Obstetrics

SANTA BARBARA, CALIF. — Children of older mothers who drank during pregnancy were shorter and had smaller head circumferences at ages 7 and 14 years than other children at those ages, it was reported at the annual meeting of the Research Society on Alcoholism.

Children of mothers who were 30 or older at delivery were affected above a threshold of moderate alcohol consumption, defined as about one alcoholic drink a day at the time of conception.

Many women reduced their drinking during pregnancy, but the heaviest drinkers reduced their drinking less.

“Even if women reduce their drinking during pregnancy, their early drinking before they realize they are pregnant may have an impact on the infant,” said Sandra W. Jacobson, Ph.D., professor of psychiatry and behavioral neurosciences at Wayne State University in Detroit, a senior author on the study.

“We see effects in infants whose mothers drink as little as one drink/day.”

Dr. Jacobson stressed that “average” drinks per day did not reflect actual drinking patterns among women in the study. Just 1 woman of 480 in the Detroit Longitudinal Prenatal Alcohol Exposure study drank daily.

Many of the others concentrated their drinking on 1–2 days a week, in some cases drinking three to four drinks at each session, she explained following the meeting.

Mean alcohol consumption at conception was two drinks per day in the study of economically disadvantaged African American women and their children.

Mean alcohol intake dropped during pregnancy to a little more than two drinks per week.

Prenatal alcohol exposure was associated with lower birthweight and length in the entire sample of women, even after researchers controlled for smoking and other possible confounders.

For mothers over 30 at conception, the repercussions were long lasting. With a cutoff point of 0.5 ounces of alcohol per day at conception, older mothers' children were 1.2 cm, 3.1 cm, and 3.7 cm shorter at birth, 7.5 years, and 14 years, respectively, than children of mothers with minimal exposure.

Their mean head circumference was smaller by 4.6 mm, 7.3 mm, and 14.5 mm at birth, 7.5 years, and 14 years.

“Prenatal alcohol exposure was not related to weight or body mass index at 7.5 or 14 years, suggesting that the effects on height and head circumference were not attributable to poor maternal nutrition,” the researchers reported in their poster presentation.

Smoking during pregnancy resulted in lower birthweight and reduced length and head circumference at birth, but had no discernible impact on children's growth over time.

In contrast, prenatal alcohol exposure's impact on size was evident at birth and became magnified over time.

Although the study suggests that children of older mothers are most vulnerable to prenatal alcohol exposure, all women considering pregnancy should be urged to stop drinking or to cut down as much as possible. “At this time, no drinking is considered safe,” said Dr. Jacobson.

The study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism and the Joseph Young, Sr., Fund of Michigan.

Douglas Fuller, a research assistant in the Wayne State University department of psychiatry and behavioral neurosciences, contributed to the study.

SANTA BARBARA, CALIF. — Children of older mothers who drank during pregnancy were shorter and had smaller head circumferences at ages 7 and 14 years than other children at those ages, it was reported at the annual meeting of the Research Society on Alcoholism.

Children of mothers who were 30 or older at delivery were affected above a threshold of moderate alcohol consumption, defined as about one alcoholic drink a day at the time of conception.

Many women reduced their drinking during pregnancy, but the heaviest drinkers reduced their drinking less.

“Even if women reduce their drinking during pregnancy, their early drinking before they realize they are pregnant may have an impact on the infant,” said Sandra W. Jacobson, Ph.D., professor of psychiatry and behavioral neurosciences at Wayne State University in Detroit, a senior author on the study.

“We see effects in infants whose mothers drink as little as one drink/day.”

Dr. Jacobson stressed that “average” drinks per day did not reflect actual drinking patterns among women in the study. Just 1 woman of 480 in the Detroit Longitudinal Prenatal Alcohol Exposure study drank daily.

Many of the others concentrated their drinking on 1–2 days a week, in some cases drinking three to four drinks at each session, she explained following the meeting.

Mean alcohol consumption at conception was two drinks per day in the study of economically disadvantaged African American women and their children.

Mean alcohol intake dropped during pregnancy to a little more than two drinks per week.

Prenatal alcohol exposure was associated with lower birthweight and length in the entire sample of women, even after researchers controlled for smoking and other possible confounders.

For mothers over 30 at conception, the repercussions were long lasting. With a cutoff point of 0.5 ounces of alcohol per day at conception, older mothers' children were 1.2 cm, 3.1 cm, and 3.7 cm shorter at birth, 7.5 years, and 14 years, respectively, than children of mothers with minimal exposure.

Their mean head circumference was smaller by 4.6 mm, 7.3 mm, and 14.5 mm at birth, 7.5 years, and 14 years.

“Prenatal alcohol exposure was not related to weight or body mass index at 7.5 or 14 years, suggesting that the effects on height and head circumference were not attributable to poor maternal nutrition,” the researchers reported in their poster presentation.

Smoking during pregnancy resulted in lower birthweight and reduced length and head circumference at birth, but had no discernible impact on children's growth over time.

In contrast, prenatal alcohol exposure's impact on size was evident at birth and became magnified over time.

Although the study suggests that children of older mothers are most vulnerable to prenatal alcohol exposure, all women considering pregnancy should be urged to stop drinking or to cut down as much as possible. “At this time, no drinking is considered safe,” said Dr. Jacobson.

The study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism and the Joseph Young, Sr., Fund of Michigan.

Douglas Fuller, a research assistant in the Wayne State University department of psychiatry and behavioral neurosciences, contributed to the study.

SANTA BARBARA, CALIF. — Children of older mothers who drank during pregnancy were shorter and had smaller head circumferences at ages 7 and 14 years than other children at those ages, it was reported at the annual meeting of the Research Society on Alcoholism.

Children of mothers who were 30 or older at delivery were affected above a threshold of moderate alcohol consumption, defined as about one alcoholic drink a day at the time of conception.

Many women reduced their drinking during pregnancy, but the heaviest drinkers reduced their drinking less.

“Even if women reduce their drinking during pregnancy, their early drinking before they realize they are pregnant may have an impact on the infant,” said Sandra W. Jacobson, Ph.D., professor of psychiatry and behavioral neurosciences at Wayne State University in Detroit, a senior author on the study.

“We see effects in infants whose mothers drink as little as one drink/day.”

Dr. Jacobson stressed that “average” drinks per day did not reflect actual drinking patterns among women in the study. Just 1 woman of 480 in the Detroit Longitudinal Prenatal Alcohol Exposure study drank daily.

Many of the others concentrated their drinking on 1–2 days a week, in some cases drinking three to four drinks at each session, she explained following the meeting.

Mean alcohol consumption at conception was two drinks per day in the study of economically disadvantaged African American women and their children.

Mean alcohol intake dropped during pregnancy to a little more than two drinks per week.

Prenatal alcohol exposure was associated with lower birthweight and length in the entire sample of women, even after researchers controlled for smoking and other possible confounders.

For mothers over 30 at conception, the repercussions were long lasting. With a cutoff point of 0.5 ounces of alcohol per day at conception, older mothers' children were 1.2 cm, 3.1 cm, and 3.7 cm shorter at birth, 7.5 years, and 14 years, respectively, than children of mothers with minimal exposure.

Their mean head circumference was smaller by 4.6 mm, 7.3 mm, and 14.5 mm at birth, 7.5 years, and 14 years.

“Prenatal alcohol exposure was not related to weight or body mass index at 7.5 or 14 years, suggesting that the effects on height and head circumference were not attributable to poor maternal nutrition,” the researchers reported in their poster presentation.

Smoking during pregnancy resulted in lower birthweight and reduced length and head circumference at birth, but had no discernible impact on children's growth over time.

In contrast, prenatal alcohol exposure's impact on size was evident at birth and became magnified over time.

Although the study suggests that children of older mothers are most vulnerable to prenatal alcohol exposure, all women considering pregnancy should be urged to stop drinking or to cut down as much as possible. “At this time, no drinking is considered safe,” said Dr. Jacobson.

The study was supported by grants from the National Institute on Alcohol Abuse and Alcoholism and the Joseph Young, Sr., Fund of Michigan.

Douglas Fuller, a research assistant in the Wayne State University department of psychiatry and behavioral neurosciences, contributed to the study.

CHARLESTON, S.C. — Rapid real-time polymerase chain reaction testing for group B streptococcus detection proved at least as sensitive and specific as standard culture screening at 35–37 weeks' gestation in a recent study.

Two vaginal-rectal swabs were collected from each of 190 women enrolled in the study after presenting in labor. One sample was tested using the Food and Drug Administration-approved IDI-Strep B assay and analyzed using the FDA-approved Smart Cycler I instrument; the other sample was used for enriched culture for GBS, Deborah M. Money, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the more than 150 women in the study who also underwent the currently recommended 35- to 37-week culture screening and had results available for analysis, the rapid test had a sensitivity of 89%, compared with 85% for the 35- to 37-week culture, and a positive predictive value of 97%, compared with 94% for the 35- to 37-week culture. The values were based on comparison with culture at delivery, said Dr. Money of the University of British Columbia, Vancouver.

The median time from specimen acquisition to availability of results with the rapid test was 90 minutes, with a range of 30 minutes to 4 hours. About 87% of results were available within 2 hours; cultures can require a few days for results. Colonization rates were about 30% with both the rapid test and the culture, she said.

Theoretically, the rapid test could be used during labor to circumvent some of the potential problems inherent in the 35− to 37-week culture method of screening, such as its reliance on the provider to do the screening properly, the uncertainty of the availability of results by delivery (which can jeopardize the chance of a colonized patient receiving the recommended 4 hours of antibiotic therapy during labor for preventing vertical transmission), and the fact that some women do not have prenatal care and would therefore not present for the 35− to 37-week culture. But with the similar sensitivity and specificity to 35− to 37-week culture demonstrated by the rapid test in this study, its usefulness for routine care is unclear.

“We were a little surprised by the lack of superiority of PCR to the culture methodology,” said Dr. Money, adding that larger studies will be required to determine if there is a statistically significant sensitivity and cost advantage with the rapid test over the 35− to 37-week culture.

One setting in which the rapid test can be of particular use now, however, is in patients who present in labor without information regarding their group B strep status. For those patients, the test is feasible, it has a reasonable turnaround time and a comparable result to culture screening, and it can be performed in a busy labor and delivery room, she said.

CHARLESTON, S.C. — Rapid real-time polymerase chain reaction testing for group B streptococcus detection proved at least as sensitive and specific as standard culture screening at 35–37 weeks' gestation in a recent study.

Two vaginal-rectal swabs were collected from each of 190 women enrolled in the study after presenting in labor. One sample was tested using the Food and Drug Administration-approved IDI-Strep B assay and analyzed using the FDA-approved Smart Cycler I instrument; the other sample was used for enriched culture for GBS, Deborah M. Money, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the more than 150 women in the study who also underwent the currently recommended 35- to 37-week culture screening and had results available for analysis, the rapid test had a sensitivity of 89%, compared with 85% for the 35- to 37-week culture, and a positive predictive value of 97%, compared with 94% for the 35- to 37-week culture. The values were based on comparison with culture at delivery, said Dr. Money of the University of British Columbia, Vancouver.

