Obstetrics

STOCKHOLM — Pregnancy in women with isolated congenital pulmonary valve stenosis is associated with an extremely high rate of obstetric and fetal complications, Willem Drenthen, M.D., reported at the annual congress of the European Society of Cardiology.

The specific nature of these complications varies depending on whether the congenital heart defect was surgically corrected before pregnancy, said Dr. Drenthen of University Medical Center, Groningen, the Netherlands.

It has generally been assumed that pregnancy in women with isolated congenital pulmonary valve stenosis is well tolerated. Data from a Dutch national registry indicate otherwise. The registry has documented 81 completed pregnancies in women with this congenital heart defect. A total of 44 cases involved those whose valvular anomaly was surgically corrected before pregnancy. Women who had not undergone surgery had only a mild pulmonary valve gradient.

Roughly 60% of the pregnancies involved at least one obstetric and/or neonatal complication. Particularly striking were the high incidence of pregnancy-induced hypertension in women with uncorrected congenital pulmonary valve stenosis, as well as the markedly elevated rates of preterm labor, preterm delivery, and postpartum hemorrhage in patients with a corrected heart defect. (See chart.) Four percent of newborns had congenital heart disease. The neonatal mortality rate was 5%, with deaths due to immaturity, meningitis, and hydrocephalus combined with prematurity.

STOCKHOLM — Pregnancy in women with isolated congenital pulmonary valve stenosis is associated with an extremely high rate of obstetric and fetal complications, Willem Drenthen, M.D., reported at the annual congress of the European Society of Cardiology.

The specific nature of these complications varies depending on whether the congenital heart defect was surgically corrected before pregnancy, said Dr. Drenthen of University Medical Center, Groningen, the Netherlands.

It has generally been assumed that pregnancy in women with isolated congenital pulmonary valve stenosis is well tolerated. Data from a Dutch national registry indicate otherwise. The registry has documented 81 completed pregnancies in women with this congenital heart defect. A total of 44 cases involved those whose valvular anomaly was surgically corrected before pregnancy. Women who had not undergone surgery had only a mild pulmonary valve gradient.

Roughly 60% of the pregnancies involved at least one obstetric and/or neonatal complication. Particularly striking were the high incidence of pregnancy-induced hypertension in women with uncorrected congenital pulmonary valve stenosis, as well as the markedly elevated rates of preterm labor, preterm delivery, and postpartum hemorrhage in patients with a corrected heart defect. (See chart.) Four percent of newborns had congenital heart disease. The neonatal mortality rate was 5%, with deaths due to immaturity, meningitis, and hydrocephalus combined with prematurity.

STOCKHOLM — Pregnancy in women with isolated congenital pulmonary valve stenosis is associated with an extremely high rate of obstetric and fetal complications, Willem Drenthen, M.D., reported at the annual congress of the European Society of Cardiology.

The specific nature of these complications varies depending on whether the congenital heart defect was surgically corrected before pregnancy, said Dr. Drenthen of University Medical Center, Groningen, the Netherlands.

It has generally been assumed that pregnancy in women with isolated congenital pulmonary valve stenosis is well tolerated. Data from a Dutch national registry indicate otherwise. The registry has documented 81 completed pregnancies in women with this congenital heart defect. A total of 44 cases involved those whose valvular anomaly was surgically corrected before pregnancy. Women who had not undergone surgery had only a mild pulmonary valve gradient.

Roughly 60% of the pregnancies involved at least one obstetric and/or neonatal complication. Particularly striking were the high incidence of pregnancy-induced hypertension in women with uncorrected congenital pulmonary valve stenosis, as well as the markedly elevated rates of preterm labor, preterm delivery, and postpartum hemorrhage in patients with a corrected heart defect. (See chart.) Four percent of newborns had congenital heart disease. The neonatal mortality rate was 5%, with deaths due to immaturity, meningitis, and hydrocephalus combined with prematurity.

The following factors are associated with an increased risk of emergency cesarean section in women who have had a previous cesarean section and are attempting vaginal birth: older maternal age, low maternal height, male gender of baby, labor induced by prostaglandin, not having had a previous vaginal birth, and later birth.

These are the key conclusions of a study that used a new method to predict the risk of failed vaginal birth after a cesarean section.

“There is, at present, no validated method that allows antepartum assessment of the risks of emergency cesarean section, and counseling of women is, at best, semiquantitative,” wrote the investigators, who were led by Gordon C.S. Smith, M.B., of the department of obstetrics and gynecology at Cambridge University, United Kingdom. “In the present study, we provide a validated model that classifies over half this population as being low or high risk of emergency cesarean section, on the basis of thresholds suggested by a previous systematic review.”

He and his associates studied 23,286 women in Scotland, each of whom had one prior cesarean delivery and who attempted vaginal birth at or after 40 weeks' gestation between 1985 and 2001 (PLoS Med. 2005;2[9]:e252). They randomly divided the women into group 1 (the model development group) and group 2 (the validation group).

In group 1, the investigators tested their method of determining risk of emergency cesarean section by examining various risk factors including the mother's age and height, the sex of the baby, gestational age, and whether and how the birth was induced. When they applied the model to the women in group 2, they predicted that 36% had a low risk of cesarean section and 16.5% had a high risk. When they compared their predictions with the actual outcomes, however, they found that the actual rate of cesarean section was 10.9% among low-risk women and 47.7% among high-risk women.

The risk of emergency cesarean section was increased by factors such as the mother being of older age and less height and not having given birth previously. Other factors include a male baby, labor induced by prostaglandin, and later birth.

The investigators also found that as the risk of cesarean section increased, so did the risk for uterine rupture. The observed incidence of uterine rupture among low-risk women was 2.0 per 1,000, compared with an incidence of 9.1 per 1,000 among high-risk women.

The investigators acknowledged certain limitations of the study, including concerns about how the model would apply to other populations. “However, we assessed the robustness of the predictors employed by selecting records for the development and validation groups on the basis of factors that might reflect variation in other populations,” they wrote.

“We found the model was similarly predictive in and out of sample when these categorizations were performed by hospital throughput, socioeconomic deprivation category, and year of birth. This finding suggests that the maternal and obstetric characteristics used in the model are likely to be robust even when applied to populations with different obstetric practices.”

The following factors are associated with an increased risk of emergency cesarean section in women who have had a previous cesarean section and are attempting vaginal birth: older maternal age, low maternal height, male gender of baby, labor induced by prostaglandin, not having had a previous vaginal birth, and later birth.

These are the key conclusions of a study that used a new method to predict the risk of failed vaginal birth after a cesarean section.

“There is, at present, no validated method that allows antepartum assessment of the risks of emergency cesarean section, and counseling of women is, at best, semiquantitative,” wrote the investigators, who were led by Gordon C.S. Smith, M.B., of the department of obstetrics and gynecology at Cambridge University, United Kingdom. “In the present study, we provide a validated model that classifies over half this population as being low or high risk of emergency cesarean section, on the basis of thresholds suggested by a previous systematic review.”

