Obstetrics

DALLAS — Smoking during pregnancy is associated with overweight in the offspring, Dr. Nicholas Stettler reported at the annual scientific sessions of the American Heart Association.

His retrospective analysis of prospectively collected prenatal and postnatal data on 20,284 women who participated in the Collaborative Perinatal Project showed that after a host of potential confounding variables were controlled for, white women who smoked in pregnancy were 33% more likely than those who didn't to give birth to a child whose body mass index was at or above the 95th percentile at age 7 years. Black smokers were 39% more likely than nonsmokers during pregnancy to have an overweight 7-year-old, said Dr. Stettler of Children's Hospital, Philadelphia.

“In utero exposure to smoking may result in metabolic programming that leads to the development of obesity,” he said. “Smoking prevention and cessation in women of childbearing age may have unintended benefits, such as reduced risk for obesity in their offspring.”

The Collaborative Perinatal Project was conducted at 12 U.S. sites during 1959–1973. Of the participating mothers, 45% reported smoking during their index pregnancy. Among the potential confounders Dr. Stettler controlled for were maternal age, body mass index, and education level, along with the child's gender, birth weight, gestational age, birth order, and weight gain during the first 4 months of life.

The maternal smoking/overweight offspring association appeared to be dose dependent. For every 10 cigarettes per day a black woman smoked during pregnancy, the chances of her child being overweight at age 7 climbed by 21%. Similarly, the risk increased in white women by 18% for every 10 cigarettes per day smoked in pregnancy.

DALLAS — Smoking during pregnancy is associated with overweight in the offspring, Dr. Nicholas Stettler reported at the annual scientific sessions of the American Heart Association.

His retrospective analysis of prospectively collected prenatal and postnatal data on 20,284 women who participated in the Collaborative Perinatal Project showed that after a host of potential confounding variables were controlled for, white women who smoked in pregnancy were 33% more likely than those who didn't to give birth to a child whose body mass index was at or above the 95th percentile at age 7 years. Black smokers were 39% more likely than nonsmokers during pregnancy to have an overweight 7-year-old, said Dr. Stettler of Children's Hospital, Philadelphia.

“In utero exposure to smoking may result in metabolic programming that leads to the development of obesity,” he said. “Smoking prevention and cessation in women of childbearing age may have unintended benefits, such as reduced risk for obesity in their offspring.”

The Collaborative Perinatal Project was conducted at 12 U.S. sites during 1959–1973. Of the participating mothers, 45% reported smoking during their index pregnancy. Among the potential confounders Dr. Stettler controlled for were maternal age, body mass index, and education level, along with the child's gender, birth weight, gestational age, birth order, and weight gain during the first 4 months of life.

The maternal smoking/overweight offspring association appeared to be dose dependent. For every 10 cigarettes per day a black woman smoked during pregnancy, the chances of her child being overweight at age 7 climbed by 21%. Similarly, the risk increased in white women by 18% for every 10 cigarettes per day smoked in pregnancy.

DALLAS — Smoking during pregnancy is associated with overweight in the offspring, Dr. Nicholas Stettler reported at the annual scientific sessions of the American Heart Association.

His retrospective analysis of prospectively collected prenatal and postnatal data on 20,284 women who participated in the Collaborative Perinatal Project showed that after a host of potential confounding variables were controlled for, white women who smoked in pregnancy were 33% more likely than those who didn't to give birth to a child whose body mass index was at or above the 95th percentile at age 7 years. Black smokers were 39% more likely than nonsmokers during pregnancy to have an overweight 7-year-old, said Dr. Stettler of Children's Hospital, Philadelphia.

“In utero exposure to smoking may result in metabolic programming that leads to the development of obesity,” he said. “Smoking prevention and cessation in women of childbearing age may have unintended benefits, such as reduced risk for obesity in their offspring.”

The Collaborative Perinatal Project was conducted at 12 U.S. sites during 1959–1973. Of the participating mothers, 45% reported smoking during their index pregnancy. Among the potential confounders Dr. Stettler controlled for were maternal age, body mass index, and education level, along with the child's gender, birth weight, gestational age, birth order, and weight gain during the first 4 months of life.

The maternal smoking/overweight offspring association appeared to be dose dependent. For every 10 cigarettes per day a black woman smoked during pregnancy, the chances of her child being overweight at age 7 climbed by 21%. Similarly, the risk increased in white women by 18% for every 10 cigarettes per day smoked in pregnancy.

Pregnant women working outside the home may be more likely than their homemaker counterparts to develop carpal tunnel syndrome, Dr. Glen D. Seidman said at the joint annual meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists.

Previous studies have shown that carpel tunnel syndrome (CTS) during pregnancy and lactation has been shown to be associated with elevated estrogen levels, but this effect is not well established in the literature. “We wanted to know how high estrogen contributes to a woman's developing CTS,” noted Dr. Seidman of South Shore Orthopedic Associates, South Weymouth, Mass.

Screening of 1,926 pregnant women scheduled to deliver within a 6-month period showed that 230 women (12%) had CTS symptoms. The onset of symptoms commonly occurred at 24–28 weeks' gestation. At 6 weeks post partum, 36% of the affected women still had symptoms, and 34% required therapeutic intervention.

Dr. Seidman noted that 76% of those with persistent CTS symptoms post partum worked outside the home and 73% were breast-feeding. By comparison, 85% of those unaffected by CTS during the postpartum period were breast-feeding.

Contrary to previous studies suggesting an association between estrogen levels and CTS, these findings indicate that CTS in pregnancy does not have a hormonal etiology, as symptoms during the postpartum period did not correlate well with breast-feeding. Instead, there appears to be a correlation between working outside the home and CTS post partum, Dr. Seidman concluded.

Pregnant women working outside the home may be more likely than their homemaker counterparts to develop carpal tunnel syndrome, Dr. Glen D. Seidman said at the joint annual meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists.

Previous studies have shown that carpel tunnel syndrome (CTS) during pregnancy and lactation has been shown to be associated with elevated estrogen levels, but this effect is not well established in the literature. “We wanted to know how high estrogen contributes to a woman's developing CTS,” noted Dr. Seidman of South Shore Orthopedic Associates, South Weymouth, Mass.

Screening of 1,926 pregnant women scheduled to deliver within a 6-month period showed that 230 women (12%) had CTS symptoms. The onset of symptoms commonly occurred at 24–28 weeks' gestation. At 6 weeks post partum, 36% of the affected women still had symptoms, and 34% required therapeutic intervention.

Dr. Seidman noted that 76% of those with persistent CTS symptoms post partum worked outside the home and 73% were breast-feeding. By comparison, 85% of those unaffected by CTS during the postpartum period were breast-feeding.

Contrary to previous studies suggesting an association between estrogen levels and CTS, these findings indicate that CTS in pregnancy does not have a hormonal etiology, as symptoms during the postpartum period did not correlate well with breast-feeding. Instead, there appears to be a correlation between working outside the home and CTS post partum, Dr. Seidman concluded.

Pregnant women working outside the home may be more likely than their homemaker counterparts to develop carpal tunnel syndrome, Dr. Glen D. Seidman said at the joint annual meeting of the American Society for Surgery of the Hand and the American Society of Hand Therapists.

