B drugs Zantac and Prevacid, and a placebo. Dr. Al-Hakeem anticipated results would be available in about a year.

The 111 patients in the first phase were described as being in good health in a pregnancy of at least 24 weeks' gestation. Patients with documented history of GERD, esophageal disorders, Zollinger-Ellison syndrome, hiatal hernia, peptic ulcer syndrome, and irritable bowel syndrome were excluded from the study.

Women were defined as GERD positive if they had a score of at least 4 on Gastrointestinal Symptom Rating Scale questions specific to reflux. The investigators found no significant differences in ethnicity, education, tobacco use, or alcohol and drug use between the 72 women deemed to be GERD positive and the 39 women who were not.

WASHINGTON — There is no evidence that lamotrigine monotherapy increases the risk of major congenital malformations in infants exposed prenatally to the drug, according to updated data from the International Lamotrigine Pregnancy Registry.

However, when the drug was used as adjunctive therapy along with valproate, the rate of major congenital malformations was significantly higher than the rate for the background population, reported Dr. John A. Messenheimer of GlaxoSmithKline, Research Triangle Park, N.C.

Since its inception in 1992, the lamotrigine registry has recorded 2,000 pregnancies exposed to the drug during the first trimester. The interim report contains data up to September 2005 and was presented as a poster at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

The updated report contained the following outcome data. Most of the women (707) were taking lamotrigine as monotherapy, 256 were on polytherapy with lamotrigine but without valproate, and 119 were on polytherapy with lamotrigine and valproate.

There were 20 major congenital malformations reported. Of those, two were club feet, two were cases of anencephaly, and three were ventricular septal defects. The remaining malformations included midline defects, urogenital defects, cortical dysplasia, hypoplastic left heart syndrome, hypoplasia of the left ventricle, and diaphragmatic hernia with abdominal organ displacement.

The malformation rate among women on lamotrigine monotherapy was 2.8%, and the rate among those on polytherapy without valproate was 2.7%.

The rate among women on polytherapy with valproate was 11.8%—significantly higher than the background population rate of 2%–3%.

There was no significant relationship between lamotrigine dosage and the incidence of malformation, Dr. Messenheimer said. The rate of malformations among women taking more than 400 mg/day was slightly elevated at 4%. But only 100 women were taking such a high dose, and the confidence intervals in the analysis were wide

Published reports have identified a significantly increased risk of major congenital malformations among women taking valproate as monotherapy (10.7%).

These studies prompted the American Epilepsy Society's pregnancy outcomes forum panel to recommend last year that valproate be avoided as a first-line therapy for any indication in women of childbearing age.

However, the lamotrigine registry could not determine whether valproate exposure alone could explain the higher frequency of defects in the lamotrigine/valproate group, said Dr. Messenheimer. The registry determined that because the numbers of antiepileptic drugs used may be inextricably tied to the frequency and severity of seizures, it would be difficult to assess the contribution of each of these factors to the risk of major malformations.

In adults, lamotrigine is approved as adjunctive therapy for the generalized seizures of Lennox-Gastaut syndrome and for conversion to monotherapy in adults with partial seizures who are receiving treatment. It is also approved for maintenance treatment of bipolar disorder, and it is a pregnancy category C drug.

Physicians are asked to report exposed pregnancies to the international registry by calling 800-336-2176 as soon as the pregnancy is identified. The complete interim report of the International Lamotrigine Pregnancy Registry is available by calling the same number.

WASHINGTON — There is no evidence that lamotrigine monotherapy increases the risk of major congenital malformations in infants exposed prenatally to the drug, according to updated data from the International Lamotrigine Pregnancy Registry.

However, when the drug was used as adjunctive therapy along with valproate, the rate of major congenital malformations was significantly higher than the rate for the background population, reported Dr. John A. Messenheimer of GlaxoSmithKline, Research Triangle Park, N.C.

Since its inception in 1992, the lamotrigine registry has recorded 2,000 pregnancies exposed to the drug during the first trimester. The interim report contains data up to September 2005 and was presented as a poster at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

The updated report contained the following outcome data. Most of the women (707) were taking lamotrigine as monotherapy, 256 were on polytherapy with lamotrigine but without valproate, and 119 were on polytherapy with lamotrigine and valproate.

There were 20 major congenital malformations reported. Of those, two were club feet, two were cases of anencephaly, and three were ventricular septal defects. The remaining malformations included midline defects, urogenital defects, cortical dysplasia, hypoplastic left heart syndrome, hypoplasia of the left ventricle, and diaphragmatic hernia with abdominal organ displacement.

The malformation rate among women on lamotrigine monotherapy was 2.8%, and the rate among those on polytherapy without valproate was 2.7%.

The rate among women on polytherapy with valproate was 11.8%—significantly higher than the background population rate of 2%–3%.

There was no significant relationship between lamotrigine dosage and the incidence of malformation, Dr. Messenheimer said. The rate of malformations among women taking more than 400 mg/day was slightly elevated at 4%. But only 100 women were taking such a high dose, and the confidence intervals in the analysis were wide

Published reports have identified a significantly increased risk of major congenital malformations among women taking valproate as monotherapy (10.7%).

These studies prompted the American Epilepsy Society's pregnancy outcomes forum panel to recommend last year that valproate be avoided as a first-line therapy for any indication in women of childbearing age.

However, the lamotrigine registry could not determine whether valproate exposure alone could explain the higher frequency of defects in the lamotrigine/valproate group, said Dr. Messenheimer. The registry determined that because the numbers of antiepileptic drugs used may be inextricably tied to the frequency and severity of seizures, it would be difficult to assess the contribution of each of these factors to the risk of major malformations.

In adults, lamotrigine is approved as adjunctive therapy for the generalized seizures of Lennox-Gastaut syndrome and for conversion to monotherapy in adults with partial seizures who are receiving treatment. It is also approved for maintenance treatment of bipolar disorder, and it is a pregnancy category C drug.

Physicians are asked to report exposed pregnancies to the international registry by calling 800-336-2176 as soon as the pregnancy is identified. The complete interim report of the International Lamotrigine Pregnancy Registry is available by calling the same number.

WASHINGTON — There is no evidence that lamotrigine monotherapy increases the risk of major congenital malformations in infants exposed prenatally to the drug, according to updated data from the International Lamotrigine Pregnancy Registry.

However, when the drug was used as adjunctive therapy along with valproate, the rate of major congenital malformations was significantly higher than the rate for the background population, reported Dr. John A. Messenheimer of GlaxoSmithKline, Research Triangle Park, N.C.

Since its inception in 1992, the lamotrigine registry has recorded 2,000 pregnancies exposed to the drug during the first trimester. The interim report contains data up to September 2005 and was presented as a poster at the joint annual meeting of the American Epilepsy Society and the American Clinical Neurophysiology Society.