He and his associates studied 23,286 women in Scotland, each of whom had one prior cesarean delivery and who attempted vaginal birth at or after 40 weeks' gestation between 1985 and 2001 (PLoS Med. 2005;2[9]:e252). They randomly divided the women into group 1 (the model development group) and group 2 (the validation group).

In group 1, the investigators tested their method of determining risk of emergency cesarean section by examining various risk factors including the mother's age and height, the sex of the baby, gestational age, and whether and how the birth was induced. When they applied the model to the women in group 2, they predicted that 36% had a low risk of cesarean section and 16.5% had a high risk. When they compared their predictions with the actual outcomes, however, they found that the actual rate of cesarean section was 10.9% among low-risk women and 47.7% among high-risk women.

The risk of emergency cesarean section was increased by factors such as the mother being of older age and less height and not having given birth previously. Other factors include a male baby, labor induced by prostaglandin, and later birth.

The investigators also found that as the risk of cesarean section increased, so did the risk for uterine rupture. The observed incidence of uterine rupture among low-risk women was 2.0 per 1,000, compared with an incidence of 9.1 per 1,000 among high-risk women.

The investigators acknowledged certain limitations of the study, including concerns about how the model would apply to other populations. “However, we assessed the robustness of the predictors employed by selecting records for the development and validation groups on the basis of factors that might reflect variation in other populations,” they wrote.

“We found the model was similarly predictive in and out of sample when these categorizations were performed by hospital throughput, socioeconomic deprivation category, and year of birth. This finding suggests that the maternal and obstetric characteristics used in the model are likely to be robust even when applied to populations with different obstetric practices.”

The following factors are associated with an increased risk of emergency cesarean section in women who have had a previous cesarean section and are attempting vaginal birth: older maternal age, low maternal height, male gender of baby, labor induced by prostaglandin, not having had a previous vaginal birth, and later birth.

These are the key conclusions of a study that used a new method to predict the risk of failed vaginal birth after a cesarean section.

“There is, at present, no validated method that allows antepartum assessment of the risks of emergency cesarean section, and counseling of women is, at best, semiquantitative,” wrote the investigators, who were led by Gordon C.S. Smith, M.B., of the department of obstetrics and gynecology at Cambridge University, United Kingdom. “In the present study, we provide a validated model that classifies over half this population as being low or high risk of emergency cesarean section, on the basis of thresholds suggested by a previous systematic review.”

He and his associates studied 23,286 women in Scotland, each of whom had one prior cesarean delivery and who attempted vaginal birth at or after 40 weeks' gestation between 1985 and 2001 (PLoS Med. 2005;2[9]:e252). They randomly divided the women into group 1 (the model development group) and group 2 (the validation group).

In group 1, the investigators tested their method of determining risk of emergency cesarean section by examining various risk factors including the mother's age and height, the sex of the baby, gestational age, and whether and how the birth was induced. When they applied the model to the women in group 2, they predicted that 36% had a low risk of cesarean section and 16.5% had a high risk. When they compared their predictions with the actual outcomes, however, they found that the actual rate of cesarean section was 10.9% among low-risk women and 47.7% among high-risk women.

The risk of emergency cesarean section was increased by factors such as the mother being of older age and less height and not having given birth previously. Other factors include a male baby, labor induced by prostaglandin, and later birth.

The investigators also found that as the risk of cesarean section increased, so did the risk for uterine rupture. The observed incidence of uterine rupture among low-risk women was 2.0 per 1,000, compared with an incidence of 9.1 per 1,000 among high-risk women.

The investigators acknowledged certain limitations of the study, including concerns about how the model would apply to other populations. “However, we assessed the robustness of the predictors employed by selecting records for the development and validation groups on the basis of factors that might reflect variation in other populations,” they wrote.

“We found the model was similarly predictive in and out of sample when these categorizations were performed by hospital throughput, socioeconomic deprivation category, and year of birth. This finding suggests that the maternal and obstetric characteristics used in the model are likely to be robust even when applied to populations with different obstetric practices.”

SAN DIEGO — A pregnant woman successfully delivered twins at term after undergoing laparoscopic cholecystectomy for symptomatic gall bladder disease during the first trimester, Kathy Gohar, M.D., said.

Cholecystectomy is one of the most common nonobstetric surgeries performed during pregnancy, but limited experience with the relatively new laparoscopic approach makes it controversial. About 10%–40% of patients with symptomatic gallstone disease require surgical treatment, said Dr. Gohar of Albert Einstein Medical Center, Philadelphia, and her associates.

Potential advantages of laparoscopic cholecystectomy include less need for narcotics that cause fetal depression, less postoperative pain, shorter hospital stay, a smaller incision, quicker return of bowel activity, and less chance of incisional hernia, compared with open cholecystectomy.

The 24-year-old woman with twins at 17 weeks' gestation came to the emergency department complaining of 4 days of abdominal pain with nausea and vomiting. She recently had been admitted to a separate hospital for biliary colic and had been treated conservatively with IV hydration, antiemetics, and analgesics. Approximately 60% of patients with symptomatic gallstone disease will require additional hospitalizations after receiving conservative medical management.

The patient had stable vital signs and no fever. Her abdomen was soft with positive bowel sounds and tenderness in the right upper quadrant with deep palpation.

Dr. Gohar and her associates resumed the medical management strategies, but the patient failed oral feeding and continued to have nausea, vomiting, diarrhea, and abdominal pain. An ultrasound exam showed a 19-mm solitary gallstone at the neck of the gall bladder. The common bile duct measured 5.3 mm on imaging, and no pericholecystic fluid or gall bladder wall thickening was observed.

The patient was given preoperative antibiotics and the tocolytic agent indomethacin and taken to the operating room for laparoscopic cholecystectomy. During surgery, her abdominal tissues were fragile and at times bled easily, Dr. Gohar said. Surgeons removed the gall bladder, found it to be filled with mucinous fluid, and diagnosed hydrops of the gall bladder.

After two postoperative days without any intrauterine contractions, the patient was discharged. She developed no complications and subsequently delivered healthy twins at 36 weeks' gestation.

The ideal time for cholecystectomy during pregnancy is not during the first trimester, as in this case, but in the second trimester. By that time, the woman has passed the time of greatest risk for spontaneous abortion, organogenesis is complete, induction of premature labor is less likely than later in pregnancy, and the uterus is not too large for operative intervention, Dr. Gohar said.

She and her associates followed recommendations in the medical literature for management of gall bladder disease during pregnancy. They obtained a preoperative obstetrical consultation and monitored for uterine contractions before and after surgery. Use of tocolytics is advised from 20 to 32 weeks' gestation in these cases, she noted.

Surgeons placed the patient in a left anterior oblique position to displace the uterus from the inferior vena cava. They used a pneumoperitoneum compression device, since pregnancy induces a hypercoagulable state and the pneumoperitoneum enhances venous stasis in the lower extremities. Fetal heart monitoring was conducted before and during surgery.

After measuring the uterine fundus height, they inserted the primary trocar via the Hasson technique (at the supraumbilical subxiphoid or left upper quadrant) and inserted the secondary trocars higher than called for in nonpregnant patients. They monitored maternal end-tidal carbon dioxide measurements to indirectly gauge fetal carbon dioxide levels.

