Obstetrics

Maternal folate status is an important predictor of infant birth weight, a prospective study has shown.

In a cohort of nearly 1,000 expectant mothers, those with lower levels of erythrocyte red blood cell (RBC) folate in early pregnancy were significantly more likely to have low-birth-weight babies, according to Caroline Relton, M.D., and her associates at the University of Newcastle upon Tyne (England).

The researchers investigated the relationship between maternal and newborn RBC folate status, vitamin B₁₂ status, maternal smoking, age, parity, and infant birth rate in 998 pregnant mothers receiving prenatal care at a hospital in northwest England and their newborns. Blood samples were collected from mothers during their first routine prenatal appointment and from the newborns' umbilical cords at birth (Br. J. Nutr. 2005;93:593–9).

In a multivariate analysis, maternal folate status was the only significant determinant of birth weight. Each standard deviation increase in maternal folic acid level was associated with a 14% weight increase in birth weight z score.

Univariate linear regression analysis associated smoking with a significant decrease in birth weight; however, multivariate analysis showed a dramatically reduced, nonsignificant influence, suggesting that smoking and maternal folate status are not independent of each other. Folate levels were significantly lower in women who smoked than in nonsmokers, thus the effect of smoking on birth weight may be mediated in part by its association with maternal folate, according to the authors.

Maternal vitamin B₁₂ status was significantly associated with both maternal and neonatal folate but not with birth weight. However, the relationship between vitamin B₁₂ and maternal folate status suggests this micronutrient has an important role in maternal nutrition during pregnancy, the authors wrote.

Neonatal vitamin B₁₂ had a small but significant influence on infant birth weight when analyzed in a univariate model, but the effect was not significant when considered in a multivariate model, nor was there any association between neonatal folate and birth weight.

Folate is of fundamental importance to cell function, including the synthesis and repair of DNA and gene expression. Although the exact nature of the relationship between folate and birth weight is not known, reductions in folate are associated with increases in the amino acid homocysteine. Elevated homocysteine has been linked to many clinical conditions that affect fetal growth, the authors stated.

Maternal folate status is an important predictor of infant birth weight, a prospective study has shown.

In a cohort of nearly 1,000 expectant mothers, those with lower levels of erythrocyte red blood cell (RBC) folate in early pregnancy were significantly more likely to have low-birth-weight babies, according to Caroline Relton, M.D., and her associates at the University of Newcastle upon Tyne (England).

The researchers investigated the relationship between maternal and newborn RBC folate status, vitamin B₁₂ status, maternal smoking, age, parity, and infant birth rate in 998 pregnant mothers receiving prenatal care at a hospital in northwest England and their newborns. Blood samples were collected from mothers during their first routine prenatal appointment and from the newborns' umbilical cords at birth (Br. J. Nutr. 2005;93:593–9).

In a multivariate analysis, maternal folate status was the only significant determinant of birth weight. Each standard deviation increase in maternal folic acid level was associated with a 14% weight increase in birth weight z score.

Univariate linear regression analysis associated smoking with a significant decrease in birth weight; however, multivariate analysis showed a dramatically reduced, nonsignificant influence, suggesting that smoking and maternal folate status are not independent of each other. Folate levels were significantly lower in women who smoked than in nonsmokers, thus the effect of smoking on birth weight may be mediated in part by its association with maternal folate, according to the authors.

Maternal vitamin B₁₂ status was significantly associated with both maternal and neonatal folate but not with birth weight. However, the relationship between vitamin B₁₂ and maternal folate status suggests this micronutrient has an important role in maternal nutrition during pregnancy, the authors wrote.

Neonatal vitamin B₁₂ had a small but significant influence on infant birth weight when analyzed in a univariate model, but the effect was not significant when considered in a multivariate model, nor was there any association between neonatal folate and birth weight.

Folate is of fundamental importance to cell function, including the synthesis and repair of DNA and gene expression. Although the exact nature of the relationship between folate and birth weight is not known, reductions in folate are associated with increases in the amino acid homocysteine. Elevated homocysteine has been linked to many clinical conditions that affect fetal growth, the authors stated.

Maternal folate status is an important predictor of infant birth weight, a prospective study has shown.

In a cohort of nearly 1,000 expectant mothers, those with lower levels of erythrocyte red blood cell (RBC) folate in early pregnancy were significantly more likely to have low-birth-weight babies, according to Caroline Relton, M.D., and her associates at the University of Newcastle upon Tyne (England).

The researchers investigated the relationship between maternal and newborn RBC folate status, vitamin B₁₂ status, maternal smoking, age, parity, and infant birth rate in 998 pregnant mothers receiving prenatal care at a hospital in northwest England and their newborns. Blood samples were collected from mothers during their first routine prenatal appointment and from the newborns' umbilical cords at birth (Br. J. Nutr. 2005;93:593–9).

In a multivariate analysis, maternal folate status was the only significant determinant of birth weight. Each standard deviation increase in maternal folic acid level was associated with a 14% weight increase in birth weight z score.

Univariate linear regression analysis associated smoking with a significant decrease in birth weight; however, multivariate analysis showed a dramatically reduced, nonsignificant influence, suggesting that smoking and maternal folate status are not independent of each other. Folate levels were significantly lower in women who smoked than in nonsmokers, thus the effect of smoking on birth weight may be mediated in part by its association with maternal folate, according to the authors.

Maternal vitamin B₁₂ status was significantly associated with both maternal and neonatal folate but not with birth weight. However, the relationship between vitamin B₁₂ and maternal folate status suggests this micronutrient has an important role in maternal nutrition during pregnancy, the authors wrote.

Neonatal vitamin B₁₂ had a small but significant influence on infant birth weight when analyzed in a univariate model, but the effect was not significant when considered in a multivariate model, nor was there any association between neonatal folate and birth weight.

Folate is of fundamental importance to cell function, including the synthesis and repair of DNA and gene expression. Although the exact nature of the relationship between folate and birth weight is not known, reductions in folate are associated with increases in the amino acid homocysteine. Elevated homocysteine has been linked to many clinical conditions that affect fetal growth, the authors stated.

ORLANDO — Adding ultrasound to maternal serum AFP screening may help clinicians identify fetal neural tube defects, according to research that was presented during the annual meeting of the American Institute of Ultrasound in Medicine.

“From the standpoint of neural tube defect detection, the maternal serum AFP screening test remains a good test —in our series, more neural tube defects were detected if the test was used than if it was not used—but the sensitivity of the test is significantly better if gestational age is confirmed with ultrasound,” explained Jodi S. Dashe, M.D., of the University of Texas Southwestern Medical Center, Dallas.

“We were also pleased to find that in this series, the detection of neural tube defects with standard ultrasound was excellent,” Dr. Dashe added during the meeting.

Dr. Dashe and her associates conducted a retrospective study at their center to examine the role of ultrasound along with AFP screening for neural tube defects. For this investigation, they reviewed prenatal and neonatal datasets to find pregnancies that were complicated by neural tube defects.

Following their standard protocol, Dr. Dashe's team offered AFP screening between 15 and 21 weeks of gestation and performed specialized ultrasound for patients with an AFP of at least 2.50 multiples of the median (MOM).

For patients with an AFP of 2.00–2.49 MOM, standard ultrasound was performed.

Investigators identified 68 singletons with neural tube defects, 60 of which were identified prenatally.