Previous studies have shown that carpel tunnel syndrome (CTS) during pregnancy and lactation has been shown to be associated with elevated estrogen levels, but this effect is not well established in the literature. “We wanted to know how high estrogen contributes to a woman's developing CTS,” noted Dr. Seidman of South Shore Orthopedic Associates, South Weymouth, Mass.

Screening of 1,926 pregnant women scheduled to deliver within a 6-month period showed that 230 women (12%) had CTS symptoms. The onset of symptoms commonly occurred at 24–28 weeks' gestation. At 6 weeks post partum, 36% of the affected women still had symptoms, and 34% required therapeutic intervention.

Dr. Seidman noted that 76% of those with persistent CTS symptoms post partum worked outside the home and 73% were breast-feeding. By comparison, 85% of those unaffected by CTS during the postpartum period were breast-feeding.

Contrary to previous studies suggesting an association between estrogen levels and CTS, these findings indicate that CTS in pregnancy does not have a hormonal etiology, as symptoms during the postpartum period did not correlate well with breast-feeding. Instead, there appears to be a correlation between working outside the home and CTS post partum, Dr. Seidman concluded.

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction of labor, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Dr. Rabbie Hanna and his colleagues reported the rate of successful induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said in an interview at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 (2%) pregnancies that ended in elective cesarean section and 45,100 (98%) in which the women underwent labor. In this latter group, 6,427 (14%) required induction of labor.

Dr. Hanna and his colleagues also reported that the proportion of women choosing cesarean delivery increased with BMI. The rate of elective cesarean delivery rose from 1.7% of women with normal weight to 6.1% of women who were morbidly obese. Elective cesarean rates were 2.5% in overweight women, 2.9% in those with class I obesity, and 4.9% in those with class II obesity.

The investigators didn't address whether trying to induce labor over two or three days is worthwhile in a morbidly obese patient. “We can't answer that question. She still has a 50–50 chance,” said Dr. Hanna, noting that cesarean delivery is associated with increased risk of complications.

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction of labor, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Dr. Rabbie Hanna and his colleagues reported the rate of successful induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said in an interview at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 (2%) pregnancies that ended in elective cesarean section and 45,100 (98%) in which the women underwent labor. In this latter group, 6,427 (14%) required induction of labor.

Dr. Hanna and his colleagues also reported that the proportion of women choosing cesarean delivery increased with BMI. The rate of elective cesarean delivery rose from 1.7% of women with normal weight to 6.1% of women who were morbidly obese. Elective cesarean rates were 2.5% in overweight women, 2.9% in those with class I obesity, and 4.9% in those with class II obesity.

The investigators didn't address whether trying to induce labor over two or three days is worthwhile in a morbidly obese patient. “We can't answer that question. She still has a 50–50 chance,” said Dr. Hanna, noting that cesarean delivery is associated with increased risk of complications.

SCOTTSDALE, ARIZ. — The more obese a woman is before becoming pregnant, the lower her chances will be for successful induction of labor, according to researchers who reviewed computerized records of 45,998 pregnancies in a German database.

Dr. Rabbie Hanna and his colleagues reported the rate of successful induction fell from a high of 79% for women of normal weight with a body mass index (BMI) below 25 kg/m

“We saw that as obesity increases, normal labor decreases and induction of labor increases,” Dr. Hanna said in an interview at the annual meeting of the Central Association of Obstetricians and Gynecologists, where he presented the data in a poster.

The study mined a perinatal database of 170,258 cases collected from 1991 to 1997 in the state of Schleswig-Holstein. The investigators selected nulliparous, low-risk women who came to full term with singleton pregnancies. Prepregnancy height and weight had to be in the database for a woman to be included in the analysis.

Among the 45,998 pregnancies that fit these criteria, there were 898 (2%) pregnancies that ended in elective cesarean section and 45,100 (98%) in which the women underwent labor. In this latter group, 6,427 (14%) required induction of labor.

Dr. Hanna and his colleagues also reported that the proportion of women choosing cesarean delivery increased with BMI. The rate of elective cesarean delivery rose from 1.7% of women with normal weight to 6.1% of women who were morbidly obese. Elective cesarean rates were 2.5% in overweight women, 2.9% in those with class I obesity, and 4.9% in those with class II obesity.

The investigators didn't address whether trying to induce labor over two or three days is worthwhile in a morbidly obese patient. “We can't answer that question. She still has a 50–50 chance,” said Dr. Hanna, noting that cesarean delivery is associated with increased risk of complications.

CHICAGO — Preevacuation hysteroscopy is useful for identifying localized and systemic defects during morphogenesis in patients with unexplained recurring pregnancy loss, said Dr. Artin Ternamian.

“we're convinced that preevacuation hysteroscopy can help us understand and maybe explain a lot of the miscarriages that we take for granted,” he said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Sonography, tissue analysis, and biochemical studies are generally used to evaluate recurrent pregnancy loss, which occurs in 1% of reproductive-age women. But once the evacuation or D&C has been performed, couple counseling becomes more difficult, if not impossible, and the willingness to investigate further wanes, he said.

Preevacuation hysteroscopy allows physicians to examine the fetoplacental environment and provides excellent visualization of the surface anatomy before the tissue is eviscerated or contaminated, said Dr. Ternamian, director of gynecologic endoscopy, St. Joseph's Health Centre, University of Toronto.

In particular, one can examine the ventral bony clefts, which can be difficult to do with ultrasound and which reveals subtle skin surface changes, such as human papillomavirus skin lesions or raised corneal lesions that can be targeted for biopsy. The procedure can demonstrate most fetal extremity deformities and the exact topography of the limbs, identifying cystic hydromas and sacral coccygeal keratomas.

The accurate surface observation of hysteroscopy can identify congenital ear abnormalities such as clefts and congenital hairy nevi that are notoriously missed on ultrasound, he said. Preevacuation hysteroscopy can also confirm or rule out amniotic bands, Meckel-Gruber syndrome, Klippel-Trénaunay-Weber syndrome, and first-trimester varicella.

In a prospective, preliminary feasibility study, preevacuation hysteroscopy was performed using a continuous-flow resectoscope with a 12-degree lens in 12 consecutive patients with confirmed spontaneous pregnancy loss. Gestational ages ranged from 9 weeks to 19 weeks.

In this procedure, the cervix is dilated and a small amniotic membrane window created at a location away from the placenta and fetus, using a monopolar 5-by-8-mm cutting loop set at 100 W pure cut power. The often stained amniotic fluid is exchanged for 1.5% glycine while the hysteroscope is navigated through the amniotic window into the fetal compartment.

Abnormalities were detected in all but one patient. None of the abnormalities observed on hysteroscopy were identified on previous ultrasound scans or subsequent surgical pathology reports.

“The objective of a pathology report is to make sure that what you've retrieved is indeed fetal tissue and you've evacuated the uterus; [it] isn't intended to detect abnormalities,” Dr. Ternamian said in an interview. “If, by chance, they see some gross histologic abnormalities that will be reported, but that's 1 in 10,000.”

Hysteroscopy adds no more than 20 minutes to an evacuation or D&C, and the majority of patients offered the additional testing consent. Patients are advised not to decide at the first interview when the fetal death is discovered, and particular care is taken if the patient is pregnant for the first time.