If an intraoperative cholangiogram is needed during pregnancy, a lead shield should be employed to protect the gravid uterus, and fluoroscopy should be used selectively, Dr. Gohar added. Patients with enlarged uteri are better candidates for open cholecystectomy than the laparoscopic approach to provide sufficient abdominal access.

SAN DIEGO — A pregnant woman successfully delivered twins at term after undergoing laparoscopic cholecystectomy for symptomatic gall bladder disease during the first trimester, Kathy Gohar, M.D., said.

Cholecystectomy is one of the most common nonobstetric surgeries performed during pregnancy, but limited experience with the relatively new laparoscopic approach makes it controversial. About 10%–40% of patients with symptomatic gallstone disease require surgical treatment, said Dr. Gohar of Albert Einstein Medical Center, Philadelphia, and her associates.

Potential advantages of laparoscopic cholecystectomy include less need for narcotics that cause fetal depression, less postoperative pain, shorter hospital stay, a smaller incision, quicker return of bowel activity, and less chance of incisional hernia, compared with open cholecystectomy.

The 24-year-old woman with twins at 17 weeks' gestation came to the emergency department complaining of 4 days of abdominal pain with nausea and vomiting. She recently had been admitted to a separate hospital for biliary colic and had been treated conservatively with IV hydration, antiemetics, and analgesics. Approximately 60% of patients with symptomatic gallstone disease will require additional hospitalizations after receiving conservative medical management.

The patient had stable vital signs and no fever. Her abdomen was soft with positive bowel sounds and tenderness in the right upper quadrant with deep palpation.

Dr. Gohar and her associates resumed the medical management strategies, but the patient failed oral feeding and continued to have nausea, vomiting, diarrhea, and abdominal pain. An ultrasound exam showed a 19-mm solitary gallstone at the neck of the gall bladder. The common bile duct measured 5.3 mm on imaging, and no pericholecystic fluid or gall bladder wall thickening was observed.

The patient was given preoperative antibiotics and the tocolytic agent indomethacin and taken to the operating room for laparoscopic cholecystectomy. During surgery, her abdominal tissues were fragile and at times bled easily, Dr. Gohar said. Surgeons removed the gall bladder, found it to be filled with mucinous fluid, and diagnosed hydrops of the gall bladder.

After two postoperative days without any intrauterine contractions, the patient was discharged. She developed no complications and subsequently delivered healthy twins at 36 weeks' gestation.

The ideal time for cholecystectomy during pregnancy is not during the first trimester, as in this case, but in the second trimester. By that time, the woman has passed the time of greatest risk for spontaneous abortion, organogenesis is complete, induction of premature labor is less likely than later in pregnancy, and the uterus is not too large for operative intervention, Dr. Gohar said.

She and her associates followed recommendations in the medical literature for management of gall bladder disease during pregnancy. They obtained a preoperative obstetrical consultation and monitored for uterine contractions before and after surgery. Use of tocolytics is advised from 20 to 32 weeks' gestation in these cases, she noted.

Surgeons placed the patient in a left anterior oblique position to displace the uterus from the inferior vena cava. They used a pneumoperitoneum compression device, since pregnancy induces a hypercoagulable state and the pneumoperitoneum enhances venous stasis in the lower extremities. Fetal heart monitoring was conducted before and during surgery.

After measuring the uterine fundus height, they inserted the primary trocar via the Hasson technique (at the supraumbilical subxiphoid or left upper quadrant) and inserted the secondary trocars higher than called for in nonpregnant patients. They monitored maternal end-tidal carbon dioxide measurements to indirectly gauge fetal carbon dioxide levels.

If an intraoperative cholangiogram is needed during pregnancy, a lead shield should be employed to protect the gravid uterus, and fluoroscopy should be used selectively, Dr. Gohar added. Patients with enlarged uteri are better candidates for open cholecystectomy than the laparoscopic approach to provide sufficient abdominal access.

SAN DIEGO — A pregnant woman successfully delivered twins at term after undergoing laparoscopic cholecystectomy for symptomatic gall bladder disease during the first trimester, Kathy Gohar, M.D., said.

Cholecystectomy is one of the most common nonobstetric surgeries performed during pregnancy, but limited experience with the relatively new laparoscopic approach makes it controversial. About 10%–40% of patients with symptomatic gallstone disease require surgical treatment, said Dr. Gohar of Albert Einstein Medical Center, Philadelphia, and her associates.

Potential advantages of laparoscopic cholecystectomy include less need for narcotics that cause fetal depression, less postoperative pain, shorter hospital stay, a smaller incision, quicker return of bowel activity, and less chance of incisional hernia, compared with open cholecystectomy.

The 24-year-old woman with twins at 17 weeks' gestation came to the emergency department complaining of 4 days of abdominal pain with nausea and vomiting. She recently had been admitted to a separate hospital for biliary colic and had been treated conservatively with IV hydration, antiemetics, and analgesics. Approximately 60% of patients with symptomatic gallstone disease will require additional hospitalizations after receiving conservative medical management.

The patient had stable vital signs and no fever. Her abdomen was soft with positive bowel sounds and tenderness in the right upper quadrant with deep palpation.

Dr. Gohar and her associates resumed the medical management strategies, but the patient failed oral feeding and continued to have nausea, vomiting, diarrhea, and abdominal pain. An ultrasound exam showed a 19-mm solitary gallstone at the neck of the gall bladder. The common bile duct measured 5.3 mm on imaging, and no pericholecystic fluid or gall bladder wall thickening was observed.

The patient was given preoperative antibiotics and the tocolytic agent indomethacin and taken to the operating room for laparoscopic cholecystectomy. During surgery, her abdominal tissues were fragile and at times bled easily, Dr. Gohar said. Surgeons removed the gall bladder, found it to be filled with mucinous fluid, and diagnosed hydrops of the gall bladder.

After two postoperative days without any intrauterine contractions, the patient was discharged. She developed no complications and subsequently delivered healthy twins at 36 weeks' gestation.

The ideal time for cholecystectomy during pregnancy is not during the first trimester, as in this case, but in the second trimester. By that time, the woman has passed the time of greatest risk for spontaneous abortion, organogenesis is complete, induction of premature labor is less likely than later in pregnancy, and the uterus is not too large for operative intervention, Dr. Gohar said.

She and her associates followed recommendations in the medical literature for management of gall bladder disease during pregnancy. They obtained a preoperative obstetrical consultation and monitored for uterine contractions before and after surgery. Use of tocolytics is advised from 20 to 32 weeks' gestation in these cases, she noted.

Surgeons placed the patient in a left anterior oblique position to displace the uterus from the inferior vena cava. They used a pneumoperitoneum compression device, since pregnancy induces a hypercoagulable state and the pneumoperitoneum enhances venous stasis in the lower extremities. Fetal heart monitoring was conducted before and during surgery.

After measuring the uterine fundus height, they inserted the primary trocar via the Hasson technique (at the supraumbilical subxiphoid or left upper quadrant) and inserted the secondary trocars higher than called for in nonpregnant patients. They monitored maternal end-tidal carbon dioxide measurements to indirectly gauge fetal carbon dioxide levels.