The updated report contained the following outcome data. Most of the women (707) were taking lamotrigine as monotherapy, 256 were on polytherapy with lamotrigine but without valproate, and 119 were on polytherapy with lamotrigine and valproate.

There were 20 major congenital malformations reported. Of those, two were club feet, two were cases of anencephaly, and three were ventricular septal defects. The remaining malformations included midline defects, urogenital defects, cortical dysplasia, hypoplastic left heart syndrome, hypoplasia of the left ventricle, and diaphragmatic hernia with abdominal organ displacement.

The malformation rate among women on lamotrigine monotherapy was 2.8%, and the rate among those on polytherapy without valproate was 2.7%.

The rate among women on polytherapy with valproate was 11.8%—significantly higher than the background population rate of 2%–3%.

There was no significant relationship between lamotrigine dosage and the incidence of malformation, Dr. Messenheimer said. The rate of malformations among women taking more than 400 mg/day was slightly elevated at 4%. But only 100 women were taking such a high dose, and the confidence intervals in the analysis were wide

Published reports have identified a significantly increased risk of major congenital malformations among women taking valproate as monotherapy (10.7%).

These studies prompted the American Epilepsy Society's pregnancy outcomes forum panel to recommend last year that valproate be avoided as a first-line therapy for any indication in women of childbearing age.

However, the lamotrigine registry could not determine whether valproate exposure alone could explain the higher frequency of defects in the lamotrigine/valproate group, said Dr. Messenheimer. The registry determined that because the numbers of antiepileptic drugs used may be inextricably tied to the frequency and severity of seizures, it would be difficult to assess the contribution of each of these factors to the risk of major malformations.

In adults, lamotrigine is approved as adjunctive therapy for the generalized seizures of Lennox-Gastaut syndrome and for conversion to monotherapy in adults with partial seizures who are receiving treatment. It is also approved for maintenance treatment of bipolar disorder, and it is a pregnancy category C drug.

Physicians are asked to report exposed pregnancies to the international registry by calling 800-336-2176 as soon as the pregnancy is identified. The complete interim report of the International Lamotrigine Pregnancy Registry is available by calling the same number.

Women who discontinue antidepressant medication when they become pregnant have nearly a 70% rate of depression relapse during the course of the pregnancy, reported Dr. Lee S. Cohen of Massachusetts General Hospital, Boston, and his associates.

“Pregnancy has historically been described as a time of emotional well-being, providing general 'protection' against psychiatric disorder.

“However, systematic data to support this impression are sparse,” the researchers noted.

They undertook what they described as the first study to examine the risk of depression relapse during pregnancy in women with recurrent depression, noting that there is an almost uniform belief that antidepressants should be discontinued during pregnancy to avert prenatal exposure to the drugs.

The 4-year prospective study involved 201 pregnant women with diverse socioeconomic backgrounds who had histories of recurrent depression and were being treated at one of three medical centers “with specific expertise in the treatment of psychiatric illness during pregnancy,” they wrote (JAMA 2006;295:499–507).

The mean age at onset of depression was 18 years, and the mean duration of depression was 15 years. A total of 44% of the women reported five or more prior recurrences. All had been taking antidepressants for at least 3 months before enrolling in the study, and almost all (92%) were taking SSRIs or dual-action antidepressants either alone or in combination with other agents.

Of the 65 women who discontinued their medication, 44 (68%) relapsed during pregnancy. About half of them relapsed during the first trimester and another 40% during the second trimester. This compares with a 26% relapse rate among women who maintained their medication throughout pregnancy.

After the data were adjusted to account for several variables such as type of medication used and number of prior episodes of depression, “women who discontinued their medication had a fivefold increased risk of relapse over the course of their pregnancy, compared with women who maintained their medication,” the researchers wrote.

Of the patients who discontinued (65 women) or decreased (34 women) their antidepressant medications, 61% resumed taking the drugs during pregnancy because of resurgence of depressive symptoms.

These findings have significant implications, “given the prevalence of depression in reproductive-age women, the prevalence of antidepressant use in this population, and the frequency of unplanned pregnancy,” according to the investigators.

Women should be made aware of the risk of depressive relapse following discontinuation of antidepressants. More of those who have recurrent depressive illness may well choose to maintain antidepressant therapy during attempts to conceive and during pregnancy, Dr. Cohen and his associates noted.

“These women must weigh concerns about prenatal exposure to these medications … [but] should also consider the risks of depressive relapse during pregnancy and the effects of untreated depression on fetal and maternal well-being,” they added.

Women who discontinue antidepressant medication when they become pregnant have nearly a 70% rate of depression relapse during the course of the pregnancy, reported Dr. Lee S. Cohen of Massachusetts General Hospital, Boston, and his associates.

“Pregnancy has historically been described as a time of emotional well-being, providing general 'protection' against psychiatric disorder.

“However, systematic data to support this impression are sparse,” the researchers noted.

They undertook what they described as the first study to examine the risk of depression relapse during pregnancy in women with recurrent depression, noting that there is an almost uniform belief that antidepressants should be discontinued during pregnancy to avert prenatal exposure to the drugs.

The 4-year prospective study involved 201 pregnant women with diverse socioeconomic backgrounds who had histories of recurrent depression and were being treated at one of three medical centers “with specific expertise in the treatment of psychiatric illness during pregnancy,” they wrote (JAMA 2006;295:499–507).

The mean age at onset of depression was 18 years, and the mean duration of depression was 15 years. A total of 44% of the women reported five or more prior recurrences. All had been taking antidepressants for at least 3 months before enrolling in the study, and almost all (92%) were taking SSRIs or dual-action antidepressants either alone or in combination with other agents.

Of the 65 women who discontinued their medication, 44 (68%) relapsed during pregnancy. About half of them relapsed during the first trimester and another 40% during the second trimester. This compares with a 26% relapse rate among women who maintained their medication throughout pregnancy.

After the data were adjusted to account for several variables such as type of medication used and number of prior episodes of depression, “women who discontinued their medication had a fivefold increased risk of relapse over the course of their pregnancy, compared with women who maintained their medication,” the researchers wrote.

Of the patients who discontinued (65 women) or decreased (34 women) their antidepressant medications, 61% resumed taking the drugs during pregnancy because of resurgence of depressive symptoms.

These findings have significant implications, “given the prevalence of depression in reproductive-age women, the prevalence of antidepressant use in this population, and the frequency of unplanned pregnancy,” according to the investigators.

Women should be made aware of the risk of depressive relapse following discontinuation of antidepressants. More of those who have recurrent depressive illness may well choose to maintain antidepressant therapy during attempts to conceive and during pregnancy, Dr. Cohen and his associates noted.

“These women must weigh concerns about prenatal exposure to these medications … [but] should also consider the risks of depressive relapse during pregnancy and the effects of untreated depression on fetal and maternal well-being,” they added.