“From the patient's point of view it's a horrendous area,” he said. “To use hysteroscopy is the next logical step to help these patients, and, hopefully, we can take it to the next level, where, if you have a miscarriage, it becomes standard of care.”

CHICAGO — Preevacuation hysteroscopy is useful for identifying localized and systemic defects during morphogenesis in patients with unexplained recurring pregnancy loss, said Dr. Artin Ternamian.

“we're convinced that preevacuation hysteroscopy can help us understand and maybe explain a lot of the miscarriages that we take for granted,” he said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Sonography, tissue analysis, and biochemical studies are generally used to evaluate recurrent pregnancy loss, which occurs in 1% of reproductive-age women. But once the evacuation or D&C has been performed, couple counseling becomes more difficult, if not impossible, and the willingness to investigate further wanes, he said.

Preevacuation hysteroscopy allows physicians to examine the fetoplacental environment and provides excellent visualization of the surface anatomy before the tissue is eviscerated or contaminated, said Dr. Ternamian, director of gynecologic endoscopy, St. Joseph's Health Centre, University of Toronto.

In particular, one can examine the ventral bony clefts, which can be difficult to do with ultrasound and which reveals subtle skin surface changes, such as human papillomavirus skin lesions or raised corneal lesions that can be targeted for biopsy. The procedure can demonstrate most fetal extremity deformities and the exact topography of the limbs, identifying cystic hydromas and sacral coccygeal keratomas.

The accurate surface observation of hysteroscopy can identify congenital ear abnormalities such as clefts and congenital hairy nevi that are notoriously missed on ultrasound, he said. Preevacuation hysteroscopy can also confirm or rule out amniotic bands, Meckel-Gruber syndrome, Klippel-Trénaunay-Weber syndrome, and first-trimester varicella.

In a prospective, preliminary feasibility study, preevacuation hysteroscopy was performed using a continuous-flow resectoscope with a 12-degree lens in 12 consecutive patients with confirmed spontaneous pregnancy loss. Gestational ages ranged from 9 weeks to 19 weeks.

In this procedure, the cervix is dilated and a small amniotic membrane window created at a location away from the placenta and fetus, using a monopolar 5-by-8-mm cutting loop set at 100 W pure cut power. The often stained amniotic fluid is exchanged for 1.5% glycine while the hysteroscope is navigated through the amniotic window into the fetal compartment.

Abnormalities were detected in all but one patient. None of the abnormalities observed on hysteroscopy were identified on previous ultrasound scans or subsequent surgical pathology reports.

“The objective of a pathology report is to make sure that what you've retrieved is indeed fetal tissue and you've evacuated the uterus; [it] isn't intended to detect abnormalities,” Dr. Ternamian said in an interview. “If, by chance, they see some gross histologic abnormalities that will be reported, but that's 1 in 10,000.”

Hysteroscopy adds no more than 20 minutes to an evacuation or D&C, and the majority of patients offered the additional testing consent. Patients are advised not to decide at the first interview when the fetal death is discovered, and particular care is taken if the patient is pregnant for the first time.

“From the patient's point of view it's a horrendous area,” he said. “To use hysteroscopy is the next logical step to help these patients, and, hopefully, we can take it to the next level, where, if you have a miscarriage, it becomes standard of care.”

CHICAGO — Preevacuation hysteroscopy is useful for identifying localized and systemic defects during morphogenesis in patients with unexplained recurring pregnancy loss, said Dr. Artin Ternamian.

“we're convinced that preevacuation hysteroscopy can help us understand and maybe explain a lot of the miscarriages that we take for granted,” he said at the annual meeting of the AAGL (formerly the American Association of Gynecologic Laparoscopists).

Sonography, tissue analysis, and biochemical studies are generally used to evaluate recurrent pregnancy loss, which occurs in 1% of reproductive-age women. But once the evacuation or D&C has been performed, couple counseling becomes more difficult, if not impossible, and the willingness to investigate further wanes, he said.

Preevacuation hysteroscopy allows physicians to examine the fetoplacental environment and provides excellent visualization of the surface anatomy before the tissue is eviscerated or contaminated, said Dr. Ternamian, director of gynecologic endoscopy, St. Joseph's Health Centre, University of Toronto.

In particular, one can examine the ventral bony clefts, which can be difficult to do with ultrasound and which reveals subtle skin surface changes, such as human papillomavirus skin lesions or raised corneal lesions that can be targeted for biopsy. The procedure can demonstrate most fetal extremity deformities and the exact topography of the limbs, identifying cystic hydromas and sacral coccygeal keratomas.

The accurate surface observation of hysteroscopy can identify congenital ear abnormalities such as clefts and congenital hairy nevi that are notoriously missed on ultrasound, he said. Preevacuation hysteroscopy can also confirm or rule out amniotic bands, Meckel-Gruber syndrome, Klippel-Trénaunay-Weber syndrome, and first-trimester varicella.

In a prospective, preliminary feasibility study, preevacuation hysteroscopy was performed using a continuous-flow resectoscope with a 12-degree lens in 12 consecutive patients with confirmed spontaneous pregnancy loss. Gestational ages ranged from 9 weeks to 19 weeks.

In this procedure, the cervix is dilated and a small amniotic membrane window created at a location away from the placenta and fetus, using a monopolar 5-by-8-mm cutting loop set at 100 W pure cut power. The often stained amniotic fluid is exchanged for 1.5% glycine while the hysteroscope is navigated through the amniotic window into the fetal compartment.

Abnormalities were detected in all but one patient. None of the abnormalities observed on hysteroscopy were identified on previous ultrasound scans or subsequent surgical pathology reports.

“The objective of a pathology report is to make sure that what you've retrieved is indeed fetal tissue and you've evacuated the uterus; [it] isn't intended to detect abnormalities,” Dr. Ternamian said in an interview. “If, by chance, they see some gross histologic abnormalities that will be reported, but that's 1 in 10,000.”

Hysteroscopy adds no more than 20 minutes to an evacuation or D&C, and the majority of patients offered the additional testing consent. Patients are advised not to decide at the first interview when the fetal death is discovered, and particular care is taken if the patient is pregnant for the first time.

“From the patient's point of view it's a horrendous area,” he said. “To use hysteroscopy is the next logical step to help these patients, and, hopefully, we can take it to the next level, where, if you have a miscarriage, it becomes standard of care.”

Neuroradiologic studies can provide valuable diagnostic information in women who present during pregnancy or the puerperium with apparent eclampsia or similar neurologic manifestations, British investigators have reported.

A host of less common neurologic conditions and manifestations may mimic or resemble eclampsia and, because signs and symptoms are often nonspecific, it can be difficult to differentiate these conditions “on clinical grounds alone,” they said in a recently published pictorial review.

“Neuroimaging in a clearly defined case of eclampsia may not be necessary but, if there is focal neurology or deterioration in neurological status, imaging should be performed,” said Dr. R. Dineen of the department of neuroradiology at Queen's Medical Centre in Nottingham, England, and his associates.

Without it, the diagnosis of various conditions—from intracranial hemorrhage and other cerebrovascular conditions, to intracranial tumors and various pituitary and metabolic conditions—may be delayed as women are mistakenly treated for eclampsia, they said.