The median time from specimen acquisition to availability of results with the rapid test was 90 minutes, with a range of 30 minutes to 4 hours. About 87% of results were available within 2 hours; cultures can require a few days for results. Colonization rates were about 30% with both the rapid test and the culture, she said.

Theoretically, the rapid test could be used during labor to circumvent some of the potential problems inherent in the 35− to 37-week culture method of screening, such as its reliance on the provider to do the screening properly, the uncertainty of the availability of results by delivery (which can jeopardize the chance of a colonized patient receiving the recommended 4 hours of antibiotic therapy during labor for preventing vertical transmission), and the fact that some women do not have prenatal care and would therefore not present for the 35− to 37-week culture. But with the similar sensitivity and specificity to 35− to 37-week culture demonstrated by the rapid test in this study, its usefulness for routine care is unclear.

“We were a little surprised by the lack of superiority of PCR to the culture methodology,” said Dr. Money, adding that larger studies will be required to determine if there is a statistically significant sensitivity and cost advantage with the rapid test over the 35− to 37-week culture.

One setting in which the rapid test can be of particular use now, however, is in patients who present in labor without information regarding their group B strep status. For those patients, the test is feasible, it has a reasonable turnaround time and a comparable result to culture screening, and it can be performed in a busy labor and delivery room, she said.

CHARLESTON, S.C. — Rapid real-time polymerase chain reaction testing for group B streptococcus detection proved at least as sensitive and specific as standard culture screening at 35–37 weeks' gestation in a recent study.

Two vaginal-rectal swabs were collected from each of 190 women enrolled in the study after presenting in labor. One sample was tested using the Food and Drug Administration-approved IDI-Strep B assay and analyzed using the FDA-approved Smart Cycler I instrument; the other sample was used for enriched culture for GBS, Deborah M. Money, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In the more than 150 women in the study who also underwent the currently recommended 35- to 37-week culture screening and had results available for analysis, the rapid test had a sensitivity of 89%, compared with 85% for the 35- to 37-week culture, and a positive predictive value of 97%, compared with 94% for the 35- to 37-week culture. The values were based on comparison with culture at delivery, said Dr. Money of the University of British Columbia, Vancouver.

The median time from specimen acquisition to availability of results with the rapid test was 90 minutes, with a range of 30 minutes to 4 hours. About 87% of results were available within 2 hours; cultures can require a few days for results. Colonization rates were about 30% with both the rapid test and the culture, she said.

Theoretically, the rapid test could be used during labor to circumvent some of the potential problems inherent in the 35− to 37-week culture method of screening, such as its reliance on the provider to do the screening properly, the uncertainty of the availability of results by delivery (which can jeopardize the chance of a colonized patient receiving the recommended 4 hours of antibiotic therapy during labor for preventing vertical transmission), and the fact that some women do not have prenatal care and would therefore not present for the 35− to 37-week culture. But with the similar sensitivity and specificity to 35− to 37-week culture demonstrated by the rapid test in this study, its usefulness for routine care is unclear.

“We were a little surprised by the lack of superiority of PCR to the culture methodology,” said Dr. Money, adding that larger studies will be required to determine if there is a statistically significant sensitivity and cost advantage with the rapid test over the 35− to 37-week culture.

One setting in which the rapid test can be of particular use now, however, is in patients who present in labor without information regarding their group B strep status. For those patients, the test is feasible, it has a reasonable turnaround time and a comparable result to culture screening, and it can be performed in a busy labor and delivery room, she said.

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

SAN DIEGO — Laparoscopic management for ectopic pregnancy was safely undertaken in 12 women who were in shock, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

He reviewed records of 12 patients with clinical hypovolemic shock due to a ruptured fallopian tube ectopic pregnancy who were treated laparoscopically in one gynecology unit where minimally invasive surgery is the norm. All patients survived and were successfully treated, said Dr. Erian of Royal Brisbane and Women's Hospital, Brisbane, Australia.

The report of the 12 cases was coauthored by Glenda McLaren, M.D., of the University of Queensland, which is in Brisbane.

Laparoscopic management is the mainstay for women with ectopic pregnancy who are not in shock, and it should still be even when shock occurs, Dr. Erian said. His unit has successfully treated an additional 5 cases of ectopic pregnancy in women with hypovolemic shock since the original series of 12 cases, he added.

The original 12 cases were seen over a period of approximately 4 years, the researchers said. Such cases are relatively rare. Some of these patients had been airlifted by helicopter to the hospital from other parts of Australia.

The patients had a mean age of 21 years (ranging from 15 to 43 years), and all had been amenorrheic for a mean of 7 weeks except two patients for whom the latest normal menstrual period was unknown. Serum β-HCG measurements showed a mean value of 4,850 IU/L. Symptoms and findings of a pelvic examination usually pointed to ectopic pregnancy. Preoperative ultrasound scans showed no intrauterine gestations or excessive peritoneal fluid, and usually showed an adnexal mass with heterogenic echogenicity.

Urgent resuscitation measures, including blood transfusion, stabilized each patient's hemodynamic status. After placing the patient in an exaggerated Trendelenburg's position with a 15− to 25-degree tilt, Dr. Erian performed laparoscopy via a left upper quadrant abdominal approach.

“I always ask the anesthetist to pass a nasogastric or an orogastric tube to make sure that when I pass my first trocar, I'm not going to find myself right inside the stomach,” he noted.

A four-portal entry technique and video laparoscopy allowed maximum access and maneuverability of instruments. In nearly every case, the pelvic organs were bathed with blood, requiring copious irrigation with warm Hartmann's or Ringer's solution and suction for adequate visualization.

The first step in management was to stop the bleeding from the ruptured fallopian tube by using monopolar coagulation diathermy, followed by controlled salpingostomy to remove the ectopic pregnancy. The specimen was sent for histologic examination to confirm the diagnosis. A negative suction drainage apparatus was placed in the pouch of Douglas and left in the pelvis for 6–8 hours following surgery.

After surgery, patients were given prescriptions for a few weeks' worth of iron supplements if needed, and β-HCG values were monitored at least weekly until they fell to nonpregnant levels.

Estimated blood loss averaged 1.8 L. Surgical treatment lasted a mean of 29 minutes. Serum β-HCG levels dropped to nonpregnant levels in 4–6 weeks in all except one patient whose β-HCG level fell but did plateau at 1,800 IU/L for 10 days.

That patient then was readmitted and given a course of methotrexate and folinic acid. Her serum β-HCG level declined to a nonpregnant level 4 weeks later.

No cases reportedly required laparotomy.

Severe intraperitoneal hemorrhage occurs as a result of a ruptured ectopic pregnancy.

This vantage point shows right broad ligament varicosities.

Broad ligament varicosities are shown after laparoscopic suturing is performed. Photos courtesy Dr. Mark Erian

SAN DIEGO — Laparoscopic management for ectopic pregnancy was safely undertaken in 12 women who were in shock, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

He reviewed records of 12 patients with clinical hypovolemic shock due to a ruptured fallopian tube ectopic pregnancy who were treated laparoscopically in one gynecology unit where minimally invasive surgery is the norm. All patients survived and were successfully treated, said Dr. Erian of Royal Brisbane and Women's Hospital, Brisbane, Australia.

The report of the 12 cases was coauthored by Glenda McLaren, M.D., of the University of Queensland, which is in Brisbane.

Laparoscopic management is the mainstay for women with ectopic pregnancy who are not in shock, and it should still be even when shock occurs, Dr. Erian said. His unit has successfully treated an additional 5 cases of ectopic pregnancy in women with hypovolemic shock since the original series of 12 cases, he added.

The original 12 cases were seen over a period of approximately 4 years, the researchers said. Such cases are relatively rare. Some of these patients had been airlifted by helicopter to the hospital from other parts of Australia.

The patients had a mean age of 21 years (ranging from 15 to 43 years), and all had been amenorrheic for a mean of 7 weeks except two patients for whom the latest normal menstrual period was unknown. Serum β-HCG measurements showed a mean value of 4,850 IU/L. Symptoms and findings of a pelvic examination usually pointed to ectopic pregnancy. Preoperative ultrasound scans showed no intrauterine gestations or excessive peritoneal fluid, and usually showed an adnexal mass with heterogenic echogenicity.

Urgent resuscitation measures, including blood transfusion, stabilized each patient's hemodynamic status. After placing the patient in an exaggerated Trendelenburg's position with a 15− to 25-degree tilt, Dr. Erian performed laparoscopy via a left upper quadrant abdominal approach.

“I always ask the anesthetist to pass a nasogastric or an orogastric tube to make sure that when I pass my first trocar, I'm not going to find myself right inside the stomach,” he noted.

A four-portal entry technique and video laparoscopy allowed maximum access and maneuverability of instruments. In nearly every case, the pelvic organs were bathed with blood, requiring copious irrigation with warm Hartmann's or Ringer's solution and suction for adequate visualization.

The first step in management was to stop the bleeding from the ruptured fallopian tube by using monopolar coagulation diathermy, followed by controlled salpingostomy to remove the ectopic pregnancy. The specimen was sent for histologic examination to confirm the diagnosis. A negative suction drainage apparatus was placed in the pouch of Douglas and left in the pelvis for 6–8 hours following surgery.

After surgery, patients were given prescriptions for a few weeks' worth of iron supplements if needed, and β-HCG values were monitored at least weekly until they fell to nonpregnant levels.

Estimated blood loss averaged 1.8 L. Surgical treatment lasted a mean of 29 minutes. Serum β-HCG levels dropped to nonpregnant levels in 4–6 weeks in all except one patient whose β-HCG level fell but did plateau at 1,800 IU/L for 10 days.

That patient then was readmitted and given a course of methotrexate and folinic acid. Her serum β-HCG level declined to a nonpregnant level 4 weeks later.

No cases reportedly required laparotomy.

Severe intraperitoneal hemorrhage occurs as a result of a ruptured ectopic pregnancy.

This vantage point shows right broad ligament varicosities.

Broad ligament varicosities are shown after laparoscopic suturing is performed. Photos courtesy Dr. Mark Erian

SAN DIEGO — Laparoscopic management for ectopic pregnancy was safely undertaken in 12 women who were in shock, Mark Erian, M.D., reported at an international congress of the Society of Laparoendoscopic Surgeons.

He reviewed records of 12 patients with clinical hypovolemic shock due to a ruptured fallopian tube ectopic pregnancy who were treated laparoscopically in one gynecology unit where minimally invasive surgery is the norm. All patients survived and were successfully treated, said Dr. Erian of Royal Brisbane and Women's Hospital, Brisbane, Australia.

The report of the 12 cases was coauthored by Glenda McLaren, M.D., of the University of Queensland, which is in Brisbane.

Laparoscopic management is the mainstay for women with ectopic pregnancy who are not in shock, and it should still be even when shock occurs, Dr. Erian said. His unit has successfully treated an additional 5 cases of ectopic pregnancy in women with hypovolemic shock since the original series of 12 cases, he added.

The original 12 cases were seen over a period of approximately 4 years, the researchers said. Such cases are relatively rare. Some of these patients had been airlifted by helicopter to the hospital from other parts of Australia.