Clinicians performed AFP screening in 33 study patients. An AFP elevation of at least 2.50 MOM occurred in 22 patients (67% sensitivity). Among patients with an AFP that was less than 2.50 MOM, the AFP calculation did not include ultrasound measurements in eight of the women.

Additionally, ultrasound was performed during the second or third trimesters in 66 women.

Using ultrasound and AFP screening, they were able to detect 98% of neural tube defects in these patients.

“Other programs may want to reevaluate their experience with the AFP screening test and how well it detects neural tube defects and ventral wall defects. Over time, having an AFP screening test might become an indication for standard ultrasound, both to improve the accuracy of the test and because these anomalies may be detected by the ultrasound,” Dr. Dashe said.

She noted that her study did not (and could not) perform a cost-benefit analysis, which would differ in different populations. She therefore is not recommending routine ultrasound for this indication.

In addition, Dr. Dashe noted a few limitations of this particular study, pointing to its retrospective nature and the fact that these results might not be generalizable in other centers.

ORLANDO — Adding ultrasound to maternal serum AFP screening may help clinicians identify fetal neural tube defects, according to research that was presented during the annual meeting of the American Institute of Ultrasound in Medicine.

“From the standpoint of neural tube defect detection, the maternal serum AFP screening test remains a good test —in our series, more neural tube defects were detected if the test was used than if it was not used—but the sensitivity of the test is significantly better if gestational age is confirmed with ultrasound,” explained Jodi S. Dashe, M.D., of the University of Texas Southwestern Medical Center, Dallas.

“We were also pleased to find that in this series, the detection of neural tube defects with standard ultrasound was excellent,” Dr. Dashe added during the meeting.

Dr. Dashe and her associates conducted a retrospective study at their center to examine the role of ultrasound along with AFP screening for neural tube defects. For this investigation, they reviewed prenatal and neonatal datasets to find pregnancies that were complicated by neural tube defects.

Following their standard protocol, Dr. Dashe's team offered AFP screening between 15 and 21 weeks of gestation and performed specialized ultrasound for patients with an AFP of at least 2.50 multiples of the median (MOM).

For patients with an AFP of 2.00–2.49 MOM, standard ultrasound was performed.

Investigators identified 68 singletons with neural tube defects, 60 of which were identified prenatally.

Clinicians performed AFP screening in 33 study patients. An AFP elevation of at least 2.50 MOM occurred in 22 patients (67% sensitivity). Among patients with an AFP that was less than 2.50 MOM, the AFP calculation did not include ultrasound measurements in eight of the women.

Additionally, ultrasound was performed during the second or third trimesters in 66 women.

Using ultrasound and AFP screening, they were able to detect 98% of neural tube defects in these patients.

“Other programs may want to reevaluate their experience with the AFP screening test and how well it detects neural tube defects and ventral wall defects. Over time, having an AFP screening test might become an indication for standard ultrasound, both to improve the accuracy of the test and because these anomalies may be detected by the ultrasound,” Dr. Dashe said.

She noted that her study did not (and could not) perform a cost-benefit analysis, which would differ in different populations. She therefore is not recommending routine ultrasound for this indication.

In addition, Dr. Dashe noted a few limitations of this particular study, pointing to its retrospective nature and the fact that these results might not be generalizable in other centers.

ORLANDO — Adding ultrasound to maternal serum AFP screening may help clinicians identify fetal neural tube defects, according to research that was presented during the annual meeting of the American Institute of Ultrasound in Medicine.

“From the standpoint of neural tube defect detection, the maternal serum AFP screening test remains a good test —in our series, more neural tube defects were detected if the test was used than if it was not used—but the sensitivity of the test is significantly better if gestational age is confirmed with ultrasound,” explained Jodi S. Dashe, M.D., of the University of Texas Southwestern Medical Center, Dallas.

“We were also pleased to find that in this series, the detection of neural tube defects with standard ultrasound was excellent,” Dr. Dashe added during the meeting.

Dr. Dashe and her associates conducted a retrospective study at their center to examine the role of ultrasound along with AFP screening for neural tube defects. For this investigation, they reviewed prenatal and neonatal datasets to find pregnancies that were complicated by neural tube defects.

Following their standard protocol, Dr. Dashe's team offered AFP screening between 15 and 21 weeks of gestation and performed specialized ultrasound for patients with an AFP of at least 2.50 multiples of the median (MOM).

For patients with an AFP of 2.00–2.49 MOM, standard ultrasound was performed.

Investigators identified 68 singletons with neural tube defects, 60 of which were identified prenatally.

Clinicians performed AFP screening in 33 study patients. An AFP elevation of at least 2.50 MOM occurred in 22 patients (67% sensitivity). Among patients with an AFP that was less than 2.50 MOM, the AFP calculation did not include ultrasound measurements in eight of the women.

Additionally, ultrasound was performed during the second or third trimesters in 66 women.

Using ultrasound and AFP screening, they were able to detect 98% of neural tube defects in these patients.

“Other programs may want to reevaluate their experience with the AFP screening test and how well it detects neural tube defects and ventral wall defects. Over time, having an AFP screening test might become an indication for standard ultrasound, both to improve the accuracy of the test and because these anomalies may be detected by the ultrasound,” Dr. Dashe said.

She noted that her study did not (and could not) perform a cost-benefit analysis, which would differ in different populations. She therefore is not recommending routine ultrasound for this indication.

In addition, Dr. Dashe noted a few limitations of this particular study, pointing to its retrospective nature and the fact that these results might not be generalizable in other centers.

Vaginal delivery after laparoscopic myomectomy can be accomplished safely without uterine rupture by using management protocols that are similar to those used for vaginal birth after cesarean section, reported Jun Kumakiri, M.D., and his associates at Juntendo University, Tokyo.

In a study of 108 women who wanted to become pregnant after undergoing laparoscopic myomectomy (LM) and were followed for at least 6 months, 40 spontaneous pregnancies and 7 pregnancies by assisted-reproductive technology occurred in 40 women over a 4-year period.

Using Cox regression analysis, the investigators found that pregnancy after LM was positively associated with the diameter of the largest myoma (odds ratio [OR] 1.06) and negatively associated with the patient's age (OR 0.88) and with the number of enucleated myomas (OR 1.17).

A total of 32 deliveries occurred after LM. Of these, vaginal birth was attempted in 23, resulting in 19 (83%) successful vaginal births, with all but one occurring after 37 weeks' gestation. Attempted vaginal birth after LM was unsuccessful in four patients (J. Minim. Invasive Gynecol. 2005;12:241–6).

Vaginal birth after LM was performed according to recommendations from the American College of Obstetricians and Gynecologists on vaginal birth after cesarean section, Dr. Kumakiri said.

In the 19 pregnancies that resulted in vaginal deliveries after LM, the average diameter of the largest myoma at LM was 68.7 mm, the average number of enucleated myomas was 2.9, and the average number of hysterotomies was 2.5.

In the 68 patients who received LM but didn't get pregnant, the average diameter of the largest myoma was 62.3 mm and the average number of enucleated myomas was 3.7.

No patient suffered uterine rupture during or after delivery, the investigators said, perhaps because all enucleation wounds were sutured, as they would be with laparotomy.

Because some patients had infertility factors other than myoma before LM, the researchers said, “it is necessary to examine a larger population, not including such patients, to evaluate whether the implantation environment alone is responsible for the reduced fertility associated with uterine myomas.”

