Obstetrics

SAN FRANCISCO — Recent data may make trials of labor to deliver twins in vertex/nonvertex positions a thing of the past, Yasser Y. El-Sayed, M.D., predicted.

A large retrospective cohort study found significantly greater safety in planned cesarean deliveries, compared with vaginal delivery of both twins or vaginal delivery of the first (vertex) twin and an emergency C-section after a failed attempt at vaginal delivery of the second (nonvertex) twin (Am. J. Obstet. Gynecol. 2005;192:840–7).

“Breech extraction of the second twin may very well go the way of the singleton breech” delivery, said Dr. El-Sayed of Stanford (Calif.) University.

Breech delivery of singletons generally has been shunned since the 2000 Term Breech Trial found greater morbidity from vaginal breech deliveries of singletons, compared with planned C-sections (Lancet 2000;356:1375–83).

The more recent study looked at all U.S. twin births in 1995–1997 and found 15,185 twin vertex/nonvertex pairs delivered when they were at or greater than 24 weeks' gestation and weighed at least 500 g. In 37.7% of cases, both twins were delivered by planned C-section, and in 46.8%, both twins were delivered vaginally. In 15.5%, the first twin was delivered vaginally and a trial of labor failed for the nonvertex twin, who then was delivered by emergency C-section.

Compared with the planned C-section group, babies in the vaginal delivery-only group had significantly higher rates of all-cause neonatal death, death not related to congenital anomalies, asphyxia-related death, newborn infant injury, low Apgar scores, ventilation use, and seizures.

The emergency C-section group had significantly higher rates of asphyxia-related death, newborn infant injury, low Apgar scores, and ventilation use, compared with the planned C-section group.

Many of these differences remained in subgroup analyses of infants weighing less than or more than 1,500 g. That finding contradicts the results of less well-designed retrospective studies suggesting that breech delivery of a nonvertex twin was safe for babies weighing at least 1,500 g, Dr. El-Sayed noted.

Authors of the twin study said their results were consistent with those of the singleton Term Breech Trial and concluded that planned C-section delivery causes the least morbidity to nonvertex second twins or to singletons.

In the twin study, emergency C-sections were needed for almost 25% of nonvertex twins who underwent an attempted vaginal delivery.

“The authors of the study suggest that perhaps this alone should lead to routine cesarean section for vertex/nonvertex twins,” Dr. El-Sayed said.

SAN FRANCISCO — Recent data may make trials of labor to deliver twins in vertex/nonvertex positions a thing of the past, Yasser Y. El-Sayed, M.D., predicted.

A large retrospective cohort study found significantly greater safety in planned cesarean deliveries, compared with vaginal delivery of both twins or vaginal delivery of the first (vertex) twin and an emergency C-section after a failed attempt at vaginal delivery of the second (nonvertex) twin (Am. J. Obstet. Gynecol. 2005;192:840–7).

“Breech extraction of the second twin may very well go the way of the singleton breech” delivery, said Dr. El-Sayed of Stanford (Calif.) University.

Breech delivery of singletons generally has been shunned since the 2000 Term Breech Trial found greater morbidity from vaginal breech deliveries of singletons, compared with planned C-sections (Lancet 2000;356:1375–83).

The more recent study looked at all U.S. twin births in 1995–1997 and found 15,185 twin vertex/nonvertex pairs delivered when they were at or greater than 24 weeks' gestation and weighed at least 500 g. In 37.7% of cases, both twins were delivered by planned C-section, and in 46.8%, both twins were delivered vaginally. In 15.5%, the first twin was delivered vaginally and a trial of labor failed for the nonvertex twin, who then was delivered by emergency C-section.

Compared with the planned C-section group, babies in the vaginal delivery-only group had significantly higher rates of all-cause neonatal death, death not related to congenital anomalies, asphyxia-related death, newborn infant injury, low Apgar scores, ventilation use, and seizures.