If an intraoperative cholangiogram is needed during pregnancy, a lead shield should be employed to protect the gravid uterus, and fluoroscopy should be used selectively, Dr. Gohar added. Patients with enlarged uteri are better candidates for open cholecystectomy than the laparoscopic approach to provide sufficient abdominal access.

CHARLESTON, S.C. — HIV-infected women were at no greater risk for postpartum depression than were their HIV-negative counterparts in a recent study, Nyota A. Peace, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The retrospective case-control study included 26 HIV-infected pregnant women. There were also 52 uninfected controls who were divided into two groups—those with a high-risk pregnancy and those with a low-risk pregnancy.

The case patients and controls were matched for age, race, and study period, and did not differ in regard to education levels, substance abuse, and history of depression, according to Dr. Peace of New Jersey Medical School, Newark.

High-risk control patients had the highest mean depression scores (8 out of a possible 30 on the Edinburgh Postnatal Depression Scale), but the scores did not differ significantly between these patients, the HIV patients (mean score of 5), or the low-risk control women (mean score of 5).

Compared with the women with low depression scores (under 11), those with high depression scores (greater than 11) did not differ in regard to the presence of typical risk factors for postpartum depression, such as young age, pregnancy-induced anxiety, life stressors, and lack of social support.

Although a high prevalence of depression in the HIV-positive population has been reported, data on the association between HIV and postpartum depression are limited.

The findings suggest that high-risk conditions other than HIV infection are linked with higher depression scores, and that factors typically associated with higher risk for postpartum depression are no more prevalent in patients with high depression scores than in those with low depression scores, Dr. Peace said at the meeting.

CHARLESTON, S.C. — HIV-infected women were at no greater risk for postpartum depression than were their HIV-negative counterparts in a recent study, Nyota A. Peace, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The retrospective case-control study included 26 HIV-infected pregnant women. There were also 52 uninfected controls who were divided into two groups—those with a high-risk pregnancy and those with a low-risk pregnancy.

The case patients and controls were matched for age, race, and study period, and did not differ in regard to education levels, substance abuse, and history of depression, according to Dr. Peace of New Jersey Medical School, Newark.

High-risk control patients had the highest mean depression scores (8 out of a possible 30 on the Edinburgh Postnatal Depression Scale), but the scores did not differ significantly between these patients, the HIV patients (mean score of 5), or the low-risk control women (mean score of 5).

Compared with the women with low depression scores (under 11), those with high depression scores (greater than 11) did not differ in regard to the presence of typical risk factors for postpartum depression, such as young age, pregnancy-induced anxiety, life stressors, and lack of social support.

Although a high prevalence of depression in the HIV-positive population has been reported, data on the association between HIV and postpartum depression are limited.

The findings suggest that high-risk conditions other than HIV infection are linked with higher depression scores, and that factors typically associated with higher risk for postpartum depression are no more prevalent in patients with high depression scores than in those with low depression scores, Dr. Peace said at the meeting.

CHARLESTON, S.C. — HIV-infected women were at no greater risk for postpartum depression than were their HIV-negative counterparts in a recent study, Nyota A. Peace, M.D., reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

The retrospective case-control study included 26 HIV-infected pregnant women. There were also 52 uninfected controls who were divided into two groups—those with a high-risk pregnancy and those with a low-risk pregnancy.

The case patients and controls were matched for age, race, and study period, and did not differ in regard to education levels, substance abuse, and history of depression, according to Dr. Peace of New Jersey Medical School, Newark.

High-risk control patients had the highest mean depression scores (8 out of a possible 30 on the Edinburgh Postnatal Depression Scale), but the scores did not differ significantly between these patients, the HIV patients (mean score of 5), or the low-risk control women (mean score of 5).

Compared with the women with low depression scores (under 11), those with high depression scores (greater than 11) did not differ in regard to the presence of typical risk factors for postpartum depression, such as young age, pregnancy-induced anxiety, life stressors, and lack of social support.

Although a high prevalence of depression in the HIV-positive population has been reported, data on the association between HIV and postpartum depression are limited.

The findings suggest that high-risk conditions other than HIV infection are linked with higher depression scores, and that factors typically associated with higher risk for postpartum depression are no more prevalent in patients with high depression scores than in those with low depression scores, Dr. Peace said at the meeting.

Pregnancy outcome in women who have an organ transplant is no worse after they undergo the procedure than it is before they have the surgery, results from a large Swedish population study have found.

“The outcome data in the present study agree well with what is known in the literature: a very high rate of preterm birth, of low birth weight, and of small for gestational age,” reported the investigators, who were led by Bengt Källén, M.D., of the Tornblad Institute, University of Lund, Sweden.

“The advantage of the present study is that it represents a total population and that the outcome data were obtained from a medical birth register, based on original medical record data,” they said (Br. J. Obstet. Gynaecol. 2005;112:904–9).

Using Sweden's hospital discharge register, the investigators identified women who had an organ transplant during 1973–2002. Their deliveries before and after transplantation were identified from the country's medical birth register over that same period.

A total of 976 deliveries occurred before organ transplantation and 149 after the procedure, which represented only about half the expected number of deliveries, after the researchers adjusted for year of delivery and maternal age.

No statistically significant differences in the odds of having a miscarriage before transplantation vs. after transplantation were seen (odds ratios of 2.2 vs. 3.2, respectively).

High rates of preeclampsia (22% following kidney transplantation and 33% for liver transplantation), preterm birth (46%), low-birth-weight (41%), and small-for-gestational-age babies (17%) were found for deliveries after transplantation, but similar frequencies were found among deliveries that occurred a few years before transplantation.

A congenital malformation was identified in 5.8% of infants born before organ transplantation and in 6.7% of those born after organ transplantation, but the two rates did not differ.

The authors pointed out that “among the 15 infants born after maternal liver transplantation, there were two with a congenital malformation, one of which was complex and serious: esophageal atresia with a heart defect and an iris malformation. This woman was the only one who had been treated with MMF [mycophenolate mofetil]. This may be a coincidence. Only few pregnancies exposed to MMF are published in the literature.”

Dr. Källén and colleagues reported that the major reason for the overall pregnancy outcomes observed in the study stems from disease morbidity, not from the transplantation itself.

In addition, the investigators found “no clear-cut effect” of fetal exposure to immunosuppressive drugs on increased morbidity in later life. Studies with longer follow-up are needed, they added.

Pregnancy outcome in women who have an organ transplant is no worse after they undergo the procedure than it is before they have the surgery, results from a large Swedish population study have found.

“The outcome data in the present study agree well with what is known in the literature: a very high rate of preterm birth, of low birth weight, and of small for gestational age,” reported the investigators, who were led by Bengt Källén, M.D., of the Tornblad Institute, University of Lund, Sweden.

“The advantage of the present study is that it represents a total population and that the outcome data were obtained from a medical birth register, based on original medical record data,” they said (Br. J. Obstet. Gynaecol. 2005;112:904–9).

Using Sweden's hospital discharge register, the investigators identified women who had an organ transplant during 1973–2002. Their deliveries before and after transplantation were identified from the country's medical birth register over that same period.