Vaginal delivery after laparoscopic myomectomy can be accomplished safely without uterine rupture by using management protocols that are similar to those used for vaginal birth after cesarean section, reported Jun Kumakiri, M.D., and his associates at Juntendo University, Tokyo.

In a study of 108 women who wanted to become pregnant after undergoing laparoscopic myomectomy (LM) and were followed for at least 6 months, 40 spontaneous pregnancies and 7 pregnancies by assisted-reproductive technology occurred in 40 women over a 4-year period.

Using Cox regression analysis, the investigators found that pregnancy after LM was positively associated with the diameter of the largest myoma (odds ratio [OR] 1.06) and negatively associated with the patient's age (OR 0.88) and with the number of enucleated myomas (OR 1.17).

A total of 32 deliveries occurred after LM. Of these, vaginal birth was attempted in 23, resulting in 19 (83%) successful vaginal births, with all but one occurring after 37 weeks' gestation. Attempted vaginal birth after LM was unsuccessful in four patients (J. Minim. Invasive Gynecol. 2005;12:241–6).

Vaginal birth after LM was performed according to recommendations from the American College of Obstetricians and Gynecologists on vaginal birth after cesarean section, Dr. Kumakiri said.

In the 19 pregnancies that resulted in vaginal deliveries after LM, the average diameter of the largest myoma at LM was 68.7 mm, the average number of enucleated myomas was 2.9, and the average number of hysterotomies was 2.5.

In the 68 patients who received LM but didn't get pregnant, the average diameter of the largest myoma was 62.3 mm and the average number of enucleated myomas was 3.7.

No patient suffered uterine rupture during or after delivery, the investigators said, perhaps because all enucleation wounds were sutured, as they would be with laparotomy.

Because some patients had infertility factors other than myoma before LM, the researchers said, “it is necessary to examine a larger population, not including such patients, to evaluate whether the implantation environment alone is responsible for the reduced fertility associated with uterine myomas.”

Vaginal delivery after laparoscopic myomectomy can be accomplished safely without uterine rupture by using management protocols that are similar to those used for vaginal birth after cesarean section, reported Jun Kumakiri, M.D., and his associates at Juntendo University, Tokyo.

In a study of 108 women who wanted to become pregnant after undergoing laparoscopic myomectomy (LM) and were followed for at least 6 months, 40 spontaneous pregnancies and 7 pregnancies by assisted-reproductive technology occurred in 40 women over a 4-year period.

Using Cox regression analysis, the investigators found that pregnancy after LM was positively associated with the diameter of the largest myoma (odds ratio [OR] 1.06) and negatively associated with the patient's age (OR 0.88) and with the number of enucleated myomas (OR 1.17).

A total of 32 deliveries occurred after LM. Of these, vaginal birth was attempted in 23, resulting in 19 (83%) successful vaginal births, with all but one occurring after 37 weeks' gestation. Attempted vaginal birth after LM was unsuccessful in four patients (J. Minim. Invasive Gynecol. 2005;12:241–6).

Vaginal birth after LM was performed according to recommendations from the American College of Obstetricians and Gynecologists on vaginal birth after cesarean section, Dr. Kumakiri said.

In the 19 pregnancies that resulted in vaginal deliveries after LM, the average diameter of the largest myoma at LM was 68.7 mm, the average number of enucleated myomas was 2.9, and the average number of hysterotomies was 2.5.

In the 68 patients who received LM but didn't get pregnant, the average diameter of the largest myoma was 62.3 mm and the average number of enucleated myomas was 3.7.

No patient suffered uterine rupture during or after delivery, the investigators said, perhaps because all enucleation wounds were sutured, as they would be with laparotomy.

Because some patients had infertility factors other than myoma before LM, the researchers said, “it is necessary to examine a larger population, not including such patients, to evaluate whether the implantation environment alone is responsible for the reduced fertility associated with uterine myomas.”

ASHEVILLE, N.C. — Focus on the woman's health in those rare cases of peripartum cardiomyopathy, said Thomas S. Ivester, M.D., at the Southern Obstetric and Gynecologic Seminar. “Maternal health is of paramount importance in this situation,” Dr. Ivester, of the department of maternal-fetal medicine said during the University of North Carolina at Chapel Hill.

Cardiomyopathy is an infrequent but potentially fatal complication of pregnancy. The mortality rate is 0.4 per 100,000 live births. Risk factors during pregnancy include multiparity, advanced age, African American race, and preeclampsia.

Care of critically ill pregnant women requires a team-based approach, with good communication among caregivers and specialists. Obstetricians can serve a vital role in educating critical care colleagues about treating pregnant patients who are critically ill.

In particular, “cardiac indices and central venous pressure are notoriously inaccurate in critically ill gravida. This is especially so with preeclampsia,” said Dr. Ivester. Use echocardiography to assess volume or use a P.A. catheter to get a wedge pressure.

Fetal decompensation is frequently a warning sign of subsequent significant maternal decompensation. “Once it's detected, cardiac monitoring of the fetus should probably be ceased until the mom is completely stabilized. Intervention in that scenario is probably ill advised,” said Dr. Ivester.

In patients who have significant hemorrhage or in those who may have suffered some type of hypovolemic insult or have been in shock, dopamine can be used to preserve and enhance renal and placental perfusion. “So a renal dose of dopamine, you can also consider as a placental dose of dopamine,” Dr. Ivester said.

Whenever possible, delivery should be reserved for obstetric indications. Vaginal delivery is preferred, because it is tolerated better by the woman. These patients should have prophylaxis for deep vein thrombosis, which can be accomplished by mechanical or chemical means.

“Close follow-up of any case of peripartum cardiomyopathy is critical,” Dr. Ivester said. He suggests serial echocardiography to evaluate the recovery of left ventricular function. Avoiding subsequent pregnancies until function improves is important, so make sure these patients are on adequate contraception. Earlier ICD implantation or placement on a transplant list should be considered for patients who suffer significant rhythm deterioration or have persistently low ejection fractions.

“Most importantly, … obstetric issues do not disappear with delivery. [The mother] is still an obstetric patient, even when the baby is delivered,” Dr. Ivester said. Peripartum changes can persist in some women for many weeks after delivery, and the obstetrician still has an important role to play in their care, especially in helping to differentiate the changes associated with pregnancy from other conditions.

In a normal pregnancy, blood volume increases 50%–100%. Systemic vascular resistance decreases 20%, and the blood is hypercoagulable. Cardiac output can fluctuate. Respiratory alkalosis may occur. The heart is displaced upward and to the left. The patient will have slight left ventricular hypertrophy and effusion that can be seen on echocardiography. There is frequently a left axis deviation due to these changes. There also may be nonspecific ST segment and T-wave changes.

Profound cardiac changes also occur during labor. Systemic vascular resistance can go up 10%–25% with each contraction. “That's a substantial increase for a patient with a very sick myocardium or those with significant valvular diseases,” Dr. Ivester said. Women in labor will autoinfuse 300–500 cc every time they contract, especially if they are near term. Cardiac output fluctuates as labor progresses. In early labor (<3 cm), cardiac output goes up about 17%. In the second stage of labor (> 8 cm), cardiac output increases at least 34%.