In women with true eclampsia, the most frequent abnormality detected on cranial MRI is high-signal change on T2-weighted and FLAIR images. Lesions are commonly seen in both deep and subcortical white matter, often with a posterior circulation distribution, and within the basal ganglia.

Lesions also occur within the pons and brainstem, and correspond to low-attenuation areas on CT scanning. The majority of lesions are reversible but some may progress to infarction, they said.

Several “overlap syndromes”—postpartum cerebral angiopathy, hypertensive encephalopathy, and reversible posterior leukoencephalopathy syndrome—may show neuroimaging features that are similar to or indistinguishable from those of eclampsia, they said (Clin. Radiol. 2005;60:1156-70).

Neuroimaging features are more distinct with other neurologic emergencies, such as the cerebrovascular disorders that can occur in pregnancy or the puerperal period: arterial ischemia and infarction, intracranial hemorrhage, venoocclusive disease, and vasculitis.

The mainstay for investigating ruptured intracranial aneurysms—the most common cause of subarachnoid hemorrhage and a cause of intracerebral hemorrhage—is CT with either CT angiography or conventional angiography. Magnetic resonance angiography, however, can be used to assess aneurysms without the need for ionizing radiation or contrast media.

Just as the risk of ruptured intracranial aneurysms increases for women who are pregnant or in the puerperal period, compared with nonpregnant women, the risk of intracranial venoocclusive disease is particularly increased around the puerperal period. Intracranial venoocclusive disease also can occur in women with preeclampsia.

Women with the condition present with headache, confusion, decreased consciousness level, papilledema, seizures, and often, focal deficits.

CT scanning shows hyperdensity in the venous sinuses, cortical veins, or deep cerebral veins. When venous infarction develops, areas of low attenuation are seen. Patterns of venous infarction on MRI “do not conform to the contours expected from an arterial occlusion,” the investigators note. T2-weighted images show high-signal change involving the white matter with absent flow void in the related cortical vein or dural venous sinus.

Precautions should be taken to limit fetal exposure to ionizing radiation, but “fetal exposure to ionizing radiation from CT of the maternal head is extremely low, and the risk to the fetus is likely to be considerably less than the risk to both the fetus and mother from an acute neurological condition,” the investigators reported.

An internal carotid catheter angiogram shows a giant intracavernous aneurysm at the underside of the C4 segment.

A CT shows high density in the left transverse sinus and hemorrhagic venous infarction in the left temporal lobe. ©Elsevier, Clinical Radiology, Vol. 60, R. Dineen, “Imaging of acute neurological conditions in pregnancy and puerperium,” 1156 - 1170, 2005, Reprinted with permission from The Royal College of Radiologists

Neuroradiologic studies can provide valuable diagnostic information in women who present during pregnancy or the puerperium with apparent eclampsia or similar neurologic manifestations, British investigators have reported.

A host of less common neurologic conditions and manifestations may mimic or resemble eclampsia and, because signs and symptoms are often nonspecific, it can be difficult to differentiate these conditions “on clinical grounds alone,” they said in a recently published pictorial review.

“Neuroimaging in a clearly defined case of eclampsia may not be necessary but, if there is focal neurology or deterioration in neurological status, imaging should be performed,” said Dr. R. Dineen of the department of neuroradiology at Queen's Medical Centre in Nottingham, England, and his associates.

Without it, the diagnosis of various conditions—from intracranial hemorrhage and other cerebrovascular conditions, to intracranial tumors and various pituitary and metabolic conditions—may be delayed as women are mistakenly treated for eclampsia, they said.

In women with true eclampsia, the most frequent abnormality detected on cranial MRI is high-signal change on T2-weighted and FLAIR images. Lesions are commonly seen in both deep and subcortical white matter, often with a posterior circulation distribution, and within the basal ganglia.

Lesions also occur within the pons and brainstem, and correspond to low-attenuation areas on CT scanning. The majority of lesions are reversible but some may progress to infarction, they said.

Several “overlap syndromes”—postpartum cerebral angiopathy, hypertensive encephalopathy, and reversible posterior leukoencephalopathy syndrome—may show neuroimaging features that are similar to or indistinguishable from those of eclampsia, they said (Clin. Radiol. 2005;60:1156-70).

Neuroimaging features are more distinct with other neurologic emergencies, such as the cerebrovascular disorders that can occur in pregnancy or the puerperal period: arterial ischemia and infarction, intracranial hemorrhage, venoocclusive disease, and vasculitis.

The mainstay for investigating ruptured intracranial aneurysms—the most common cause of subarachnoid hemorrhage and a cause of intracerebral hemorrhage—is CT with either CT angiography or conventional angiography. Magnetic resonance angiography, however, can be used to assess aneurysms without the need for ionizing radiation or contrast media.

Just as the risk of ruptured intracranial aneurysms increases for women who are pregnant or in the puerperal period, compared with nonpregnant women, the risk of intracranial venoocclusive disease is particularly increased around the puerperal period. Intracranial venoocclusive disease also can occur in women with preeclampsia.

Women with the condition present with headache, confusion, decreased consciousness level, papilledema, seizures, and often, focal deficits.

CT scanning shows hyperdensity in the venous sinuses, cortical veins, or deep cerebral veins. When venous infarction develops, areas of low attenuation are seen. Patterns of venous infarction on MRI “do not conform to the contours expected from an arterial occlusion,” the investigators note. T2-weighted images show high-signal change involving the white matter with absent flow void in the related cortical vein or dural venous sinus.

Precautions should be taken to limit fetal exposure to ionizing radiation, but “fetal exposure to ionizing radiation from CT of the maternal head is extremely low, and the risk to the fetus is likely to be considerably less than the risk to both the fetus and mother from an acute neurological condition,” the investigators reported.

An internal carotid catheter angiogram shows a giant intracavernous aneurysm at the underside of the C4 segment.

A CT shows high density in the left transverse sinus and hemorrhagic venous infarction in the left temporal lobe. ©Elsevier, Clinical Radiology, Vol. 60, R. Dineen, “Imaging of acute neurological conditions in pregnancy and puerperium,” 1156 - 1170, 2005, Reprinted with permission from The Royal College of Radiologists

Neuroradiologic studies can provide valuable diagnostic information in women who present during pregnancy or the puerperium with apparent eclampsia or similar neurologic manifestations, British investigators have reported.

A host of less common neurologic conditions and manifestations may mimic or resemble eclampsia and, because signs and symptoms are often nonspecific, it can be difficult to differentiate these conditions “on clinical grounds alone,” they said in a recently published pictorial review.

“Neuroimaging in a clearly defined case of eclampsia may not be necessary but, if there is focal neurology or deterioration in neurological status, imaging should be performed,” said Dr. R. Dineen of the department of neuroradiology at Queen's Medical Centre in Nottingham, England, and his associates.

Without it, the diagnosis of various conditions—from intracranial hemorrhage and other cerebrovascular conditions, to intracranial tumors and various pituitary and metabolic conditions—may be delayed as women are mistakenly treated for eclampsia, they said.

In women with true eclampsia, the most frequent abnormality detected on cranial MRI is high-signal change on T2-weighted and FLAIR images. Lesions are commonly seen in both deep and subcortical white matter, often with a posterior circulation distribution, and within the basal ganglia.