A total of 976 deliveries occurred before organ transplantation and 149 after the procedure, which represented only about half the expected number of deliveries, after the researchers adjusted for year of delivery and maternal age.

No statistically significant differences in the odds of having a miscarriage before transplantation vs. after transplantation were seen (odds ratios of 2.2 vs. 3.2, respectively).

High rates of preeclampsia (22% following kidney transplantation and 33% for liver transplantation), preterm birth (46%), low-birth-weight (41%), and small-for-gestational-age babies (17%) were found for deliveries after transplantation, but similar frequencies were found among deliveries that occurred a few years before transplantation.

A congenital malformation was identified in 5.8% of infants born before organ transplantation and in 6.7% of those born after organ transplantation, but the two rates did not differ.

The authors pointed out that “among the 15 infants born after maternal liver transplantation, there were two with a congenital malformation, one of which was complex and serious: esophageal atresia with a heart defect and an iris malformation. This woman was the only one who had been treated with MMF [mycophenolate mofetil]. This may be a coincidence. Only few pregnancies exposed to MMF are published in the literature.”

Dr. Källén and colleagues reported that the major reason for the overall pregnancy outcomes observed in the study stems from disease morbidity, not from the transplantation itself.

In addition, the investigators found “no clear-cut effect” of fetal exposure to immunosuppressive drugs on increased morbidity in later life. Studies with longer follow-up are needed, they added.

Pregnancy outcome in women who have an organ transplant is no worse after they undergo the procedure than it is before they have the surgery, results from a large Swedish population study have found.

“The outcome data in the present study agree well with what is known in the literature: a very high rate of preterm birth, of low birth weight, and of small for gestational age,” reported the investigators, who were led by Bengt Källén, M.D., of the Tornblad Institute, University of Lund, Sweden.

“The advantage of the present study is that it represents a total population and that the outcome data were obtained from a medical birth register, based on original medical record data,” they said (Br. J. Obstet. Gynaecol. 2005;112:904–9).

Using Sweden's hospital discharge register, the investigators identified women who had an organ transplant during 1973–2002. Their deliveries before and after transplantation were identified from the country's medical birth register over that same period.

A total of 976 deliveries occurred before organ transplantation and 149 after the procedure, which represented only about half the expected number of deliveries, after the researchers adjusted for year of delivery and maternal age.

No statistically significant differences in the odds of having a miscarriage before transplantation vs. after transplantation were seen (odds ratios of 2.2 vs. 3.2, respectively).

High rates of preeclampsia (22% following kidney transplantation and 33% for liver transplantation), preterm birth (46%), low-birth-weight (41%), and small-for-gestational-age babies (17%) were found for deliveries after transplantation, but similar frequencies were found among deliveries that occurred a few years before transplantation.

A congenital malformation was identified in 5.8% of infants born before organ transplantation and in 6.7% of those born after organ transplantation, but the two rates did not differ.

The authors pointed out that “among the 15 infants born after maternal liver transplantation, there were two with a congenital malformation, one of which was complex and serious: esophageal atresia with a heart defect and an iris malformation. This woman was the only one who had been treated with MMF [mycophenolate mofetil]. This may be a coincidence. Only few pregnancies exposed to MMF are published in the literature.”

Dr. Källén and colleagues reported that the major reason for the overall pregnancy outcomes observed in the study stems from disease morbidity, not from the transplantation itself.

In addition, the investigators found “no clear-cut effect” of fetal exposure to immunosuppressive drugs on increased morbidity in later life. Studies with longer follow-up are needed, they added.

CHARLESTON, S.C. — Asymptomatic trichomoniasis during pregnancy appears to elicit a maternal inflammatory response, and should not be ignored, Brenna L. Anderson, M.D., said during the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a nested case-control study of 199 serum samples from women enrolled in the Vaginal Infections and Prematurity Study between 23 and 26 weeks' gestation and followed until delivery, median concentrations of granulocyte-macrophage colony-stimulating factor (GM-CSF) were significantly higher in samples from women with asymptomatic trichomoniasis than in those without the infection, indicating a systemic inflammatory response.

Also, those with trichomoniasis were significantly more likely to have a GM-CSF concentration in the highest quartile.

The association between infection and GM-CSF concentrations persisted even after the investigators controlled for center, tobacco use, and bacterial vaginosis, said Dr. Anderson of the University of Pittsburgh.

She noted that both the case and control samples were matched for race and sexually transmitted disease coinfection.

The two groups did not differ in regard to maternal age, gestational age at delivery, and rate of chlamydia or gonorrhea, she reported.

The inflammatory response appears to be exacerbated by coinfection with other sexually transmitted infections. There was a significant test for trend in those coinfected with gonorrhea or chlamydia, compared with those infected with only trichomoniasis and those with no sexually transmitted infection, she said.

In addition to GM-CSF, Dr. Anderson compared concentrations of five other cytokines, interleukin-β (IL-β, IL-6, IL-8, macrophage inflammatory protein-1α, and regulated on activation, normal T-cell expressed and secreted, in the serum samples.

The concentrations of these cytokines were uniformly unchanged between the groups, Dr. Anderson said during the meeting.

The cytokines IL-2, IL-4, IL-10, interferon-γ, and IL-12p40 were not measured, because a pilot analysis of 40 serum samples showed they did not have reliably detectable concentrations.

The local host response to a number of sexually transmitted infections has been well studied, providing evidence of a local host inflammatory response to organisms including Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis.

In addition, there is a long-established association between lower genital tract infection and preterm birth and premature rupture of membranes. Furthermore, inflammatory mediators of local host response have been found in cervicovaginal fluid.

But the current study is one of few that attempt to characterize systemic inflammatory response to such infections, Dr. Anderson said.

Although one large multicenter trial showed a link between preterm birth and treatment of trichomoniasis in pregnancy, the study had several limitations, and failed to explain the mechanism for preterm birth in treated patients. Therefore, the option of not treating patients with asymptomatic trichomoniasis remains unattractive due to medical and public health concerns, Dr. Anderson said.

“We believe that GM-CSF represents a biologically plausible link between a local infection and a systemic response,” Dr. Anderson said at the meeting, explaining that serum GM-CSF has been shown to be elevated in other systemic response syndromes, and has been shown to be an important mediator of local infection in animal models of trichomoniasis.

The cytokine may be an important growth factor in placental implantation, she added.

“We therefore conclude that trichomoniasis in pregnancy should not be regarded as a benign condition,” Dr. Anderson said.

Further study to “more fully characterize the inflammatory response” to trichomoniasis and other sexually transmitted infections in pregnancy will be planned, Dr. Anderson noted at the meeting.

CHARLESTON, S.C. — Asymptomatic trichomoniasis during pregnancy appears to elicit a maternal inflammatory response, and should not be ignored, Brenna L. Anderson, M.D., said during the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a nested case-control study of 199 serum samples from women enrolled in the Vaginal Infections and Prematurity Study between 23 and 26 weeks' gestation and followed until delivery, median concentrations of granulocyte-macrophage colony-stimulating factor (GM-CSF) were significantly higher in samples from women with asymptomatic trichomoniasis than in those without the infection, indicating a systemic inflammatory response.