Women who discontinue antidepressant medication when they become pregnant have nearly a 70% rate of depression relapse during the course of the pregnancy, reported Dr. Lee S. Cohen of Massachusetts General Hospital, Boston, and his associates.

“Pregnancy has historically been described as a time of emotional well-being, providing general 'protection' against psychiatric disorder.

“However, systematic data to support this impression are sparse,” the researchers noted.

They undertook what they described as the first study to examine the risk of depression relapse during pregnancy in women with recurrent depression, noting that there is an almost uniform belief that antidepressants should be discontinued during pregnancy to avert prenatal exposure to the drugs.

The 4-year prospective study involved 201 pregnant women with diverse socioeconomic backgrounds who had histories of recurrent depression and were being treated at one of three medical centers “with specific expertise in the treatment of psychiatric illness during pregnancy,” they wrote (JAMA 2006;295:499–507).

The mean age at onset of depression was 18 years, and the mean duration of depression was 15 years. A total of 44% of the women reported five or more prior recurrences. All had been taking antidepressants for at least 3 months before enrolling in the study, and almost all (92%) were taking SSRIs or dual-action antidepressants either alone or in combination with other agents.

Of the 65 women who discontinued their medication, 44 (68%) relapsed during pregnancy. About half of them relapsed during the first trimester and another 40% during the second trimester. This compares with a 26% relapse rate among women who maintained their medication throughout pregnancy.

After the data were adjusted to account for several variables such as type of medication used and number of prior episodes of depression, “women who discontinued their medication had a fivefold increased risk of relapse over the course of their pregnancy, compared with women who maintained their medication,” the researchers wrote.

Of the patients who discontinued (65 women) or decreased (34 women) their antidepressant medications, 61% resumed taking the drugs during pregnancy because of resurgence of depressive symptoms.

These findings have significant implications, “given the prevalence of depression in reproductive-age women, the prevalence of antidepressant use in this population, and the frequency of unplanned pregnancy,” according to the investigators.

Women should be made aware of the risk of depressive relapse following discontinuation of antidepressants. More of those who have recurrent depressive illness may well choose to maintain antidepressant therapy during attempts to conceive and during pregnancy, Dr. Cohen and his associates noted.

“These women must weigh concerns about prenatal exposure to these medications … [but] should also consider the risks of depressive relapse during pregnancy and the effects of untreated depression on fetal and maternal well-being,” they added.

KAILUA KONA, HAWAII — Many people—and many jurors—assume that a large pregnant woman has a large birth canal. If shoulder dystocia during delivery leads to neurologic injury of the baby, they reason that the physician must have done something wrong.

Educate patients early on in pregnancy that they way they are built on the outside doesn't necessarily reflect the way they are built on the inside, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law. “That may sound really simplistic, but I can't tell you the number of times I've taken the testimony of the mother, who had shoulders like a football player and said, 'I don't understand. It never occurred to me that my pelvis wouldn't be as big as the rest of me,'” said Ms. Baker, a defense attorney in Seattle who also holds a BS degree in nursing.

In addition, follow the patient's weight, assess her for diabetes, estimate fetal weight, and discuss the potential for a macrosomic infant with the patient and her partner. Talk about the risk for shoulder dystocia and injury and the risks and benefits of choosing a vaginal birth or an elective C-section in the case of a small maternal pelvis or an estimated large baby.

If you get sued for not predicting shoulder dystocia, data in the literature provide a very good defense, she said. Studies show that fetal size, shoulder dystocia, and brachial plexus injury don't necessarily go hand in hand, Ms. Baker said.

That doesn't mean you won't be sued anyway, plaintiffs' attorney Michael F. Becker, J.D., commented during the same session at the meeting sponsored by Boston University. If you can reasonably anticipate that shoulder dystocia might become a problem during vaginal delivery, you may have a duty to discuss the option of a C-section, to allow the mother an informed choice of delivery mode.

Ultrasounds or maternal weight gain suggesting cephalopelvic disproportion or macrosomia may make it reasonable to anticipate shoulder dystocia, he suggested. “We know that women under 5 feet tall have a tendency to have a smaller pelvis,” and physicians should be discussing shoulder dystocia as a possibility with these patients, said Mr. Becker, who practices law in Cleveland.

Other reasons for malpractice suits include improper management of shoulder dystocia, such as applying fundal pressure, or failing to apply suprapubic pressure or the McRoberts maneuver. Shoulder dystocia brings Mr. Becker many clients.

“These are the cases that we see an awful lot of in my office. We must have six or eight currently pending,” he said.

In close to a third of the cases, shoulder dystocia is not documented in the patient's chart. That's no defense for the physician, however. “All we have to do is talk to the family members or look at the videotapes to see what really happened,” he said.

Ms. Baker advised physicians to think long and hard before allowing people to take photos or videos in the delivery room. She also urged them to be candid in their account of events in notes. If shoulder dystocia leads to an injured baby, be compassionate and sympathetic and engaged, she suggested. “It's a very big deal for the mother and the father or partner.”

Get a pediatric neurologist involved in the case. Place a tickler in your file system so that when the mother comes in for postpartum care, you ask about the child. Ask the mother's permission to speak with the neurologist to see how the child is doing.

If you end up in court, remember that jurors respond to visual evidence. Show them your chart notes or photos of the mother's weight gain if you have them.

Ms. Baker defended one case in which a woman ballooned up to 300 pounds during pregnancy but slimmed down to 122 pounds by the time of the trial. The jurors could not believe the argument that her weight gain increased the risk for macrosomia until the defense produced a photo taken 2 weeks before delivery.

You may have a duty to discuss the option of a C-section, to allow the mother an informed choice. MR. BECKER

KAILUA KONA, HAWAII — Many people—and many jurors—assume that a large pregnant woman has a large birth canal. If shoulder dystocia during delivery leads to neurologic injury of the baby, they reason that the physician must have done something wrong.

Educate patients early on in pregnancy that they way they are built on the outside doesn't necessarily reflect the way they are built on the inside, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law. “That may sound really simplistic, but I can't tell you the number of times I've taken the testimony of the mother, who had shoulders like a football player and said, 'I don't understand. It never occurred to me that my pelvis wouldn't be as big as the rest of me,'” said Ms. Baker, a defense attorney in Seattle who also holds a BS degree in nursing.

In addition, follow the patient's weight, assess her for diabetes, estimate fetal weight, and discuss the potential for a macrosomic infant with the patient and her partner. Talk about the risk for shoulder dystocia and injury and the risks and benefits of choosing a vaginal birth or an elective C-section in the case of a small maternal pelvis or an estimated large baby.

If you get sued for not predicting shoulder dystocia, data in the literature provide a very good defense, she said. Studies show that fetal size, shoulder dystocia, and brachial plexus injury don't necessarily go hand in hand, Ms. Baker said.