Lesions also occur within the pons and brainstem, and correspond to low-attenuation areas on CT scanning. The majority of lesions are reversible but some may progress to infarction, they said.

Several “overlap syndromes”—postpartum cerebral angiopathy, hypertensive encephalopathy, and reversible posterior leukoencephalopathy syndrome—may show neuroimaging features that are similar to or indistinguishable from those of eclampsia, they said (Clin. Radiol. 2005;60:1156-70).

Neuroimaging features are more distinct with other neurologic emergencies, such as the cerebrovascular disorders that can occur in pregnancy or the puerperal period: arterial ischemia and infarction, intracranial hemorrhage, venoocclusive disease, and vasculitis.

The mainstay for investigating ruptured intracranial aneurysms—the most common cause of subarachnoid hemorrhage and a cause of intracerebral hemorrhage—is CT with either CT angiography or conventional angiography. Magnetic resonance angiography, however, can be used to assess aneurysms without the need for ionizing radiation or contrast media.

Just as the risk of ruptured intracranial aneurysms increases for women who are pregnant or in the puerperal period, compared with nonpregnant women, the risk of intracranial venoocclusive disease is particularly increased around the puerperal period. Intracranial venoocclusive disease also can occur in women with preeclampsia.

Women with the condition present with headache, confusion, decreased consciousness level, papilledema, seizures, and often, focal deficits.

CT scanning shows hyperdensity in the venous sinuses, cortical veins, or deep cerebral veins. When venous infarction develops, areas of low attenuation are seen. Patterns of venous infarction on MRI “do not conform to the contours expected from an arterial occlusion,” the investigators note. T2-weighted images show high-signal change involving the white matter with absent flow void in the related cortical vein or dural venous sinus.

Precautions should be taken to limit fetal exposure to ionizing radiation, but “fetal exposure to ionizing radiation from CT of the maternal head is extremely low, and the risk to the fetus is likely to be considerably less than the risk to both the fetus and mother from an acute neurological condition,” the investigators reported.

An internal carotid catheter angiogram shows a giant intracavernous aneurysm at the underside of the C4 segment.

A CT shows high density in the left transverse sinus and hemorrhagic venous infarction in the left temporal lobe. ©Elsevier, Clinical Radiology, Vol. 60, R. Dineen, “Imaging of acute neurological conditions in pregnancy and puerperium,” 1156 - 1170, 2005, Reprinted with permission from The Royal College of Radiologists

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

SAN FRANCISCO — Acute hepatitis E is rare in the United States, but an increasing number of travelers to India and China could make the disease more common here, Gregory L. Armstrong, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Most U.S. patients with hepatitis E have traveled to countries where the virus is endemic. Although hepatitis E shares many commonalities with hepatitis A, it has a number of unique characteristics—most notably severe disease during pregnancy, said Dr. Armstrong of the Centers for Disease Control and Prevention, Atlanta.

Clinically, acute hepatitis E is indistinguishable from acute hepatitis A, B, or C. Its clinical spectrum is highly variable, ranging from asymptomatic infection to fulminant hepatic failure. Hepatitis E disease is most severe when it is acquired in the third trimester of pregnancy, he said. The reasons for poor outcomes in pregnancy are unclear.

About half of pregnant women who acquire the virus during the third trimester remain asymptomatic. In the resource-poor settings where these cases usually occur, the other half of third-trimester infections result in acute hepatitis E, with fulminant hepatic failure in about a third and preterm delivery in about two-thirds of pregnant women with acute hepatitis E. Clinical outcome in infants also is variable, ranging from asymptomatic infection to hepatic necrosis.

Commercially available serologic assays to diagnose hepatitis E are not very sensitive or specific, and results must be interpreted based on the pretest probability of hepatitis E infection, he said. A better serologic assay developed by the National Institutes of Health is not commercially available. Viral RNA testing is even more accurate, but also is available only for research.

There is no specific antiviral therapy for hepatitis E; treatment is supportive care. There are no published data on the benefits of early delivery of the child in cases of acute hepatitis E during pregnancy.

Results of a phase II/III trial of a hepatitis E vaccine developed by the National Institutes of Health should be released soon. “Most people who work in this field feel that this vaccine is likely to be very effective,” Dr. Armstrong said.

There have been five domestically acquired cases of acute hepatitis E in addition to travel-related cases, he added. All five cases involved a viral genotype found in almost all U.S. pigs. Workers in the swine industry also have higher rates of hepatitis E antibodies.

SAN FRANCISCO — Acute hepatitis E is rare in the United States, but an increasing number of travelers to India and China could make the disease more common here, Gregory L. Armstrong, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Most U.S. patients with hepatitis E have traveled to countries where the virus is endemic. Although hepatitis E shares many commonalities with hepatitis A, it has a number of unique characteristics—most notably severe disease during pregnancy, said Dr. Armstrong of the Centers for Disease Control and Prevention, Atlanta.

Clinically, acute hepatitis E is indistinguishable from acute hepatitis A, B, or C. Its clinical spectrum is highly variable, ranging from asymptomatic infection to fulminant hepatic failure. Hepatitis E disease is most severe when it is acquired in the third trimester of pregnancy, he said. The reasons for poor outcomes in pregnancy are unclear.

About half of pregnant women who acquire the virus during the third trimester remain asymptomatic. In the resource-poor settings where these cases usually occur, the other half of third-trimester infections result in acute hepatitis E, with fulminant hepatic failure in about a third and preterm delivery in about two-thirds of pregnant women with acute hepatitis E. Clinical outcome in infants also is variable, ranging from asymptomatic infection to hepatic necrosis.

Commercially available serologic assays to diagnose hepatitis E are not very sensitive or specific, and results must be interpreted based on the pretest probability of hepatitis E infection, he said. A better serologic assay developed by the National Institutes of Health is not commercially available. Viral RNA testing is even more accurate, but also is available only for research.

There is no specific antiviral therapy for hepatitis E; treatment is supportive care. There are no published data on the benefits of early delivery of the child in cases of acute hepatitis E during pregnancy.

Results of a phase II/III trial of a hepatitis E vaccine developed by the National Institutes of Health should be released soon. “Most people who work in this field feel that this vaccine is likely to be very effective,” Dr. Armstrong said.

There have been five domestically acquired cases of acute hepatitis E in addition to travel-related cases, he added. All five cases involved a viral genotype found in almost all U.S. pigs. Workers in the swine industry also have higher rates of hepatitis E antibodies.

SAN FRANCISCO — Acute hepatitis E is rare in the United States, but an increasing number of travelers to India and China could make the disease more common here, Gregory L. Armstrong, M.D., said at the annual meeting of the Infectious Diseases Society of America.

Most U.S. patients with hepatitis E have traveled to countries where the virus is endemic. Although hepatitis E shares many commonalities with hepatitis A, it has a number of unique characteristics—most notably severe disease during pregnancy, said Dr. Armstrong of the Centers for Disease Control and Prevention, Atlanta.

Clinically, acute hepatitis E is indistinguishable from acute hepatitis A, B, or C. Its clinical spectrum is highly variable, ranging from asymptomatic infection to fulminant hepatic failure. Hepatitis E disease is most severe when it is acquired in the third trimester of pregnancy, he said. The reasons for poor outcomes in pregnancy are unclear.

