Obstetrics

A woman's risk of premenopausal breast cancer appears to be related to the weight of the placentas from her pregnancies, Sven Cnattingius, M.D., Ph.D., of the Karolinska Institutet, Stockholm, and his associates reported.

The heavier the placental weight, the higher the risk that breast cancer will develop before the woman reaches 50 years of age, the researchers said.

Placental weight can serve as an indirect marker of hormonal exposure during pregnancy, since the placenta is the major source of most pregnancy hormones. “Our findings support the hypothesis that exposure to pregnancy hormones during the limited time-window represented by a pregnancy appears to influence mothers' subsequent risk of breast cancer,” Dr. Cnattingius and his associates said (JAMA 2005;294:2474–80).

The findings appear to show that higher levels of pregnancy hormones substantially raise the risk of breast cancer. Alternatively, it is possible that higher placental weights are associated with lower maternal levels of antiestrogenic hormones such as testosterone and α-fetoprotein, which may play an inhibitory role in the development of breast cancer. Or it may turn out that higher placental weights are related to higher levels of other substances, such as insulinlike growth factor, that may promote carcinogenesis in the breast.

It is also possible that some other, as yet unidentified, factor acts simultaneously to increase placental weight and raise the mother's risk of breast cancer, they said.

They studied prospectively collected data on the singleton births of 314,019 Swedish women who delivered between 1982 and 1989. More than 121,000 of these women also had a second singleton birth during that study period. The women were followed until 2002. A total of 2,216 of these women (0.7%) developed breast cancer during follow-up, and 95% of them were diagnosed before they reached age 50.

The incidence of breast cancer consistently increased with rising placental weight, from 3.99 per 10,000 person-years when placental weight was 499 g or less to 5.30 when placental weight was 700 g or more. In the subset of women who had multiple deliveries, those with higher placental weights in two pregnancies had double the breast cancer risk of women who had lower placental weights in two pregnancies.

In contrast, breast cancer incidence was not related to birth weight or length of gestation, after the data were adjusted for placental weight. This finding indicates that placental weight is “a better indicator of the hormonal milieu than birth weight” or other birth parameters, Dr. Cnattingius and his associates said.

They added that in their study, breast cancer risk was not found to be related to other potentially relevant risk factors such as the infant's gender, pregnancy complications, and maternal demographic traits.

The link between placental weight and breast cancer risk was more pronounced among women who were 30 years of age or older when they had their first child. This finding supports the suggestion that elevated pregnancy hormones may promote the growth of either premalignant cells or preexisting malignant cells in the breast, because women of older childbearing age would be more likely to harbor cells whose malignant transformation has already begun, the investigators said.

They noted that placental weight is “an imprecise measure of the endocrine capacity of placental tissue.” Placental weight includes both vital tissue and degenerative tissue, since the placenta stops growing before the fetus does. “Moreover, the amount of blood in the placenta influences placental weight, and routines to clear the placenta from blood after childbirth may differ between hospitals.”

Despite this limitation, the study “was able to demonstrate a substantially increased risk in maternal breast cancer associated with higher placental weight,” they said.

A woman's risk of premenopausal breast cancer appears to be related to the weight of the placentas from her pregnancies, Sven Cnattingius, M.D., Ph.D., of the Karolinska Institutet, Stockholm, and his associates reported.

The heavier the placental weight, the higher the risk that breast cancer will develop before the woman reaches 50 years of age, the researchers said.

Placental weight can serve as an indirect marker of hormonal exposure during pregnancy, since the placenta is the major source of most pregnancy hormones. “Our findings support the hypothesis that exposure to pregnancy hormones during the limited time-window represented by a pregnancy appears to influence mothers' subsequent risk of breast cancer,” Dr. Cnattingius and his associates said (JAMA 2005;294:2474–80).

The findings appear to show that higher levels of pregnancy hormones substantially raise the risk of breast cancer. Alternatively, it is possible that higher placental weights are associated with lower maternal levels of antiestrogenic hormones such as testosterone and α-fetoprotein, which may play an inhibitory role in the development of breast cancer. Or it may turn out that higher placental weights are related to higher levels of other substances, such as insulinlike growth factor, that may promote carcinogenesis in the breast.

It is also possible that some other, as yet unidentified, factor acts simultaneously to increase placental weight and raise the mother's risk of breast cancer, they said.

They studied prospectively collected data on the singleton births of 314,019 Swedish women who delivered between 1982 and 1989. More than 121,000 of these women also had a second singleton birth during that study period. The women were followed until 2002. A total of 2,216 of these women (0.7%) developed breast cancer during follow-up, and 95% of them were diagnosed before they reached age 50.

The incidence of breast cancer consistently increased with rising placental weight, from 3.99 per 10,000 person-years when placental weight was 499 g or less to 5.30 when placental weight was 700 g or more. In the subset of women who had multiple deliveries, those with higher placental weights in two pregnancies had double the breast cancer risk of women who had lower placental weights in two pregnancies.

In contrast, breast cancer incidence was not related to birth weight or length of gestation, after the data were adjusted for placental weight. This finding indicates that placental weight is “a better indicator of the hormonal milieu than birth weight” or other birth parameters, Dr. Cnattingius and his associates said.

They added that in their study, breast cancer risk was not found to be related to other potentially relevant risk factors such as the infant's gender, pregnancy complications, and maternal demographic traits.

The link between placental weight and breast cancer risk was more pronounced among women who were 30 years of age or older when they had their first child. This finding supports the suggestion that elevated pregnancy hormones may promote the growth of either premalignant cells or preexisting malignant cells in the breast, because women of older childbearing age would be more likely to harbor cells whose malignant transformation has already begun, the investigators said.

They noted that placental weight is “an imprecise measure of the endocrine capacity of placental tissue.” Placental weight includes both vital tissue and degenerative tissue, since the placenta stops growing before the fetus does. “Moreover, the amount of blood in the placenta influences placental weight, and routines to clear the placenta from blood after childbirth may differ between hospitals.”

Despite this limitation, the study “was able to demonstrate a substantially increased risk in maternal breast cancer associated with higher placental weight,” they said.

A woman's risk of premenopausal breast cancer appears to be related to the weight of the placentas from her pregnancies, Sven Cnattingius, M.D., Ph.D., of the Karolinska Institutet, Stockholm, and his associates reported.

The heavier the placental weight, the higher the risk that breast cancer will develop before the woman reaches 50 years of age, the researchers said.

Placental weight can serve as an indirect marker of hormonal exposure during pregnancy, since the placenta is the major source of most pregnancy hormones. “Our findings support the hypothesis that exposure to pregnancy hormones during the limited time-window represented by a pregnancy appears to influence mothers' subsequent risk of breast cancer,” Dr. Cnattingius and his associates said (JAMA 2005;294:2474–80).

The findings appear to show that higher levels of pregnancy hormones substantially raise the risk of breast cancer. Alternatively, it is possible that higher placental weights are associated with lower maternal levels of antiestrogenic hormones such as testosterone and α-fetoprotein, which may play an inhibitory role in the development of breast cancer. Or it may turn out that higher placental weights are related to higher levels of other substances, such as insulinlike growth factor, that may promote carcinogenesis in the breast.

It is also possible that some other, as yet unidentified, factor acts simultaneously to increase placental weight and raise the mother's risk of breast cancer, they said.

They studied prospectively collected data on the singleton births of 314,019 Swedish women who delivered between 1982 and 1989. More than 121,000 of these women also had a second singleton birth during that study period. The women were followed until 2002. A total of 2,216 of these women (0.7%) developed breast cancer during follow-up, and 95% of them were diagnosed before they reached age 50.

The incidence of breast cancer consistently increased with rising placental weight, from 3.99 per 10,000 person-years when placental weight was 499 g or less to 5.30 when placental weight was 700 g or more. In the subset of women who had multiple deliveries, those with higher placental weights in two pregnancies had double the breast cancer risk of women who had lower placental weights in two pregnancies.

In contrast, breast cancer incidence was not related to birth weight or length of gestation, after the data were adjusted for placental weight. This finding indicates that placental weight is “a better indicator of the hormonal milieu than birth weight” or other birth parameters, Dr. Cnattingius and his associates said.

They added that in their study, breast cancer risk was not found to be related to other potentially relevant risk factors such as the infant's gender, pregnancy complications, and maternal demographic traits.

The link between placental weight and breast cancer risk was more pronounced among women who were 30 years of age or older when they had their first child. This finding supports the suggestion that elevated pregnancy hormones may promote the growth of either premalignant cells or preexisting malignant cells in the breast, because women of older childbearing age would be more likely to harbor cells whose malignant transformation has already begun, the investigators said.