The patients had a mean age of 21 years (ranging from 15 to 43 years), and all had been amenorrheic for a mean of 7 weeks except two patients for whom the latest normal menstrual period was unknown. Serum β-HCG measurements showed a mean value of 4,850 IU/L. Symptoms and findings of a pelvic examination usually pointed to ectopic pregnancy. Preoperative ultrasound scans showed no intrauterine gestations or excessive peritoneal fluid, and usually showed an adnexal mass with heterogenic echogenicity.

Urgent resuscitation measures, including blood transfusion, stabilized each patient's hemodynamic status. After placing the patient in an exaggerated Trendelenburg's position with a 15− to 25-degree tilt, Dr. Erian performed laparoscopy via a left upper quadrant abdominal approach.

“I always ask the anesthetist to pass a nasogastric or an orogastric tube to make sure that when I pass my first trocar, I'm not going to find myself right inside the stomach,” he noted.

A four-portal entry technique and video laparoscopy allowed maximum access and maneuverability of instruments. In nearly every case, the pelvic organs were bathed with blood, requiring copious irrigation with warm Hartmann's or Ringer's solution and suction for adequate visualization.

The first step in management was to stop the bleeding from the ruptured fallopian tube by using monopolar coagulation diathermy, followed by controlled salpingostomy to remove the ectopic pregnancy. The specimen was sent for histologic examination to confirm the diagnosis. A negative suction drainage apparatus was placed in the pouch of Douglas and left in the pelvis for 6–8 hours following surgery.

After surgery, patients were given prescriptions for a few weeks' worth of iron supplements if needed, and β-HCG values were monitored at least weekly until they fell to nonpregnant levels.

Estimated blood loss averaged 1.8 L. Surgical treatment lasted a mean of 29 minutes. Serum β-HCG levels dropped to nonpregnant levels in 4–6 weeks in all except one patient whose β-HCG level fell but did plateau at 1,800 IU/L for 10 days.

That patient then was readmitted and given a course of methotrexate and folinic acid. Her serum β-HCG level declined to a nonpregnant level 4 weeks later.

No cases reportedly required laparotomy.

Severe intraperitoneal hemorrhage occurs as a result of a ruptured ectopic pregnancy.

This vantage point shows right broad ligament varicosities.

Broad ligament varicosities are shown after laparoscopic suturing is performed. Photos courtesy Dr. Mark Erian

When a second woman died from complications of maternal hemorrhage at his hospital between 2000 and 2001, Isaac P. Lowenwirt, M.D., knew that an institutional approach to systemic change was necessary to provide a safety net.

“When we had two maternal deaths that were secondary to hemorrhage-related complications, we sat down and used a multidisciplinary approach to develop detailed guidelines to help manage these cases and improve outcomes,” said Dr. Lowenwirt of the New York Hospital Queens. The hospital implemented the guidelines in 2001 and has had no maternal deaths since that time.

The New York Hospital Queens is a 439-bed hospital in Flushing, New York, affiliated with the Weill Medical College of Cornell University and the New York Presbyterian Hospital. It is designated as a level III neonatal intensive care center and serves an urban population, including many with Medicaid or other publicly funded insurance. The hospital handles about 3,500 deliveries a year, approximately 1,000 of which are cesarean deliveries.

Dr. Lowenwirt and his colleague Daniel W. Skupski, M.D., director of maternal-fetal medicine, were part of a multidisciplinary task force that included personnel from the divisions of maternal-fetal medicine, obstetric anesthesiology, neonatology, and the blood bank, as well as the departments of nursing, administration, and communications. The trauma team and operating room staff also helped shape the protocols.

The task force designed a multifaceted approach that included the following:

▸ Development of a rapid-response program, called Team Blue, based on the team approach used for cardiac arrest patients, with quarterly mock drills conducted on all shifts for various obstetric emergency clinical scenarios.

▸ Development of clinical pathways, guidelines, and protocols designed to provide for early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations.

▸ Revision of the duties of the in-house obstetrician to include monitoring all patients on the labor and delivery unit, including patients who had other private obstetricians.

▸ Empowerment of care providers (including physician assistants, nurses, and residents) to involve senior members of the department whenever there was a disagreement with the treatment plan concerning patients with hemorrhage.

Since the rapid-response plan's inception, the efforts have paid off. Maternal morbidity and mortality from hemorrhage dropped significantly at the hospital from 2002–2004, compared with 2000–2001.

In addition to the emergency response, the emergency team has developed strategies to care for the obstetric patient with known placenta previa. These strategies include prenatal consultation with the senior gynecologic surgeon and the divisions of maternal-fetal medicine and obstetric anesthesiology.

Ultrasound is used to identify placenta accreta in patients with prior uterine surgery, and the patients undergo a twice-weekly type and screen test to allow for faster availability of blood products in the event of hemorrhage.

In addition, patients with suspected placenta accreta are scheduled for cesarean deliveries at 36 weeks' gestation, following amniocentesis to determine fetal lung maturity. Other management strategies for patients at risk of hemorrhage include weekly autologous blood donations and the administration of erythropoietin, iron, and vitamin therapy, as well as the use of intraoperative blood collection and autotransfusion after delivery. The protocols call for judicious placement of extra intravenous lines for fluid volume resuscitation, as well as intraoperative monitoring and transfer to the postanesthesia unit or the surgical intensive care unit as needed.

Although the number of deliveries at the New York Hospital Queens has increased in recent years, there have been no deaths or major end-organ damage due to hemorrhage since they initiated emergency protocols and procedures, Dr. Lowenwirt said.

The rapid-response team includes members of various specialties involved with labor and delivery. In the event of an emergency, all team members are notified simultaneously by a special beeper.

“We disseminated the changes and protocols with the entire attending physician staff and ancillary staff through weekly didactic sessions,” Dr. Lowenwirt explained.

As with anything new, there was some resistance. “The resistance comes when you work across different departments,” he said. The challenge was to look at the situation in a nonthreatening way and to consider the end products, which are patient safety and good outcomes.

Once the staff experienced the system with real cases, they bought in, and the institution and its patients have benefited.

Although no insurance companies currently sponsor training programs for the management of maternal hemorrhage, Dr. Lowenwirt said that he could envision such programs in the future. “The rising payouts in the New York area have resulted in a particular awareness of this problem,” he said.

In 2004, the State of New York Department of Health and the New York City Department of Health announced that maternal mortality from obstetric hemorrhage had reached an all-time high. They issued a memorandum outlining systematic steps to prevent maternal deaths from hemorrhage and to offer a safety net for obstetric patients.

“Our team began systematic change three years earlier, and the changes we outline can serve as a guide for many institutions around the country,” Dr. Lowenwirt noted.

At the national level, the American College of Obstetricians and Gynecologists is developing an updated practice bulletin for dealing with maternal hemorrhage, said Jeffrey C. King, M.D., professor and chair of the department of obstetrics and gynecology at New York Medical College, Valhalla, and chair of ACOG's National Maternal Mortality Interest Group.

“ACOG tries to fit its guidelines to the vast array of hospitals providing obstetric service throughout the country; they try not to be dogmatic,” he said. The guidelines focus on the systems that enable response to an obstetric emergency, and local institutions work out their own protocols, specific to their resources and personnel.

The New York State Department of Health and ACOG District II issued an alert in August 2004 that highlighted strategies to prevent death from maternal hemorrhage, and those guidelines are still current, said Dr. King, who helped develop the guidelines. (See sidebar.)

“We had a significant response to the health alert, with many hospitals at least looking at how their processes work,” he noted.

“Clearly, operative deliveries in and of themselves increase the risk of excessive blood loss,” he said. “There are certain situations in which hemorrhage is more likely to occur, but most of [those] occur in an unexpected situation.”

Although many malpractice insurance companies have become involved in risk-reduction programs, those programs have more to do with patient communications and documentation than specific management strategies, Dr. King said. No malpractice insurance companies in the United States currently sponsor any training programs to improve the management of maternal hemorrhage.

Recommendations for Managing Maternal Hemorrhage

The complete document is available at

www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1517

The New York State Department of Health and ACOG District II continue to support their joint recommendations for preventing maternal deaths by improving management of hemorrhage.

Seven steps to reduce the risk of maternal death from hemorrhage include:

▸ Perform antepartum and postpartum assessments. Identify women at increased risk of complications during pregnancy and childbirth. Women at risk include those with a history of postpartum hemorrhage, placenta previa, grand multiparity, current macrosomia, or several cesarean births. In addition, women with a history of bleeding disorders or hematologic disease are at increased risk for hemorrhage. Uterine atony is a frequent cause of postpartum hemorrhage, and women with multiple gestation, a macrosomic fetus, or a uterine abnormality are at particular risk.

▸ Be aware of blood loss during pregnancy, labor, and delivery. Blood loss often is underestimated. Gradual blood loss can add up to large amounts over time. Medications such as magnesium sulfate and terbutaline can increase the risk of hemorrhage. Keep in mind that 1 cup=250 cc=1 large clot=1 unit of packed red blood cells. Use clinical judgment about the need for transfusion.

▸ Monitor fluids and urine output. Poor urine output may indicate poor intravascular volume as a result of blood loss. Use fluid resuscitation and transfusion to replace current blood loss and continued bleeding, regardless of the mother's apparent hemodynamic stability. By the time women of reproductive age show instability, there may already be severe compromise. Keep in mind that laboratory results may not accurately reflect hemodynamic status.

▸ Develop rapid-response protocols. Hemorrhage is an infrequent occurrence, and hospitals with effective emergency protocols to respond to maternal hemorrhage are best able to prevent it. Rapid emergency blood transfusions and plenty of compatible un-crossmatched blood should be easily accessible for obstetric emergencies.

▸ Conduct drills. Conduct “hemorrhage drills” with the labor and delivery staff to improve efficiency during emergencies. The staff should treat maternal hemorrhage with the same urgency as a cardiac code and conduct drills at different times of day to ensure experience for all team members. The team should include a surgeon with experience in hemorrhage, a critical care specialist or anesthesiologist, and a hematologist and support from the blood bank.

▸ Support the family. Call social workers or support staff as soon as possible to provide support to the immediate family while the medical staff attends to the crisis at hand.

▸ Educate the staff. Continue to train the entire hospital staff on procedures for managing maternal hemorrhage. Incorporate the information into mandatory staff education and new staff training.

Sources: The American College of Obstetricians and Gynecologists, the State of New York Department of Health, and the New York City Department of Health and Mental Hygiene

When a second woman died from complications of maternal hemorrhage at his hospital between 2000 and 2001, Isaac P. Lowenwirt, M.D., knew that an institutional approach to systemic change was necessary to provide a safety net.

“When we had two maternal deaths that were secondary to hemorrhage-related complications, we sat down and used a multidisciplinary approach to develop detailed guidelines to help manage these cases and improve outcomes,” said Dr. Lowenwirt of the New York Hospital Queens. The hospital implemented the guidelines in 2001 and has had no maternal deaths since that time.

The New York Hospital Queens is a 439-bed hospital in Flushing, New York, affiliated with the Weill Medical College of Cornell University and the New York Presbyterian Hospital. It is designated as a level III neonatal intensive care center and serves an urban population, including many with Medicaid or other publicly funded insurance. The hospital handles about 3,500 deliveries a year, approximately 1,000 of which are cesarean deliveries.