About half of pregnant women who acquire the virus during the third trimester remain asymptomatic. In the resource-poor settings where these cases usually occur, the other half of third-trimester infections result in acute hepatitis E, with fulminant hepatic failure in about a third and preterm delivery in about two-thirds of pregnant women with acute hepatitis E. Clinical outcome in infants also is variable, ranging from asymptomatic infection to hepatic necrosis.

Commercially available serologic assays to diagnose hepatitis E are not very sensitive or specific, and results must be interpreted based on the pretest probability of hepatitis E infection, he said. A better serologic assay developed by the National Institutes of Health is not commercially available. Viral RNA testing is even more accurate, but also is available only for research.

There is no specific antiviral therapy for hepatitis E; treatment is supportive care. There are no published data on the benefits of early delivery of the child in cases of acute hepatitis E during pregnancy.

Results of a phase II/III trial of a hepatitis E vaccine developed by the National Institutes of Health should be released soon. “Most people who work in this field feel that this vaccine is likely to be very effective,” Dr. Armstrong said.

There have been five domestically acquired cases of acute hepatitis E in addition to travel-related cases, he added. All five cases involved a viral genotype found in almost all U.S. pigs. Workers in the swine industry also have higher rates of hepatitis E antibodies.

SAN FRANCISCO — The incidence of early-onset group B streptococcal disease fell significantly in term infants after 2002 recommendations called for culture-based screening of all pregnant women, Matthew Eberly, M.D., said.

A retrospective review of all 736,984 live births at U.S. Department of Defense hospitals from October 1992 to December 2004 found 828 term infants and 128 preterm infants who developed group B streptococcal (GBS) disease in the first 7 days of life, he said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Dr. Eberly and his associates at the San Antonio Military Pediatric Center divided these births into three periods: the years before the Centers for Disease Control and Prevention's 1997 recommendations to give antibiotics to women who had either clinical high-risk factors for GBS colonization or culture results showing colonization; 1997 through November 2002, before the CDC's 2002 recommendation to screen all women via vaginal-rectal culture at 35–37 weeks' gestation; and December 2002 to the present (the period since the recommendation for universal culture-based GBS screening and treatment).

The incidence of early-onset GBS disease in all infants fell from a rate of 2.18 per 1,000 live births before 1997, to 0.84 per 1,000 through November 2002, and to 0.70 per 1,000 in the third period. The differences were significant. “The new guidelines since 2002 are more effective in preventing early-onset GBS disease,” he said.

The universal culture-based screening strategy did not reduce early-onset GBS infections in preterm infants, since cultures are not obtained until about 36 weeks' gestation.

As the incidence of early-onset GBS in term infants fell from 2.08 per 1,000, to 0.76 per 1,000, to 0.50 per 1,000 over time, the proportion of preterm infants among those with early-onset GBS disease increased from 10% to 15% to 33% over the three periods studied, he noted.

Of the 78 cases of early-onset GBS disease since the 2002 guidelines were issued, 26 occurred in preterm infants. Twelve weighed less than 1,000 g at birth, and 14 were delivered before 30 weeks' gestation. “These are the extremely low-birth-weight infants” who are most likely to develop early-onset GBS disease under the current strategy, Dr. Eberly said.

SAN FRANCISCO — The incidence of early-onset group B streptococcal disease fell significantly in term infants after 2002 recommendations called for culture-based screening of all pregnant women, Matthew Eberly, M.D., said.

A retrospective review of all 736,984 live births at U.S. Department of Defense hospitals from October 1992 to December 2004 found 828 term infants and 128 preterm infants who developed group B streptococcal (GBS) disease in the first 7 days of life, he said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Dr. Eberly and his associates at the San Antonio Military Pediatric Center divided these births into three periods: the years before the Centers for Disease Control and Prevention's 1997 recommendations to give antibiotics to women who had either clinical high-risk factors for GBS colonization or culture results showing colonization; 1997 through November 2002, before the CDC's 2002 recommendation to screen all women via vaginal-rectal culture at 35–37 weeks' gestation; and December 2002 to the present (the period since the recommendation for universal culture-based GBS screening and treatment).

The incidence of early-onset GBS disease in all infants fell from a rate of 2.18 per 1,000 live births before 1997, to 0.84 per 1,000 through November 2002, and to 0.70 per 1,000 in the third period. The differences were significant. “The new guidelines since 2002 are more effective in preventing early-onset GBS disease,” he said.

The universal culture-based screening strategy did not reduce early-onset GBS infections in preterm infants, since cultures are not obtained until about 36 weeks' gestation.

As the incidence of early-onset GBS in term infants fell from 2.08 per 1,000, to 0.76 per 1,000, to 0.50 per 1,000 over time, the proportion of preterm infants among those with early-onset GBS disease increased from 10% to 15% to 33% over the three periods studied, he noted.

Of the 78 cases of early-onset GBS disease since the 2002 guidelines were issued, 26 occurred in preterm infants. Twelve weighed less than 1,000 g at birth, and 14 were delivered before 30 weeks' gestation. “These are the extremely low-birth-weight infants” who are most likely to develop early-onset GBS disease under the current strategy, Dr. Eberly said.

SAN FRANCISCO — The incidence of early-onset group B streptococcal disease fell significantly in term infants after 2002 recommendations called for culture-based screening of all pregnant women, Matthew Eberly, M.D., said.

A retrospective review of all 736,984 live births at U.S. Department of Defense hospitals from October 1992 to December 2004 found 828 term infants and 128 preterm infants who developed group B streptococcal (GBS) disease in the first 7 days of life, he said in a poster presentation at the annual meeting of the Infectious Diseases Society of America.

Dr. Eberly and his associates at the San Antonio Military Pediatric Center divided these births into three periods: the years before the Centers for Disease Control and Prevention's 1997 recommendations to give antibiotics to women who had either clinical high-risk factors for GBS colonization or culture results showing colonization; 1997 through November 2002, before the CDC's 2002 recommendation to screen all women via vaginal-rectal culture at 35–37 weeks' gestation; and December 2002 to the present (the period since the recommendation for universal culture-based GBS screening and treatment).

The incidence of early-onset GBS disease in all infants fell from a rate of 2.18 per 1,000 live births before 1997, to 0.84 per 1,000 through November 2002, and to 0.70 per 1,000 in the third period. The differences were significant. “The new guidelines since 2002 are more effective in preventing early-onset GBS disease,” he said.

The universal culture-based screening strategy did not reduce early-onset GBS infections in preterm infants, since cultures are not obtained until about 36 weeks' gestation.

As the incidence of early-onset GBS in term infants fell from 2.08 per 1,000, to 0.76 per 1,000, to 0.50 per 1,000 over time, the proportion of preterm infants among those with early-onset GBS disease increased from 10% to 15% to 33% over the three periods studied, he noted.