The emergency C-section group had significantly higher rates of asphyxia-related death, newborn infant injury, low Apgar scores, and ventilation use, compared with the planned C-section group.

Many of these differences remained in subgroup analyses of infants weighing less than or more than 1,500 g. That finding contradicts the results of less well-designed retrospective studies suggesting that breech delivery of a nonvertex twin was safe for babies weighing at least 1,500 g, Dr. El-Sayed noted.

Authors of the twin study said their results were consistent with those of the singleton Term Breech Trial and concluded that planned C-section delivery causes the least morbidity to nonvertex second twins or to singletons.

In the twin study, emergency C-sections were needed for almost 25% of nonvertex twins who underwent an attempted vaginal delivery.

“The authors of the study suggest that perhaps this alone should lead to routine cesarean section for vertex/nonvertex twins,” Dr. El-Sayed said.

SAN FRANCISCO — Recent data may make trials of labor to deliver twins in vertex/nonvertex positions a thing of the past, Yasser Y. El-Sayed, M.D., predicted.

A large retrospective cohort study found significantly greater safety in planned cesarean deliveries, compared with vaginal delivery of both twins or vaginal delivery of the first (vertex) twin and an emergency C-section after a failed attempt at vaginal delivery of the second (nonvertex) twin (Am. J. Obstet. Gynecol. 2005;192:840–7).

“Breech extraction of the second twin may very well go the way of the singleton breech” delivery, said Dr. El-Sayed of Stanford (Calif.) University.

Breech delivery of singletons generally has been shunned since the 2000 Term Breech Trial found greater morbidity from vaginal breech deliveries of singletons, compared with planned C-sections (Lancet 2000;356:1375–83).

The more recent study looked at all U.S. twin births in 1995–1997 and found 15,185 twin vertex/nonvertex pairs delivered when they were at or greater than 24 weeks' gestation and weighed at least 500 g. In 37.7% of cases, both twins were delivered by planned C-section, and in 46.8%, both twins were delivered vaginally. In 15.5%, the first twin was delivered vaginally and a trial of labor failed for the nonvertex twin, who then was delivered by emergency C-section.

Compared with the planned C-section group, babies in the vaginal delivery-only group had significantly higher rates of all-cause neonatal death, death not related to congenital anomalies, asphyxia-related death, newborn infant injury, low Apgar scores, ventilation use, and seizures.

The emergency C-section group had significantly higher rates of asphyxia-related death, newborn infant injury, low Apgar scores, and ventilation use, compared with the planned C-section group.

Many of these differences remained in subgroup analyses of infants weighing less than or more than 1,500 g. That finding contradicts the results of less well-designed retrospective studies suggesting that breech delivery of a nonvertex twin was safe for babies weighing at least 1,500 g, Dr. El-Sayed noted.

Authors of the twin study said their results were consistent with those of the singleton Term Breech Trial and concluded that planned C-section delivery causes the least morbidity to nonvertex second twins or to singletons.

In the twin study, emergency C-sections were needed for almost 25% of nonvertex twins who underwent an attempted vaginal delivery.

“The authors of the study suggest that perhaps this alone should lead to routine cesarean section for vertex/nonvertex twins,” Dr. El-Sayed said.

ST. PETE BEACH, FLA. — Young pregnant women who smoke cigarettes or marijuana or who are malnourished have a significantly increased risk of having an infant with gastroschisis, a case-control study suggests.

Those who have both risk factors have an even greater risk of having an infant with this severe birth defect, Phung Kim Lam, Ph.D., reported at the annual meeting of the Teratology Society.

Dr. Lam studied 55 infants with gastroschisis and 94 age-matched controls. Maternal information was based on interviews and food-frequency questionnaires.

Mothers were said to have high carbon monoxide (CO) exposure if they smoked at least one pack of cigarettes daily near the time of conception or if they smoked marijuana habitually around that time, said Dr. Lam of the University of California, San Diego.