Also, those with trichomoniasis were significantly more likely to have a GM-CSF concentration in the highest quartile.

The association between infection and GM-CSF concentrations persisted even after the investigators controlled for center, tobacco use, and bacterial vaginosis, said Dr. Anderson of the University of Pittsburgh.

She noted that both the case and control samples were matched for race and sexually transmitted disease coinfection.

The two groups did not differ in regard to maternal age, gestational age at delivery, and rate of chlamydia or gonorrhea, she reported.

The inflammatory response appears to be exacerbated by coinfection with other sexually transmitted infections. There was a significant test for trend in those coinfected with gonorrhea or chlamydia, compared with those infected with only trichomoniasis and those with no sexually transmitted infection, she said.

In addition to GM-CSF, Dr. Anderson compared concentrations of five other cytokines, interleukin-β (IL-β, IL-6, IL-8, macrophage inflammatory protein-1α, and regulated on activation, normal T-cell expressed and secreted, in the serum samples.

The concentrations of these cytokines were uniformly unchanged between the groups, Dr. Anderson said during the meeting.

The cytokines IL-2, IL-4, IL-10, interferon-γ, and IL-12p40 were not measured, because a pilot analysis of 40 serum samples showed they did not have reliably detectable concentrations.

The local host response to a number of sexually transmitted infections has been well studied, providing evidence of a local host inflammatory response to organisms including Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis.

In addition, there is a long-established association between lower genital tract infection and preterm birth and premature rupture of membranes. Furthermore, inflammatory mediators of local host response have been found in cervicovaginal fluid.

But the current study is one of few that attempt to characterize systemic inflammatory response to such infections, Dr. Anderson said.

Although one large multicenter trial showed a link between preterm birth and treatment of trichomoniasis in pregnancy, the study had several limitations, and failed to explain the mechanism for preterm birth in treated patients. Therefore, the option of not treating patients with asymptomatic trichomoniasis remains unattractive due to medical and public health concerns, Dr. Anderson said.

“We believe that GM-CSF represents a biologically plausible link between a local infection and a systemic response,” Dr. Anderson said at the meeting, explaining that serum GM-CSF has been shown to be elevated in other systemic response syndromes, and has been shown to be an important mediator of local infection in animal models of trichomoniasis.

The cytokine may be an important growth factor in placental implantation, she added.

“We therefore conclude that trichomoniasis in pregnancy should not be regarded as a benign condition,” Dr. Anderson said.

Further study to “more fully characterize the inflammatory response” to trichomoniasis and other sexually transmitted infections in pregnancy will be planned, Dr. Anderson noted at the meeting.

CHARLESTON, S.C. — Asymptomatic trichomoniasis during pregnancy appears to elicit a maternal inflammatory response, and should not be ignored, Brenna L. Anderson, M.D., said during the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a nested case-control study of 199 serum samples from women enrolled in the Vaginal Infections and Prematurity Study between 23 and 26 weeks' gestation and followed until delivery, median concentrations of granulocyte-macrophage colony-stimulating factor (GM-CSF) were significantly higher in samples from women with asymptomatic trichomoniasis than in those without the infection, indicating a systemic inflammatory response.

Also, those with trichomoniasis were significantly more likely to have a GM-CSF concentration in the highest quartile.

The association between infection and GM-CSF concentrations persisted even after the investigators controlled for center, tobacco use, and bacterial vaginosis, said Dr. Anderson of the University of Pittsburgh.

She noted that both the case and control samples were matched for race and sexually transmitted disease coinfection.

The two groups did not differ in regard to maternal age, gestational age at delivery, and rate of chlamydia or gonorrhea, she reported.

The inflammatory response appears to be exacerbated by coinfection with other sexually transmitted infections. There was a significant test for trend in those coinfected with gonorrhea or chlamydia, compared with those infected with only trichomoniasis and those with no sexually transmitted infection, she said.

In addition to GM-CSF, Dr. Anderson compared concentrations of five other cytokines, interleukin-β (IL-β, IL-6, IL-8, macrophage inflammatory protein-1α, and regulated on activation, normal T-cell expressed and secreted, in the serum samples.

The concentrations of these cytokines were uniformly unchanged between the groups, Dr. Anderson said during the meeting.

The cytokines IL-2, IL-4, IL-10, interferon-γ, and IL-12p40 were not measured, because a pilot analysis of 40 serum samples showed they did not have reliably detectable concentrations.

The local host response to a number of sexually transmitted infections has been well studied, providing evidence of a local host inflammatory response to organisms including Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis.

In addition, there is a long-established association between lower genital tract infection and preterm birth and premature rupture of membranes. Furthermore, inflammatory mediators of local host response have been found in cervicovaginal fluid.

But the current study is one of few that attempt to characterize systemic inflammatory response to such infections, Dr. Anderson said.

Although one large multicenter trial showed a link between preterm birth and treatment of trichomoniasis in pregnancy, the study had several limitations, and failed to explain the mechanism for preterm birth in treated patients. Therefore, the option of not treating patients with asymptomatic trichomoniasis remains unattractive due to medical and public health concerns, Dr. Anderson said.

“We believe that GM-CSF represents a biologically plausible link between a local infection and a systemic response,” Dr. Anderson said at the meeting, explaining that serum GM-CSF has been shown to be elevated in other systemic response syndromes, and has been shown to be an important mediator of local infection in animal models of trichomoniasis.

The cytokine may be an important growth factor in placental implantation, she added.

“We therefore conclude that trichomoniasis in pregnancy should not be regarded as a benign condition,” Dr. Anderson said.

Further study to “more fully characterize the inflammatory response” to trichomoniasis and other sexually transmitted infections in pregnancy will be planned, Dr. Anderson noted at the meeting.

Cesarean section in a first pregnancy may reduce a woman's risk of having pelvic floor surgery later in life, reported Ramalingam Uma, M.B., and colleagues at the University of Dundee, Scotland.

The researchers said their study was prompted by the increasing attention to pelvic floor morbidity following childbirth, and by indications that cesarean section may be protective against damage to the pelvic floor support structures and impairment of pelvic floor innervation that can occur during vaginal delivery.

The nested case-control study of first-time mothers was drawn from a population of 7,556 women who had given birth in the hospital between 1952 and 1966. Of these women, 5% underwent pelvic floor surgery in later years (BJOG 2005;112:1043–6).

On univariate analysis, cesarean section (odds ratio 0.24) and greater gestational age at birth (OR 0.20) were associated with a reduced risk of pelvic floor surgery, compared with spontaneous vaginal delivery. In the final multivariate model, only cesarean section was associated with reduced odds of future surgery (OR 0.16).

Subgroup analyses comparing the 61 elective and 68 emergency cesarean sections suggested that both were protective against pelvic floor surgery, compared with spontaneous vaginal delivery (OR of 0.19 and 0.29, respectively).

Dr. Uma and colleagues caution that “the absolute risk of pelvic floor surgery in relation to mode of delivery needs to be put in the context of the adverse effect of pregnancy itself. It has been reported that 46% of nullipara have pelvic organ prolapse at 36 weeks antepartum. … Cesarean section may reduce the risk of pelvic floor surgery relating to the mode of delivery but it will not eliminate the risks associated with pregnancy itself.”