ASHEVILLE, N.C. — Focus on the woman's health in those rare cases of peripartum cardiomyopathy, said Thomas S. Ivester, M.D., at the Southern Obstetric and Gynecologic Seminar. “Maternal health is of paramount importance in this situation,” Dr. Ivester, of the department of maternal-fetal medicine said during the University of North Carolina at Chapel Hill.

Cardiomyopathy is an infrequent but potentially fatal complication of pregnancy. The mortality rate is 0.4 per 100,000 live births. Risk factors during pregnancy include multiparity, advanced age, African American race, and preeclampsia.

Care of critically ill pregnant women requires a team-based approach, with good communication among caregivers and specialists. Obstetricians can serve a vital role in educating critical care colleagues about treating pregnant patients who are critically ill.

In particular, “cardiac indices and central venous pressure are notoriously inaccurate in critically ill gravida. This is especially so with preeclampsia,” said Dr. Ivester. Use echocardiography to assess volume or use a P.A. catheter to get a wedge pressure.

Fetal decompensation is frequently a warning sign of subsequent significant maternal decompensation. “Once it's detected, cardiac monitoring of the fetus should probably be ceased until the mom is completely stabilized. Intervention in that scenario is probably ill advised,” said Dr. Ivester.

In patients who have significant hemorrhage or in those who may have suffered some type of hypovolemic insult or have been in shock, dopamine can be used to preserve and enhance renal and placental perfusion. “So a renal dose of dopamine, you can also consider as a placental dose of dopamine,” Dr. Ivester said.

Whenever possible, delivery should be reserved for obstetric indications. Vaginal delivery is preferred, because it is tolerated better by the woman. These patients should have prophylaxis for deep vein thrombosis, which can be accomplished by mechanical or chemical means.

“Close follow-up of any case of peripartum cardiomyopathy is critical,” Dr. Ivester said. He suggests serial echocardiography to evaluate the recovery of left ventricular function. Avoiding subsequent pregnancies until function improves is important, so make sure these patients are on adequate contraception. Earlier ICD implantation or placement on a transplant list should be considered for patients who suffer significant rhythm deterioration or have persistently low ejection fractions.

“Most importantly, … obstetric issues do not disappear with delivery. [The mother] is still an obstetric patient, even when the baby is delivered,” Dr. Ivester said. Peripartum changes can persist in some women for many weeks after delivery, and the obstetrician still has an important role to play in their care, especially in helping to differentiate the changes associated with pregnancy from other conditions.

In a normal pregnancy, blood volume increases 50%–100%. Systemic vascular resistance decreases 20%, and the blood is hypercoagulable. Cardiac output can fluctuate. Respiratory alkalosis may occur. The heart is displaced upward and to the left. The patient will have slight left ventricular hypertrophy and effusion that can be seen on echocardiography. There is frequently a left axis deviation due to these changes. There also may be nonspecific ST segment and T-wave changes.

Profound cardiac changes also occur during labor. Systemic vascular resistance can go up 10%–25% with each contraction. “That's a substantial increase for a patient with a very sick myocardium or those with significant valvular diseases,” Dr. Ivester said. Women in labor will autoinfuse 300–500 cc every time they contract, especially if they are near term. Cardiac output fluctuates as labor progresses. In early labor (<3 cm), cardiac output goes up about 17%. In the second stage of labor (> 8 cm), cardiac output increases at least 34%.

ASHEVILLE, N.C. — Focus on the woman's health in those rare cases of peripartum cardiomyopathy, said Thomas S. Ivester, M.D., at the Southern Obstetric and Gynecologic Seminar. “Maternal health is of paramount importance in this situation,” Dr. Ivester, of the department of maternal-fetal medicine said during the University of North Carolina at Chapel Hill.

Cardiomyopathy is an infrequent but potentially fatal complication of pregnancy. The mortality rate is 0.4 per 100,000 live births. Risk factors during pregnancy include multiparity, advanced age, African American race, and preeclampsia.

Care of critically ill pregnant women requires a team-based approach, with good communication among caregivers and specialists. Obstetricians can serve a vital role in educating critical care colleagues about treating pregnant patients who are critically ill.

In particular, “cardiac indices and central venous pressure are notoriously inaccurate in critically ill gravida. This is especially so with preeclampsia,” said Dr. Ivester. Use echocardiography to assess volume or use a P.A. catheter to get a wedge pressure.

Fetal decompensation is frequently a warning sign of subsequent significant maternal decompensation. “Once it's detected, cardiac monitoring of the fetus should probably be ceased until the mom is completely stabilized. Intervention in that scenario is probably ill advised,” said Dr. Ivester.

In patients who have significant hemorrhage or in those who may have suffered some type of hypovolemic insult or have been in shock, dopamine can be used to preserve and enhance renal and placental perfusion. “So a renal dose of dopamine, you can also consider as a placental dose of dopamine,” Dr. Ivester said.

Whenever possible, delivery should be reserved for obstetric indications. Vaginal delivery is preferred, because it is tolerated better by the woman. These patients should have prophylaxis for deep vein thrombosis, which can be accomplished by mechanical or chemical means.

“Close follow-up of any case of peripartum cardiomyopathy is critical,” Dr. Ivester said. He suggests serial echocardiography to evaluate the recovery of left ventricular function. Avoiding subsequent pregnancies until function improves is important, so make sure these patients are on adequate contraception. Earlier ICD implantation or placement on a transplant list should be considered for patients who suffer significant rhythm deterioration or have persistently low ejection fractions.

“Most importantly, … obstetric issues do not disappear with delivery. [The mother] is still an obstetric patient, even when the baby is delivered,” Dr. Ivester said. Peripartum changes can persist in some women for many weeks after delivery, and the obstetrician still has an important role to play in their care, especially in helping to differentiate the changes associated with pregnancy from other conditions.

In a normal pregnancy, blood volume increases 50%–100%. Systemic vascular resistance decreases 20%, and the blood is hypercoagulable. Cardiac output can fluctuate. Respiratory alkalosis may occur. The heart is displaced upward and to the left. The patient will have slight left ventricular hypertrophy and effusion that can be seen on echocardiography. There is frequently a left axis deviation due to these changes. There also may be nonspecific ST segment and T-wave changes.

Profound cardiac changes also occur during labor. Systemic vascular resistance can go up 10%–25% with each contraction. “That's a substantial increase for a patient with a very sick myocardium or those with significant valvular diseases,” Dr. Ivester said. Women in labor will autoinfuse 300–500 cc every time they contract, especially if they are near term. Cardiac output fluctuates as labor progresses. In early labor (<3 cm), cardiac output goes up about 17%. In the second stage of labor (> 8 cm), cardiac output increases at least 34%.

QUEBEC CITY — Placental compensation may influence fetal growth in women with gestational hypertension, according to research presented at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Pregnancies complicated by gestational hypertension and to a greater extent preeclampsia had significantly lower birth weight/placental weight ratios, compared with the controls at 38 and 39 weeks,” said Rebecca Cash, M.D., a resident in obstetrics and gynecology at the University of Toronto.

In the retrospective cohort study, Dr. Cash and her associates analyzed information on 12,422 term pregnancies (37–41 weeks) using data from the St. Joseph's Health Care, London perinatal database on births from Nov. 1, 1995 to November 1999. Singleton pregnancies complicated by gestational hypertension (1,084 cases), preeclampsia (144), or chronic hypertension (129) were compared with pregnancies in normotensive controls (11,065).