Malnutrition was characterized by protein intake of less than 72 g/day, zinc intake of less than 10 mg/day, and maternal body mass index of less than 22 kg/m₂; these three factors were highly correlated (low zinc with low protein, and low protein with BMI). They are also correlated with numerous other markers of nutritional status, such as intake of certain other vitamins and minerals.

On multiple conditional logistic regression, gastroschisis was associated with high CO exposure (odds ratio 2.64) and low animal protein intake (OR 2.45).

Young mothers without low BMI but with high CO exposure were more likely than controls to have a baby with gastroschisis (odds ratio 16.81), as were those with low BMI and no CO exposure (OR 19.69). But the finding was much more marked in those with low BMI and high CO exposure, compared with controls (OR 26.49), she said.

The findings support those of an animal model in which exposure to high levels of carbon monoxide and low protein and zinc intake in pregnant mice led to this birth defect.

ST. PETE BEACH, FLA. — Young pregnant women who smoke cigarettes or marijuana or who are malnourished have a significantly increased risk of having an infant with gastroschisis, a case-control study suggests.

Those who have both risk factors have an even greater risk of having an infant with this severe birth defect, Phung Kim Lam, Ph.D., reported at the annual meeting of the Teratology Society.

Dr. Lam studied 55 infants with gastroschisis and 94 age-matched controls. Maternal information was based on interviews and food-frequency questionnaires.

Mothers were said to have high carbon monoxide (CO) exposure if they smoked at least one pack of cigarettes daily near the time of conception or if they smoked marijuana habitually around that time, said Dr. Lam of the University of California, San Diego.

Malnutrition was characterized by protein intake of less than 72 g/day, zinc intake of less than 10 mg/day, and maternal body mass index of less than 22 kg/m₂; these three factors were highly correlated (low zinc with low protein, and low protein with BMI). They are also correlated with numerous other markers of nutritional status, such as intake of certain other vitamins and minerals.

On multiple conditional logistic regression, gastroschisis was associated with high CO exposure (odds ratio 2.64) and low animal protein intake (OR 2.45).

Young mothers without low BMI but with high CO exposure were more likely than controls to have a baby with gastroschisis (odds ratio 16.81), as were those with low BMI and no CO exposure (OR 19.69). But the finding was much more marked in those with low BMI and high CO exposure, compared with controls (OR 26.49), she said.

The findings support those of an animal model in which exposure to high levels of carbon monoxide and low protein and zinc intake in pregnant mice led to this birth defect.

ST. PETE BEACH, FLA. — Young pregnant women who smoke cigarettes or marijuana or who are malnourished have a significantly increased risk of having an infant with gastroschisis, a case-control study suggests.

Those who have both risk factors have an even greater risk of having an infant with this severe birth defect, Phung Kim Lam, Ph.D., reported at the annual meeting of the Teratology Society.

Dr. Lam studied 55 infants with gastroschisis and 94 age-matched controls. Maternal information was based on interviews and food-frequency questionnaires.

Mothers were said to have high carbon monoxide (CO) exposure if they smoked at least one pack of cigarettes daily near the time of conception or if they smoked marijuana habitually around that time, said Dr. Lam of the University of California, San Diego.

Malnutrition was characterized by protein intake of less than 72 g/day, zinc intake of less than 10 mg/day, and maternal body mass index of less than 22 kg/m₂; these three factors were highly correlated (low zinc with low protein, and low protein with BMI). They are also correlated with numerous other markers of nutritional status, such as intake of certain other vitamins and minerals.

On multiple conditional logistic regression, gastroschisis was associated with high CO exposure (odds ratio 2.64) and low animal protein intake (OR 2.45).

Young mothers without low BMI but with high CO exposure were more likely than controls to have a baby with gastroschisis (odds ratio 16.81), as were those with low BMI and no CO exposure (OR 19.69). But the finding was much more marked in those with low BMI and high CO exposure, compared with controls (OR 26.49), she said.