They noted that placental weight is “an imprecise measure of the endocrine capacity of placental tissue.” Placental weight includes both vital tissue and degenerative tissue, since the placenta stops growing before the fetus does. “Moreover, the amount of blood in the placenta influences placental weight, and routines to clear the placenta from blood after childbirth may differ between hospitals.”

Despite this limitation, the study “was able to demonstrate a substantially increased risk in maternal breast cancer associated with higher placental weight,” they said.

Women who have placental syndromes are at high risk for premature cardiovascular disease, particularly if there is associated fetal compromise, according to Joel G. Ray, M.D., of the University of Toronto, and his associates.

The level of cardiovascular risk conferred by a placental syndrome—preeclampsia, gestational hypertension, placental abruption, or placental infarction—is comparable with that of such conventional risk factors as hypertension, obesity, diabetes, and dyslipidemia. “We believe that maternal placental syndrome should be considered an additional risk factor for cardiovascular disease in women, especially when the woman's fetus is adversely affected,” Dr. Ray, of the division of obstetrics and gynecology at the university, and his associates said (Lancet 2005;366:1797–803).

They assessed outcomes in a population-based study of Ontario residents who gave birth between 1990 and 2004. The mean maternal age at delivery was 28 years. Of 1,026,265 subjects, 75,380 (7%) were diagnosed as having a placental syndrome.

After a mean of 8.7 years' follow-up, cardiovascular events occurred in more than twice as many women with placental syndromes as in women without placental syndromes, irrespective of the presence of potential confounders such as diabetes. The rate of events was 500/million person-years among those with placental syndromes, compared with 200/million in those without placental syndromes.

The women's mean age was 38 years at the time of the first cardiovascular event. These included coronary, cerebrovascular, or peripheral artery events, or the need for a revascularization procedure.

The risk for cardiovascular events was even higher if the placental syndromes led to fetal growth restriction or intrauterine fetal death. It was higher still in women who had preexisting cardiovascular risk factors when they became pregnant, such as smoking or various features of the metabolic syndrome.

The findings do not imply placental disorders cause cardiovascular events to occur in the near future, the investigators said. “Rather, a more plausible explanation relates to a woman's abnormal metabolic milieu that predates her pregnancy and continues after delivery. This chronic state of dysmetabolism might create an inhospitable environment during the development of the placental spiral arteries, which can adversely affect fetal health, while negatively affecting the large arteries of a woman's heart, brain, and extremities over a broader period of time,” they noted.

Physicians “should try to ensure that women are a healthy weight before they enter their reproductive years.” This should reduce their risk for placental syndromes and fetal compromise as well as for cardiovascular disease, the researchers said.

It remains unknown whether women who have had placental syndromes might lower their risk of premature cardiovascular disease by making lifestyle changes, they added.

Women who have placental syndromes are at high risk for premature cardiovascular disease, particularly if there is associated fetal compromise, according to Joel G. Ray, M.D., of the University of Toronto, and his associates.

The level of cardiovascular risk conferred by a placental syndrome—preeclampsia, gestational hypertension, placental abruption, or placental infarction—is comparable with that of such conventional risk factors as hypertension, obesity, diabetes, and dyslipidemia. “We believe that maternal placental syndrome should be considered an additional risk factor for cardiovascular disease in women, especially when the woman's fetus is adversely affected,” Dr. Ray, of the division of obstetrics and gynecology at the university, and his associates said (Lancet 2005;366:1797–803).

They assessed outcomes in a population-based study of Ontario residents who gave birth between 1990 and 2004. The mean maternal age at delivery was 28 years. Of 1,026,265 subjects, 75,380 (7%) were diagnosed as having a placental syndrome.

After a mean of 8.7 years' follow-up, cardiovascular events occurred in more than twice as many women with placental syndromes as in women without placental syndromes, irrespective of the presence of potential confounders such as diabetes. The rate of events was 500/million person-years among those with placental syndromes, compared with 200/million in those without placental syndromes.

The women's mean age was 38 years at the time of the first cardiovascular event. These included coronary, cerebrovascular, or peripheral artery events, or the need for a revascularization procedure.

The risk for cardiovascular events was even higher if the placental syndromes led to fetal growth restriction or intrauterine fetal death. It was higher still in women who had preexisting cardiovascular risk factors when they became pregnant, such as smoking or various features of the metabolic syndrome.

The findings do not imply placental disorders cause cardiovascular events to occur in the near future, the investigators said. “Rather, a more plausible explanation relates to a woman's abnormal metabolic milieu that predates her pregnancy and continues after delivery. This chronic state of dysmetabolism might create an inhospitable environment during the development of the placental spiral arteries, which can adversely affect fetal health, while negatively affecting the large arteries of a woman's heart, brain, and extremities over a broader period of time,” they noted.

Physicians “should try to ensure that women are a healthy weight before they enter their reproductive years.” This should reduce their risk for placental syndromes and fetal compromise as well as for cardiovascular disease, the researchers said.

It remains unknown whether women who have had placental syndromes might lower their risk of premature cardiovascular disease by making lifestyle changes, they added.

Women who have placental syndromes are at high risk for premature cardiovascular disease, particularly if there is associated fetal compromise, according to Joel G. Ray, M.D., of the University of Toronto, and his associates.

The level of cardiovascular risk conferred by a placental syndrome—preeclampsia, gestational hypertension, placental abruption, or placental infarction—is comparable with that of such conventional risk factors as hypertension, obesity, diabetes, and dyslipidemia. “We believe that maternal placental syndrome should be considered an additional risk factor for cardiovascular disease in women, especially when the woman's fetus is adversely affected,” Dr. Ray, of the division of obstetrics and gynecology at the university, and his associates said (Lancet 2005;366:1797–803).

They assessed outcomes in a population-based study of Ontario residents who gave birth between 1990 and 2004. The mean maternal age at delivery was 28 years. Of 1,026,265 subjects, 75,380 (7%) were diagnosed as having a placental syndrome.

After a mean of 8.7 years' follow-up, cardiovascular events occurred in more than twice as many women with placental syndromes as in women without placental syndromes, irrespective of the presence of potential confounders such as diabetes. The rate of events was 500/million person-years among those with placental syndromes, compared with 200/million in those without placental syndromes.

The women's mean age was 38 years at the time of the first cardiovascular event. These included coronary, cerebrovascular, or peripheral artery events, or the need for a revascularization procedure.

The risk for cardiovascular events was even higher if the placental syndromes led to fetal growth restriction or intrauterine fetal death. It was higher still in women who had preexisting cardiovascular risk factors when they became pregnant, such as smoking or various features of the metabolic syndrome.

The findings do not imply placental disorders cause cardiovascular events to occur in the near future, the investigators said. “Rather, a more plausible explanation relates to a woman's abnormal metabolic milieu that predates her pregnancy and continues after delivery. This chronic state of dysmetabolism might create an inhospitable environment during the development of the placental spiral arteries, which can adversely affect fetal health, while negatively affecting the large arteries of a woman's heart, brain, and extremities over a broader period of time,” they noted.

Physicians “should try to ensure that women are a healthy weight before they enter their reproductive years.” This should reduce their risk for placental syndromes and fetal compromise as well as for cardiovascular disease, the researchers said.

It remains unknown whether women who have had placental syndromes might lower their risk of premature cardiovascular disease by making lifestyle changes, they added.

SCOTTSDALE, ARIZ. — Noninvasive genetic screening has a higher detection rate when done in the first trimester of pregnancy and should be offered with prompt disclosure of results, Joe Leigh Simpson, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

An offer of amniocentesis or chorionic villus sampling (CVS) to every pregnant woman regardless of age also should be considered, according to Dr. Simpson, chairman of obstetrics and gynecology at Baylor College of Medicine, Houston.

“I believe a good case could be made for universal invasive screening,” he said. “I believe amniocentesis and CVS are much safer than generally touted. The 1-in-200 [loss rate] figure we have told our patients is doing them a disservice, because it is not a valid figure in 2005.”

He predicted karyotyping will become obsolete as a diagnostic tool within the next 5–10 years. Chromosomal microarrays currently in development are more accurate than karyotypes, and should soon be able to detect many common Mendelian disorders, Dr. Simpson said after describing ongoing research at Baylor, where he also is a professor in the department of molecular and human genetics.