Dr. Lowenwirt and his colleague Daniel W. Skupski, M.D., director of maternal-fetal medicine, were part of a multidisciplinary task force that included personnel from the divisions of maternal-fetal medicine, obstetric anesthesiology, neonatology, and the blood bank, as well as the departments of nursing, administration, and communications. The trauma team and operating room staff also helped shape the protocols.

The task force designed a multifaceted approach that included the following:

▸ Development of a rapid-response program, called Team Blue, based on the team approach used for cardiac arrest patients, with quarterly mock drills conducted on all shifts for various obstetric emergency clinical scenarios.

▸ Development of clinical pathways, guidelines, and protocols designed to provide for early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations.

▸ Revision of the duties of the in-house obstetrician to include monitoring all patients on the labor and delivery unit, including patients who had other private obstetricians.

▸ Empowerment of care providers (including physician assistants, nurses, and residents) to involve senior members of the department whenever there was a disagreement with the treatment plan concerning patients with hemorrhage.

Since the rapid-response plan's inception, the efforts have paid off. Maternal morbidity and mortality from hemorrhage dropped significantly at the hospital from 2002–2004, compared with 2000–2001.

In addition to the emergency response, the emergency team has developed strategies to care for the obstetric patient with known placenta previa. These strategies include prenatal consultation with the senior gynecologic surgeon and the divisions of maternal-fetal medicine and obstetric anesthesiology.

Ultrasound is used to identify placenta accreta in patients with prior uterine surgery, and the patients undergo a twice-weekly type and screen test to allow for faster availability of blood products in the event of hemorrhage.

In addition, patients with suspected placenta accreta are scheduled for cesarean deliveries at 36 weeks' gestation, following amniocentesis to determine fetal lung maturity. Other management strategies for patients at risk of hemorrhage include weekly autologous blood donations and the administration of erythropoietin, iron, and vitamin therapy, as well as the use of intraoperative blood collection and autotransfusion after delivery. The protocols call for judicious placement of extra intravenous lines for fluid volume resuscitation, as well as intraoperative monitoring and transfer to the postanesthesia unit or the surgical intensive care unit as needed.

Although the number of deliveries at the New York Hospital Queens has increased in recent years, there have been no deaths or major end-organ damage due to hemorrhage since they initiated emergency protocols and procedures, Dr. Lowenwirt said.

The rapid-response team includes members of various specialties involved with labor and delivery. In the event of an emergency, all team members are notified simultaneously by a special beeper.

“We disseminated the changes and protocols with the entire attending physician staff and ancillary staff through weekly didactic sessions,” Dr. Lowenwirt explained.

As with anything new, there was some resistance. “The resistance comes when you work across different departments,” he said. The challenge was to look at the situation in a nonthreatening way and to consider the end products, which are patient safety and good outcomes.

Once the staff experienced the system with real cases, they bought in, and the institution and its patients have benefited.

Although no insurance companies currently sponsor training programs for the management of maternal hemorrhage, Dr. Lowenwirt said that he could envision such programs in the future. “The rising payouts in the New York area have resulted in a particular awareness of this problem,” he said.

In 2004, the State of New York Department of Health and the New York City Department of Health announced that maternal mortality from obstetric hemorrhage had reached an all-time high. They issued a memorandum outlining systematic steps to prevent maternal deaths from hemorrhage and to offer a safety net for obstetric patients.

“Our team began systematic change three years earlier, and the changes we outline can serve as a guide for many institutions around the country,” Dr. Lowenwirt noted.

At the national level, the American College of Obstetricians and Gynecologists is developing an updated practice bulletin for dealing with maternal hemorrhage, said Jeffrey C. King, M.D., professor and chair of the department of obstetrics and gynecology at New York Medical College, Valhalla, and chair of ACOG's National Maternal Mortality Interest Group.

“ACOG tries to fit its guidelines to the vast array of hospitals providing obstetric service throughout the country; they try not to be dogmatic,” he said. The guidelines focus on the systems that enable response to an obstetric emergency, and local institutions work out their own protocols, specific to their resources and personnel.

The New York State Department of Health and ACOG District II issued an alert in August 2004 that highlighted strategies to prevent death from maternal hemorrhage, and those guidelines are still current, said Dr. King, who helped develop the guidelines. (See sidebar.)

“We had a significant response to the health alert, with many hospitals at least looking at how their processes work,” he noted.

“Clearly, operative deliveries in and of themselves increase the risk of excessive blood loss,” he said. “There are certain situations in which hemorrhage is more likely to occur, but most of [those] occur in an unexpected situation.”

Although many malpractice insurance companies have become involved in risk-reduction programs, those programs have more to do with patient communications and documentation than specific management strategies, Dr. King said. No malpractice insurance companies in the United States currently sponsor any training programs to improve the management of maternal hemorrhage.

Recommendations for Managing Maternal Hemorrhage

The complete document is available at

www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1517

The New York State Department of Health and ACOG District II continue to support their joint recommendations for preventing maternal deaths by improving management of hemorrhage.

Seven steps to reduce the risk of maternal death from hemorrhage include:

▸ Perform antepartum and postpartum assessments. Identify women at increased risk of complications during pregnancy and childbirth. Women at risk include those with a history of postpartum hemorrhage, placenta previa, grand multiparity, current macrosomia, or several cesarean births. In addition, women with a history of bleeding disorders or hematologic disease are at increased risk for hemorrhage. Uterine atony is a frequent cause of postpartum hemorrhage, and women with multiple gestation, a macrosomic fetus, or a uterine abnormality are at particular risk.

▸ Be aware of blood loss during pregnancy, labor, and delivery. Blood loss often is underestimated. Gradual blood loss can add up to large amounts over time. Medications such as magnesium sulfate and terbutaline can increase the risk of hemorrhage. Keep in mind that 1 cup=250 cc=1 large clot=1 unit of packed red blood cells. Use clinical judgment about the need for transfusion.

▸ Monitor fluids and urine output. Poor urine output may indicate poor intravascular volume as a result of blood loss. Use fluid resuscitation and transfusion to replace current blood loss and continued bleeding, regardless of the mother's apparent hemodynamic stability. By the time women of reproductive age show instability, there may already be severe compromise. Keep in mind that laboratory results may not accurately reflect hemodynamic status.

▸ Develop rapid-response protocols. Hemorrhage is an infrequent occurrence, and hospitals with effective emergency protocols to respond to maternal hemorrhage are best able to prevent it. Rapid emergency blood transfusions and plenty of compatible un-crossmatched blood should be easily accessible for obstetric emergencies.

▸ Conduct drills. Conduct “hemorrhage drills” with the labor and delivery staff to improve efficiency during emergencies. The staff should treat maternal hemorrhage with the same urgency as a cardiac code and conduct drills at different times of day to ensure experience for all team members. The team should include a surgeon with experience in hemorrhage, a critical care specialist or anesthesiologist, and a hematologist and support from the blood bank.

▸ Support the family. Call social workers or support staff as soon as possible to provide support to the immediate family while the medical staff attends to the crisis at hand.

▸ Educate the staff. Continue to train the entire hospital staff on procedures for managing maternal hemorrhage. Incorporate the information into mandatory staff education and new staff training.

Sources: The American College of Obstetricians and Gynecologists, the State of New York Department of Health, and the New York City Department of Health and Mental Hygiene

When a second woman died from complications of maternal hemorrhage at his hospital between 2000 and 2001, Isaac P. Lowenwirt, M.D., knew that an institutional approach to systemic change was necessary to provide a safety net.

“When we had two maternal deaths that were secondary to hemorrhage-related complications, we sat down and used a multidisciplinary approach to develop detailed guidelines to help manage these cases and improve outcomes,” said Dr. Lowenwirt of the New York Hospital Queens. The hospital implemented the guidelines in 2001 and has had no maternal deaths since that time.

The New York Hospital Queens is a 439-bed hospital in Flushing, New York, affiliated with the Weill Medical College of Cornell University and the New York Presbyterian Hospital. It is designated as a level III neonatal intensive care center and serves an urban population, including many with Medicaid or other publicly funded insurance. The hospital handles about 3,500 deliveries a year, approximately 1,000 of which are cesarean deliveries.

Dr. Lowenwirt and his colleague Daniel W. Skupski, M.D., director of maternal-fetal medicine, were part of a multidisciplinary task force that included personnel from the divisions of maternal-fetal medicine, obstetric anesthesiology, neonatology, and the blood bank, as well as the departments of nursing, administration, and communications. The trauma team and operating room staff also helped shape the protocols.

The task force designed a multifaceted approach that included the following:

▸ Development of a rapid-response program, called Team Blue, based on the team approach used for cardiac arrest patients, with quarterly mock drills conducted on all shifts for various obstetric emergency clinical scenarios.

▸ Development of clinical pathways, guidelines, and protocols designed to provide for early diagnosis of patients at risk for major obstetric hemorrhage and for streamlined care in emergency situations.

▸ Revision of the duties of the in-house obstetrician to include monitoring all patients on the labor and delivery unit, including patients who had other private obstetricians.

▸ Empowerment of care providers (including physician assistants, nurses, and residents) to involve senior members of the department whenever there was a disagreement with the treatment plan concerning patients with hemorrhage.

Since the rapid-response plan's inception, the efforts have paid off. Maternal morbidity and mortality from hemorrhage dropped significantly at the hospital from 2002–2004, compared with 2000–2001.

In addition to the emergency response, the emergency team has developed strategies to care for the obstetric patient with known placenta previa. These strategies include prenatal consultation with the senior gynecologic surgeon and the divisions of maternal-fetal medicine and obstetric anesthesiology.

Ultrasound is used to identify placenta accreta in patients with prior uterine surgery, and the patients undergo a twice-weekly type and screen test to allow for faster availability of blood products in the event of hemorrhage.

In addition, patients with suspected placenta accreta are scheduled for cesarean deliveries at 36 weeks' gestation, following amniocentesis to determine fetal lung maturity. Other management strategies for patients at risk of hemorrhage include weekly autologous blood donations and the administration of erythropoietin, iron, and vitamin therapy, as well as the use of intraoperative blood collection and autotransfusion after delivery. The protocols call for judicious placement of extra intravenous lines for fluid volume resuscitation, as well as intraoperative monitoring and transfer to the postanesthesia unit or the surgical intensive care unit as needed.

Although the number of deliveries at the New York Hospital Queens has increased in recent years, there have been no deaths or major end-organ damage due to hemorrhage since they initiated emergency protocols and procedures, Dr. Lowenwirt said.

The rapid-response team includes members of various specialties involved with labor and delivery. In the event of an emergency, all team members are notified simultaneously by a special beeper.

“We disseminated the changes and protocols with the entire attending physician staff and ancillary staff through weekly didactic sessions,” Dr. Lowenwirt explained.

As with anything new, there was some resistance. “The resistance comes when you work across different departments,” he said. The challenge was to look at the situation in a nonthreatening way and to consider the end products, which are patient safety and good outcomes.

Once the staff experienced the system with real cases, they bought in, and the institution and its patients have benefited.

Although no insurance companies currently sponsor training programs for the management of maternal hemorrhage, Dr. Lowenwirt said that he could envision such programs in the future. “The rising payouts in the New York area have resulted in a particular awareness of this problem,” he said.