The findings support those of an animal model in which exposure to high levels of carbon monoxide and low protein and zinc intake in pregnant mice led to this birth defect.

ST. PETE BEACH, FLA. — The use of oral steroids for asthma during pregnancy has long been discussed as a possible cause of orofacial clefts in newborns, but findings from a large cohort study suggest this is not the case.

In nearly 82,000 mother/infant pairs, not a single infant with an orofacial cleft was born to any of the more than 400 women who received at least one oral steroid prescription in the 90 days before pregnancy or during early pregnancy, Janet R. Hardy, Ph.D., reported at the annual meeting of the Teratology Society.

The findings could put an end to long-held beliefs—based on findings in laboratory animals decades ago—that a link exists between the medication and an increased risk for such defects.

About 6% of mothers in the retrospective population-based cohort study were asthmatic, and nearly 2% had other respiratory conditions. A total of 130 babies included in the study were born with orofacial cleft; only 6 of these were born to asthmatic mothers, and 3 others were born to women with other respiratory conditions. None of the nine mothers had received a prescription for an oral steroid during pregnancy, said Dr. Hardy, of the University of Massachusetts, Worcester.

The relative risk of cleft overall in this study was 1.30; the relative risk in babies born to women who received a prescription for any type of steroid medication was 1.26.

Dr. Hardy noted that the study, based on data in automated medical records from 1991 to 1999, is limited by its basis on prescribed medications. Medications prescribed do not necessarily equate to medications taken, she said, noting that she also was unable to study asthma severity, maternal smoking, family history, and racial and ethnic background.

Adjustment for other possible confounders, including other medications used, did not affect the results, however, she said.

Asthma complicates 3.7%–8.4% of pregnancies, and these findings suggest that any steroid use is associated with only a slightly increased risk of orofacial clefts.

Given the small overall risk with any steroid use and the apparent absence of risk with oral steroids, it is of concern that the data show a decline in the prescribing of oral steroids for the treatment of asthma in the first trimester, Dr. Hardy said.

In the prepregnancy period, 318 mothers (including 203 who were asthmatic) received at least one oral steroid prescription. In early pregnancy, however, only 149 (including 89 who were asthmatic) received at least one oral steroid prescription.

The risks associated with uncontrolled asthma are likely to be worse for the fetus than the risks of asthma medications, she concluded.

ST. PETE BEACH, FLA. — The use of oral steroids for asthma during pregnancy has long been discussed as a possible cause of orofacial clefts in newborns, but findings from a large cohort study suggest this is not the case.

In nearly 82,000 mother/infant pairs, not a single infant with an orofacial cleft was born to any of the more than 400 women who received at least one oral steroid prescription in the 90 days before pregnancy or during early pregnancy, Janet R. Hardy, Ph.D., reported at the annual meeting of the Teratology Society.

The findings could put an end to long-held beliefs—based on findings in laboratory animals decades ago—that a link exists between the medication and an increased risk for such defects.

About 6% of mothers in the retrospective population-based cohort study were asthmatic, and nearly 2% had other respiratory conditions. A total of 130 babies included in the study were born with orofacial cleft; only 6 of these were born to asthmatic mothers, and 3 others were born to women with other respiratory conditions. None of the nine mothers had received a prescription for an oral steroid during pregnancy, said Dr. Hardy, of the University of Massachusetts, Worcester.

The relative risk of cleft overall in this study was 1.30; the relative risk in babies born to women who received a prescription for any type of steroid medication was 1.26.

Dr. Hardy noted that the study, based on data in automated medical records from 1991 to 1999, is limited by its basis on prescribed medications. Medications prescribed do not necessarily equate to medications taken, she said, noting that she also was unable to study asthma severity, maternal smoking, family history, and racial and ethnic background.

Adjustment for other possible confounders, including other medications used, did not affect the results, however, she said.

Asthma complicates 3.7%–8.4% of pregnancies, and these findings suggest that any steroid use is associated with only a slightly increased risk of orofacial clefts.