At 38 weeks, women with preeclampsia had significantly smaller babies than did controls (3,350 g vs. 3,520 g), whereas there was no significant difference in birth weight in infants born to women with gestational hypertension and controls.

“In preeclampsia, the reduction in the ratio indicates that the fetus is undergrown in relation to placental size, suggesting functional placental impairment,” Dr. Cash said.

Pregnancies complicated by gestational hypertension showed statistically significantly larger placenta weights vs. pregnancies in the control group at 38 and 39 weeks (692 g vs. 682 g, respectively), but not at 40 and 41 weeks.

Larger placenta size suggests there is a compensatory increase in placental weight for decreased function in gestational hypertension, which may influence fetal growth. “Abnormal placentation is thought to play a central role in the pathophysiology of preeclampsia,” said Dr. Cash. She added that this may have an effect on long-term outcomes, as findings of low birth weight and large placenta are independent risk factors for cardiovascular disease in adulthood.

In the study, gestational hypertension was defined as maternal blood pressure greater than 140/90 after 20 weeks' gestation without proteinuria. Preeclampsia was defined as maternal blood pressure greater than 140/90 after 20 weeks' gestation, accompanied by proteinuria or other end organ abnormalities. Chronic hypertension was defined as maternal blood pressure greater than 140/90 before 20 weeks' gestation.

Pregnancies complicated by diabetes, stillbirth, and congenital or chromosomal abnormalities were excluded from the analysis. Placental weights were routinely determined without trimming membranes or draining blood.

Dr. Cash's associate in the study was Rob Gratton, M.D., of the University of Western Ontario, London.

QUEBEC CITY — Placental compensation may influence fetal growth in women with gestational hypertension, according to research presented at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Pregnancies complicated by gestational hypertension and to a greater extent preeclampsia had significantly lower birth weight/placental weight ratios, compared with the controls at 38 and 39 weeks,” said Rebecca Cash, M.D., a resident in obstetrics and gynecology at the University of Toronto.

In the retrospective cohort study, Dr. Cash and her associates analyzed information on 12,422 term pregnancies (37–41 weeks) using data from the St. Joseph's Health Care, London perinatal database on births from Nov. 1, 1995 to November 1999. Singleton pregnancies complicated by gestational hypertension (1,084 cases), preeclampsia (144), or chronic hypertension (129) were compared with pregnancies in normotensive controls (11,065).

At 38 weeks, women with preeclampsia had significantly smaller babies than did controls (3,350 g vs. 3,520 g), whereas there was no significant difference in birth weight in infants born to women with gestational hypertension and controls.

“In preeclampsia, the reduction in the ratio indicates that the fetus is undergrown in relation to placental size, suggesting functional placental impairment,” Dr. Cash said.

Pregnancies complicated by gestational hypertension showed statistically significantly larger placenta weights vs. pregnancies in the control group at 38 and 39 weeks (692 g vs. 682 g, respectively), but not at 40 and 41 weeks.

Larger placenta size suggests there is a compensatory increase in placental weight for decreased function in gestational hypertension, which may influence fetal growth. “Abnormal placentation is thought to play a central role in the pathophysiology of preeclampsia,” said Dr. Cash. She added that this may have an effect on long-term outcomes, as findings of low birth weight and large placenta are independent risk factors for cardiovascular disease in adulthood.

In the study, gestational hypertension was defined as maternal blood pressure greater than 140/90 after 20 weeks' gestation without proteinuria. Preeclampsia was defined as maternal blood pressure greater than 140/90 after 20 weeks' gestation, accompanied by proteinuria or other end organ abnormalities. Chronic hypertension was defined as maternal blood pressure greater than 140/90 before 20 weeks' gestation.

Pregnancies complicated by diabetes, stillbirth, and congenital or chromosomal abnormalities were excluded from the analysis. Placental weights were routinely determined without trimming membranes or draining blood.

Dr. Cash's associate in the study was Rob Gratton, M.D., of the University of Western Ontario, London.

QUEBEC CITY — Placental compensation may influence fetal growth in women with gestational hypertension, according to research presented at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

“Pregnancies complicated by gestational hypertension and to a greater extent preeclampsia had significantly lower birth weight/placental weight ratios, compared with the controls at 38 and 39 weeks,” said Rebecca Cash, M.D., a resident in obstetrics and gynecology at the University of Toronto.

In the retrospective cohort study, Dr. Cash and her associates analyzed information on 12,422 term pregnancies (37–41 weeks) using data from the St. Joseph's Health Care, London perinatal database on births from Nov. 1, 1995 to November 1999. Singleton pregnancies complicated by gestational hypertension (1,084 cases), preeclampsia (144), or chronic hypertension (129) were compared with pregnancies in normotensive controls (11,065).

At 38 weeks, women with preeclampsia had significantly smaller babies than did controls (3,350 g vs. 3,520 g), whereas there was no significant difference in birth weight in infants born to women with gestational hypertension and controls.

“In preeclampsia, the reduction in the ratio indicates that the fetus is undergrown in relation to placental size, suggesting functional placental impairment,” Dr. Cash said.

Pregnancies complicated by gestational hypertension showed statistically significantly larger placenta weights vs. pregnancies in the control group at 38 and 39 weeks (692 g vs. 682 g, respectively), but not at 40 and 41 weeks.

Larger placenta size suggests there is a compensatory increase in placental weight for decreased function in gestational hypertension, which may influence fetal growth. “Abnormal placentation is thought to play a central role in the pathophysiology of preeclampsia,” said Dr. Cash. She added that this may have an effect on long-term outcomes, as findings of low birth weight and large placenta are independent risk factors for cardiovascular disease in adulthood.

In the study, gestational hypertension was defined as maternal blood pressure greater than 140/90 after 20 weeks' gestation without proteinuria. Preeclampsia was defined as maternal blood pressure greater than 140/90 after 20 weeks' gestation, accompanied by proteinuria or other end organ abnormalities. Chronic hypertension was defined as maternal blood pressure greater than 140/90 before 20 weeks' gestation.

Pregnancies complicated by diabetes, stillbirth, and congenital or chromosomal abnormalities were excluded from the analysis. Placental weights were routinely determined without trimming membranes or draining blood.

Dr. Cash's associate in the study was Rob Gratton, M.D., of the University of Western Ontario, London.

ASHEVILLE, N.C. — If you suspect a postdural puncture headache but aren't sure, order a T1-weighted MRI with gadolinium contrast for the patient, David C. Mayer, M.D., advised at the Southern Obstetric and Gynecologic Seminar.

“It used to be that there were no imaging studies available to make the diagnosis of postdural puncture headache. That has now changed,” said Dr. Mayer, a professor of obstetrics and gynecology and of anesthesiology at the University of North Carolina at Chapel Hill.

Signs of postdural puncture headaches (PDPH) cannot be seen on CT scans (with and without contrast) or noncontrast MRI.

MRI (T1 weighted) with gadolinium contrast, however, reveals changes that can make a difference in the diagnosis of PDPH. This particular type of MRI rules out more serious conditions, such as subdural hematoma and intracranial masses. The two key findings using T1-weighted contrast MRI are meningeal enhancement and descent or sagging of the brain. Diffuse meningeal enhancement is seen on the MRI. “The meninges … light up with gadolinium,” Dr. Mayer explained.