That doesn't mean you won't be sued anyway, plaintiffs' attorney Michael F. Becker, J.D., commented during the same session at the meeting sponsored by Boston University. If you can reasonably anticipate that shoulder dystocia might become a problem during vaginal delivery, you may have a duty to discuss the option of a C-section, to allow the mother an informed choice of delivery mode.

Ultrasounds or maternal weight gain suggesting cephalopelvic disproportion or macrosomia may make it reasonable to anticipate shoulder dystocia, he suggested. “We know that women under 5 feet tall have a tendency to have a smaller pelvis,” and physicians should be discussing shoulder dystocia as a possibility with these patients, said Mr. Becker, who practices law in Cleveland.

Other reasons for malpractice suits include improper management of shoulder dystocia, such as applying fundal pressure, or failing to apply suprapubic pressure or the McRoberts maneuver. Shoulder dystocia brings Mr. Becker many clients.

“These are the cases that we see an awful lot of in my office. We must have six or eight currently pending,” he said.

In close to a third of the cases, shoulder dystocia is not documented in the patient's chart. That's no defense for the physician, however. “All we have to do is talk to the family members or look at the videotapes to see what really happened,” he said.

Ms. Baker advised physicians to think long and hard before allowing people to take photos or videos in the delivery room. She also urged them to be candid in their account of events in notes. If shoulder dystocia leads to an injured baby, be compassionate and sympathetic and engaged, she suggested. “It's a very big deal for the mother and the father or partner.”

Get a pediatric neurologist involved in the case. Place a tickler in your file system so that when the mother comes in for postpartum care, you ask about the child. Ask the mother's permission to speak with the neurologist to see how the child is doing.

If you end up in court, remember that jurors respond to visual evidence. Show them your chart notes or photos of the mother's weight gain if you have them.

Ms. Baker defended one case in which a woman ballooned up to 300 pounds during pregnancy but slimmed down to 122 pounds by the time of the trial. The jurors could not believe the argument that her weight gain increased the risk for macrosomia until the defense produced a photo taken 2 weeks before delivery.

You may have a duty to discuss the option of a C-section, to allow the mother an informed choice. MR. BECKER

KAILUA KONA, HAWAII — Many people—and many jurors—assume that a large pregnant woman has a large birth canal. If shoulder dystocia during delivery leads to neurologic injury of the baby, they reason that the physician must have done something wrong.

Educate patients early on in pregnancy that they way they are built on the outside doesn't necessarily reflect the way they are built on the inside, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law. “That may sound really simplistic, but I can't tell you the number of times I've taken the testimony of the mother, who had shoulders like a football player and said, 'I don't understand. It never occurred to me that my pelvis wouldn't be as big as the rest of me,'” said Ms. Baker, a defense attorney in Seattle who also holds a BS degree in nursing.

In addition, follow the patient's weight, assess her for diabetes, estimate fetal weight, and discuss the potential for a macrosomic infant with the patient and her partner. Talk about the risk for shoulder dystocia and injury and the risks and benefits of choosing a vaginal birth or an elective C-section in the case of a small maternal pelvis or an estimated large baby.

If you get sued for not predicting shoulder dystocia, data in the literature provide a very good defense, she said. Studies show that fetal size, shoulder dystocia, and brachial plexus injury don't necessarily go hand in hand, Ms. Baker said.

That doesn't mean you won't be sued anyway, plaintiffs' attorney Michael F. Becker, J.D., commented during the same session at the meeting sponsored by Boston University. If you can reasonably anticipate that shoulder dystocia might become a problem during vaginal delivery, you may have a duty to discuss the option of a C-section, to allow the mother an informed choice of delivery mode.

Ultrasounds or maternal weight gain suggesting cephalopelvic disproportion or macrosomia may make it reasonable to anticipate shoulder dystocia, he suggested. “We know that women under 5 feet tall have a tendency to have a smaller pelvis,” and physicians should be discussing shoulder dystocia as a possibility with these patients, said Mr. Becker, who practices law in Cleveland.

Other reasons for malpractice suits include improper management of shoulder dystocia, such as applying fundal pressure, or failing to apply suprapubic pressure or the McRoberts maneuver. Shoulder dystocia brings Mr. Becker many clients.

“These are the cases that we see an awful lot of in my office. We must have six or eight currently pending,” he said.

In close to a third of the cases, shoulder dystocia is not documented in the patient's chart. That's no defense for the physician, however. “All we have to do is talk to the family members or look at the videotapes to see what really happened,” he said.

Ms. Baker advised physicians to think long and hard before allowing people to take photos or videos in the delivery room. She also urged them to be candid in their account of events in notes. If shoulder dystocia leads to an injured baby, be compassionate and sympathetic and engaged, she suggested. “It's a very big deal for the mother and the father or partner.”

Get a pediatric neurologist involved in the case. Place a tickler in your file system so that when the mother comes in for postpartum care, you ask about the child. Ask the mother's permission to speak with the neurologist to see how the child is doing.

If you end up in court, remember that jurors respond to visual evidence. Show them your chart notes or photos of the mother's weight gain if you have them.

Ms. Baker defended one case in which a woman ballooned up to 300 pounds during pregnancy but slimmed down to 122 pounds by the time of the trial. The jurors could not believe the argument that her weight gain increased the risk for macrosomia until the defense produced a photo taken 2 weeks before delivery.

You may have a duty to discuss the option of a C-section, to allow the mother an informed choice. MR. BECKER

KAILUA KONA, HAWAII — Tell pregnant patients to wear seat belts when in a car, and chances are that they'll do it, Dr. William G. Barsan said at a meeting on medical negligence and risk management.

One study found that 92% of mothers who got some prenatal education about seat belt use later reported using seat belts, and 83% could describe proper seat belt placement. Only 71% of mothers who did not get seat-belt advice reported using seat belts, and only 65% could describe proper seat belt placement, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

This did not require extensive, 20-minute education sessions but simply telling the patients at an office visit, “The studies are clear—you're better off wearing a seat belt. If you wear it, here's how you want to do it,” he added.

There seems to be some confusion among the lay public and even among some clinicians about the benefits of wearing seat belts during pregnancy. Dr. Barsan argued with his own wife about it during her pregnancy, he said at the meeting, sponsored by Boston University.

Modeling studies suggest that the risk of fetal death from a car crash is similar for an improperly restrained woman in a 10-mph crash and a properly restrained woman in a 22-mph crash. “Without wearing a seat belt, it doesn't take much to potentially cause a very bad injury to the fetus,” he said.

In another study of pregnant Michigan women in 1993, 32% reported sometimes, rarely, or never wearing seat belts, compared with 23% who said they usually wear seat belts and 45% who reported always wearing them. Those kinds of numbers may help explain results of a 2001 study in Pennsylvania that reported 500 fetal deaths after motor vehicle crashes, compared with 300 deaths of children up to age 4 years who were involved in vehicle crashes in the same time period.