Given the small overall risk with any steroid use and the apparent absence of risk with oral steroids, it is of concern that the data show a decline in the prescribing of oral steroids for the treatment of asthma in the first trimester, Dr. Hardy said.

In the prepregnancy period, 318 mothers (including 203 who were asthmatic) received at least one oral steroid prescription. In early pregnancy, however, only 149 (including 89 who were asthmatic) received at least one oral steroid prescription.

The risks associated with uncontrolled asthma are likely to be worse for the fetus than the risks of asthma medications, she concluded.

ST. PETE BEACH, FLA. — The use of oral steroids for asthma during pregnancy has long been discussed as a possible cause of orofacial clefts in newborns, but findings from a large cohort study suggest this is not the case.

In nearly 82,000 mother/infant pairs, not a single infant with an orofacial cleft was born to any of the more than 400 women who received at least one oral steroid prescription in the 90 days before pregnancy or during early pregnancy, Janet R. Hardy, Ph.D., reported at the annual meeting of the Teratology Society.

The findings could put an end to long-held beliefs—based on findings in laboratory animals decades ago—that a link exists between the medication and an increased risk for such defects.

About 6% of mothers in the retrospective population-based cohort study were asthmatic, and nearly 2% had other respiratory conditions. A total of 130 babies included in the study were born with orofacial cleft; only 6 of these were born to asthmatic mothers, and 3 others were born to women with other respiratory conditions. None of the nine mothers had received a prescription for an oral steroid during pregnancy, said Dr. Hardy, of the University of Massachusetts, Worcester.

The relative risk of cleft overall in this study was 1.30; the relative risk in babies born to women who received a prescription for any type of steroid medication was 1.26.

Dr. Hardy noted that the study, based on data in automated medical records from 1991 to 1999, is limited by its basis on prescribed medications. Medications prescribed do not necessarily equate to medications taken, she said, noting that she also was unable to study asthma severity, maternal smoking, family history, and racial and ethnic background.

Adjustment for other possible confounders, including other medications used, did not affect the results, however, she said.

Asthma complicates 3.7%–8.4% of pregnancies, and these findings suggest that any steroid use is associated with only a slightly increased risk of orofacial clefts.

Given the small overall risk with any steroid use and the apparent absence of risk with oral steroids, it is of concern that the data show a decline in the prescribing of oral steroids for the treatment of asthma in the first trimester, Dr. Hardy said.

In the prepregnancy period, 318 mothers (including 203 who were asthmatic) received at least one oral steroid prescription. In early pregnancy, however, only 149 (including 89 who were asthmatic) received at least one oral steroid prescription.

The risks associated with uncontrolled asthma are likely to be worse for the fetus than the risks of asthma medications, she concluded.

QUEBEC CITY — Women who've had a prior preterm birth are at increased risk for a subsequent preterm birth and associated neonatal morbidity and mortality, and this risk is inversely related to the gestational age at which their first spontaneous preterm birth occurred.

That finding emerged from a population-based cohort study of more than 25,000 women that was presented at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Women with a previous preterm birth, especially if it's earlier than 34 weeks, are at high risk and should be monitored carefully, said Erica Frecker, M.D., a resident in obstetrics and gynecology at Dalhousie University in Halifax, N.S., working under B. Anthony Armson, M.D.

The study offers useful information for obstetricians who give preconceptional counseling to women with previous preterm births, who are often worried about the outcome of their next pregnancy, said Dr. Frecker, the study's lead author.

Using the Nova Scotia Atlee Perinatal Database, researchers identified 25,525 women who had their first and second deliveries in 1988–2001. All of the women had spontaneous births; stillbirths and major fetal anomalies in the first pregnancy were excluded.

The women were categorized into four groups based on their babies' gestational ages at first delivery. The risks of preterm birth and serious neonatal morbidity or mortality in the subsequent pregnancy were calculated using multivariate analysis.