In contrast to previous studies, this analysis did not find an association between forceps delivery and increased risk of pelvic floor surgery.

Cesarean section in a first pregnancy may reduce a woman's risk of having pelvic floor surgery later in life, reported Ramalingam Uma, M.B., and colleagues at the University of Dundee, Scotland.

The researchers said their study was prompted by the increasing attention to pelvic floor morbidity following childbirth, and by indications that cesarean section may be protective against damage to the pelvic floor support structures and impairment of pelvic floor innervation that can occur during vaginal delivery.

The nested case-control study of first-time mothers was drawn from a population of 7,556 women who had given birth in the hospital between 1952 and 1966. Of these women, 5% underwent pelvic floor surgery in later years (BJOG 2005;112:1043–6).

On univariate analysis, cesarean section (odds ratio 0.24) and greater gestational age at birth (OR 0.20) were associated with a reduced risk of pelvic floor surgery, compared with spontaneous vaginal delivery. In the final multivariate model, only cesarean section was associated with reduced odds of future surgery (OR 0.16).

Subgroup analyses comparing the 61 elective and 68 emergency cesarean sections suggested that both were protective against pelvic floor surgery, compared with spontaneous vaginal delivery (OR of 0.19 and 0.29, respectively).

Dr. Uma and colleagues caution that “the absolute risk of pelvic floor surgery in relation to mode of delivery needs to be put in the context of the adverse effect of pregnancy itself. It has been reported that 46% of nullipara have pelvic organ prolapse at 36 weeks antepartum. … Cesarean section may reduce the risk of pelvic floor surgery relating to the mode of delivery but it will not eliminate the risks associated with pregnancy itself.”

In contrast to previous studies, this analysis did not find an association between forceps delivery and increased risk of pelvic floor surgery.

Cesarean section in a first pregnancy may reduce a woman's risk of having pelvic floor surgery later in life, reported Ramalingam Uma, M.B., and colleagues at the University of Dundee, Scotland.

The researchers said their study was prompted by the increasing attention to pelvic floor morbidity following childbirth, and by indications that cesarean section may be protective against damage to the pelvic floor support structures and impairment of pelvic floor innervation that can occur during vaginal delivery.

The nested case-control study of first-time mothers was drawn from a population of 7,556 women who had given birth in the hospital between 1952 and 1966. Of these women, 5% underwent pelvic floor surgery in later years (BJOG 2005;112:1043–6).

On univariate analysis, cesarean section (odds ratio 0.24) and greater gestational age at birth (OR 0.20) were associated with a reduced risk of pelvic floor surgery, compared with spontaneous vaginal delivery. In the final multivariate model, only cesarean section was associated with reduced odds of future surgery (OR 0.16).

Subgroup analyses comparing the 61 elective and 68 emergency cesarean sections suggested that both were protective against pelvic floor surgery, compared with spontaneous vaginal delivery (OR of 0.19 and 0.29, respectively).

Dr. Uma and colleagues caution that “the absolute risk of pelvic floor surgery in relation to mode of delivery needs to be put in the context of the adverse effect of pregnancy itself. It has been reported that 46% of nullipara have pelvic organ prolapse at 36 weeks antepartum. … Cesarean section may reduce the risk of pelvic floor surgery relating to the mode of delivery but it will not eliminate the risks associated with pregnancy itself.”

In contrast to previous studies, this analysis did not find an association between forceps delivery and increased risk of pelvic floor surgery.

SANTA BARBARA, CALIF. — Prenatal alcohol exposure is most likely to affect children's attention problems when it occurs during the third trimester, a prospective study of 492 children determined.

There is a high degree of correlation between teacher- and parent-assessed attention deficits in children exposed to alcohol in late pregnancy, compared with alcohol exposure during the first or second trimesters, Beth Nordstrom Bailey, Ph.D., and her associates reported at the annual meeting of the Research Society on Alcoholism.

“These findings provide yet one more piece of evidence that the timing of prenatal alcohol exposure impacts child outcomes,” concluded the investigators, who presented their study in poster form.

The study from East Tennessee State University in Johnson City, where Dr. Bailey serves on the department of family medicine faculty, carries substantial weight because it prospectively tracked women's substance abuse throughout pregnancy and followed their children for 6–7 years.

The cohort was from urban Detroit and was mostly made up of African Americans with a low socioeconomic status, 90% of whom agreed to participate in the follow-up study.

Caregivers completed the Achenbach Child Behavior Checklist. Classroom teachers completed the Achenbach Teacher Report Form. Both standardized tools include Attention Problems scales.

In a logistic regression analysis, third-trimester prenatal alcohol exposure independently correlated with attention problems as assessed by both caregivers and teachers. Lead levels and custody changes also correlated with attention scores as assessed by parents and caregivers. Violence exposure factored into the equation only when teachers' assessments were considered.

Prenatal exposure to cocaine, cigarettes, or alcohol during the first and second trimesters failed to independently correlate with later attention problems in children.

In an interview, Dr. Bailey explained that first-trimester exposures have the potential to affect global development of the fetus, possibly resulting in physical deformities, major cognitive impairment, and diminished growth.

In the third trimester, higher order functions are most affected. Alcohol exposure during this time appears to affect children's specific attention and behavior functions that can be readily assessed during the school-age years.

SANTA BARBARA, CALIF. — Prenatal alcohol exposure is most likely to affect children's attention problems when it occurs during the third trimester, a prospective study of 492 children determined.

There is a high degree of correlation between teacher- and parent-assessed attention deficits in children exposed to alcohol in late pregnancy, compared with alcohol exposure during the first or second trimesters, Beth Nordstrom Bailey, Ph.D., and her associates reported at the annual meeting of the Research Society on Alcoholism.

“These findings provide yet one more piece of evidence that the timing of prenatal alcohol exposure impacts child outcomes,” concluded the investigators, who presented their study in poster form.

The study from East Tennessee State University in Johnson City, where Dr. Bailey serves on the department of family medicine faculty, carries substantial weight because it prospectively tracked women's substance abuse throughout pregnancy and followed their children for 6–7 years.

The cohort was from urban Detroit and was mostly made up of African Americans with a low socioeconomic status, 90% of whom agreed to participate in the follow-up study.

Caregivers completed the Achenbach Child Behavior Checklist. Classroom teachers completed the Achenbach Teacher Report Form. Both standardized tools include Attention Problems scales.

In a logistic regression analysis, third-trimester prenatal alcohol exposure independently correlated with attention problems as assessed by both caregivers and teachers. Lead levels and custody changes also correlated with attention scores as assessed by parents and caregivers. Violence exposure factored into the equation only when teachers' assessments were considered.

Prenatal exposure to cocaine, cigarettes, or alcohol during the first and second trimesters failed to independently correlate with later attention problems in children.

In an interview, Dr. Bailey explained that first-trimester exposures have the potential to affect global development of the fetus, possibly resulting in physical deformities, major cognitive impairment, and diminished growth.

In the third trimester, higher order functions are most affected. Alcohol exposure during this time appears to affect children's specific attention and behavior functions that can be readily assessed during the school-age years.