Of the 78 cases of early-onset GBS disease since the 2002 guidelines were issued, 26 occurred in preterm infants. Twelve weighed less than 1,000 g at birth, and 14 were delivered before 30 weeks' gestation. “These are the extremely low-birth-weight infants” who are most likely to develop early-onset GBS disease under the current strategy, Dr. Eberly said.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy vs. those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy vs. those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

SAN FRANCISCO — Pregnant women given a single dose of nevirapine during pregnancy to prevent vertical transmission of HIV were more likely to fail their own HIV treatment if it was started within 6 months of taking the nevirapine, Shahin Lockman, M.D., reported.

The randomized study of 218 women and 30 infants in Botswana found that, for the cohorts as a whole, the peripartum nevirapine dose led to higher rates of virologic failure in women and their infants, compared with women who received a peripartum dose of placebo and their infants, she said at the annual meeting of the Infectious Diseases Society of America.

Most resource-poor nations include nevirapine in their first-line treatment regimens for women and infants. More than 500,000 women each year are believed to receive single-dose nevirapine during pregnancy. This is a simple and affordable measure that halves the risk of vertical transmission, but previous data suggest that it can cause resistance to subsequent nevirapine therapy in 25%–70% of women and 40%–90% of infants, said Dr. Lockman of Brigham and Women's Hospital, Boston.

The current data came from the Mashi study of 12,000 HIV-infected women and 491 infants randomized to receive a single peripartum dose of nevirapine or placebo plus a short course of zidovudine starting at 34 weeks' gestation. Infants received 1 month of zidovudine if formula-fed or 6 months of zidovudine if breast-fed.

Women who developed an AIDS-defining illness or whose CD4 counts fell below 200 cells/mm

Of the 218 women who started antiretroviral therapy and had adequate follow-up, 18% of 112 who previously received single-dose nevirapine and 5% of 106 who previously received single-dose placebo developed virologic failure by 6 months after starting the combination antiretroviral regimen.

At 12 months, 20% of the nevirapine group and 10% of the placebo group had developed virologic failure, defined as an HIV RNA load greater than 400 copies/mL. At 24 months, 28% of the nevirapine group and 11% of the placebo group had failed combination therapy. All differences were statistically significant.

Further analysis showed that the failures occurred in women who started their antiretroviral therapy within 6 months of receiving the single dose of nevirapine but not in women whose therapy began at least 6 months after the single nevirapine dose.

Of the 60 women who started combination antiretroviral therapy within 6 months of the peripartum dose, 42% of the 24 women in the nevirapine group and none of the 36 women in the placebo group developed virologic failure by 6 months. Virologic failure was seen at 12 and 24 months in 46% of the nevirapine group and 3% of the placebo group. All differences were highly significant.

Virologic failure rates did not differ significantly between the nevirapine and placebo groups in the 158 women who started combination therapy at least 6 months after the peripartum dose.

A total of 30 HIV-infected infants were given the same combination antiretroviral therapy. Of 15 infants whose mothers got single-dose nevirapine during pregnancy, 10 developed virologic failure during 2 years of follow-up, compared with 2 of 15 infants in the placebo group. Two infants in the nevirapine group and three in the placebo group died.

Infants in the nevirapine group showed a smaller increase in CD4 counts on combination therapy vs. those in the placebo group. For mothers, the CD4 counts did not differ significantly between groups.

Only nevirapine exposure predicted the risk of virologic failure in women and infants. Other factors such as maternal age, clinic location, or infant feeding strategy (breast vs. formula) were not predictors.

Pregnant women perform fewer intense physical activities, with less duration and frequency than nonpregnant women, and only 16% of pregnant women and 27% of nonpregnant women meet physical activity recommendations, said Ann M. Petersen, Ph.D., and her colleagues at Saint Louis University.

“This study has vital public health implications that can assist physicians to identify patients who are at high risk for inactivity during pregnancy,” the investigators said (Med. Sci. Sports Exerc. 2005;37:1748–53).

“Obstetricians and gynecologists should focus on encouraging continued physical activity during pregnancy among those already active, and should specifically target physical activity promotion among those women performing irregular or no activity,” Dr. Petersen said.

“The message is not getting out that women should continue to exercise during pregnancy, at least at moderate intensity,” study coauthor Terry Leet, Ph.D., noted in a separate written statement. “Only one of every six pregnant women is meeting the current physical activity recommendations of 30 or more minutes of moderate physical activity on most, if not all, days of the week,” Dr. Leet said.

The population-based, cross-sectional study used data from the 1994, 1996, 1998, and 2000 Behavioural Risk Factor Surveillance System (BRFSS) on more than 150,000 women.

A total of 6,528 pregnant and 143,731 nonpregnant women between the ages of 18 and 44 were categorized into groups based on vigorous or moderate levels of exercise, according to guidelines established by the Centers for Disease Control and the American College of Sports Medicine (ACSM). These consisted of 20 minutes or more of exercise, three or more times per week at an intensity of 6 or more metabolic equivalents or METs, and 30 minutes or more, five or more times per week, at an intensity of 3–5.9 METs, respectively; vigorous or moderate activity not meeting the guidelines (150 minutes or more per week, regardless of frequency, at an intensity of 3 METs or more); irregular physical activity; or no physical activity.

The study found that overall, nonpregnant women were more likely to meet the vigorous and moderate exercise recommendations, compared with pregnant women, and more pregnant women were inactive or performing irregular activity.

Walking was the most common activity reported equally by pregnant (52%) and nonpregnant (45%) women. However, there were notable differences between pregnant and nonpregnant women reporting aerobics (8% vs. 14%), and running and/or jogging (2% vs. 7%). Similar percentages reported gardening (3% and 5%) and swimming (4% and 3%).

The findings confirm the need for a multidisciplinary intervention from school educators, medical school instructors, and faculty aimed at promoting exercise in pregnancy, according to Raul Artal, M.D., professor and chair of the department of obstetrics, gynecology, and women's health at the university.

“It has to start at all levels—early school years, medical schools, physician education. A total effort is needed, and it needs to start in childhood,” Dr. Artal said in an interview. “We don't look at physical education as a health benefit but, instead, always seem to emphasize the competitive aspect. If the competitive aspect could be deemphasized, and we could agree that physical education is part of health maintenance and prevention of disease, then the whole attitude toward exercise would change.”

Dr. Artal was lead author of the American College of Obstetricians and Gynecologists 2002 guidelines on exercise during pregnancy.

According to the authors of the study, evidence-based guidelines should be reassuring to health care providers regarding the safety of exercise in pregnancy. The guidelines, published jointly by the Society of Obstetricians and Gynaecologists of Canada, and the Canadian Society for Exercise Physiology in 2003 (and endorsed in 2004 by the ACSM), show that exercise is not associated with any increase in early pregnancy loss, late pregnancy complications, abnormal fetal growth, or adverse neonatal outcomes. The Physical Activity Readiness Medical Examination for Pregnancy in the guidelines describes the medical clearance for prenatal exercise participation.

“These safety procedures will further educate health care providers about the appropriate promotion of exercise during pregnancy,” the authors said.

Researchers say evidence-based guidelines should reassure medical providers of the safety of exercise in pregnancy. Stanford W. Carpenter

Pregnant women perform fewer intense physical activities, with less duration and frequency than nonpregnant women, and only 16% of pregnant women and 27% of nonpregnant women meet physical activity recommendations, said Ann M. Petersen, Ph.D., and her colleagues at Saint Louis University.