Pregnant women should wear lap belts under the protuberant part of the abdomen, low down on the abdomen and pelvis, Dr. Barsan said. Shoulder belts should be worn off to the side of the uterus, between the breasts and over the mid-portion of the clavicle. There is no evidence to suggest that air bags should be disconnected in vehicles for pregnant drivers or passengers, he added.

“Wearing a seat belt properly can give a lot of protection to the baby,” he said.

This did not require extensive, 20-minute sessions but simply telling the patients at an office visit. DR. BARSAN

“Wearing a seat belt properly can give a lot of protection to the baby.” Stanford W. Carpenter

KAILUA KONA, HAWAII — Tell pregnant patients to wear seat belts when in a car, and chances are that they'll do it, Dr. William G. Barsan said at a meeting on medical negligence and risk management.

One study found that 92% of mothers who got some prenatal education about seat belt use later reported using seat belts, and 83% could describe proper seat belt placement. Only 71% of mothers who did not get seat-belt advice reported using seat belts, and only 65% could describe proper seat belt placement, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

This did not require extensive, 20-minute education sessions but simply telling the patients at an office visit, “The studies are clear—you're better off wearing a seat belt. If you wear it, here's how you want to do it,” he added.

There seems to be some confusion among the lay public and even among some clinicians about the benefits of wearing seat belts during pregnancy. Dr. Barsan argued with his own wife about it during her pregnancy, he said at the meeting, sponsored by Boston University.

Modeling studies suggest that the risk of fetal death from a car crash is similar for an improperly restrained woman in a 10-mph crash and a properly restrained woman in a 22-mph crash. “Without wearing a seat belt, it doesn't take much to potentially cause a very bad injury to the fetus,” he said.

In another study of pregnant Michigan women in 1993, 32% reported sometimes, rarely, or never wearing seat belts, compared with 23% who said they usually wear seat belts and 45% who reported always wearing them. Those kinds of numbers may help explain results of a 2001 study in Pennsylvania that reported 500 fetal deaths after motor vehicle crashes, compared with 300 deaths of children up to age 4 years who were involved in vehicle crashes in the same time period.

Pregnant women should wear lap belts under the protuberant part of the abdomen, low down on the abdomen and pelvis, Dr. Barsan said. Shoulder belts should be worn off to the side of the uterus, between the breasts and over the mid-portion of the clavicle. There is no evidence to suggest that air bags should be disconnected in vehicles for pregnant drivers or passengers, he added.

“Wearing a seat belt properly can give a lot of protection to the baby,” he said.

This did not require extensive, 20-minute sessions but simply telling the patients at an office visit. DR. BARSAN

“Wearing a seat belt properly can give a lot of protection to the baby.” Stanford W. Carpenter

KAILUA KONA, HAWAII — Tell pregnant patients to wear seat belts when in a car, and chances are that they'll do it, Dr. William G. Barsan said at a meeting on medical negligence and risk management.

One study found that 92% of mothers who got some prenatal education about seat belt use later reported using seat belts, and 83% could describe proper seat belt placement. Only 71% of mothers who did not get seat-belt advice reported using seat belts, and only 65% could describe proper seat belt placement, said Dr. Barsan, professor and chair of emergency medicine at the University of Michigan, Ann Arbor.

This did not require extensive, 20-minute education sessions but simply telling the patients at an office visit, “The studies are clear—you're better off wearing a seat belt. If you wear it, here's how you want to do it,” he added.

There seems to be some confusion among the lay public and even among some clinicians about the benefits of wearing seat belts during pregnancy. Dr. Barsan argued with his own wife about it during her pregnancy, he said at the meeting, sponsored by Boston University.

Modeling studies suggest that the risk of fetal death from a car crash is similar for an improperly restrained woman in a 10-mph crash and a properly restrained woman in a 22-mph crash. “Without wearing a seat belt, it doesn't take much to potentially cause a very bad injury to the fetus,” he said.

In another study of pregnant Michigan women in 1993, 32% reported sometimes, rarely, or never wearing seat belts, compared with 23% who said they usually wear seat belts and 45% who reported always wearing them. Those kinds of numbers may help explain results of a 2001 study in Pennsylvania that reported 500 fetal deaths after motor vehicle crashes, compared with 300 deaths of children up to age 4 years who were involved in vehicle crashes in the same time period.

Pregnant women should wear lap belts under the protuberant part of the abdomen, low down on the abdomen and pelvis, Dr. Barsan said. Shoulder belts should be worn off to the side of the uterus, between the breasts and over the mid-portion of the clavicle. There is no evidence to suggest that air bags should be disconnected in vehicles for pregnant drivers or passengers, he added.

“Wearing a seat belt properly can give a lot of protection to the baby,” he said.

This did not require extensive, 20-minute sessions but simply telling the patients at an office visit. DR. BARSAN

“Wearing a seat belt properly can give a lot of protection to the baby.” Stanford W. Carpenter

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said at the conference sponsored by Boston University.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned.

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may [come back] with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay, and you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs and either he or his staff call the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

As for labs, not every patient needs a coagulogram but get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura.

“The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted.

Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained in terms of survival of the fetus” by delaying delivery and risking a catastrophic outcome, he said.

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said at the conference sponsored by Boston University.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned.

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may [come back] with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay, and you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs and either he or his staff call the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

As for labs, not every patient needs a coagulogram but get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura.

“The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted.

Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained in terms of survival of the fetus” by delaying delivery and risking a catastrophic outcome, he said.

KAILUA KONA, HAWAII — Don't rely on dipsticks to detect proteinuria in pregnant patients with suspected preeclampsia, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Instead, get a 24-hour urine collection. If there's not time for that, get a 12-hour urine collection, and order a pregnancy-induced hypertension panel if there is new-onset hypertension, said Dr. Belfort, professor of maternal-fetal medicine at the University of Utah, Salt Lake City.

Dipstick results depend on protein concentrations, which are altered by urine volume. A preeclamptic woman on bed rest will mobilize fluid and increase urine output, potentially diluting urine enough that the protein concentration falls below the minimum level of 20 mg/dL read by dipsticks, he said at the conference sponsored by Boston University.

A dipstick for a woman with 3.2 g of protein in 1,500 cc/day of urine will report 20 mg/dL of protein, erroneously suggesting that only a trace of protein is present. “Until we have more sophisticated ways of determining proteinuria, the dipstick is a screening kit, and the gold standard is 24-hour urine collection,” he said.

To diagnose preeclampsia, look for proteinuria (urinary excretion of 0.3 g protein or higher in a 24-hour urine specimen) and new-onset hypertension (at least 140 mm Hg systolic or 90 mm Hg diastolic after 20 weeks' gestation).

Consider not only the blood pressure on a particular day but also the trend in blood pressure over weeks, Dr. Belfort said.

The American College of Obstetricians and Gynecologists recommends checking platelets, liver enzymes, renal function, and 12− or 24-hour urine collection for protein to rule out preeclampsia. If you order lab tests, be sure to get the results, he cautioned.