Less frequently, the pituitary may appear large—though this can be seen with CT as well—and engorged cerebral venous sinuses may also be seen.

Downward displacement of the brain can also be seen (similar to a Chiari malformation) with this type of imaging. There may also be descent of the cerebellar tonsils, obliteration of prepontine, perichiasmatic cisterns, flattening of the optic chiasm, crowding of the posterior fossa, as well as decreased ventricular size, according to Dr. Mayer.

PDPH onset commonly occurs while the patient is in the hospital. The headache usually has a postural component—worsening on standing and decreasing in a prone position. Other common symptoms include neck pain, nausea and vomiting, changes in hearing, and visual blurring or field cuts. However, atypical symptoms include interscapular pain, low-back pain, face numbness or weakness, galactorrhea, and radicular upper-limb symptoms.

“What people are now learning is that it is not just a pressure problem, it's a volume problem,” Dr. Mayer said.

CSF volume is a very well-regulated system. When volume changes occur, the system compensates. Intracranial veins dilate to maintain intracranial volume. Extensive venodilation may exert pressure on pain-sensitive structures (such as the meninges). The pituitary may enlarge. Brain sag—possibly as a result of reduced CSF pressure/volume—can compress and stretch structures and veins in the brain, leading to an increased risk of subdural hematoma.

ASHEVILLE, N.C. — If you suspect a postdural puncture headache but aren't sure, order a T1-weighted MRI with gadolinium contrast for the patient, David C. Mayer, M.D., advised at the Southern Obstetric and Gynecologic Seminar.

“It used to be that there were no imaging studies available to make the diagnosis of postdural puncture headache. That has now changed,” said Dr. Mayer, a professor of obstetrics and gynecology and of anesthesiology at the University of North Carolina at Chapel Hill.

Signs of postdural puncture headaches (PDPH) cannot be seen on CT scans (with and without contrast) or noncontrast MRI.

MRI (T1 weighted) with gadolinium contrast, however, reveals changes that can make a difference in the diagnosis of PDPH. This particular type of MRI rules out more serious conditions, such as subdural hematoma and intracranial masses. The two key findings using T1-weighted contrast MRI are meningeal enhancement and descent or sagging of the brain. Diffuse meningeal enhancement is seen on the MRI. “The meninges … light up with gadolinium,” Dr. Mayer explained.

Less frequently, the pituitary may appear large—though this can be seen with CT as well—and engorged cerebral venous sinuses may also be seen.

Downward displacement of the brain can also be seen (similar to a Chiari malformation) with this type of imaging. There may also be descent of the cerebellar tonsils, obliteration of prepontine, perichiasmatic cisterns, flattening of the optic chiasm, crowding of the posterior fossa, as well as decreased ventricular size, according to Dr. Mayer.

PDPH onset commonly occurs while the patient is in the hospital. The headache usually has a postural component—worsening on standing and decreasing in a prone position. Other common symptoms include neck pain, nausea and vomiting, changes in hearing, and visual blurring or field cuts. However, atypical symptoms include interscapular pain, low-back pain, face numbness or weakness, galactorrhea, and radicular upper-limb symptoms.

“What people are now learning is that it is not just a pressure problem, it's a volume problem,” Dr. Mayer said.

CSF volume is a very well-regulated system. When volume changes occur, the system compensates. Intracranial veins dilate to maintain intracranial volume. Extensive venodilation may exert pressure on pain-sensitive structures (such as the meninges). The pituitary may enlarge. Brain sag—possibly as a result of reduced CSF pressure/volume—can compress and stretch structures and veins in the brain, leading to an increased risk of subdural hematoma.

ASHEVILLE, N.C. — If you suspect a postdural puncture headache but aren't sure, order a T1-weighted MRI with gadolinium contrast for the patient, David C. Mayer, M.D., advised at the Southern Obstetric and Gynecologic Seminar.

“It used to be that there were no imaging studies available to make the diagnosis of postdural puncture headache. That has now changed,” said Dr. Mayer, a professor of obstetrics and gynecology and of anesthesiology at the University of North Carolina at Chapel Hill.

Signs of postdural puncture headaches (PDPH) cannot be seen on CT scans (with and without contrast) or noncontrast MRI.

MRI (T1 weighted) with gadolinium contrast, however, reveals changes that can make a difference in the diagnosis of PDPH. This particular type of MRI rules out more serious conditions, such as subdural hematoma and intracranial masses. The two key findings using T1-weighted contrast MRI are meningeal enhancement and descent or sagging of the brain. Diffuse meningeal enhancement is seen on the MRI. “The meninges … light up with gadolinium,” Dr. Mayer explained.

Less frequently, the pituitary may appear large—though this can be seen with CT as well—and engorged cerebral venous sinuses may also be seen.

Downward displacement of the brain can also be seen (similar to a Chiari malformation) with this type of imaging. There may also be descent of the cerebellar tonsils, obliteration of prepontine, perichiasmatic cisterns, flattening of the optic chiasm, crowding of the posterior fossa, as well as decreased ventricular size, according to Dr. Mayer.

PDPH onset commonly occurs while the patient is in the hospital. The headache usually has a postural component—worsening on standing and decreasing in a prone position. Other common symptoms include neck pain, nausea and vomiting, changes in hearing, and visual blurring or field cuts. However, atypical symptoms include interscapular pain, low-back pain, face numbness or weakness, galactorrhea, and radicular upper-limb symptoms.

“What people are now learning is that it is not just a pressure problem, it's a volume problem,” Dr. Mayer said.

CSF volume is a very well-regulated system. When volume changes occur, the system compensates. Intracranial veins dilate to maintain intracranial volume. Extensive venodilation may exert pressure on pain-sensitive structures (such as the meninges). The pituitary may enlarge. Brain sag—possibly as a result of reduced CSF pressure/volume—can compress and stretch structures and veins in the brain, leading to an increased risk of subdural hematoma.

ORLANDO — MRI for evaluating fetal and intracranial lesions shows promise, but challenges remain, Asad U. Sheikh, M.D., said at the annual meeting of the American Institute of Ultrasound in Medicine.

“MRI has become more useful for evaluating fetal and intracranial lesions. We're starting to see application as the technology advances for abdominal lesions as well. But still, we have considerable difficulty with interpretation,” explained Dr. Sheikh, director of the division of maternal-fetal medicine at the University of South Alabama.

Dr. Sheikh reported on two specific cases of schizencephaly, a brain lesion characterized by abnormal choronal migration.

The first case was of a 20-year-old woman at 19 weeks' gestation who presented with maternal serum alpha fetoprotein (AFP) elevated by 4.4 multiples of the median (MOM). Initial ultrasound evaluation indicated a left-sided intracranial cyst, Dr. Sheikh said. Investigators found that tests for karyotype and infection proved negative.

When they performed another sonogram, they found a large cystic structure replacing the left frontal temporal region. After the 35th week of gestation, they performed MRI, which showed bilateral schizencephaly. The patient delivered vaginally at term.

The second case was a 27-year-old woman at 21 weeks' gestation with an elevated AFP of 3.6 MOM; she was in her fourth pregnancy. Ultrasound revealed bilateral ventriculomegaly.

Amniocentesis was declined, and infection studies were negative. The physicians performed fetal MRI at 24 weeks' gestation and found left-sided schizencephaly and agenesis of the corpus callosum. The image quality was poor, due to fetal movement, however. The patient delivered vaginally at term.