In 2004, the State of New York Department of Health and the New York City Department of Health announced that maternal mortality from obstetric hemorrhage had reached an all-time high. They issued a memorandum outlining systematic steps to prevent maternal deaths from hemorrhage and to offer a safety net for obstetric patients.

“Our team began systematic change three years earlier, and the changes we outline can serve as a guide for many institutions around the country,” Dr. Lowenwirt noted.

At the national level, the American College of Obstetricians and Gynecologists is developing an updated practice bulletin for dealing with maternal hemorrhage, said Jeffrey C. King, M.D., professor and chair of the department of obstetrics and gynecology at New York Medical College, Valhalla, and chair of ACOG's National Maternal Mortality Interest Group.

“ACOG tries to fit its guidelines to the vast array of hospitals providing obstetric service throughout the country; they try not to be dogmatic,” he said. The guidelines focus on the systems that enable response to an obstetric emergency, and local institutions work out their own protocols, specific to their resources and personnel.

The New York State Department of Health and ACOG District II issued an alert in August 2004 that highlighted strategies to prevent death from maternal hemorrhage, and those guidelines are still current, said Dr. King, who helped develop the guidelines. (See sidebar.)

“We had a significant response to the health alert, with many hospitals at least looking at how their processes work,” he noted.

“Clearly, operative deliveries in and of themselves increase the risk of excessive blood loss,” he said. “There are certain situations in which hemorrhage is more likely to occur, but most of [those] occur in an unexpected situation.”

Although many malpractice insurance companies have become involved in risk-reduction programs, those programs have more to do with patient communications and documentation than specific management strategies, Dr. King said. No malpractice insurance companies in the United States currently sponsor any training programs to improve the management of maternal hemorrhage.

Recommendations for Managing Maternal Hemorrhage

The complete document is available at

www.acog.org/acog_districts/dist_notice.cfm?recno=1&bulletin=1517

The New York State Department of Health and ACOG District II continue to support their joint recommendations for preventing maternal deaths by improving management of hemorrhage.

Seven steps to reduce the risk of maternal death from hemorrhage include:

▸ Perform antepartum and postpartum assessments. Identify women at increased risk of complications during pregnancy and childbirth. Women at risk include those with a history of postpartum hemorrhage, placenta previa, grand multiparity, current macrosomia, or several cesarean births. In addition, women with a history of bleeding disorders or hematologic disease are at increased risk for hemorrhage. Uterine atony is a frequent cause of postpartum hemorrhage, and women with multiple gestation, a macrosomic fetus, or a uterine abnormality are at particular risk.

▸ Be aware of blood loss during pregnancy, labor, and delivery. Blood loss often is underestimated. Gradual blood loss can add up to large amounts over time. Medications such as magnesium sulfate and terbutaline can increase the risk of hemorrhage. Keep in mind that 1 cup=250 cc=1 large clot=1 unit of packed red blood cells. Use clinical judgment about the need for transfusion.

▸ Monitor fluids and urine output. Poor urine output may indicate poor intravascular volume as a result of blood loss. Use fluid resuscitation and transfusion to replace current blood loss and continued bleeding, regardless of the mother's apparent hemodynamic stability. By the time women of reproductive age show instability, there may already be severe compromise. Keep in mind that laboratory results may not accurately reflect hemodynamic status.

▸ Develop rapid-response protocols. Hemorrhage is an infrequent occurrence, and hospitals with effective emergency protocols to respond to maternal hemorrhage are best able to prevent it. Rapid emergency blood transfusions and plenty of compatible un-crossmatched blood should be easily accessible for obstetric emergencies.

▸ Conduct drills. Conduct “hemorrhage drills” with the labor and delivery staff to improve efficiency during emergencies. The staff should treat maternal hemorrhage with the same urgency as a cardiac code and conduct drills at different times of day to ensure experience for all team members. The team should include a surgeon with experience in hemorrhage, a critical care specialist or anesthesiologist, and a hematologist and support from the blood bank.

▸ Support the family. Call social workers or support staff as soon as possible to provide support to the immediate family while the medical staff attends to the crisis at hand.

▸ Educate the staff. Continue to train the entire hospital staff on procedures for managing maternal hemorrhage. Incorporate the information into mandatory staff education and new staff training.

Sources: The American College of Obstetricians and Gynecologists, the State of New York Department of Health, and the New York City Department of Health and Mental Hygiene

SAN DIEGO — Results from the first population-based study of its kind have found that about one in three mothers of inconsolable, crying infants reported having postpartum depressive symptoms, Pamela C. High, M.D., said at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Dr. High and her associates analyzed data from Rhode Island's Pregnancy Risk Assessment Monitoring System (PRAMS) that was weighted to represent all births that occurred in the state in 2002 and 2003. Sponsored by the Centers for Disease Control and Prevention, PRAMS is an ongoing state-specific population-based survey that identifies and monitors selected maternal behaviors and experiences before, during, and after pregnancy. Rhode Island is one of 32 states that has the system.

The investigators mailed a survey to 4,214 mothers that included a question about their infants' consolability as well as a question about maternal depressive symptoms, said Dr. High, director of developmental and behavioral pediatrics at Rhode Island Hospital/Hasbro Children's Hospital, Providence.

Of the 4,214 mothers, 2,947 returned questionnaires, for a response rate of 70%.

Nearly 10% of respondents were in their teens, almost half in their 20s and an additional 27% were aged 30–34 years. The majority of them (87%) were white, while 8% were black. The rest were of Hispanic, Asian, or American Indian background.

The mean infant age was 16 weeks and nearly half were males.

Overall, mothers identified 8.3% of the infants as being “somewhat difficult” or “very difficult” to console. Infants who weighed less than 2,500 g at birth were reported to be more difficult to console compared with heavier newborns (11.2% vs. 8.1%, respectively).

Among the respondents, 7.7% of whites, 9.4% of blacks, and 17.1% of those from other racial backgrounds said they had infants who were difficult to console.

No significant differences were seen with maternal age, Hispanic ethnicity, maternal education, marital status, household income, parity, or breast-feeding.

In the assessment, 19.2% of mothers reported that in the months after delivery, they felt “moderately depressed,” “very depressed,” or “very depressed and had to get help.”

Higher levels of postpartum depression were reported by mothers who had not completed high school or who only had a high school education. Other risk factors included being unmarried, having an annual household income of less than $40,000, and being on public health insurance.

Mothers of infants who weighed less than 2,500 g at birth reported more depression than did those with heavier newborns (29.2% vs. 18.4%), while mothers with unintended pregnancies reported more depression than did those with planned pregnancies (22.8% vs. 16.8%).

Maternal age, race, ethnicity, and parity did not predict depression in these mothers. Slightly more than one-third of mothers with inconsolable infants (34.7%) also reported postpartum depressive symptoms, compared with 17.4% of mothers with infants described as more easily consoled. Physicians, then, should consider screening for postpartum depression when a new mother comes in with an inconsolable infant, the researchers suggested.

Logistic regression analysis, adjusted for socioeconomic factors, revealed that mothers with postpartum depressive symptoms were 2.59 times more likely to report infant inconsolability than were mothers who did not report postpartum depressive symptoms.

Dr. High called the association between maternal depression and infant inconsolability “robust,” but noted that a limitation of the study includes the fact that infant inconsolability and maternal depression were measured by a single question. “Also, the population sampled is not necessarily representative of the rest of the United States,” she said.

SAN DIEGO — Results from the first population-based study of its kind have found that about one in three mothers of inconsolable, crying infants reported having postpartum depressive symptoms, Pamela C. High, M.D., said at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Dr. High and her associates analyzed data from Rhode Island's Pregnancy Risk Assessment Monitoring System (PRAMS) that was weighted to represent all births that occurred in the state in 2002 and 2003. Sponsored by the Centers for Disease Control and Prevention, PRAMS is an ongoing state-specific population-based survey that identifies and monitors selected maternal behaviors and experiences before, during, and after pregnancy. Rhode Island is one of 32 states that has the system.

The investigators mailed a survey to 4,214 mothers that included a question about their infants' consolability as well as a question about maternal depressive symptoms, said Dr. High, director of developmental and behavioral pediatrics at Rhode Island Hospital/Hasbro Children's Hospital, Providence.

Of the 4,214 mothers, 2,947 returned questionnaires, for a response rate of 70%.

Nearly 10% of respondents were in their teens, almost half in their 20s and an additional 27% were aged 30–34 years. The majority of them (87%) were white, while 8% were black. The rest were of Hispanic, Asian, or American Indian background.

The mean infant age was 16 weeks and nearly half were males.

Overall, mothers identified 8.3% of the infants as being “somewhat difficult” or “very difficult” to console. Infants who weighed less than 2,500 g at birth were reported to be more difficult to console compared with heavier newborns (11.2% vs. 8.1%, respectively).

Among the respondents, 7.7% of whites, 9.4% of blacks, and 17.1% of those from other racial backgrounds said they had infants who were difficult to console.

No significant differences were seen with maternal age, Hispanic ethnicity, maternal education, marital status, household income, parity, or breast-feeding.

In the assessment, 19.2% of mothers reported that in the months after delivery, they felt “moderately depressed,” “very depressed,” or “very depressed and had to get help.”

Higher levels of postpartum depression were reported by mothers who had not completed high school or who only had a high school education. Other risk factors included being unmarried, having an annual household income of less than $40,000, and being on public health insurance.

Mothers of infants who weighed less than 2,500 g at birth reported more depression than did those with heavier newborns (29.2% vs. 18.4%), while mothers with unintended pregnancies reported more depression than did those with planned pregnancies (22.8% vs. 16.8%).

Maternal age, race, ethnicity, and parity did not predict depression in these mothers. Slightly more than one-third of mothers with inconsolable infants (34.7%) also reported postpartum depressive symptoms, compared with 17.4% of mothers with infants described as more easily consoled. Physicians, then, should consider screening for postpartum depression when a new mother comes in with an inconsolable infant, the researchers suggested.

Logistic regression analysis, adjusted for socioeconomic factors, revealed that mothers with postpartum depressive symptoms were 2.59 times more likely to report infant inconsolability than were mothers who did not report postpartum depressive symptoms.

Dr. High called the association between maternal depression and infant inconsolability “robust,” but noted that a limitation of the study includes the fact that infant inconsolability and maternal depression were measured by a single question. “Also, the population sampled is not necessarily representative of the rest of the United States,” she said.

SAN DIEGO — Results from the first population-based study of its kind have found that about one in three mothers of inconsolable, crying infants reported having postpartum depressive symptoms, Pamela C. High, M.D., said at the annual meeting of the Society for Developmental and Behavioral Pediatrics.

Dr. High and her associates analyzed data from Rhode Island's Pregnancy Risk Assessment Monitoring System (PRAMS) that was weighted to represent all births that occurred in the state in 2002 and 2003. Sponsored by the Centers for Disease Control and Prevention, PRAMS is an ongoing state-specific population-based survey that identifies and monitors selected maternal behaviors and experiences before, during, and after pregnancy. Rhode Island is one of 32 states that has the system.