“I don't think there is any question the public will demand this approach and not karyotypes,” he said. “Karyotypes have a limited future in terms of the diagnostic field.”

The American College of Obstetricians and Gynecologists is reviewing the current guideline for invasive and noninvasive screening, adopted in 1996, according to Dr. Simpson. He predicted a revision with a “cafeteria of options” will be announced early next year.

Among the noninvasive options he listed are sequential first and second trimester screening with various serum analytes, nuchal translucency ultrasound, and nasal bone inspection.

“Noninvasive first-trimester screening shows clear improvement, 5%–10%, over second-trimester screening, and is more applicable to multiple gestations,” he said, citing recent results from a new analysis of data from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial. “Successful incorporation with nasal bone [screening] could yield over 90% detection.”

Dr. Simpson said nuchal translucency ultrasound in the first trimester is especially useful in women with multiple gestations, as it allows assessment of individual fetuses. With serum testing alone, he said, detection rates in this population can dip as low as 25% with second-trimester screening.

First-trimester screening for absence of nasal bone was not successful in a 2003 report from the FASTER trial, but other studies have reported Down syndrome detection rates as high as 73%, according to Dr. Simpson. He advocated using nasal bone inspection with other noninvasive tests rather than as the sole measure.

In two recent studies from the United Kingdom, he said 30,564 women and 15,822 women, respectively, were screened by four measures: pregnancy-associated plasma protein A (PAPP-A), human chorionic gonadotropin (hCG), nuchal translucency, and nasal bone inspection. The detection rates were 93% and 97%, respectively.

“Early is better for issues of privacy and access to management, but it is also [better] for sensitivity,” Dr. Simpson said.

Addressing the controversy over disclosure of first-trimester results before a woman returns for second-trimester screening, he warned of the potential for litigation if the patient fails to return or is somehow lost to follow-up without learning she is at high risk.

“What if you have someone who would have had a procedure if you told her the results in the first trimester, and she just did not get around to coming back to you, or there is a hurricane or whatever?” he said, adding that second-trimester detection rates have been shown not to decline as feared when high-risk women were advised of first-trimester results.

As for invasive procedures, Dr. Simpson said the fetal loss rates are “probably no more than 1 in 500.” He cited several large studies showing fetal loss rates as low as 1 in 667 amniocentesis procedures.

SCOTTSDALE, ARIZ. — Noninvasive genetic screening has a higher detection rate when done in the first trimester of pregnancy and should be offered with prompt disclosure of results, Joe Leigh Simpson, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

An offer of amniocentesis or chorionic villus sampling (CVS) to every pregnant woman regardless of age also should be considered, according to Dr. Simpson, chairman of obstetrics and gynecology at Baylor College of Medicine, Houston.

“I believe a good case could be made for universal invasive screening,” he said. “I believe amniocentesis and CVS are much safer than generally touted. The 1-in-200 [loss rate] figure we have told our patients is doing them a disservice, because it is not a valid figure in 2005.”

He predicted karyotyping will become obsolete as a diagnostic tool within the next 5–10 years. Chromosomal microarrays currently in development are more accurate than karyotypes, and should soon be able to detect many common Mendelian disorders, Dr. Simpson said after describing ongoing research at Baylor, where he also is a professor in the department of molecular and human genetics.

“I don't think there is any question the public will demand this approach and not karyotypes,” he said. “Karyotypes have a limited future in terms of the diagnostic field.”

The American College of Obstetricians and Gynecologists is reviewing the current guideline for invasive and noninvasive screening, adopted in 1996, according to Dr. Simpson. He predicted a revision with a “cafeteria of options” will be announced early next year.

Among the noninvasive options he listed are sequential first and second trimester screening with various serum analytes, nuchal translucency ultrasound, and nasal bone inspection.

“Noninvasive first-trimester screening shows clear improvement, 5%–10%, over second-trimester screening, and is more applicable to multiple gestations,” he said, citing recent results from a new analysis of data from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial. “Successful incorporation with nasal bone [screening] could yield over 90% detection.”

Dr. Simpson said nuchal translucency ultrasound in the first trimester is especially useful in women with multiple gestations, as it allows assessment of individual fetuses. With serum testing alone, he said, detection rates in this population can dip as low as 25% with second-trimester screening.

First-trimester screening for absence of nasal bone was not successful in a 2003 report from the FASTER trial, but other studies have reported Down syndrome detection rates as high as 73%, according to Dr. Simpson. He advocated using nasal bone inspection with other noninvasive tests rather than as the sole measure.

In two recent studies from the United Kingdom, he said 30,564 women and 15,822 women, respectively, were screened by four measures: pregnancy-associated plasma protein A (PAPP-A), human chorionic gonadotropin (hCG), nuchal translucency, and nasal bone inspection. The detection rates were 93% and 97%, respectively.

“Early is better for issues of privacy and access to management, but it is also [better] for sensitivity,” Dr. Simpson said.

Addressing the controversy over disclosure of first-trimester results before a woman returns for second-trimester screening, he warned of the potential for litigation if the patient fails to return or is somehow lost to follow-up without learning she is at high risk.

“What if you have someone who would have had a procedure if you told her the results in the first trimester, and she just did not get around to coming back to you, or there is a hurricane or whatever?” he said, adding that second-trimester detection rates have been shown not to decline as feared when high-risk women were advised of first-trimester results.

As for invasive procedures, Dr. Simpson said the fetal loss rates are “probably no more than 1 in 500.” He cited several large studies showing fetal loss rates as low as 1 in 667 amniocentesis procedures.

SCOTTSDALE, ARIZ. — Noninvasive genetic screening has a higher detection rate when done in the first trimester of pregnancy and should be offered with prompt disclosure of results, Joe Leigh Simpson, M.D., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

An offer of amniocentesis or chorionic villus sampling (CVS) to every pregnant woman regardless of age also should be considered, according to Dr. Simpson, chairman of obstetrics and gynecology at Baylor College of Medicine, Houston.

“I believe a good case could be made for universal invasive screening,” he said. “I believe amniocentesis and CVS are much safer than generally touted. The 1-in-200 [loss rate] figure we have told our patients is doing them a disservice, because it is not a valid figure in 2005.”

He predicted karyotyping will become obsolete as a diagnostic tool within the next 5–10 years. Chromosomal microarrays currently in development are more accurate than karyotypes, and should soon be able to detect many common Mendelian disorders, Dr. Simpson said after describing ongoing research at Baylor, where he also is a professor in the department of molecular and human genetics.

“I don't think there is any question the public will demand this approach and not karyotypes,” he said. “Karyotypes have a limited future in terms of the diagnostic field.”

The American College of Obstetricians and Gynecologists is reviewing the current guideline for invasive and noninvasive screening, adopted in 1996, according to Dr. Simpson. He predicted a revision with a “cafeteria of options” will be announced early next year.

Among the noninvasive options he listed are sequential first and second trimester screening with various serum analytes, nuchal translucency ultrasound, and nasal bone inspection.

“Noninvasive first-trimester screening shows clear improvement, 5%–10%, over second-trimester screening, and is more applicable to multiple gestations,” he said, citing recent results from a new analysis of data from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial. “Successful incorporation with nasal bone [screening] could yield over 90% detection.”

Dr. Simpson said nuchal translucency ultrasound in the first trimester is especially useful in women with multiple gestations, as it allows assessment of individual fetuses. With serum testing alone, he said, detection rates in this population can dip as low as 25% with second-trimester screening.

First-trimester screening for absence of nasal bone was not successful in a 2003 report from the FASTER trial, but other studies have reported Down syndrome detection rates as high as 73%, according to Dr. Simpson. He advocated using nasal bone inspection with other noninvasive tests rather than as the sole measure.

In two recent studies from the United Kingdom, he said 30,564 women and 15,822 women, respectively, were screened by four measures: pregnancy-associated plasma protein A (PAPP-A), human chorionic gonadotropin (hCG), nuchal translucency, and nasal bone inspection. The detection rates were 93% and 97%, respectively.

“Early is better for issues of privacy and access to management, but it is also [better] for sensitivity,” Dr. Simpson said.

Addressing the controversy over disclosure of first-trimester results before a woman returns for second-trimester screening, he warned of the potential for litigation if the patient fails to return or is somehow lost to follow-up without learning she is at high risk.

“What if you have someone who would have had a procedure if you told her the results in the first trimester, and she just did not get around to coming back to you, or there is a hurricane or whatever?” he said, adding that second-trimester detection rates have been shown not to decline as feared when high-risk women were advised of first-trimester results.