“It is possible that a physician may choose to admit the patient, order the lab, and get a dipstick the next morning before seeing the protein level in a timed collection of urine. The physician then sends the patient home on the strength of the dipstick. If you do not wait for the 24-hour urine collection … some of these patients may [come back] with a cerebral infarct,” he said.

Physicians in a consultative practice, as Dr. Belfort is, often advise other people to order labs instead of doing it themselves. It may be dangerous to send a pregnant patient with very elevated blood pressure home with a letter suggesting that her doctor order lab tests.

“There's an onus upon you to make sure that patient is going to be okay, and you don't find out about some wacky result like really low platelets or very elevated liver enzymes 3 days later as you're flipping through the paperwork on your desk,” he said.

Dr. Belfort orders the labs and either he or his staff call the patient's doctor to say the labs have been sent. They instruct the patient to call her doctor that evening if she has not been contacted about the results. All this is documented in the patient's chart.

As for labs, not every patient needs a coagulogram but get one for a patient with less than 100,000 platelets, he said. A patient with a very low platelet count and a normal coagulogram may have thrombotic thrombocytopenic purpura.

“The worst thing you can do for somebody with [thrombotic thrombocytopenic purpura] is give them a bag of platelets. It's like throwing kerosene on a fire,” he said.

Be conservative when deciding whether to admit a patient with suspected preeclampsia, Dr. Belfort suggested. Certainly any patients with headache, visual disturbances (scotomata), bruising, bleeding, significant edema, any kind of head or abdominal pain, or other complicating features should be admitted.

Think carefully about what is to be gained or lost by delaying delivery in a preeclamptic patient with a viable fetus, he added. “Beyond 32 weeks [gestation] in severe preeclampsia, there is very little to be gained in terms of survival of the fetus” by delaying delivery and risking a catastrophic outcome, he said.

Consider congenital rubella syndrome in infants with compatible signs, particularly immigrants from countries without rubella control programs, the Centers for Disease Control and Prevention advised.

In 2004, a 10-week-old infant born to a mother who had emigrated from the Côte d'Ivoire was brought to an emergency department in New Hampshire with fever, vomiting, irritability, and poor feeding.

While she was in the hospital, the infant—who had been born with a cataract in her left eye—was diagnosed with microcephaly, patent ductus arteriosus, bilateral hearing impairment, and hepatosplenomegaly, as well as failure to thrive (MMWR 2005;54:1160–1).

Congenital rubella syndrome was suspected and confirmed by positive rubella IgM and positive urine and nasopharyngeal cultures. The genetic sequence was found to be that of a wild-type rubella virus similar to one found in Uganda in 2001, the CDC said.

Soon after conception, the mother had come into contact with refugees from one of four transit centers in Cote d'Ivoire where there had been a rubella outbreak during February-April 2004.

She had reported no history of symptoms of acute rubella infection such as rash, fever, lymphadenopathy, or arthralgia.

However, subclinical infections are estimated to occur in up to 50% of rubella cases.

Consider congenital rubella syndrome in infants with compatible signs, particularly immigrants from countries without rubella control programs, the Centers for Disease Control and Prevention advised.

In 2004, a 10-week-old infant born to a mother who had emigrated from the Côte d'Ivoire was brought to an emergency department in New Hampshire with fever, vomiting, irritability, and poor feeding.

While she was in the hospital, the infant—who had been born with a cataract in her left eye—was diagnosed with microcephaly, patent ductus arteriosus, bilateral hearing impairment, and hepatosplenomegaly, as well as failure to thrive (MMWR 2005;54:1160–1).

Congenital rubella syndrome was suspected and confirmed by positive rubella IgM and positive urine and nasopharyngeal cultures. The genetic sequence was found to be that of a wild-type rubella virus similar to one found in Uganda in 2001, the CDC said.

Soon after conception, the mother had come into contact with refugees from one of four transit centers in Cote d'Ivoire where there had been a rubella outbreak during February-April 2004.

She had reported no history of symptoms of acute rubella infection such as rash, fever, lymphadenopathy, or arthralgia.

However, subclinical infections are estimated to occur in up to 50% of rubella cases.

Consider congenital rubella syndrome in infants with compatible signs, particularly immigrants from countries without rubella control programs, the Centers for Disease Control and Prevention advised.

In 2004, a 10-week-old infant born to a mother who had emigrated from the Côte d'Ivoire was brought to an emergency department in New Hampshire with fever, vomiting, irritability, and poor feeding.

While she was in the hospital, the infant—who had been born with a cataract in her left eye—was diagnosed with microcephaly, patent ductus arteriosus, bilateral hearing impairment, and hepatosplenomegaly, as well as failure to thrive (MMWR 2005;54:1160–1).

Congenital rubella syndrome was suspected and confirmed by positive rubella IgM and positive urine and nasopharyngeal cultures. The genetic sequence was found to be that of a wild-type rubella virus similar to one found in Uganda in 2001, the CDC said.

Soon after conception, the mother had come into contact with refugees from one of four transit centers in Cote d'Ivoire where there had been a rubella outbreak during February-April 2004.

She had reported no history of symptoms of acute rubella infection such as rash, fever, lymphadenopathy, or arthralgia.

However, subclinical infections are estimated to occur in up to 50% of rubella cases.

There was a slight uptick in the number of abortions reported in 2002, according to figures published by the Centers for Disease Control and Prevention.

The number of abortions increased by 637 to 854,122 between 2001 and 2002. But the abortion rate—16 per 1,000 women—has remained constant since 2000. The figures are based on data reported from 47 states, the District of Columbia, and New York City. The analysis does not include information from Alaska, California, and New Hampshire.

The 0.1% increase follows 5 years of decline in the number of abortions from 1997 through 2001, researchers reported in the CDC's Morbidity and Mortality Weekly Report (MMWR Surveillance Summaries 2005;54[SS07]:1–31).

The CDC findings conflict with an analysis released in May 2005 by the Guttmacher Institute that showed that the number of abortions performed in the United States fell from 2001 to 2002. Their analysis showed that the number of abortions had declined from 1.30 million in 2001 to 1.29 million in 2002. The discrepancy may be due to differences in methodology. The Guttmacher Institute analysis used CDC data and figures collected for state health departments to project changes from a 2000 survey of all known abortion providers.

Regardless of the precise figures, there is still a lot of work to be done, said Rachel Jones, senior research associate with the Guttmacher Institute. Women need increased access to contraception and better information about pregnancy prevention, she said.

Most of the abortions (87%) reported to the CDC were performed at less than 13 weeks' gestation. Only 4% of abortions occurred between 16 and 20 weeks, and 1.4% of abortions were reported to have occurred after 21 weeks.