The investigators mailed a survey to 4,214 mothers that included a question about their infants' consolability as well as a question about maternal depressive symptoms, said Dr. High, director of developmental and behavioral pediatrics at Rhode Island Hospital/Hasbro Children's Hospital, Providence.

Of the 4,214 mothers, 2,947 returned questionnaires, for a response rate of 70%.

Nearly 10% of respondents were in their teens, almost half in their 20s and an additional 27% were aged 30–34 years. The majority of them (87%) were white, while 8% were black. The rest were of Hispanic, Asian, or American Indian background.

The mean infant age was 16 weeks and nearly half were males.

Overall, mothers identified 8.3% of the infants as being “somewhat difficult” or “very difficult” to console. Infants who weighed less than 2,500 g at birth were reported to be more difficult to console compared with heavier newborns (11.2% vs. 8.1%, respectively).

Among the respondents, 7.7% of whites, 9.4% of blacks, and 17.1% of those from other racial backgrounds said they had infants who were difficult to console.

No significant differences were seen with maternal age, Hispanic ethnicity, maternal education, marital status, household income, parity, or breast-feeding.

In the assessment, 19.2% of mothers reported that in the months after delivery, they felt “moderately depressed,” “very depressed,” or “very depressed and had to get help.”

Higher levels of postpartum depression were reported by mothers who had not completed high school or who only had a high school education. Other risk factors included being unmarried, having an annual household income of less than $40,000, and being on public health insurance.

Mothers of infants who weighed less than 2,500 g at birth reported more depression than did those with heavier newborns (29.2% vs. 18.4%), while mothers with unintended pregnancies reported more depression than did those with planned pregnancies (22.8% vs. 16.8%).

Maternal age, race, ethnicity, and parity did not predict depression in these mothers. Slightly more than one-third of mothers with inconsolable infants (34.7%) also reported postpartum depressive symptoms, compared with 17.4% of mothers with infants described as more easily consoled. Physicians, then, should consider screening for postpartum depression when a new mother comes in with an inconsolable infant, the researchers suggested.

Logistic regression analysis, adjusted for socioeconomic factors, revealed that mothers with postpartum depressive symptoms were 2.59 times more likely to report infant inconsolability than were mothers who did not report postpartum depressive symptoms.

Dr. High called the association between maternal depression and infant inconsolability “robust,” but noted that a limitation of the study includes the fact that infant inconsolability and maternal depression were measured by a single question. “Also, the population sampled is not necessarily representative of the rest of the United States,” she said.

New data linking paroxetine use in the first trimester of pregnancy with increased risk of major congenital malformations has prompted changes to the drug's label.

Preliminary results of a retrospective epidemiologic study sponsored by GlaxoSmithKline Inc., the drug's maker, show paroxetine (marketed as Paxil) was associated with more congenital malformations (adjusted odds ratio 2.20) and more cardiovascular malformations (adjusted odds ratio 2.08) than other antidepressants in almost 3,600 pregnant women.

The prevalence of congenital malformations in the study was 4%, compared with about 3% in the general population. The prevalence of cardiovascular malformations was 2%, compared with about 1% in the general population, according to a “Dear Healthcare Professional” letter issued by the company and the Food and Drug Administration. Ventricular septal defects were the most common cardiovascular malformation in the study.

The findings, along with those of two other recent abstracts, warrant the voluntary label change, the company indicated.

In one of the abstracts, Pia Wogelius, Ph.D., of the epidemiology department at Aarhus University Hospital, Denmark, and colleagues reported a link between SSRIs and major congenital malformations, including cardiac malformations. The risk of malformation was increased among women who had prescriptions for SSRIs filled in the 30 days before conception through the end of the first trimester, compared with those who had no SSRI prescriptions filled in the same period. These data did not specifically look at Paxil use.

The other abstract described a preliminary analysis of data obtained from the National Birth Defects Prevention Study suggesting an association between SSRI use between 1 month before and 3 months after conception and a significantly increased risk of omphalocele. The risk was greatest among paroxetine users, Sura Alwan, a Ph.D. student at the University of British Columbia, Vancouver, reported at the annual meeting of the Teratology Society.

SSRIs' use in that study also was linked with an increased risk of tetralogy of Fallot, she told this newspaper.

The Paxil labeling changes will be in the pregnancy subsection of the “precautions” section of the labels for Paxil and Paxil CR. The new language cites the GSK data but also notes these data conflict with those from previous studies, including those from the Swedish Medical Birth Registry, which showed no increased risk of major malformations in infants born to 708 women exposed to SSRIs—including paroxetine—during pregnancy.

The conflicting data make it difficult to establish a causal relationship between SSRI use and major congenital malformations. Due to the lack of adequate and well-controlled studies in humans, Paxil maintains its Pregnancy Category C status, according to GSK. However, the company said physicians should discuss the findings with their patients. Results of the GSK study are posted at the company's Clinical Trial Register at http://ctr.gsk.co.uk/welcome.asp

New data linking paroxetine use in the first trimester of pregnancy with increased risk of major congenital malformations has prompted changes to the drug's label.

Preliminary results of a retrospective epidemiologic study sponsored by GlaxoSmithKline Inc., the drug's maker, show paroxetine (marketed as Paxil) was associated with more congenital malformations (adjusted odds ratio 2.20) and more cardiovascular malformations (adjusted odds ratio 2.08) than other antidepressants in almost 3,600 pregnant women.

The prevalence of congenital malformations in the study was 4%, compared with about 3% in the general population. The prevalence of cardiovascular malformations was 2%, compared with about 1% in the general population, according to a “Dear Healthcare Professional” letter issued by the company and the Food and Drug Administration. Ventricular septal defects were the most common cardiovascular malformation in the study.

The findings, along with those of two other recent abstracts, warrant the voluntary label change, the company indicated.

In one of the abstracts, Pia Wogelius, Ph.D., of the epidemiology department at Aarhus University Hospital, Denmark, and colleagues reported a link between SSRIs and major congenital malformations, including cardiac malformations. The risk of malformation was increased among women who had prescriptions for SSRIs filled in the 30 days before conception through the end of the first trimester, compared with those who had no SSRI prescriptions filled in the same period. These data did not specifically look at Paxil use.

The other abstract described a preliminary analysis of data obtained from the National Birth Defects Prevention Study suggesting an association between SSRI use between 1 month before and 3 months after conception and a significantly increased risk of omphalocele. The risk was greatest among paroxetine users, Sura Alwan, a Ph.D. student at the University of British Columbia, Vancouver, reported at the annual meeting of the Teratology Society.

SSRIs' use in that study also was linked with an increased risk of tetralogy of Fallot, she told this newspaper.

The Paxil labeling changes will be in the pregnancy subsection of the “precautions” section of the labels for Paxil and Paxil CR. The new language cites the GSK data but also notes these data conflict with those from previous studies, including those from the Swedish Medical Birth Registry, which showed no increased risk of major malformations in infants born to 708 women exposed to SSRIs—including paroxetine—during pregnancy.

The conflicting data make it difficult to establish a causal relationship between SSRI use and major congenital malformations. Due to the lack of adequate and well-controlled studies in humans, Paxil maintains its Pregnancy Category C status, according to GSK. However, the company said physicians should discuss the findings with their patients. Results of the GSK study are posted at the company's Clinical Trial Register at http://ctr.gsk.co.uk/welcome.asp

New data linking paroxetine use in the first trimester of pregnancy with increased risk of major congenital malformations has prompted changes to the drug's label.

Preliminary results of a retrospective epidemiologic study sponsored by GlaxoSmithKline Inc., the drug's maker, show paroxetine (marketed as Paxil) was associated with more congenital malformations (adjusted odds ratio 2.20) and more cardiovascular malformations (adjusted odds ratio 2.08) than other antidepressants in almost 3,600 pregnant women.

The prevalence of congenital malformations in the study was 4%, compared with about 3% in the general population. The prevalence of cardiovascular malformations was 2%, compared with about 1% in the general population, according to a “Dear Healthcare Professional” letter issued by the company and the Food and Drug Administration. Ventricular septal defects were the most common cardiovascular malformation in the study.

The findings, along with those of two other recent abstracts, warrant the voluntary label change, the company indicated.

In one of the abstracts, Pia Wogelius, Ph.D., of the epidemiology department at Aarhus University Hospital, Denmark, and colleagues reported a link between SSRIs and major congenital malformations, including cardiac malformations. The risk of malformation was increased among women who had prescriptions for SSRIs filled in the 30 days before conception through the end of the first trimester, compared with those who had no SSRI prescriptions filled in the same period. These data did not specifically look at Paxil use.

The other abstract described a preliminary analysis of data obtained from the National Birth Defects Prevention Study suggesting an association between SSRI use between 1 month before and 3 months after conception and a significantly increased risk of omphalocele. The risk was greatest among paroxetine users, Sura Alwan, a Ph.D. student at the University of British Columbia, Vancouver, reported at the annual meeting of the Teratology Society.

SSRIs' use in that study also was linked with an increased risk of tetralogy of Fallot, she told this newspaper.

The Paxil labeling changes will be in the pregnancy subsection of the “precautions” section of the labels for Paxil and Paxil CR. The new language cites the GSK data but also notes these data conflict with those from previous studies, including those from the Swedish Medical Birth Registry, which showed no increased risk of major malformations in infants born to 708 women exposed to SSRIs—including paroxetine—during pregnancy.

The conflicting data make it difficult to establish a causal relationship between SSRI use and major congenital malformations. Due to the lack of adequate and well-controlled studies in humans, Paxil maintains its Pregnancy Category C status, according to GSK. However, the company said physicians should discuss the findings with their patients. Results of the GSK study are posted at the company's Clinical Trial Register at http://ctr.gsk.co.uk/welcome.asp

A broad coalition of public and private sector groups has launched a secure Web site where physicians and pharmacists can access medication histories for patients who were evacuated from their homes in the aftermath of Hurricane Katrina.

The Web site—www.KatrinaHealth.org

The effort is aimed at providing timely information to help physicians renew prescriptions, prescribe new medications, and coordinate care for the hundreds of thousands of people who have been displaced by Hurricane Katrina—many with chronic health conditions.

“With access to [these records] physicians I think can begin to piece together medical histories and avoid drug interactions and renew prescriptions that are vital to these patients' health,” J. Edward Hill, M.D., president of the American Medical Association said during a telephone briefing to announce the launch of KatrinaHealth.org

The information in the network comes from electronic databases from commercial pharmacies, government health insurance programs, private insurers, and pharmacy benefits managers in states affected by the storm.

At press time, the network contained more than 1 million patient records representing more than 7 million prescriptions, according to Kevin Hutchinson, president and CEO of SureScripts, an electronic prescribing service provider.

On the Web site, physicians can obtain allergy information; view prescription history as well as drug interaction and therapeutic duplication reports; and query clinical pharmacology drug information. Physicians who want access to the site can contact AMA's 24-hour Unified Service Center at 800-262-3211 to obtain a user name and password.

A broad coalition of public and private sector groups has launched a secure Web site where physicians and pharmacists can access medication histories for patients who were evacuated from their homes in the aftermath of Hurricane Katrina.

The Web site—www.KatrinaHealth.org

The effort is aimed at providing timely information to help physicians renew prescriptions, prescribe new medications, and coordinate care for the hundreds of thousands of people who have been displaced by Hurricane Katrina—many with chronic health conditions.