As for invasive procedures, Dr. Simpson said the fetal loss rates are “probably no more than 1 in 500.” He cited several large studies showing fetal loss rates as low as 1 in 667 amniocentesis procedures.

CHARLESTON, S.C. — The association between maternal periodontal disease and increased risk for preterm birth is strongest among black women with moderate or severe periodontal disease, Kim A. Boggess, M.D., reported at the annual meeting of the Infectious Disease Society for Obstetrics and Gynecology.

In a longitudinal observational study of 958 women, 30% had no periodontal disease at enrollment, 60% had mild periodontal disease, and 14% had moderate/severe periodontal disease. Of those with moderate/severe disease, 79% were black, suggesting that the rate of periodontal disease in the pregnant population mirrors that of the nonpregnant population, said Dr. Boggess of the University of North Carolina at Chapel Hill.

The literature shows that, compared with white women, black women have a higher rate of periodontal disease, she noted.

Black women also have a higher rate of preterm birth, and this was true in the current study, as well. Preterm birth occurred in 23% of the 471 black women in the study, compared with 6% of the 487 white women.

Furthermore, the study supports previous research that suggests periodontal disease is associated with preterm delivery. Delivery before 37 weeks' gestation occurred in 29% of those with moderate/severe disease, compared with 19% of those with mild disease, and 11% of those with periodontal health, Dr. Boggess said.

A multivariable logistic regression model that adjusted for maternal age, parity, marital status, insurance use, smoking, and prior preterm birth showed that, taken together, the risk ratios for preterm birth before 37 weeks' and 35 weeks' gestation were highest for those who were black and had moderate or severe periodontal disease. (See box.)

The rate of preterm birth in this population was much higher than would have been expected if race and disease were acting independently. “It looks like race and periodontal disease are acting together in a multiplicative way,” she said.

Possible mechanisms for the differences between black and white women in this study include access to care issues and differences between black and white women in oral microbiology, maternal host response to oral microbes, and stress levels (which have been identified as a risk factor for periodontal disease), Dr. Boggess said, noting that further study is warranted.

Teasing out the mechanisms for the findings in this study could help in the development—and appropriate targeting—of intervention strategies, she said.

CHARLESTON, S.C. — The association between maternal periodontal disease and increased risk for preterm birth is strongest among black women with moderate or severe periodontal disease, Kim A. Boggess, M.D., reported at the annual meeting of the Infectious Disease Society for Obstetrics and Gynecology.

In a longitudinal observational study of 958 women, 30% had no periodontal disease at enrollment, 60% had mild periodontal disease, and 14% had moderate/severe periodontal disease. Of those with moderate/severe disease, 79% were black, suggesting that the rate of periodontal disease in the pregnant population mirrors that of the nonpregnant population, said Dr. Boggess of the University of North Carolina at Chapel Hill.

The literature shows that, compared with white women, black women have a higher rate of periodontal disease, she noted.

Black women also have a higher rate of preterm birth, and this was true in the current study, as well. Preterm birth occurred in 23% of the 471 black women in the study, compared with 6% of the 487 white women.

Furthermore, the study supports previous research that suggests periodontal disease is associated with preterm delivery. Delivery before 37 weeks' gestation occurred in 29% of those with moderate/severe disease, compared with 19% of those with mild disease, and 11% of those with periodontal health, Dr. Boggess said.

A multivariable logistic regression model that adjusted for maternal age, parity, marital status, insurance use, smoking, and prior preterm birth showed that, taken together, the risk ratios for preterm birth before 37 weeks' and 35 weeks' gestation were highest for those who were black and had moderate or severe periodontal disease. (See box.)

The rate of preterm birth in this population was much higher than would have been expected if race and disease were acting independently. “It looks like race and periodontal disease are acting together in a multiplicative way,” she said.

Possible mechanisms for the differences between black and white women in this study include access to care issues and differences between black and white women in oral microbiology, maternal host response to oral microbes, and stress levels (which have been identified as a risk factor for periodontal disease), Dr. Boggess said, noting that further study is warranted.

Teasing out the mechanisms for the findings in this study could help in the development—and appropriate targeting—of intervention strategies, she said.

CHARLESTON, S.C. — The association between maternal periodontal disease and increased risk for preterm birth is strongest among black women with moderate or severe periodontal disease, Kim A. Boggess, M.D., reported at the annual meeting of the Infectious Disease Society for Obstetrics and Gynecology.

In a longitudinal observational study of 958 women, 30% had no periodontal disease at enrollment, 60% had mild periodontal disease, and 14% had moderate/severe periodontal disease. Of those with moderate/severe disease, 79% were black, suggesting that the rate of periodontal disease in the pregnant population mirrors that of the nonpregnant population, said Dr. Boggess of the University of North Carolina at Chapel Hill.

The literature shows that, compared with white women, black women have a higher rate of periodontal disease, she noted.

Black women also have a higher rate of preterm birth, and this was true in the current study, as well. Preterm birth occurred in 23% of the 471 black women in the study, compared with 6% of the 487 white women.

Furthermore, the study supports previous research that suggests periodontal disease is associated with preterm delivery. Delivery before 37 weeks' gestation occurred in 29% of those with moderate/severe disease, compared with 19% of those with mild disease, and 11% of those with periodontal health, Dr. Boggess said.

A multivariable logistic regression model that adjusted for maternal age, parity, marital status, insurance use, smoking, and prior preterm birth showed that, taken together, the risk ratios for preterm birth before 37 weeks' and 35 weeks' gestation were highest for those who were black and had moderate or severe periodontal disease. (See box.)

The rate of preterm birth in this population was much higher than would have been expected if race and disease were acting independently. “It looks like race and periodontal disease are acting together in a multiplicative way,” she said.

Possible mechanisms for the differences between black and white women in this study include access to care issues and differences between black and white women in oral microbiology, maternal host response to oral microbes, and stress levels (which have been identified as a risk factor for periodontal disease), Dr. Boggess said, noting that further study is warranted.

Teasing out the mechanisms for the findings in this study could help in the development—and appropriate targeting—of intervention strategies, she said.

Two recently published studies demonstrate that the risk of transmission of hepatitis C from mother to infant is increased by concomitant HIV infection, but unlike HIV, the risk of vertical transmission of hepatitis C is not reduced by elective cesarean section.

Additionally, the larger of the two studies turned up the surprising result that girl babies are at twice the risk of vertical transmission as are boys (J. Infect. Dis. 2005;192:1872–9).

That study, by the European Paediatric Hepatitis C Virus Network, involved 1,479 pregnant women with confirmed hepatitis C infections from 33 sites across Europe. They and their babies were followed prospectively over at least 24 months.

Infants were counted as being infected only if they tested positive (by an RNA polymerase chain reaction test and/or by the presence of anti-hepatitis C antibodies) after the age of 18 months. This is the age by which passively acquired maternal antibodies have almost always disappeared.

The overall hepatitis C vertical transmission rate was 6.2%. Among mothers who were coinfected with HIV, the transmission rate was 8.7%, significantly higher than the 5.5% rate seen among mothers who were infected only with hepatitis C.

After adjusting for maternal HIV infection status, mode of delivery, prematurity, and infant feeding type, the study showed that female infants had 2.07 times the risk of vertical transmission as males, a statistically significant increase.

In this study, a number of factors showed no significant association with vertical transmission.

Among them were whether the mothers had a history of intravenous drug use, whether they were using such drugs during pregnancy, the mode of delivery (vaginal vs. elective cesarean section vs. emergency cesarean section), and whether the infant was taking formula or was breast-fed.

The second study by Eric E. Mast, M.D., of the Centers for Disease Control and Prevention, Atlanta, and his colleagues analyzed 242 women who were confirmed as positive for hepatitis C during pregnancy and their 244 live-born infants (J. Infect. Dis. 2005;192:1880–9).

The overall vertical transmission rate in this study was 3.7%. Women who were coinfected with HIV were 6.5 times more likely to transmit hepatitis C than those who were not coinfected.

Among the HIV-negative women, vertical hepatitis C transmission was significantly associated with several factors, including membrane rupture more than 6 hours before delivery and the use of internal fetal monitoring devices.

The investigators concluded that avoiding internal fetal monitoring and/or performing a cesarean section before or soon after membrane rupture could decrease the risk of vertical hepatitis C transmission.

Some infants who turned out ultimately to be uninfected with hepatitis C nevertheless tested positive for anti-hepatitis C antibodies as late as 15 months following birth, a result of passively acquired maternal antibodies.