Dr. Sheikh and his team performed MRIs to confirm their earlier diagnoses.

In the first case, they confirmed the findings of bilateral schizencephaly.

For the second patient, they performed cranial computed tomography, which illustrated bilateral schizencephaly with left more involved than right. Additionally, they observed agenesis of the corpus callosum.

Dr. Sheikh notes that these cases are unique in terms of the elevation in maternal serum AFP, which led to further evaluation. However, he points out that ventricular anomalies detected by ultrasound studies were more “precisely defined by prenatal MRI.”

He believes MRI should be considered to further delineate intracranial anomalies to better prepare families and care providers for postnatal expectations; however, there are limitations, he noted.

“One of the current limitations is that MRI is much more costly than ultrasound is, and there is limited availability. In addition, we don't know what the false-positive and false-negative diagnoses will be with fetal application of MRI. Nevertheless, it seems to be a promising new tool,” he concluded.

ORLANDO — MRI for evaluating fetal and intracranial lesions shows promise, but challenges remain, Asad U. Sheikh, M.D., said at the annual meeting of the American Institute of Ultrasound in Medicine.

“MRI has become more useful for evaluating fetal and intracranial lesions. We're starting to see application as the technology advances for abdominal lesions as well. But still, we have considerable difficulty with interpretation,” explained Dr. Sheikh, director of the division of maternal-fetal medicine at the University of South Alabama.

Dr. Sheikh reported on two specific cases of schizencephaly, a brain lesion characterized by abnormal choronal migration.

The first case was of a 20-year-old woman at 19 weeks' gestation who presented with maternal serum alpha fetoprotein (AFP) elevated by 4.4 multiples of the median (MOM). Initial ultrasound evaluation indicated a left-sided intracranial cyst, Dr. Sheikh said. Investigators found that tests for karyotype and infection proved negative.

When they performed another sonogram, they found a large cystic structure replacing the left frontal temporal region. After the 35th week of gestation, they performed MRI, which showed bilateral schizencephaly. The patient delivered vaginally at term.

The second case was a 27-year-old woman at 21 weeks' gestation with an elevated AFP of 3.6 MOM; she was in her fourth pregnancy. Ultrasound revealed bilateral ventriculomegaly.

Amniocentesis was declined, and infection studies were negative. The physicians performed fetal MRI at 24 weeks' gestation and found left-sided schizencephaly and agenesis of the corpus callosum. The image quality was poor, due to fetal movement, however. The patient delivered vaginally at term.

Dr. Sheikh and his team performed MRIs to confirm their earlier diagnoses.

In the first case, they confirmed the findings of bilateral schizencephaly.

For the second patient, they performed cranial computed tomography, which illustrated bilateral schizencephaly with left more involved than right. Additionally, they observed agenesis of the corpus callosum.

Dr. Sheikh notes that these cases are unique in terms of the elevation in maternal serum AFP, which led to further evaluation. However, he points out that ventricular anomalies detected by ultrasound studies were more “precisely defined by prenatal MRI.”

He believes MRI should be considered to further delineate intracranial anomalies to better prepare families and care providers for postnatal expectations; however, there are limitations, he noted.

“One of the current limitations is that MRI is much more costly than ultrasound is, and there is limited availability. In addition, we don't know what the false-positive and false-negative diagnoses will be with fetal application of MRI. Nevertheless, it seems to be a promising new tool,” he concluded.

ORLANDO — MRI for evaluating fetal and intracranial lesions shows promise, but challenges remain, Asad U. Sheikh, M.D., said at the annual meeting of the American Institute of Ultrasound in Medicine.

“MRI has become more useful for evaluating fetal and intracranial lesions. We're starting to see application as the technology advances for abdominal lesions as well. But still, we have considerable difficulty with interpretation,” explained Dr. Sheikh, director of the division of maternal-fetal medicine at the University of South Alabama.

Dr. Sheikh reported on two specific cases of schizencephaly, a brain lesion characterized by abnormal choronal migration.

The first case was of a 20-year-old woman at 19 weeks' gestation who presented with maternal serum alpha fetoprotein (AFP) elevated by 4.4 multiples of the median (MOM). Initial ultrasound evaluation indicated a left-sided intracranial cyst, Dr. Sheikh said. Investigators found that tests for karyotype and infection proved negative.

When they performed another sonogram, they found a large cystic structure replacing the left frontal temporal region. After the 35th week of gestation, they performed MRI, which showed bilateral schizencephaly. The patient delivered vaginally at term.

The second case was a 27-year-old woman at 21 weeks' gestation with an elevated AFP of 3.6 MOM; she was in her fourth pregnancy. Ultrasound revealed bilateral ventriculomegaly.

Amniocentesis was declined, and infection studies were negative. The physicians performed fetal MRI at 24 weeks' gestation and found left-sided schizencephaly and agenesis of the corpus callosum. The image quality was poor, due to fetal movement, however. The patient delivered vaginally at term.

Dr. Sheikh and his team performed MRIs to confirm their earlier diagnoses.

In the first case, they confirmed the findings of bilateral schizencephaly.

For the second patient, they performed cranial computed tomography, which illustrated bilateral schizencephaly with left more involved than right. Additionally, they observed agenesis of the corpus callosum.

Dr. Sheikh notes that these cases are unique in terms of the elevation in maternal serum AFP, which led to further evaluation. However, he points out that ventricular anomalies detected by ultrasound studies were more “precisely defined by prenatal MRI.”

He believes MRI should be considered to further delineate intracranial anomalies to better prepare families and care providers for postnatal expectations; however, there are limitations, he noted.

“One of the current limitations is that MRI is much more costly than ultrasound is, and there is limited availability. In addition, we don't know what the false-positive and false-negative diagnoses will be with fetal application of MRI. Nevertheless, it seems to be a promising new tool,” he concluded.

KEVIN FOLEY, RESEARCH/JULIE KELLER, DESIGN

KEVIN FOLEY, RESEARCH/JULIE KELLER, DESIGN

KEVIN FOLEY, RESEARCH/JULIE KELLER, DESIGN

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, who is professor of obstetrics and gynecology at the University of California, Irvine.

Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women who participated were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute. Rates of oxytocin use or intrapartum fever did not differ between groups.

In addition, Dr. Nageotte said he has reviewed two unpublished studies from Israel and from the United States that also suggest that delaying epidurals is not beneficial.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, who is professor of obstetrics and gynecology at the University of California, Irvine.

Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women who participated were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute. Rates of oxytocin use or intrapartum fever did not differ between groups.

In addition, Dr. Nageotte said he has reviewed two unpublished studies from Israel and from the United States that also suggest that delaying epidurals is not beneficial.

SAN FRANCISCO — Data from recent studies call into question the recommendation that physicians delay administration of epidural anesthesia to nulliparous women in labor, Michael P. Nageotte, M.D., said at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

The American College of Obstetricians and Gynecologists has recommended that “when feasible, obstetric practitioners should delay the administration of epidural anesthesia in nulliparous women until the cervical dilatation reaches 4–5 cm, and that other forms of analgesia be used until that time,” noted Dr. Nageotte, who is professor of obstetrics and gynecology at the University of California, Irvine.

Giving an epidural when the cervix is dilated less than 4 cm has been associated with a higher rate of cesarean delivery.