The incidence of preterm birth earlier than 37 weeks, earlier than 34 weeks, and earlier than 28 weeks was 4.66%, 1.25%, and 0.3%, respectively, in the first pregnancy, followed by an incidence of 3.66%, 0.94%, and 0.24%, respectively, in the second pregnancy.

The relative risk of having a preterm birth in the second pregnancy was inversely related to the gestational age at birth in the first pregnancy, except in the youngest gestational age category. (See chart.)

The numbers were adjusted for multiple gestation and uterine anomaly by multivariate regression.

The proportions of neonatal morbidity/mortality in the second pregnancy increased as the gestational age category decreased. The proportions increased from 1.21% for gestational ages greater than 37 weeks to 8.18% for gestational ages of less than 28 weeks. Serious neonatal morbidity cases included necrotizing enterocolitis, severe respiratory distress syndrome, bronchopulmonary dysplasia, sepsis, pneumonia, and meningitis.

Commenting on the study, David Young, M.D., past president of the Society of Obstetricians and Gynaecologists of Canada, noted that the results from the provincial perinatal database may be applicable to the general population, as they represent every birth in Nova Scotia for 1988–2001. “Researchers or clinicians in the field, particularly of preterm birth, would not be surprised by these results, but it adds substantially to the information that already is available and what might have been our best guess,” said Dr. Young, now head of the department of obstetrics and gynecology at Dalhousie University's IWK Health Centre in Halifax.

Although “we don't have a proven, effective method of intervention,” Dr. Young said, the study may shed light on the controversy surrounding intramuscular progesterone, which was the subject of several studies, including a randomized, controlled trial (N. Engl. J. Med 2003;348:2379–85). Since then, a more recent review has been published on the prevention of preterm delivery using the same medication (Obstet. Gynecol. 2005;105:1128–35).

“It [progesterone] may be the closest thing that might be effective,” Dr. Young said.

The study results also provide evidence that women who have a prior preterm birth—particularly those who delivered earlier than 34 weeks—should be monitored more closely, noted Dr. Young. These patients may be considered for investigations such as cervical length surveillance through transvaginal ultrasound, for the treatment of prophylactic steroids for lung maturity, and for modification of activity.

QUEBEC CITY — Women who've had a prior preterm birth are at increased risk for a subsequent preterm birth and associated neonatal morbidity and mortality, and this risk is inversely related to the gestational age at which their first spontaneous preterm birth occurred.

That finding emerged from a population-based cohort study of more than 25,000 women that was presented at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Women with a previous preterm birth, especially if it's earlier than 34 weeks, are at high risk and should be monitored carefully, said Erica Frecker, M.D., a resident in obstetrics and gynecology at Dalhousie University in Halifax, N.S., working under B. Anthony Armson, M.D.

The study offers useful information for obstetricians who give preconceptional counseling to women with previous preterm births, who are often worried about the outcome of their next pregnancy, said Dr. Frecker, the study's lead author.

Using the Nova Scotia Atlee Perinatal Database, researchers identified 25,525 women who had their first and second deliveries in 1988–2001. All of the women had spontaneous births; stillbirths and major fetal anomalies in the first pregnancy were excluded.

The women were categorized into four groups based on their babies' gestational ages at first delivery. The risks of preterm birth and serious neonatal morbidity or mortality in the subsequent pregnancy were calculated using multivariate analysis.

The incidence of preterm birth earlier than 37 weeks, earlier than 34 weeks, and earlier than 28 weeks was 4.66%, 1.25%, and 0.3%, respectively, in the first pregnancy, followed by an incidence of 3.66%, 0.94%, and 0.24%, respectively, in the second pregnancy.

The relative risk of having a preterm birth in the second pregnancy was inversely related to the gestational age at birth in the first pregnancy, except in the youngest gestational age category. (See chart.)

The numbers were adjusted for multiple gestation and uterine anomaly by multivariate regression.