The investigators recommended that infants be tested after the age of 18 months to avoid false-positive results.

In this study, vertical transmission occurred in six girls, compared with three boys, but the small sample size prevented this difference from reaching statistical significance.

Two recently published studies demonstrate that the risk of transmission of hepatitis C from mother to infant is increased by concomitant HIV infection, but unlike HIV, the risk of vertical transmission of hepatitis C is not reduced by elective cesarean section.

Additionally, the larger of the two studies turned up the surprising result that girl babies are at twice the risk of vertical transmission as are boys (J. Infect. Dis. 2005;192:1872–9).

That study, by the European Paediatric Hepatitis C Virus Network, involved 1,479 pregnant women with confirmed hepatitis C infections from 33 sites across Europe. They and their babies were followed prospectively over at least 24 months.

Infants were counted as being infected only if they tested positive (by an RNA polymerase chain reaction test and/or by the presence of anti-hepatitis C antibodies) after the age of 18 months. This is the age by which passively acquired maternal antibodies have almost always disappeared.

The overall hepatitis C vertical transmission rate was 6.2%. Among mothers who were coinfected with HIV, the transmission rate was 8.7%, significantly higher than the 5.5% rate seen among mothers who were infected only with hepatitis C.

After adjusting for maternal HIV infection status, mode of delivery, prematurity, and infant feeding type, the study showed that female infants had 2.07 times the risk of vertical transmission as males, a statistically significant increase.

In this study, a number of factors showed no significant association with vertical transmission.

Among them were whether the mothers had a history of intravenous drug use, whether they were using such drugs during pregnancy, the mode of delivery (vaginal vs. elective cesarean section vs. emergency cesarean section), and whether the infant was taking formula or was breast-fed.

The second study by Eric E. Mast, M.D., of the Centers for Disease Control and Prevention, Atlanta, and his colleagues analyzed 242 women who were confirmed as positive for hepatitis C during pregnancy and their 244 live-born infants (J. Infect. Dis. 2005;192:1880–9).

The overall vertical transmission rate in this study was 3.7%. Women who were coinfected with HIV were 6.5 times more likely to transmit hepatitis C than those who were not coinfected.

Among the HIV-negative women, vertical hepatitis C transmission was significantly associated with several factors, including membrane rupture more than 6 hours before delivery and the use of internal fetal monitoring devices.

The investigators concluded that avoiding internal fetal monitoring and/or performing a cesarean section before or soon after membrane rupture could decrease the risk of vertical hepatitis C transmission.

Some infants who turned out ultimately to be uninfected with hepatitis C nevertheless tested positive for anti-hepatitis C antibodies as late as 15 months following birth, a result of passively acquired maternal antibodies.

The investigators recommended that infants be tested after the age of 18 months to avoid false-positive results.

In this study, vertical transmission occurred in six girls, compared with three boys, but the small sample size prevented this difference from reaching statistical significance.

Two recently published studies demonstrate that the risk of transmission of hepatitis C from mother to infant is increased by concomitant HIV infection, but unlike HIV, the risk of vertical transmission of hepatitis C is not reduced by elective cesarean section.

Additionally, the larger of the two studies turned up the surprising result that girl babies are at twice the risk of vertical transmission as are boys (J. Infect. Dis. 2005;192:1872–9).

That study, by the European Paediatric Hepatitis C Virus Network, involved 1,479 pregnant women with confirmed hepatitis C infections from 33 sites across Europe. They and their babies were followed prospectively over at least 24 months.

Infants were counted as being infected only if they tested positive (by an RNA polymerase chain reaction test and/or by the presence of anti-hepatitis C antibodies) after the age of 18 months. This is the age by which passively acquired maternal antibodies have almost always disappeared.

The overall hepatitis C vertical transmission rate was 6.2%. Among mothers who were coinfected with HIV, the transmission rate was 8.7%, significantly higher than the 5.5% rate seen among mothers who were infected only with hepatitis C.

After adjusting for maternal HIV infection status, mode of delivery, prematurity, and infant feeding type, the study showed that female infants had 2.07 times the risk of vertical transmission as males, a statistically significant increase.

In this study, a number of factors showed no significant association with vertical transmission.

Among them were whether the mothers had a history of intravenous drug use, whether they were using such drugs during pregnancy, the mode of delivery (vaginal vs. elective cesarean section vs. emergency cesarean section), and whether the infant was taking formula or was breast-fed.

The second study by Eric E. Mast, M.D., of the Centers for Disease Control and Prevention, Atlanta, and his colleagues analyzed 242 women who were confirmed as positive for hepatitis C during pregnancy and their 244 live-born infants (J. Infect. Dis. 2005;192:1880–9).

The overall vertical transmission rate in this study was 3.7%. Women who were coinfected with HIV were 6.5 times more likely to transmit hepatitis C than those who were not coinfected.

Among the HIV-negative women, vertical hepatitis C transmission was significantly associated with several factors, including membrane rupture more than 6 hours before delivery and the use of internal fetal monitoring devices.

The investigators concluded that avoiding internal fetal monitoring and/or performing a cesarean section before or soon after membrane rupture could decrease the risk of vertical hepatitis C transmission.

Some infants who turned out ultimately to be uninfected with hepatitis C nevertheless tested positive for anti-hepatitis C antibodies as late as 15 months following birth, a result of passively acquired maternal antibodies.

The investigators recommended that infants be tested after the age of 18 months to avoid false-positive results.

In this study, vertical transmission occurred in six girls, compared with three boys, but the small sample size prevented this difference from reaching statistical significance.

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

SCOTTSDALE, ARIZ. — A prospective observational study of 1,656 cesarean deliveries has produced a detailed portrait of factors leading to longer than usual operating times and the effects of long procedures on pregnancy outcomes.

Cesarean delivery is likely to be prolonged when a woman is older or overweight, according to data presented by investigator Everett F. Magann, M.D., at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Magann reported that maternal age above 35 years and a body mass index of 30 kg/m

Dr. Magann suggested that obstetricians may want to consider requesting stronger backup when they perform a cesarean delivery on a woman who is older and overweight.

“Maybe call a partner in and get more experienced help,” he said, noting that longer procedures had negative effects on pregnancy outcomes.

“The most significant is that blood loss was increased, so you want to do your operation in a timely manner,” Dr. Magann of the Naval Medical Center in Portsmouth, Va., said in an interview.

He and his associates were surprised by two factors that turned out not to prolong cesarean delivery. “Surprisingly, endometriosis and wound separation were unrelated to the operation time,” they reported in a list of conclusions on the poster.

In the interview, Dr. Magann mentioned that the review also brought another surprise: “We didn't find [that] the longer you operate, the greater your risk of infection,” he said, noting that increased risk of infection is often assumed in this situation.

Women with preexisting hypertension or a low segment transverse scar from a previous cesarean operation were more likely to have longer procedures.

Other factors that contributed significantly to added time in the operating room were a uterus incision other than a transverse incision, having a first-year resident as the primary physician, and performance of a sterilization procedure during the operation.

Blood loss in excess of 1,000 mL was more than twice as likely (odds ratio 2.16) in operations lasting 30–60 minutes, compared with those lasting 30 minutes or less. The odds ratio rose to 6.93 in operations that lasted longer.

Patients whose cesarean delivery lasted longer than 60 minutes also were nearly three times more likely to have their umbilical artery pH level register below 7.1. In addition, their babies were nearly three times more likely to have Apgar scores below 7 at 5 minutes.

Risk of respiratory distress syndrome also increased with longer operating time; the odds ratio became 2.43 at 30–60 minutes and 4.07 after 60 minutes.

Nearly three-quarters (1,207/1,656) of women in the study were African American. Another 19% (315/1,656) were white. The women, more than half of whom were nulliparous, were 24.8 years old on average.

The investigators reported that 693 women had a previous cesarean delivery. About a third of this group (232 women) had at least two prior cesarean deliveries.

Complications occurred in 728 pregnancies (44%). Preeclampsia was the most common, occurring in 337 women. It was followed by gestational diabetes in 134 women, preterm premature rupture of membranes (76), congenital abnormalities (53), and intrauterine growth restriction (28).

Forty minutes was the median operative time in the study, which divided the women into three cohorts for the analysis. Only 386 deliveries (23%) were completed in 30 minutes or less. Nearly two-thirds (1,070 deliveries) took 31–60 minutes. The remaining 200 deliveries lasted longer than 60 minutes.

The study showed that the only factors associated with shortened delivery time were maternal age less than 18 years and fetal distress.