“This study has vital public health implications that can assist physicians to identify patients who are at high risk for inactivity during pregnancy,” the investigators said (Med. Sci. Sports Exerc. 2005;37:1748–53).

“Obstetricians and gynecologists should focus on encouraging continued physical activity during pregnancy among those already active, and should specifically target physical activity promotion among those women performing irregular or no activity,” Dr. Petersen said.

“The message is not getting out that women should continue to exercise during pregnancy, at least at moderate intensity,” study coauthor Terry Leet, Ph.D., noted in a separate written statement. “Only one of every six pregnant women is meeting the current physical activity recommendations of 30 or more minutes of moderate physical activity on most, if not all, days of the week,” Dr. Leet said.

The population-based, cross-sectional study used data from the 1994, 1996, 1998, and 2000 Behavioural Risk Factor Surveillance System (BRFSS) on more than 150,000 women.

A total of 6,528 pregnant and 143,731 nonpregnant women between the ages of 18 and 44 were categorized into groups based on vigorous or moderate levels of exercise, according to guidelines established by the Centers for Disease Control and the American College of Sports Medicine (ACSM). These consisted of 20 minutes or more of exercise, three or more times per week at an intensity of 6 or more metabolic equivalents or METs, and 30 minutes or more, five or more times per week, at an intensity of 3–5.9 METs, respectively; vigorous or moderate activity not meeting the guidelines (150 minutes or more per week, regardless of frequency, at an intensity of 3 METs or more); irregular physical activity; or no physical activity.

The study found that overall, nonpregnant women were more likely to meet the vigorous and moderate exercise recommendations, compared with pregnant women, and more pregnant women were inactive or performing irregular activity.

Walking was the most common activity reported equally by pregnant (52%) and nonpregnant (45%) women. However, there were notable differences between pregnant and nonpregnant women reporting aerobics (8% vs. 14%), and running and/or jogging (2% vs. 7%). Similar percentages reported gardening (3% and 5%) and swimming (4% and 3%).

The findings confirm the need for a multidisciplinary intervention from school educators, medical school instructors, and faculty aimed at promoting exercise in pregnancy, according to Raul Artal, M.D., professor and chair of the department of obstetrics, gynecology, and women's health at the university.

“It has to start at all levels—early school years, medical schools, physician education. A total effort is needed, and it needs to start in childhood,” Dr. Artal said in an interview. “We don't look at physical education as a health benefit but, instead, always seem to emphasize the competitive aspect. If the competitive aspect could be deemphasized, and we could agree that physical education is part of health maintenance and prevention of disease, then the whole attitude toward exercise would change.”

Dr. Artal was lead author of the American College of Obstetricians and Gynecologists 2002 guidelines on exercise during pregnancy.

According to the authors of the study, evidence-based guidelines should be reassuring to health care providers regarding the safety of exercise in pregnancy. The guidelines, published jointly by the Society of Obstetricians and Gynaecologists of Canada, and the Canadian Society for Exercise Physiology in 2003 (and endorsed in 2004 by the ACSM), show that exercise is not associated with any increase in early pregnancy loss, late pregnancy complications, abnormal fetal growth, or adverse neonatal outcomes. The Physical Activity Readiness Medical Examination for Pregnancy in the guidelines describes the medical clearance for prenatal exercise participation.

“These safety procedures will further educate health care providers about the appropriate promotion of exercise during pregnancy,” the authors said.

Researchers say evidence-based guidelines should reassure medical providers of the safety of exercise in pregnancy. Stanford W. Carpenter

Pregnant women perform fewer intense physical activities, with less duration and frequency than nonpregnant women, and only 16% of pregnant women and 27% of nonpregnant women meet physical activity recommendations, said Ann M. Petersen, Ph.D., and her colleagues at Saint Louis University.

“This study has vital public health implications that can assist physicians to identify patients who are at high risk for inactivity during pregnancy,” the investigators said (Med. Sci. Sports Exerc. 2005;37:1748–53).

“Obstetricians and gynecologists should focus on encouraging continued physical activity during pregnancy among those already active, and should specifically target physical activity promotion among those women performing irregular or no activity,” Dr. Petersen said.

“The message is not getting out that women should continue to exercise during pregnancy, at least at moderate intensity,” study coauthor Terry Leet, Ph.D., noted in a separate written statement. “Only one of every six pregnant women is meeting the current physical activity recommendations of 30 or more minutes of moderate physical activity on most, if not all, days of the week,” Dr. Leet said.

The population-based, cross-sectional study used data from the 1994, 1996, 1998, and 2000 Behavioural Risk Factor Surveillance System (BRFSS) on more than 150,000 women.

A total of 6,528 pregnant and 143,731 nonpregnant women between the ages of 18 and 44 were categorized into groups based on vigorous or moderate levels of exercise, according to guidelines established by the Centers for Disease Control and the American College of Sports Medicine (ACSM). These consisted of 20 minutes or more of exercise, three or more times per week at an intensity of 6 or more metabolic equivalents or METs, and 30 minutes or more, five or more times per week, at an intensity of 3–5.9 METs, respectively; vigorous or moderate activity not meeting the guidelines (150 minutes or more per week, regardless of frequency, at an intensity of 3 METs or more); irregular physical activity; or no physical activity.

The study found that overall, nonpregnant women were more likely to meet the vigorous and moderate exercise recommendations, compared with pregnant women, and more pregnant women were inactive or performing irregular activity.

Walking was the most common activity reported equally by pregnant (52%) and nonpregnant (45%) women. However, there were notable differences between pregnant and nonpregnant women reporting aerobics (8% vs. 14%), and running and/or jogging (2% vs. 7%). Similar percentages reported gardening (3% and 5%) and swimming (4% and 3%).

The findings confirm the need for a multidisciplinary intervention from school educators, medical school instructors, and faculty aimed at promoting exercise in pregnancy, according to Raul Artal, M.D., professor and chair of the department of obstetrics, gynecology, and women's health at the university.

“It has to start at all levels—early school years, medical schools, physician education. A total effort is needed, and it needs to start in childhood,” Dr. Artal said in an interview. “We don't look at physical education as a health benefit but, instead, always seem to emphasize the competitive aspect. If the competitive aspect could be deemphasized, and we could agree that physical education is part of health maintenance and prevention of disease, then the whole attitude toward exercise would change.”

Dr. Artal was lead author of the American College of Obstetricians and Gynecologists 2002 guidelines on exercise during pregnancy.

According to the authors of the study, evidence-based guidelines should be reassuring to health care providers regarding the safety of exercise in pregnancy. The guidelines, published jointly by the Society of Obstetricians and Gynaecologists of Canada, and the Canadian Society for Exercise Physiology in 2003 (and endorsed in 2004 by the ACSM), show that exercise is not associated with any increase in early pregnancy loss, late pregnancy complications, abnormal fetal growth, or adverse neonatal outcomes. The Physical Activity Readiness Medical Examination for Pregnancy in the guidelines describes the medical clearance for prenatal exercise participation.

“These safety procedures will further educate health care providers about the appropriate promotion of exercise during pregnancy,” the authors said.

Researchers say evidence-based guidelines should reassure medical providers of the safety of exercise in pregnancy. Stanford W. Carpenter