The CDC also reported a jump in the number of medical abortions between 2001 and 2002. Medical abortions accounted for about 5% of all procedures in 2002, with 36,297 medical abortion procedures reported. This is approximately a 77% increase from 2001 in the 31 areas that reported medical abortion information in both years. About 94% of medical abortions were performed at 8 weeks' gestation or earlier.

There was a slight uptick in the number of abortions reported in 2002, according to figures published by the Centers for Disease Control and Prevention.

The number of abortions increased by 637 to 854,122 between 2001 and 2002. But the abortion rate—16 per 1,000 women—has remained constant since 2000. The figures are based on data reported from 47 states, the District of Columbia, and New York City. The analysis does not include information from Alaska, California, and New Hampshire.

The 0.1% increase follows 5 years of decline in the number of abortions from 1997 through 2001, researchers reported in the CDC's Morbidity and Mortality Weekly Report (MMWR Surveillance Summaries 2005;54[SS07]:1–31).

The CDC findings conflict with an analysis released in May 2005 by the Guttmacher Institute that showed that the number of abortions performed in the United States fell from 2001 to 2002. Their analysis showed that the number of abortions had declined from 1.30 million in 2001 to 1.29 million in 2002. The discrepancy may be due to differences in methodology. The Guttmacher Institute analysis used CDC data and figures collected for state health departments to project changes from a 2000 survey of all known abortion providers.

Regardless of the precise figures, there is still a lot of work to be done, said Rachel Jones, senior research associate with the Guttmacher Institute. Women need increased access to contraception and better information about pregnancy prevention, she said.

Most of the abortions (87%) reported to the CDC were performed at less than 13 weeks' gestation. Only 4% of abortions occurred between 16 and 20 weeks, and 1.4% of abortions were reported to have occurred after 21 weeks.

The CDC also reported a jump in the number of medical abortions between 2001 and 2002. Medical abortions accounted for about 5% of all procedures in 2002, with 36,297 medical abortion procedures reported. This is approximately a 77% increase from 2001 in the 31 areas that reported medical abortion information in both years. About 94% of medical abortions were performed at 8 weeks' gestation or earlier.

There was a slight uptick in the number of abortions reported in 2002, according to figures published by the Centers for Disease Control and Prevention.

The number of abortions increased by 637 to 854,122 between 2001 and 2002. But the abortion rate—16 per 1,000 women—has remained constant since 2000. The figures are based on data reported from 47 states, the District of Columbia, and New York City. The analysis does not include information from Alaska, California, and New Hampshire.

The 0.1% increase follows 5 years of decline in the number of abortions from 1997 through 2001, researchers reported in the CDC's Morbidity and Mortality Weekly Report (MMWR Surveillance Summaries 2005;54[SS07]:1–31).

The CDC findings conflict with an analysis released in May 2005 by the Guttmacher Institute that showed that the number of abortions performed in the United States fell from 2001 to 2002. Their analysis showed that the number of abortions had declined from 1.30 million in 2001 to 1.29 million in 2002. The discrepancy may be due to differences in methodology. The Guttmacher Institute analysis used CDC data and figures collected for state health departments to project changes from a 2000 survey of all known abortion providers.

Regardless of the precise figures, there is still a lot of work to be done, said Rachel Jones, senior research associate with the Guttmacher Institute. Women need increased access to contraception and better information about pregnancy prevention, she said.

Most of the abortions (87%) reported to the CDC were performed at less than 13 weeks' gestation. Only 4% of abortions occurred between 16 and 20 weeks, and 1.4% of abortions were reported to have occurred after 21 weeks.

The CDC also reported a jump in the number of medical abortions between 2001 and 2002. Medical abortions accounted for about 5% of all procedures in 2002, with 36,297 medical abortion procedures reported. This is approximately a 77% increase from 2001 in the 31 areas that reported medical abortion information in both years. About 94% of medical abortions were performed at 8 weeks' gestation or earlier.

The incidence of early-onset neonatal group B streptococcal disease in the United States has dropped by a third since guidelines for universal screening of pregnant women were issued, the Centers for Disease Control and Prevention reported.

The guidelines, which call for routine screening of pregnant women for rectovaginal group B streptococcal (GBS) colonization at 35–37 weeks' gestation and administration of intrapartum antimicrobial prophylaxis to carriers, were jointly issued in 2002 by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the CDC (MMWR Recomm. Rep. 2002;51[RR-11]:1–22).

In 2004, the incidence of GBS disease in newborns aged 0–6 days (early-onset disease) had decreased by 31% from the period of 2000–2001, immediately before universal screening was implemented, the CDC said (MMWR 2005;54:1205–8).

Late-onset GBS disease—occurring in infants aged 7–89 days—did not change during 1996–2004, the period for which data were analyzed from the CDC's Active Bacterial Core surveillance (ABCs) system. The ABCs areas represented approximately 337,000 live births in 1996 and 427,000 live births in 2004. A total of 308 cases of neonatal GBS disease were reported in 2004, 47% early-onset and 53% late-onset. Overall, 55% with neonatal GBS disease were white, 42% black, and 3% other races; 51% were female.

Among early-onset cases with complete data, the proportion born at less than 37 weeks' gestation increased significantly, from 20% (40 of 204) in 2000 to 29% (41 of 141) in 2004. Among late-onset cases with complete data in 2004, 55% (81 of 147) were born preterm. Case-fatality ratios were consistently higher among preterm infants, both in the early- and late-disease groups. Nine of the 40 preterm infants with early-onset disease died (23%) vs. none of the 66 term infants with late-onset GBS.

The rate of late-onset disease surpassed that of early-onset disease for the first time in 2003, a trend that continued in 2004. Racial disparities in the incidence of both early- and late-onset GBS disease persisted: In 2004, rates of early-onset disease were 0.73 per 1,000 live births for black infants vs. 0.26 per 1,000 for white infants. For late-onset disease, those rates were 0.83 per 1,000 live births for black infants vs. 0.28 per 1,000 for whites.

The incidence of early-onset neonatal group B streptococcal disease in the United States has dropped by a third since guidelines for universal screening of pregnant women were issued, the Centers for Disease Control and Prevention reported.

The guidelines, which call for routine screening of pregnant women for rectovaginal group B streptococcal (GBS) colonization at 35–37 weeks' gestation and administration of intrapartum antimicrobial prophylaxis to carriers, were jointly issued in 2002 by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the CDC (MMWR Recomm. Rep. 2002;51[RR-11]:1–22).

In 2004, the incidence of GBS disease in newborns aged 0–6 days (early-onset disease) had decreased by 31% from the period of 2000–2001, immediately before universal screening was implemented, the CDC said (MMWR 2005;54:1205–8).

Late-onset GBS disease—occurring in infants aged 7–89 days—did not change during 1996–2004, the period for which data were analyzed from the CDC's Active Bacterial Core surveillance (ABCs) system. The ABCs areas represented approximately 337,000 live births in 1996 and 427,000 live births in 2004. A total of 308 cases of neonatal GBS disease were reported in 2004, 47% early-onset and 53% late-onset. Overall, 55% with neonatal GBS disease were white, 42% black, and 3% other races; 51% were female.