SCOTTSDALE, ARIZ. — A prospective observational study of 1,656 cesarean deliveries has produced a detailed portrait of factors leading to longer than usual operating times and the effects of long procedures on pregnancy outcomes.

Cesarean delivery is likely to be prolonged when a woman is older or overweight, according to data presented by investigator Everett F. Magann, M.D., at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Magann reported that maternal age above 35 years and a body mass index of 30 kg/m

Dr. Magann suggested that obstetricians may want to consider requesting stronger backup when they perform a cesarean delivery on a woman who is older and overweight.

“Maybe call a partner in and get more experienced help,” he said, noting that longer procedures had negative effects on pregnancy outcomes.

“The most significant is that blood loss was increased, so you want to do your operation in a timely manner,” Dr. Magann of the Naval Medical Center in Portsmouth, Va., said in an interview.

He and his associates were surprised by two factors that turned out not to prolong cesarean delivery. “Surprisingly, endometriosis and wound separation were unrelated to the operation time,” they reported in a list of conclusions on the poster.

In the interview, Dr. Magann mentioned that the review also brought another surprise: “We didn't find [that] the longer you operate, the greater your risk of infection,” he said, noting that increased risk of infection is often assumed in this situation.

Women with preexisting hypertension or a low segment transverse scar from a previous cesarean operation were more likely to have longer procedures.

Other factors that contributed significantly to added time in the operating room were a uterus incision other than a transverse incision, having a first-year resident as the primary physician, and performance of a sterilization procedure during the operation.

Blood loss in excess of 1,000 mL was more than twice as likely (odds ratio 2.16) in operations lasting 30–60 minutes, compared with those lasting 30 minutes or less. The odds ratio rose to 6.93 in operations that lasted longer.

Patients whose cesarean delivery lasted longer than 60 minutes also were nearly three times more likely to have their umbilical artery pH level register below 7.1. In addition, their babies were nearly three times more likely to have Apgar scores below 7 at 5 minutes.

Risk of respiratory distress syndrome also increased with longer operating time; the odds ratio became 2.43 at 30–60 minutes and 4.07 after 60 minutes.

Nearly three-quarters (1,207/1,656) of women in the study were African American. Another 19% (315/1,656) were white. The women, more than half of whom were nulliparous, were 24.8 years old on average.

The investigators reported that 693 women had a previous cesarean delivery. About a third of this group (232 women) had at least two prior cesarean deliveries.

Complications occurred in 728 pregnancies (44%). Preeclampsia was the most common, occurring in 337 women. It was followed by gestational diabetes in 134 women, preterm premature rupture of membranes (76), congenital abnormalities (53), and intrauterine growth restriction (28).

Forty minutes was the median operative time in the study, which divided the women into three cohorts for the analysis. Only 386 deliveries (23%) were completed in 30 minutes or less. Nearly two-thirds (1,070 deliveries) took 31–60 minutes. The remaining 200 deliveries lasted longer than 60 minutes.

The study showed that the only factors associated with shortened delivery time were maternal age less than 18 years and fetal distress.

SCOTTSDALE, ARIZ. — A prospective observational study of 1,656 cesarean deliveries has produced a detailed portrait of factors leading to longer than usual operating times and the effects of long procedures on pregnancy outcomes.

Cesarean delivery is likely to be prolonged when a woman is older or overweight, according to data presented by investigator Everett F. Magann, M.D., at the annual meeting of the Central Association of Obstetricians and Gynecologists.

Dr. Magann reported that maternal age above 35 years and a body mass index of 30 kg/m

Dr. Magann suggested that obstetricians may want to consider requesting stronger backup when they perform a cesarean delivery on a woman who is older and overweight.

“Maybe call a partner in and get more experienced help,” he said, noting that longer procedures had negative effects on pregnancy outcomes.

“The most significant is that blood loss was increased, so you want to do your operation in a timely manner,” Dr. Magann of the Naval Medical Center in Portsmouth, Va., said in an interview.

He and his associates were surprised by two factors that turned out not to prolong cesarean delivery. “Surprisingly, endometriosis and wound separation were unrelated to the operation time,” they reported in a list of conclusions on the poster.

In the interview, Dr. Magann mentioned that the review also brought another surprise: “We didn't find [that] the longer you operate, the greater your risk of infection,” he said, noting that increased risk of infection is often assumed in this situation.

Women with preexisting hypertension or a low segment transverse scar from a previous cesarean operation were more likely to have longer procedures.

Other factors that contributed significantly to added time in the operating room were a uterus incision other than a transverse incision, having a first-year resident as the primary physician, and performance of a sterilization procedure during the operation.

Blood loss in excess of 1,000 mL was more than twice as likely (odds ratio 2.16) in operations lasting 30–60 minutes, compared with those lasting 30 minutes or less. The odds ratio rose to 6.93 in operations that lasted longer.

Patients whose cesarean delivery lasted longer than 60 minutes also were nearly three times more likely to have their umbilical artery pH level register below 7.1. In addition, their babies were nearly three times more likely to have Apgar scores below 7 at 5 minutes.

Risk of respiratory distress syndrome also increased with longer operating time; the odds ratio became 2.43 at 30–60 minutes and 4.07 after 60 minutes.

Nearly three-quarters (1,207/1,656) of women in the study were African American. Another 19% (315/1,656) were white. The women, more than half of whom were nulliparous, were 24.8 years old on average.

The investigators reported that 693 women had a previous cesarean delivery. About a third of this group (232 women) had at least two prior cesarean deliveries.

Complications occurred in 728 pregnancies (44%). Preeclampsia was the most common, occurring in 337 women. It was followed by gestational diabetes in 134 women, preterm premature rupture of membranes (76), congenital abnormalities (53), and intrauterine growth restriction (28).

Forty minutes was the median operative time in the study, which divided the women into three cohorts for the analysis. Only 386 deliveries (23%) were completed in 30 minutes or less. Nearly two-thirds (1,070 deliveries) took 31–60 minutes. The remaining 200 deliveries lasted longer than 60 minutes.

The study showed that the only factors associated with shortened delivery time were maternal age less than 18 years and fetal distress.

SCOTTSDALE, ARIZ. — Perioperative use of magnesium sulfate during cesarean delivery did not relieve short- or long-term pain for women in a double-blind, randomized controlled trial of 120 women.

Neither high nor low doses produced any benefit in pain control or satisfaction compared with saline solution in the intent-to-treat analysis.

Other than the expected variation in serum concentrations of magnesium, the only significant differences were slightly greater blood loss and longer time to solid foods for the women given magnesium sulfate, study investigator Everett F. Magann, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“Given the absence of any apparent analgesic benefit and the apparent increase in blood loss, we do not believe that the perioperative administration is clinically useful,” said Dr. Magann, a captain in the U.S. Naval Reserve who currently practices at Naval Medical Center Portsmouth (Va.).

The investigators wanted to test magnesium sulfate because it has been used successfully to control pain from cancer and some surgical procedures in other fields of medicine, according to Dr. Magann. He said they had found one abstract reporting that preeclamptic women undergoing cesarean deliveries had less pain than did matched controls.

“The use of magnesium is very familiar to obstetricians,” he said. “It is used in pregnancies complicated by preeclampsia and in pregnancies complicated by preterm labor to delay delivery until corticosteroids have been administered to accelerate fetal lung maturity and lessen neonatal morbidity.”

Magnesium is believed to alter pain processing, because it acts as an antagonist to receptors in the spinal cord.

“There is experimental evidence that magnesium may modulate acute pain [and] reduce postsurgical pain intensity and/or the dosage of analgesics,” Dr. Magann said.

He conducted the study at King Edward Memorial Hospital for Women, Perth, Western Australia, with colleagues from the hospital and the University of Western Australia.

From October 2002 to June 2004, they enrolled 131 women aged 18 years or older who were undergoing a planned cesarean delivery of a single infant, had no contraindication to magnesium sulfate, and consented to a combined spinal-epidural anesthetic.

Patients and health care providers were blinded to the randomization of the women. Eleven women withdrew consent or did not proceed to cesarean delivery. Although 15 women did not receive a full 24-hour infusion of magnesium sulfate and 9 did not adhere to analgesic protocol, these patients were included in the intent-to-treat analysis.

The high-dose group of 42 patients was given 50 mg/kg of magnesium sulfate an hour before surgery and 2 g/hour afterward.

A low-dose cohort of 38 women received a 25 mg/kg loading dose followed by 1 g/hour after surgery.

Forty women in a control group received a saline solution.