“With access to [these records] physicians I think can begin to piece together medical histories and avoid drug interactions and renew prescriptions that are vital to these patients' health,” J. Edward Hill, M.D., president of the American Medical Association said during a telephone briefing to announce the launch of KatrinaHealth.org

The information in the network comes from electronic databases from commercial pharmacies, government health insurance programs, private insurers, and pharmacy benefits managers in states affected by the storm.

At press time, the network contained more than 1 million patient records representing more than 7 million prescriptions, according to Kevin Hutchinson, president and CEO of SureScripts, an electronic prescribing service provider.

On the Web site, physicians can obtain allergy information; view prescription history as well as drug interaction and therapeutic duplication reports; and query clinical pharmacology drug information. Physicians who want access to the site can contact AMA's 24-hour Unified Service Center at 800-262-3211 to obtain a user name and password.

A broad coalition of public and private sector groups has launched a secure Web site where physicians and pharmacists can access medication histories for patients who were evacuated from their homes in the aftermath of Hurricane Katrina.

The Web site—www.KatrinaHealth.org

The effort is aimed at providing timely information to help physicians renew prescriptions, prescribe new medications, and coordinate care for the hundreds of thousands of people who have been displaced by Hurricane Katrina—many with chronic health conditions.

“With access to [these records] physicians I think can begin to piece together medical histories and avoid drug interactions and renew prescriptions that are vital to these patients' health,” J. Edward Hill, M.D., president of the American Medical Association said during a telephone briefing to announce the launch of KatrinaHealth.org

The information in the network comes from electronic databases from commercial pharmacies, government health insurance programs, private insurers, and pharmacy benefits managers in states affected by the storm.

At press time, the network contained more than 1 million patient records representing more than 7 million prescriptions, according to Kevin Hutchinson, president and CEO of SureScripts, an electronic prescribing service provider.

On the Web site, physicians can obtain allergy information; view prescription history as well as drug interaction and therapeutic duplication reports; and query clinical pharmacology drug information. Physicians who want access to the site can contact AMA's 24-hour Unified Service Center at 800-262-3211 to obtain a user name and password.

Edgar Mandeville, M.D., had to step out of his traditional role as an ob.gyn. when he responded to a call from a colleague to care for displaced patients in Baton Rouge, La., following Hurricane Katrina.

“We had 6,000 patients under one roof at one point, although the numbers were always in flux,” said Dr. Mandeville, who traveled from New York City to volunteer for a week at the Baton Rouge River Center.

For the first few days, he did standard emergency department work and primary care work, “taking care of people who had run out of their medications, who had gastroenteritis, upper respiratory infections, asthma,” he said in a recent interview.

The shelter was able to establish an ob.gyn. clinic when things settled down a few days later. Among the displaced pregnant women he cared for, several with severe preeclampsia had to be sent to a local hospital.

One patient went into labor, “so I rode with her in an ambulance to the hospital,” he said. On average, he worked from 9 p.m. to 9 a.m. each day. “I can't tell you how many people I saw daily.”

The goal was to get people out of the shelter as quickly as possible, and place them with relatives in other parts of the country or in resettlement areas, he said. Countless other ob.gyns. have been offering their practices or volunteer services to displaced patients in the Gulf Coast region.

At the University of Mississippi Medical Center in Jackson, James Martin, M.D., said he and other ob.gyns. “have cared for quite a few evacuees, sometimes keeping a few in-house for a few extra days until they could find housing or return home.” In one preparatory effort, his staff picked up several patients by helicopter in the 24–36 hours before Hurricane Katrina made landfall.

In addition, Dr. Martin helped place the patients of a fellow ob.gyn. with a group in Oxford, Miss., when that physician and her family fled to Atlanta.

Christopher Wiggs, M.D., an ob.gyn. who works at Woman's Hospital at River Oaks, River Oaks Hospital, and St. Dominic Hospital in Jackson, has added patients to his daily roster since Katrina. “We'll probably see that [number] increase a bit,” he said in an interview. “There's been more families absorbed into the Jackson area. A lot of people are calling this home for a while.”

As far as Dr. Wiggs knows, the majority of ob.gyn. practices in the Jackson area have taken in displaced patients from New Orleans and other places affected by the storm, Dr. Wiggs said. Many of these evacuated patients have been admitted through referrals of existing patients. One of the patients in his practice, for example, referred a sister who had come to stay with family.

For the past month, his medical practice has been on “referred call,” delivering babies and seeing patients who need ob.gyn. care. One of the patients whose baby he delivered was a woman from Ocean Springs, Miss., located east of Biloxi, who was at term when the hurricane hit.

“Most of the patients are pregnant, but several needed birth control pills, so we called in prescriptions,” he noted. Another evacuee who was going to settle in Jackson for a while was due for an annual checkup, so Dr. Wiggs gave her a yearly exam and gave her oral contraceptives.

The insurance status of these patients is uncertain “because every situation is different.” At least for the Louisiana patients, providers in Mississippi probably would be taking care of them out of network, as “Louisiana has a heavy managed care environment, whereas Mississippi does not,” he said.

Dr. Wiggs has seen some advertisements in newspapers announcing arrangements where Louisiana Medicaid and other insurance companies are waiving out-of-network penalties.

In the meantime, “we've taken care of folks who just have shown up. That's part of our job in a crisis like this.”

Dr. Wiggs has heard many stories from displaced patients about their homes being under water, about losing all of their possessions.

Others were more fortunate.

One patient who gave birth to her baby under Dr. Wiggs' care after the storm “was uplifted from her home, but her everyday life should get back to normal because her house is still intact.”

Theories exist that high levels of stress or physical problems such as dehydration can trigger a preterm labor, Dr. Wiggs said. Psychological issues factor significantly into pregnancy, but it's hard to measure, he said. So far, in his experience, most of these displaced patients have had a good attitude, despite the fact that many have lost their homes, he said. “They're happy to be in a place where they can have medical care provided for them.”

March of Dimes Eyes Long-Term Needs

The March of Dimes, which has been providing resources to sick and premature babies and pregnant women affected by Katrina, anticipates a number of long-term needs for these patients over the next 3–12 months. These include:

▸ The number of babies born prematurely is expected to rise, and these babies will require specialized neonatal intensive care units (NICUs), equipment, and care.

▸ A potentially large increase in the number of births in towns and cities such as Baton Rouge and Jackson that are housing evacuees is expected; this will strain existing facilities and services.

▸ More outreach workers and trained health professionals will need to be organized and deployed to provide prenatal care and counseling for displaced pregnant women.

▸ Updated information on available services for pregnant women and families will need to be provided as situations change; multivitamins with folic acid for women of childbearing age and pregnant women to reduce the risk of birth defects will also be needed.

▸ Infant and child vaccines will have to be purchased for shelters and clinics.

The voluntary health agency has been assisting hospitals, shelters, and towns throughout Louisiana and Mississippi. In one effort, about 100 sick and premature babies from hospitals in New Orleans and Mississippi were airlifted or transported to NICUs at Women's Hospital in Baton Rouge, the site of a new March of Dimes NICU Family Support project. The hospital also asked the March of Dimes for help with supplies such as formula and diapers for healthy babies and those being discharged.

The agency also activated and expanded its national network of 171 “Stork's Nests,” a cooperative program with Zeta Phi Beta Sorority. The program provides pregnant women with maternity clothes, baby clothes, and furniture at little or no cost; it will also enable women living in shelters and temporary housing to access health education seminars on topics such as prenatal care, nutrition, infant care, and parenting.

Edgar Mandeville, M.D., had to step out of his traditional role as an ob.gyn. when he responded to a call from a colleague to care for displaced patients in Baton Rouge, La., following Hurricane Katrina.

“We had 6,000 patients under one roof at one point, although the numbers were always in flux,” said Dr. Mandeville, who traveled from New York City to volunteer for a week at the Baton Rouge River Center.

For the first few days, he did standard emergency department work and primary care work, “taking care of people who had run out of their medications, who had gastroenteritis, upper respiratory infections, asthma,” he said in a recent interview.

The shelter was able to establish an ob.gyn. clinic when things settled down a few days later. Among the displaced pregnant women he cared for, several with severe preeclampsia had to be sent to a local hospital.

One patient went into labor, “so I rode with her in an ambulance to the hospital,” he said. On average, he worked from 9 p.m. to 9 a.m. each day. “I can't tell you how many people I saw daily.”

The goal was to get people out of the shelter as quickly as possible, and place them with relatives in other parts of the country or in resettlement areas, he said. Countless other ob.gyns. have been offering their practices or volunteer services to displaced patients in the Gulf Coast region.

At the University of Mississippi Medical Center in Jackson, James Martin, M.D., said he and other ob.gyns. “have cared for quite a few evacuees, sometimes keeping a few in-house for a few extra days until they could find housing or return home.” In one preparatory effort, his staff picked up several patients by helicopter in the 24–36 hours before Hurricane Katrina made landfall.

In addition, Dr. Martin helped place the patients of a fellow ob.gyn. with a group in Oxford, Miss., when that physician and her family fled to Atlanta.

Christopher Wiggs, M.D., an ob.gyn. who works at Woman's Hospital at River Oaks, River Oaks Hospital, and St. Dominic Hospital in Jackson, has added patients to his daily roster since Katrina. “We'll probably see that [number] increase a bit,” he said in an interview. “There's been more families absorbed into the Jackson area. A lot of people are calling this home for a while.”

As far as Dr. Wiggs knows, the majority of ob.gyn. practices in the Jackson area have taken in displaced patients from New Orleans and other places affected by the storm, Dr. Wiggs said. Many of these evacuated patients have been admitted through referrals of existing patients. One of the patients in his practice, for example, referred a sister who had come to stay with family.

For the past month, his medical practice has been on “referred call,” delivering babies and seeing patients who need ob.gyn. care. One of the patients whose baby he delivered was a woman from Ocean Springs, Miss., located east of Biloxi, who was at term when the hurricane hit.

“Most of the patients are pregnant, but several needed birth control pills, so we called in prescriptions,” he noted. Another evacuee who was going to settle in Jackson for a while was due for an annual checkup, so Dr. Wiggs gave her a yearly exam and gave her oral contraceptives.

The insurance status of these patients is uncertain “because every situation is different.” At least for the Louisiana patients, providers in Mississippi probably would be taking care of them out of network, as “Louisiana has a heavy managed care environment, whereas Mississippi does not,” he said.

Dr. Wiggs has seen some advertisements in newspapers announcing arrangements where Louisiana Medicaid and other insurance companies are waiving out-of-network penalties.

In the meantime, “we've taken care of folks who just have shown up. That's part of our job in a crisis like this.”

Dr. Wiggs has heard many stories from displaced patients about their homes being under water, about losing all of their possessions.

Others were more fortunate.

One patient who gave birth to her baby under Dr. Wiggs' care after the storm “was uplifted from her home, but her everyday life should get back to normal because her house is still intact.”

Theories exist that high levels of stress or physical problems such as dehydration can trigger a preterm labor, Dr. Wiggs said. Psychological issues factor significantly into pregnancy, but it's hard to measure, he said. So far, in his experience, most of these displaced patients have had a good attitude, despite the fact that many have lost their homes, he said. “They're happy to be in a place where they can have medical care provided for them.”