Investigators at Northwestern University, Chicago, led a recent study of 750 term nulliparous women who had experienced spontaneous labor or spontaneous rupture of the membranes. All of the women had a cervix that was dilated less than 4 cm on the initial exam and were told at the time of randomization that they would get an epidural if needed.

The women who participated were randomly assigned to receive either an intrathecal injection of fentanyl or systemic hydromorphone when they first requested analgesia. A woman's second request for analgesia resulted in administration of an epidural in the intrathecal group or assessment of cervical dilation in the systemic analgesia group. Women in the systemic group got an epidural if the cervix was dilated at least 4 cm, or received a second dose of systemic hydromorphone and were given an epidural upon their third request for analgesia.

The rate of cesarean delivery did not differ significantly between groups, but it was slightly higher in the delayed-epidural group, compared with the early-epidural group—21% vs. 18% (N. Engl. J. Med. 2005;352:655–65). The early-epidural group also had a significantly shorter time from receiving the first analgesia to complete cervical dilation (295 vs. 385 minutes) and a significantly shorter time from first analgesia to vaginal birth (398 vs. 479 minutes).

Women in the early-epidural group had better pain scores and were less likely to have babies with low Apgar scores at 1 minute. Rates of oxytocin use or intrapartum fever did not differ between groups.

In addition, Dr. Nageotte said he has reviewed two unpublished studies from Israel and from the United States that also suggest that delaying epidurals is not beneficial.

Approximately 1 in 23 uncomplicated monochorionic diamniotic twin pregnancies could be at risk for late fetal death, an observational study has shown.

The prospective risk of antepartum stillbirth after 32 weeks in this population appears to be independent of intensive ultrasound surveillance for such complications as twin-twin transfusion syndrome (TTTS) and intrauterine growth restriction, according to lead investigator Olivia Barigye, M.D., of the center for fetal care at Queen Charlotte's and Chelsea Hospital, London, and colleagues (PLoS Med. 2005;2:521–7).

If borne out by additional investigations, the findings could support the practice of elective preterm deliveries in such pregnancies, the authors wrote.

Dr. Barigye and colleagues audited the outcomes of 151 uncomplicated monochorionic diamniotic (MCDA) twin pregnancies seen by the hospital's fetal medicine service over a 12-year period. In all of the pregnancies, fetal growth and amniotic fluid volume were normal, as were the results of biweekly ultrasound studies, suggesting that neither TTTS nor intrauterine growth restriction was present.

Seven of the 151 pregnancies resulted in 10 unexpected fetal deaths within 2 weeks of a normal ultrasound scan at a median gestational age of 34 weeks. Autopsies were conducted for the deaths in five of the seven pregnancies. The autopsies for two double-death cases revealed features suggestive of acute late-onset TTTS. Specifically, postmortem evidence of cardiac hypertrophy was seen in the larger plethoric twins, although no such evidence was noted in ultrasound scans taken within 2 weeks of the intrauterine deaths, the investigators reported.

Although previous studies have suggested the main risk of fetal death in MCDA pregnancies occurred before 24 weeks' gestation, the new data “suggest instead that even intensively monitored, apparently healthy MCDA pregnancies remain at substantial risk of [intrauterine death] after 24 weeks,” the authors wrote.

Notwithstanding the study's small numbers, the findings offer useful information for counseling women and “may be used to inform decisions regarding the optimal timing of delivery,” Dr. Barigye and colleagues said.

Approximately 1 in 23 uncomplicated monochorionic diamniotic twin pregnancies could be at risk for late fetal death, an observational study has shown.

The prospective risk of antepartum stillbirth after 32 weeks in this population appears to be independent of intensive ultrasound surveillance for such complications as twin-twin transfusion syndrome (TTTS) and intrauterine growth restriction, according to lead investigator Olivia Barigye, M.D., of the center for fetal care at Queen Charlotte's and Chelsea Hospital, London, and colleagues (PLoS Med. 2005;2:521–7).

If borne out by additional investigations, the findings could support the practice of elective preterm deliveries in such pregnancies, the authors wrote.

Dr. Barigye and colleagues audited the outcomes of 151 uncomplicated monochorionic diamniotic (MCDA) twin pregnancies seen by the hospital's fetal medicine service over a 12-year period. In all of the pregnancies, fetal growth and amniotic fluid volume were normal, as were the results of biweekly ultrasound studies, suggesting that neither TTTS nor intrauterine growth restriction was present.

Seven of the 151 pregnancies resulted in 10 unexpected fetal deaths within 2 weeks of a normal ultrasound scan at a median gestational age of 34 weeks. Autopsies were conducted for the deaths in five of the seven pregnancies. The autopsies for two double-death cases revealed features suggestive of acute late-onset TTTS. Specifically, postmortem evidence of cardiac hypertrophy was seen in the larger plethoric twins, although no such evidence was noted in ultrasound scans taken within 2 weeks of the intrauterine deaths, the investigators reported.

Although previous studies have suggested the main risk of fetal death in MCDA pregnancies occurred before 24 weeks' gestation, the new data “suggest instead that even intensively monitored, apparently healthy MCDA pregnancies remain at substantial risk of [intrauterine death] after 24 weeks,” the authors wrote.

Notwithstanding the study's small numbers, the findings offer useful information for counseling women and “may be used to inform decisions regarding the optimal timing of delivery,” Dr. Barigye and colleagues said.

Approximately 1 in 23 uncomplicated monochorionic diamniotic twin pregnancies could be at risk for late fetal death, an observational study has shown.

The prospective risk of antepartum stillbirth after 32 weeks in this population appears to be independent of intensive ultrasound surveillance for such complications as twin-twin transfusion syndrome (TTTS) and intrauterine growth restriction, according to lead investigator Olivia Barigye, M.D., of the center for fetal care at Queen Charlotte's and Chelsea Hospital, London, and colleagues (PLoS Med. 2005;2:521–7).

If borne out by additional investigations, the findings could support the practice of elective preterm deliveries in such pregnancies, the authors wrote.

Dr. Barigye and colleagues audited the outcomes of 151 uncomplicated monochorionic diamniotic (MCDA) twin pregnancies seen by the hospital's fetal medicine service over a 12-year period. In all of the pregnancies, fetal growth and amniotic fluid volume were normal, as were the results of biweekly ultrasound studies, suggesting that neither TTTS nor intrauterine growth restriction was present.

Seven of the 151 pregnancies resulted in 10 unexpected fetal deaths within 2 weeks of a normal ultrasound scan at a median gestational age of 34 weeks. Autopsies were conducted for the deaths in five of the seven pregnancies. The autopsies for two double-death cases revealed features suggestive of acute late-onset TTTS. Specifically, postmortem evidence of cardiac hypertrophy was seen in the larger plethoric twins, although no such evidence was noted in ultrasound scans taken within 2 weeks of the intrauterine deaths, the investigators reported.

Although previous studies have suggested the main risk of fetal death in MCDA pregnancies occurred before 24 weeks' gestation, the new data “suggest instead that even intensively monitored, apparently healthy MCDA pregnancies remain at substantial risk of [intrauterine death] after 24 weeks,” the authors wrote.

Notwithstanding the study's small numbers, the findings offer useful information for counseling women and “may be used to inform decisions regarding the optimal timing of delivery,” Dr. Barigye and colleagues said.