There were no significant differences between groups in baseline characteristics such as age and weight.

Although none of the women had serious complications requiring transfusions, Dr. Magann reported blood loss as 400 mL for the control group, 475 mL for the low-dose patients, and 500 mL in women at the higher dose.

Time to solid foods was 3 hours in the control group and 6 hours in the two cohorts on magnesium sulfate.

At 6 weeks, none of the women were using analgesic drugs. They also did not have any wound pain with movement or pressure.

Discussant Paul Ogburn, M.D., said the paper answered “fairly definitively no” to the question of whether magnesium sulfate would relieve cesarean pain.

Dr. Ogburn, director of maternal-fetal medicine at the State University of New York at Stony Brook, also suggested that the incidental findings of increased blood loss and delay until solid food is consumed may be important clinically.

SCOTTSDALE, ARIZ. — Perioperative use of magnesium sulfate during cesarean delivery did not relieve short- or long-term pain for women in a double-blind, randomized controlled trial of 120 women.

Neither high nor low doses produced any benefit in pain control or satisfaction compared with saline solution in the intent-to-treat analysis.

Other than the expected variation in serum concentrations of magnesium, the only significant differences were slightly greater blood loss and longer time to solid foods for the women given magnesium sulfate, study investigator Everett F. Magann, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“Given the absence of any apparent analgesic benefit and the apparent increase in blood loss, we do not believe that the perioperative administration is clinically useful,” said Dr. Magann, a captain in the U.S. Naval Reserve who currently practices at Naval Medical Center Portsmouth (Va.).

The investigators wanted to test magnesium sulfate because it has been used successfully to control pain from cancer and some surgical procedures in other fields of medicine, according to Dr. Magann. He said they had found one abstract reporting that preeclamptic women undergoing cesarean deliveries had less pain than did matched controls.

“The use of magnesium is very familiar to obstetricians,” he said. “It is used in pregnancies complicated by preeclampsia and in pregnancies complicated by preterm labor to delay delivery until corticosteroids have been administered to accelerate fetal lung maturity and lessen neonatal morbidity.”

Magnesium is believed to alter pain processing, because it acts as an antagonist to receptors in the spinal cord.

“There is experimental evidence that magnesium may modulate acute pain [and] reduce postsurgical pain intensity and/or the dosage of analgesics,” Dr. Magann said.

He conducted the study at King Edward Memorial Hospital for Women, Perth, Western Australia, with colleagues from the hospital and the University of Western Australia.

From October 2002 to June 2004, they enrolled 131 women aged 18 years or older who were undergoing a planned cesarean delivery of a single infant, had no contraindication to magnesium sulfate, and consented to a combined spinal-epidural anesthetic.

Patients and health care providers were blinded to the randomization of the women. Eleven women withdrew consent or did not proceed to cesarean delivery. Although 15 women did not receive a full 24-hour infusion of magnesium sulfate and 9 did not adhere to analgesic protocol, these patients were included in the intent-to-treat analysis.

The high-dose group of 42 patients was given 50 mg/kg of magnesium sulfate an hour before surgery and 2 g/hour afterward.

A low-dose cohort of 38 women received a 25 mg/kg loading dose followed by 1 g/hour after surgery.

Forty women in a control group received a saline solution.

There were no significant differences between groups in baseline characteristics such as age and weight.

Although none of the women had serious complications requiring transfusions, Dr. Magann reported blood loss as 400 mL for the control group, 475 mL for the low-dose patients, and 500 mL in women at the higher dose.

Time to solid foods was 3 hours in the control group and 6 hours in the two cohorts on magnesium sulfate.

At 6 weeks, none of the women were using analgesic drugs. They also did not have any wound pain with movement or pressure.

Discussant Paul Ogburn, M.D., said the paper answered “fairly definitively no” to the question of whether magnesium sulfate would relieve cesarean pain.

Dr. Ogburn, director of maternal-fetal medicine at the State University of New York at Stony Brook, also suggested that the incidental findings of increased blood loss and delay until solid food is consumed may be important clinically.

SCOTTSDALE, ARIZ. — Perioperative use of magnesium sulfate during cesarean delivery did not relieve short- or long-term pain for women in a double-blind, randomized controlled trial of 120 women.

Neither high nor low doses produced any benefit in pain control or satisfaction compared with saline solution in the intent-to-treat analysis.

Other than the expected variation in serum concentrations of magnesium, the only significant differences were slightly greater blood loss and longer time to solid foods for the women given magnesium sulfate, study investigator Everett F. Magann, M.D., reported at the annual meeting of the Central Association of Obstetricians and Gynecologists.

“Given the absence of any apparent analgesic benefit and the apparent increase in blood loss, we do not believe that the perioperative administration is clinically useful,” said Dr. Magann, a captain in the U.S. Naval Reserve who currently practices at Naval Medical Center Portsmouth (Va.).

The investigators wanted to test magnesium sulfate because it has been used successfully to control pain from cancer and some surgical procedures in other fields of medicine, according to Dr. Magann. He said they had found one abstract reporting that preeclamptic women undergoing cesarean deliveries had less pain than did matched controls.

“The use of magnesium is very familiar to obstetricians,” he said. “It is used in pregnancies complicated by preeclampsia and in pregnancies complicated by preterm labor to delay delivery until corticosteroids have been administered to accelerate fetal lung maturity and lessen neonatal morbidity.”

Magnesium is believed to alter pain processing, because it acts as an antagonist to receptors in the spinal cord.

“There is experimental evidence that magnesium may modulate acute pain [and] reduce postsurgical pain intensity and/or the dosage of analgesics,” Dr. Magann said.

He conducted the study at King Edward Memorial Hospital for Women, Perth, Western Australia, with colleagues from the hospital and the University of Western Australia.

From October 2002 to June 2004, they enrolled 131 women aged 18 years or older who were undergoing a planned cesarean delivery of a single infant, had no contraindication to magnesium sulfate, and consented to a combined spinal-epidural anesthetic.

Patients and health care providers were blinded to the randomization of the women. Eleven women withdrew consent or did not proceed to cesarean delivery. Although 15 women did not receive a full 24-hour infusion of magnesium sulfate and 9 did not adhere to analgesic protocol, these patients were included in the intent-to-treat analysis.

The high-dose group of 42 patients was given 50 mg/kg of magnesium sulfate an hour before surgery and 2 g/hour afterward.

A low-dose cohort of 38 women received a 25 mg/kg loading dose followed by 1 g/hour after surgery.

Forty women in a control group received a saline solution.

There were no significant differences between groups in baseline characteristics such as age and weight.

Although none of the women had serious complications requiring transfusions, Dr. Magann reported blood loss as 400 mL for the control group, 475 mL for the low-dose patients, and 500 mL in women at the higher dose.

Time to solid foods was 3 hours in the control group and 6 hours in the two cohorts on magnesium sulfate.

At 6 weeks, none of the women were using analgesic drugs. They also did not have any wound pain with movement or pressure.

Discussant Paul Ogburn, M.D., said the paper answered “fairly definitively no” to the question of whether magnesium sulfate would relieve cesarean pain.

Dr. Ogburn, director of maternal-fetal medicine at the State University of New York at Stony Brook, also suggested that the incidental findings of increased blood loss and delay until solid food is consumed may be important clinically.

ATLANTA — Women with postpartum depression are more likely than are nondepressed women to have urge urinary incontinence, according to findings presented in a poster at the annual meeting of the American Urogynecologic Society.

Of 146 women in the cross-sectional study, 12% had postpartum depression at the 6-week visit as measured by the Edinburgh Postnatal Depression Scale. At that time, those with depression had a fourfold increase in overall and subscale scores on the Urge-Incontinence Impact Questionnaire (UIIQ), compared with nondepressed women.

This finding suggests depressed patients have more symptoms and a greater impact on their lives from urge urinary incontinence, Dee Fenner, M.D., said.

Depressed and nondepressed patients were similar in age, race, parity, and body mass index. On multivariate analysis, depression scores were shown to be affected by UIIQ score, smoking, and infant feeding mode (bottle vs. breast). But urge incontinence symptoms had the greatest effect on depression scores.

In addition, depressed patients were more than twice as likely to have had a cesarean delivery, Dr. Fenner said.

That finding amplifies the association between urinary incontinence and postpartum depression because studies have shown women who have a C-section are less likely to develop urge urinary incontinence than are those who deliver vaginally, Dr. Fenner noted.