Among early-onset cases with complete data, the proportion born at less than 37 weeks' gestation increased significantly, from 20% (40 of 204) in 2000 to 29% (41 of 141) in 2004. Among late-onset cases with complete data in 2004, 55% (81 of 147) were born preterm. Case-fatality ratios were consistently higher among preterm infants, both in the early- and late-disease groups. Nine of the 40 preterm infants with early-onset disease died (23%) vs. none of the 66 term infants with late-onset GBS.

The rate of late-onset disease surpassed that of early-onset disease for the first time in 2003, a trend that continued in 2004. Racial disparities in the incidence of both early- and late-onset GBS disease persisted: In 2004, rates of early-onset disease were 0.73 per 1,000 live births for black infants vs. 0.26 per 1,000 for white infants. For late-onset disease, those rates were 0.83 per 1,000 live births for black infants vs. 0.28 per 1,000 for whites.

The incidence of early-onset neonatal group B streptococcal disease in the United States has dropped by a third since guidelines for universal screening of pregnant women were issued, the Centers for Disease Control and Prevention reported.

The guidelines, which call for routine screening of pregnant women for rectovaginal group B streptococcal (GBS) colonization at 35–37 weeks' gestation and administration of intrapartum antimicrobial prophylaxis to carriers, were jointly issued in 2002 by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the CDC (MMWR Recomm. Rep. 2002;51[RR-11]:1–22).

In 2004, the incidence of GBS disease in newborns aged 0–6 days (early-onset disease) had decreased by 31% from the period of 2000–2001, immediately before universal screening was implemented, the CDC said (MMWR 2005;54:1205–8).

Late-onset GBS disease—occurring in infants aged 7–89 days—did not change during 1996–2004, the period for which data were analyzed from the CDC's Active Bacterial Core surveillance (ABCs) system. The ABCs areas represented approximately 337,000 live births in 1996 and 427,000 live births in 2004. A total of 308 cases of neonatal GBS disease were reported in 2004, 47% early-onset and 53% late-onset. Overall, 55% with neonatal GBS disease were white, 42% black, and 3% other races; 51% were female.

Among early-onset cases with complete data, the proportion born at less than 37 weeks' gestation increased significantly, from 20% (40 of 204) in 2000 to 29% (41 of 141) in 2004. Among late-onset cases with complete data in 2004, 55% (81 of 147) were born preterm. Case-fatality ratios were consistently higher among preterm infants, both in the early- and late-disease groups. Nine of the 40 preterm infants with early-onset disease died (23%) vs. none of the 66 term infants with late-onset GBS.

The rate of late-onset disease surpassed that of early-onset disease for the first time in 2003, a trend that continued in 2004. Racial disparities in the incidence of both early- and late-onset GBS disease persisted: In 2004, rates of early-onset disease were 0.73 per 1,000 live births for black infants vs. 0.26 per 1,000 for white infants. For late-onset disease, those rates were 0.83 per 1,000 live births for black infants vs. 0.28 per 1,000 for whites.

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in a about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other mistakes were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8 vs. 2.5–7.2 for women without these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

“So if an institution has a coding problem, they may seem to have 'better' quality than an institution with an identical rate and truly better coding,” she said.

“More importantly, researchers commonly use large databases that use discharge codes for estimating the number of 'events',” she added. “If our data can be reproduced, it suggests that research using discharge coding may not be wise.”

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network has opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter lacerations at vaginal delivery with women who had cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial. The two women with codes for anal sphincter lacerations that did not occur came from the control groups.

An institution with a coding problem may seem to have 'better' quality than one with an identical rate and better coding. DR. BRUBAKER

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in a about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other mistakes were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8 vs. 2.5–7.2 for women without these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

“So if an institution has a coding problem, they may seem to have 'better' quality than an institution with an identical rate and truly better coding,” she said.

“More importantly, researchers commonly use large databases that use discharge codes for estimating the number of 'events',” she added. “If our data can be reproduced, it suggests that research using discharge coding may not be wise.”

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network has opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter lacerations at vaginal delivery with women who had cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial. The two women with codes for anal sphincter lacerations that did not occur came from the control groups.

An institution with a coding problem may seem to have 'better' quality than one with an identical rate and better coding. DR. BRUBAKER

SCOTTSDALE, ARIZ. — Anal sphincter laceration during childbirth is not accurately coded in many hospital discharge records and may be underestimated as a result.

The Pelvic Floor Disorders Network found mistakes in a about one-quarter of 392 hospital discharge records from nine institutions participating in one of its trials, according to a poster presented at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Linda Brubaker reported an average coding error rate of 24% across the nine centers. Just one institution was free of mistakes. The three highest error rates were 62%, 48.6%, and 27.2%.

Only two patients had codes listed for anal sphincter lacerations that did not occur, said Dr. Brubaker, director of female pelvic medicine and reconstructive surgery at Loyola University Medical Center in Maywood, Ill. All the other mistakes were omissions of coding for anal sphincter lacerations that had been recorded in clinical records as occurring during delivery.

Dr. Brubaker reported that the coding error rates were not related to the number of deliveries at each institution or to the number of hospital discharge codes for each patient. Women with anal sphincter lacerations tended to have more codes, however, with a range of 2.9–7.8 vs. 2.5–7.2 for women without these injuries.

The network warned that the result of this type of coding error could be a substantial underassessment of delivery-associated anal sphincter laceration as a maternal morbidity. It recommended against using hospital discharge coding as a source of data.

The discrepancies could have significant implications for quality assurance and research initiatives. Dr. Brubaker told this newspaper subsequently that both the Joint Commission on Accreditation of Health Care Organizations and the Annual Public Health Report will be using the incidence of obstetric third- and fourth-degree lacerations as indicators of care quality.

“So if an institution has a coding problem, they may seem to have 'better' quality than an institution with an identical rate and truly better coding,” she said.

“More importantly, researchers commonly use large databases that use discharge codes for estimating the number of 'events',” she added. “If our data can be reproduced, it suggests that research using discharge coding may not be wise.”

The bottom line, Dr. Brubaker concluded, is that these lacerations have not received the attention they deserve. “Improved coding [and the use of these events as quality indicators] may provide an opportunity to improve patient care and identify women who may benefit from postdelivery pelvic floor assessment,” she said.

Sponsored by the National Institutes of Health, the network has opened a Web site at www.pfdn.org

The trial is comparing women with anal sphincter lacerations at vaginal delivery with women who had cesarean delivery without labor and women who delivered vaginally without anal sphincter laceration in the trial. The two women with codes for anal sphincter lacerations that did not occur came from the control groups.

An institution with a coding problem may seem to have 'better' quality than one with an identical rate and better coding. DR. BRUBAKER