March of Dimes Eyes Long-Term Needs

The March of Dimes, which has been providing resources to sick and premature babies and pregnant women affected by Katrina, anticipates a number of long-term needs for these patients over the next 3–12 months. These include:

▸ The number of babies born prematurely is expected to rise, and these babies will require specialized neonatal intensive care units (NICUs), equipment, and care.

▸ A potentially large increase in the number of births in towns and cities such as Baton Rouge and Jackson that are housing evacuees is expected; this will strain existing facilities and services.

▸ More outreach workers and trained health professionals will need to be organized and deployed to provide prenatal care and counseling for displaced pregnant women.

▸ Updated information on available services for pregnant women and families will need to be provided as situations change; multivitamins with folic acid for women of childbearing age and pregnant women to reduce the risk of birth defects will also be needed.

▸ Infant and child vaccines will have to be purchased for shelters and clinics.

The voluntary health agency has been assisting hospitals, shelters, and towns throughout Louisiana and Mississippi. In one effort, about 100 sick and premature babies from hospitals in New Orleans and Mississippi were airlifted or transported to NICUs at Women's Hospital in Baton Rouge, the site of a new March of Dimes NICU Family Support project. The hospital also asked the March of Dimes for help with supplies such as formula and diapers for healthy babies and those being discharged.

The agency also activated and expanded its national network of 171 “Stork's Nests,” a cooperative program with Zeta Phi Beta Sorority. The program provides pregnant women with maternity clothes, baby clothes, and furniture at little or no cost; it will also enable women living in shelters and temporary housing to access health education seminars on topics such as prenatal care, nutrition, infant care, and parenting.

Edgar Mandeville, M.D., had to step out of his traditional role as an ob.gyn. when he responded to a call from a colleague to care for displaced patients in Baton Rouge, La., following Hurricane Katrina.

“We had 6,000 patients under one roof at one point, although the numbers were always in flux,” said Dr. Mandeville, who traveled from New York City to volunteer for a week at the Baton Rouge River Center.

For the first few days, he did standard emergency department work and primary care work, “taking care of people who had run out of their medications, who had gastroenteritis, upper respiratory infections, asthma,” he said in a recent interview.

The shelter was able to establish an ob.gyn. clinic when things settled down a few days later. Among the displaced pregnant women he cared for, several with severe preeclampsia had to be sent to a local hospital.

One patient went into labor, “so I rode with her in an ambulance to the hospital,” he said. On average, he worked from 9 p.m. to 9 a.m. each day. “I can't tell you how many people I saw daily.”

The goal was to get people out of the shelter as quickly as possible, and place them with relatives in other parts of the country or in resettlement areas, he said. Countless other ob.gyns. have been offering their practices or volunteer services to displaced patients in the Gulf Coast region.

At the University of Mississippi Medical Center in Jackson, James Martin, M.D., said he and other ob.gyns. “have cared for quite a few evacuees, sometimes keeping a few in-house for a few extra days until they could find housing or return home.” In one preparatory effort, his staff picked up several patients by helicopter in the 24–36 hours before Hurricane Katrina made landfall.

In addition, Dr. Martin helped place the patients of a fellow ob.gyn. with a group in Oxford, Miss., when that physician and her family fled to Atlanta.

Christopher Wiggs, M.D., an ob.gyn. who works at Woman's Hospital at River Oaks, River Oaks Hospital, and St. Dominic Hospital in Jackson, has added patients to his daily roster since Katrina. “We'll probably see that [number] increase a bit,” he said in an interview. “There's been more families absorbed into the Jackson area. A lot of people are calling this home for a while.”

As far as Dr. Wiggs knows, the majority of ob.gyn. practices in the Jackson area have taken in displaced patients from New Orleans and other places affected by the storm, Dr. Wiggs said. Many of these evacuated patients have been admitted through referrals of existing patients. One of the patients in his practice, for example, referred a sister who had come to stay with family.

For the past month, his medical practice has been on “referred call,” delivering babies and seeing patients who need ob.gyn. care. One of the patients whose baby he delivered was a woman from Ocean Springs, Miss., located east of Biloxi, who was at term when the hurricane hit.

“Most of the patients are pregnant, but several needed birth control pills, so we called in prescriptions,” he noted. Another evacuee who was going to settle in Jackson for a while was due for an annual checkup, so Dr. Wiggs gave her a yearly exam and gave her oral contraceptives.

The insurance status of these patients is uncertain “because every situation is different.” At least for the Louisiana patients, providers in Mississippi probably would be taking care of them out of network, as “Louisiana has a heavy managed care environment, whereas Mississippi does not,” he said.

Dr. Wiggs has seen some advertisements in newspapers announcing arrangements where Louisiana Medicaid and other insurance companies are waiving out-of-network penalties.

In the meantime, “we've taken care of folks who just have shown up. That's part of our job in a crisis like this.”

Dr. Wiggs has heard many stories from displaced patients about their homes being under water, about losing all of their possessions.

Others were more fortunate.

One patient who gave birth to her baby under Dr. Wiggs' care after the storm “was uplifted from her home, but her everyday life should get back to normal because her house is still intact.”

Theories exist that high levels of stress or physical problems such as dehydration can trigger a preterm labor, Dr. Wiggs said. Psychological issues factor significantly into pregnancy, but it's hard to measure, he said. So far, in his experience, most of these displaced patients have had a good attitude, despite the fact that many have lost their homes, he said. “They're happy to be in a place where they can have medical care provided for them.”

March of Dimes Eyes Long-Term Needs

The March of Dimes, which has been providing resources to sick and premature babies and pregnant women affected by Katrina, anticipates a number of long-term needs for these patients over the next 3–12 months. These include:

▸ The number of babies born prematurely is expected to rise, and these babies will require specialized neonatal intensive care units (NICUs), equipment, and care.

▸ A potentially large increase in the number of births in towns and cities such as Baton Rouge and Jackson that are housing evacuees is expected; this will strain existing facilities and services.

▸ More outreach workers and trained health professionals will need to be organized and deployed to provide prenatal care and counseling for displaced pregnant women.

▸ Updated information on available services for pregnant women and families will need to be provided as situations change; multivitamins with folic acid for women of childbearing age and pregnant women to reduce the risk of birth defects will also be needed.

▸ Infant and child vaccines will have to be purchased for shelters and clinics.

The voluntary health agency has been assisting hospitals, shelters, and towns throughout Louisiana and Mississippi. In one effort, about 100 sick and premature babies from hospitals in New Orleans and Mississippi were airlifted or transported to NICUs at Women's Hospital in Baton Rouge, the site of a new March of Dimes NICU Family Support project. The hospital also asked the March of Dimes for help with supplies such as formula and diapers for healthy babies and those being discharged.

The agency also activated and expanded its national network of 171 “Stork's Nests,” a cooperative program with Zeta Phi Beta Sorority. The program provides pregnant women with maternity clothes, baby clothes, and furniture at little or no cost; it will also enable women living in shelters and temporary housing to access health education seminars on topics such as prenatal care, nutrition, infant care, and parenting.

STOCKHOLM — Autoantibodies directed against the β₁-adrenergic receptor appear to play a role in the pathogenesis of postpartum cardiomyopathy, Gerd Wallukat, M.D., said at the annual congress of the European Society of Cardiology.

Evidence has implicated autoantibodies against the β₁-adrenergic receptor in the development of dilated cardiomyopathy. In light of that, Dr. Wallukat and coworkers sought evidence of a similar phenomenon in 26 women with postpartum cardiomyopathy.

They found it. Serum obtained when the women presented in New York Heart Association functional class III or IV with postpartum cardiomyopathy did show such autoantibodies in all 26 patients and in none of a healthy age-matched control group. The autoantibodies appeared to have a dose-dependent agonist effect, said Dr. Wallukat of the Max Delbrück Center, Berlin.

The autoantibodies were identified using a bioassay that utilized cultured, spontaneously beating, neonatal rat cardiomyocytes, which beat faster on β-adrenergic stimulation. Prolonged exposure did not desensitize the β₁-adrenergic receptors.

The agonist effect was inhibited in vitro by β₁-adrenergic receptor antagonists, which explains the improvement of postpartum cardiomyopathy patients when treated with β-blockers.

Sera obtained after 6 months showed a sharp reduction in autoantibody activity. This improvement was paralleled in the New York Heart Association functional class and cardiac function in 24 of the 26 women.

STOCKHOLM — Autoantibodies directed against the β₁-adrenergic receptor appear to play a role in the pathogenesis of postpartum cardiomyopathy, Gerd Wallukat, M.D., said at the annual congress of the European Society of Cardiology.

Evidence has implicated autoantibodies against the β₁-adrenergic receptor in the development of dilated cardiomyopathy. In light of that, Dr. Wallukat and coworkers sought evidence of a similar phenomenon in 26 women with postpartum cardiomyopathy.

They found it. Serum obtained when the women presented in New York Heart Association functional class III or IV with postpartum cardiomyopathy did show such autoantibodies in all 26 patients and in none of a healthy age-matched control group. The autoantibodies appeared to have a dose-dependent agonist effect, said Dr. Wallukat of the Max Delbrück Center, Berlin.

The autoantibodies were identified using a bioassay that utilized cultured, spontaneously beating, neonatal rat cardiomyocytes, which beat faster on β-adrenergic stimulation. Prolonged exposure did not desensitize the β₁-adrenergic receptors.

The agonist effect was inhibited in vitro by β₁-adrenergic receptor antagonists, which explains the improvement of postpartum cardiomyopathy patients when treated with β-blockers.

Sera obtained after 6 months showed a sharp reduction in autoantibody activity. This improvement was paralleled in the New York Heart Association functional class and cardiac function in 24 of the 26 women.

STOCKHOLM — Autoantibodies directed against the β₁-adrenergic receptor appear to play a role in the pathogenesis of postpartum cardiomyopathy, Gerd Wallukat, M.D., said at the annual congress of the European Society of Cardiology.

Evidence has implicated autoantibodies against the β₁-adrenergic receptor in the development of dilated cardiomyopathy. In light of that, Dr. Wallukat and coworkers sought evidence of a similar phenomenon in 26 women with postpartum cardiomyopathy.

They found it. Serum obtained when the women presented in New York Heart Association functional class III or IV with postpartum cardiomyopathy did show such autoantibodies in all 26 patients and in none of a healthy age-matched control group. The autoantibodies appeared to have a dose-dependent agonist effect, said Dr. Wallukat of the Max Delbrück Center, Berlin.

The autoantibodies were identified using a bioassay that utilized cultured, spontaneously beating, neonatal rat cardiomyocytes, which beat faster on β-adrenergic stimulation. Prolonged exposure did not desensitize the β₁-adrenergic receptors.

The agonist effect was inhibited in vitro by β₁-adrenergic receptor antagonists, which explains the improvement of postpartum cardiomyopathy patients when treated with β-blockers.

Sera obtained after 6 months showed a sharp reduction in autoantibody activity. This improvement was paralleled in the New York Heart Association functional class and cardiac function in 24 of the 26 women.