“We hope this will serve for future studies as a model to predict the onset of depression and to actually work out whether or not this is the depression causing the incontinence or the incontinence causing the depression,” she said.

The model could also aid in assessing the role of various markers, such as cortisol levels, hormone fluctuations, and neurotransmitters in depression and incontinence.

ATLANTA — Women with postpartum depression are more likely than are nondepressed women to have urge urinary incontinence, according to findings presented in a poster at the annual meeting of the American Urogynecologic Society.

Of 146 women in the cross-sectional study, 12% had postpartum depression at the 6-week visit as measured by the Edinburgh Postnatal Depression Scale. At that time, those with depression had a fourfold increase in overall and subscale scores on the Urge-Incontinence Impact Questionnaire (UIIQ), compared with nondepressed women.

This finding suggests depressed patients have more symptoms and a greater impact on their lives from urge urinary incontinence, Dee Fenner, M.D., said.

Depressed and nondepressed patients were similar in age, race, parity, and body mass index. On multivariate analysis, depression scores were shown to be affected by UIIQ score, smoking, and infant feeding mode (bottle vs. breast). But urge incontinence symptoms had the greatest effect on depression scores.

In addition, depressed patients were more than twice as likely to have had a cesarean delivery, Dr. Fenner said.

That finding amplifies the association between urinary incontinence and postpartum depression because studies have shown women who have a C-section are less likely to develop urge urinary incontinence than are those who deliver vaginally, Dr. Fenner noted.

“We hope this will serve for future studies as a model to predict the onset of depression and to actually work out whether or not this is the depression causing the incontinence or the incontinence causing the depression,” she said.

The model could also aid in assessing the role of various markers, such as cortisol levels, hormone fluctuations, and neurotransmitters in depression and incontinence.

ATLANTA — Women with postpartum depression are more likely than are nondepressed women to have urge urinary incontinence, according to findings presented in a poster at the annual meeting of the American Urogynecologic Society.

Of 146 women in the cross-sectional study, 12% had postpartum depression at the 6-week visit as measured by the Edinburgh Postnatal Depression Scale. At that time, those with depression had a fourfold increase in overall and subscale scores on the Urge-Incontinence Impact Questionnaire (UIIQ), compared with nondepressed women.

This finding suggests depressed patients have more symptoms and a greater impact on their lives from urge urinary incontinence, Dee Fenner, M.D., said.

Depressed and nondepressed patients were similar in age, race, parity, and body mass index. On multivariate analysis, depression scores were shown to be affected by UIIQ score, smoking, and infant feeding mode (bottle vs. breast). But urge incontinence symptoms had the greatest effect on depression scores.

In addition, depressed patients were more than twice as likely to have had a cesarean delivery, Dr. Fenner said.

That finding amplifies the association between urinary incontinence and postpartum depression because studies have shown women who have a C-section are less likely to develop urge urinary incontinence than are those who deliver vaginally, Dr. Fenner noted.

“We hope this will serve for future studies as a model to predict the onset of depression and to actually work out whether or not this is the depression causing the incontinence or the incontinence causing the depression,” she said.

The model could also aid in assessing the role of various markers, such as cortisol levels, hormone fluctuations, and neurotransmitters in depression and incontinence.

SAN DIEGO — Children with fetal alcohol spectrum disorders receive a wide variety of psychiatric diagnoses and medications, Julia Murray, M.D., reported in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

“Out in the community, people are trying to address the needs of these kids, but it looks as if [they] are being given all kinds of diagnoses. They have a full spectrum of psychiatric symptoms, and they're receiving a wide range of diagnoses and psychotropic medications,” said Dr. Murray, a psychiatrist at Odessa Brown Children's Clinic, Seattle.

As part of a study funded by the Centers for Disease Control and Prevention, Dr. Murray and associates reviewed medical charts of 50 children with fetal alcohol spectrum disorders or alcohol-related neurodevelopmental disorders and behavioral problems who were enrolled in community-based therapeutic programs. The records covered about 18 months.

“It's been reported that kids with fetal alcohol spectrum disorders do have depression, bipolar syndromes, and psychosis syndromes, but there has been very little quantitative and qualitative description,” Dr. Murray said. “The literature primarily addresses an [attention-deficit hyperactivity disorder]-type behavioral syndrome and the use of stimulants. There's not much about treatment for any other diagnoses.”

The mean baseline age of participants was about 9 years. Of 50 children, 76% had received psychiatric diagnoses. Overall, 23 psychiatric conditions were found, including attention-deficit hyperactivity disorder (74%), learning disorders (26%), cognitive disorders (26%), disruptive behavior disorders (21%), and anxiety disorders (18%).

More than half (56%) had been prescribed a mean of 2.23 simultaneous medications, ranging from stimulants to atypical antipsychotics. Primary care clinicians were the most frequent prescribers (50%), followed by psychiatrists (42%), and both (8%). The study was limited because the investigators “didn't try to verify the diagnoses or look at the efficacy of the medications that we used,” Dr. Murray said.

SAN DIEGO — Children with fetal alcohol spectrum disorders receive a wide variety of psychiatric diagnoses and medications, Julia Murray, M.D., reported in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

“Out in the community, people are trying to address the needs of these kids, but it looks as if [they] are being given all kinds of diagnoses. They have a full spectrum of psychiatric symptoms, and they're receiving a wide range of diagnoses and psychotropic medications,” said Dr. Murray, a psychiatrist at Odessa Brown Children's Clinic, Seattle.

As part of a study funded by the Centers for Disease Control and Prevention, Dr. Murray and associates reviewed medical charts of 50 children with fetal alcohol spectrum disorders or alcohol-related neurodevelopmental disorders and behavioral problems who were enrolled in community-based therapeutic programs. The records covered about 18 months.

“It's been reported that kids with fetal alcohol spectrum disorders do have depression, bipolar syndromes, and psychosis syndromes, but there has been very little quantitative and qualitative description,” Dr. Murray said. “The literature primarily addresses an [attention-deficit hyperactivity disorder]-type behavioral syndrome and the use of stimulants. There's not much about treatment for any other diagnoses.”

The mean baseline age of participants was about 9 years. Of 50 children, 76% had received psychiatric diagnoses. Overall, 23 psychiatric conditions were found, including attention-deficit hyperactivity disorder (74%), learning disorders (26%), cognitive disorders (26%), disruptive behavior disorders (21%), and anxiety disorders (18%).

More than half (56%) had been prescribed a mean of 2.23 simultaneous medications, ranging from stimulants to atypical antipsychotics. Primary care clinicians were the most frequent prescribers (50%), followed by psychiatrists (42%), and both (8%). The study was limited because the investigators “didn't try to verify the diagnoses or look at the efficacy of the medications that we used,” Dr. Murray said.

SAN DIEGO — Children with fetal alcohol spectrum disorders receive a wide variety of psychiatric diagnoses and medications, Julia Murray, M.D., reported in a poster presentation at the American Psychiatric Association's Institute on Psychiatric Services.

“Out in the community, people are trying to address the needs of these kids, but it looks as if [they] are being given all kinds of diagnoses. They have a full spectrum of psychiatric symptoms, and they're receiving a wide range of diagnoses and psychotropic medications,” said Dr. Murray, a psychiatrist at Odessa Brown Children's Clinic, Seattle.

As part of a study funded by the Centers for Disease Control and Prevention, Dr. Murray and associates reviewed medical charts of 50 children with fetal alcohol spectrum disorders or alcohol-related neurodevelopmental disorders and behavioral problems who were enrolled in community-based therapeutic programs. The records covered about 18 months.

“It's been reported that kids with fetal alcohol spectrum disorders do have depression, bipolar syndromes, and psychosis syndromes, but there has been very little quantitative and qualitative description,” Dr. Murray said. “The literature primarily addresses an [attention-deficit hyperactivity disorder]-type behavioral syndrome and the use of stimulants. There's not much about treatment for any other diagnoses.”

The mean baseline age of participants was about 9 years. Of 50 children, 76% had received psychiatric diagnoses. Overall, 23 psychiatric conditions were found, including attention-deficit hyperactivity disorder (74%), learning disorders (26%), cognitive disorders (26%), disruptive behavior disorders (21%), and anxiety disorders (18%).

More than half (56%) had been prescribed a mean of 2.23 simultaneous medications, ranging from stimulants to atypical antipsychotics. Primary care clinicians were the most frequent prescribers (50%), followed by psychiatrists (42%), and both (8%). The study was limited because the investigators “didn't try to verify the diagnoses or look at the efficacy of the medications that we used,” Dr. Murray said.