SANTA BARBARA, CALIF. — Prenatal alcohol exposure is most likely to affect children's attention problems when it occurs during the third trimester, a prospective study of 492 children determined.

There is a high degree of correlation between teacher- and parent-assessed attention deficits in children exposed to alcohol in late pregnancy, compared with alcohol exposure during the first or second trimesters, Beth Nordstrom Bailey, Ph.D., and her associates reported at the annual meeting of the Research Society on Alcoholism.

“These findings provide yet one more piece of evidence that the timing of prenatal alcohol exposure impacts child outcomes,” concluded the investigators, who presented their study in poster form.

The study from East Tennessee State University in Johnson City, where Dr. Bailey serves on the department of family medicine faculty, carries substantial weight because it prospectively tracked women's substance abuse throughout pregnancy and followed their children for 6–7 years.

The cohort was from urban Detroit and was mostly made up of African Americans with a low socioeconomic status, 90% of whom agreed to participate in the follow-up study.

Caregivers completed the Achenbach Child Behavior Checklist. Classroom teachers completed the Achenbach Teacher Report Form. Both standardized tools include Attention Problems scales.

In a logistic regression analysis, third-trimester prenatal alcohol exposure independently correlated with attention problems as assessed by both caregivers and teachers. Lead levels and custody changes also correlated with attention scores as assessed by parents and caregivers. Violence exposure factored into the equation only when teachers' assessments were considered.

Prenatal exposure to cocaine, cigarettes, or alcohol during the first and second trimesters failed to independently correlate with later attention problems in children.

In an interview, Dr. Bailey explained that first-trimester exposures have the potential to affect global development of the fetus, possibly resulting in physical deformities, major cognitive impairment, and diminished growth.

In the third trimester, higher order functions are most affected. Alcohol exposure during this time appears to affect children's specific attention and behavior functions that can be readily assessed during the school-age years.

CHARLESTON, S.C. — Oral and vaginal metronidazole appear to have comparable efficacy for the treatment of bacterial vaginosis in low-risk pregnant women, but neither is optimal for prevention of infectious complications at delivery, Jane Hitti, M.D., reported during the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a double-blind, placebo-controlled study of 126 women with bacterial vaginosis who were randomized at or before 20 weeks' gestation to receive either oral or vaginal metronidazole, the treatment failure rate was similar for both groups (29% for oral administration vs. 35% for vaginal administration), Dr. Hitti of the University of Washington, Seattle, reported in a poster presentation at the meeting.

The oral administration group received 250 mg of metronidazole three times daily for 1 week; the vaginal administration group was treated with 5 g of 0.75% gel twice daily for 5 days. Treatment failure was defined as persistent BV at 4 weeks after treatment, she noted.

Although treatment outcomes in regard to bacterial vaginosis persistence were statistically similar for the two groups, the rate of certain infectious complications at delivery was of concern.

For example, the cesarean wound infection rate was 33% in the oral metronidazole group, compared with 18% in the vaginal metronidazole group, 0% in a group of 47 women with intermediate Gram stain results, and 6% in a group of 190 women with normal Gram stain results.

The difference between the oral treatment group and the normal controls reached statistical significance.

Furthermore, the rate of chorioamnionitis was 20% in the vaginal treatment group, compared with 9% in the oral treatment group, 7% in the intermediate Gram stain group, and 10% in the controls. These differences did not reach statistical significance, but the findings suggest that infectious complications remain a concern in patients with bacterial vaginosis, regardless of metronidazole treatment delivery method.

CHARLESTON, S.C. — Oral and vaginal metronidazole appear to have comparable efficacy for the treatment of bacterial vaginosis in low-risk pregnant women, but neither is optimal for prevention of infectious complications at delivery, Jane Hitti, M.D., reported during the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a double-blind, placebo-controlled study of 126 women with bacterial vaginosis who were randomized at or before 20 weeks' gestation to receive either oral or vaginal metronidazole, the treatment failure rate was similar for both groups (29% for oral administration vs. 35% for vaginal administration), Dr. Hitti of the University of Washington, Seattle, reported in a poster presentation at the meeting.

The oral administration group received 250 mg of metronidazole three times daily for 1 week; the vaginal administration group was treated with 5 g of 0.75% gel twice daily for 5 days. Treatment failure was defined as persistent BV at 4 weeks after treatment, she noted.

Although treatment outcomes in regard to bacterial vaginosis persistence were statistically similar for the two groups, the rate of certain infectious complications at delivery was of concern.

For example, the cesarean wound infection rate was 33% in the oral metronidazole group, compared with 18% in the vaginal metronidazole group, 0% in a group of 47 women with intermediate Gram stain results, and 6% in a group of 190 women with normal Gram stain results.

The difference between the oral treatment group and the normal controls reached statistical significance.

Furthermore, the rate of chorioamnionitis was 20% in the vaginal treatment group, compared with 9% in the oral treatment group, 7% in the intermediate Gram stain group, and 10% in the controls. These differences did not reach statistical significance, but the findings suggest that infectious complications remain a concern in patients with bacterial vaginosis, regardless of metronidazole treatment delivery method.

CHARLESTON, S.C. — Oral and vaginal metronidazole appear to have comparable efficacy for the treatment of bacterial vaginosis in low-risk pregnant women, but neither is optimal for prevention of infectious complications at delivery, Jane Hitti, M.D., reported during the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology.

In a double-blind, placebo-controlled study of 126 women with bacterial vaginosis who were randomized at or before 20 weeks' gestation to receive either oral or vaginal metronidazole, the treatment failure rate was similar for both groups (29% for oral administration vs. 35% for vaginal administration), Dr. Hitti of the University of Washington, Seattle, reported in a poster presentation at the meeting.

The oral administration group received 250 mg of metronidazole three times daily for 1 week; the vaginal administration group was treated with 5 g of 0.75% gel twice daily for 5 days. Treatment failure was defined as persistent BV at 4 weeks after treatment, she noted.

Although treatment outcomes in regard to bacterial vaginosis persistence were statistically similar for the two groups, the rate of certain infectious complications at delivery was of concern.

For example, the cesarean wound infection rate was 33% in the oral metronidazole group, compared with 18% in the vaginal metronidazole group, 0% in a group of 47 women with intermediate Gram stain results, and 6% in a group of 190 women with normal Gram stain results.

The difference between the oral treatment group and the normal controls reached statistical significance.

Furthermore, the rate of chorioamnionitis was 20% in the vaginal treatment group, compared with 9% in the oral treatment group, 7% in the intermediate Gram stain group, and 10% in the controls. These differences did not reach statistical significance, but the findings suggest that infectious complications remain a concern in patients with bacterial vaginosis, regardless of metronidazole treatment delivery method.

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin, recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.”

Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who could not arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop.

Cultural differences go beyond words, Ms. Martin noted. For example, in Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.”

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” which can be taken literally.

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin, recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.”

Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who could not arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop.

Cultural differences go beyond words, Ms. Martin noted. For example, in Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.”

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” which can be taken literally.

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin, recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.”

Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who could not arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop.

Cultural differences go beyond words, Ms. Martin noted. For example, in Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.”

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” which can be taken literally.