The proportions of neonatal morbidity/mortality in the second pregnancy increased as the gestational age category decreased. The proportions increased from 1.21% for gestational ages greater than 37 weeks to 8.18% for gestational ages of less than 28 weeks. Serious neonatal morbidity cases included necrotizing enterocolitis, severe respiratory distress syndrome, bronchopulmonary dysplasia, sepsis, pneumonia, and meningitis.

Commenting on the study, David Young, M.D., past president of the Society of Obstetricians and Gynaecologists of Canada, noted that the results from the provincial perinatal database may be applicable to the general population, as they represent every birth in Nova Scotia for 1988–2001. “Researchers or clinicians in the field, particularly of preterm birth, would not be surprised by these results, but it adds substantially to the information that already is available and what might have been our best guess,” said Dr. Young, now head of the department of obstetrics and gynecology at Dalhousie University's IWK Health Centre in Halifax.

Although “we don't have a proven, effective method of intervention,” Dr. Young said, the study may shed light on the controversy surrounding intramuscular progesterone, which was the subject of several studies, including a randomized, controlled trial (N. Engl. J. Med 2003;348:2379–85). Since then, a more recent review has been published on the prevention of preterm delivery using the same medication (Obstet. Gynecol. 2005;105:1128–35).

“It [progesterone] may be the closest thing that might be effective,” Dr. Young said.

The study results also provide evidence that women who have a prior preterm birth—particularly those who delivered earlier than 34 weeks—should be monitored more closely, noted Dr. Young. These patients may be considered for investigations such as cervical length surveillance through transvaginal ultrasound, for the treatment of prophylactic steroids for lung maturity, and for modification of activity.

QUEBEC CITY — Women who've had a prior preterm birth are at increased risk for a subsequent preterm birth and associated neonatal morbidity and mortality, and this risk is inversely related to the gestational age at which their first spontaneous preterm birth occurred.

That finding emerged from a population-based cohort study of more than 25,000 women that was presented at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Women with a previous preterm birth, especially if it's earlier than 34 weeks, are at high risk and should be monitored carefully, said Erica Frecker, M.D., a resident in obstetrics and gynecology at Dalhousie University in Halifax, N.S., working under B. Anthony Armson, M.D.

The study offers useful information for obstetricians who give preconceptional counseling to women with previous preterm births, who are often worried about the outcome of their next pregnancy, said Dr. Frecker, the study's lead author.

Using the Nova Scotia Atlee Perinatal Database, researchers identified 25,525 women who had their first and second deliveries in 1988–2001. All of the women had spontaneous births; stillbirths and major fetal anomalies in the first pregnancy were excluded.

The women were categorized into four groups based on their babies' gestational ages at first delivery. The risks of preterm birth and serious neonatal morbidity or mortality in the subsequent pregnancy were calculated using multivariate analysis.

The incidence of preterm birth earlier than 37 weeks, earlier than 34 weeks, and earlier than 28 weeks was 4.66%, 1.25%, and 0.3%, respectively, in the first pregnancy, followed by an incidence of 3.66%, 0.94%, and 0.24%, respectively, in the second pregnancy.

The relative risk of having a preterm birth in the second pregnancy was inversely related to the gestational age at birth in the first pregnancy, except in the youngest gestational age category. (See chart.)

The numbers were adjusted for multiple gestation and uterine anomaly by multivariate regression.

The proportions of neonatal morbidity/mortality in the second pregnancy increased as the gestational age category decreased. The proportions increased from 1.21% for gestational ages greater than 37 weeks to 8.18% for gestational ages of less than 28 weeks. Serious neonatal morbidity cases included necrotizing enterocolitis, severe respiratory distress syndrome, bronchopulmonary dysplasia, sepsis, pneumonia, and meningitis.

Commenting on the study, David Young, M.D., past president of the Society of Obstetricians and Gynaecologists of Canada, noted that the results from the provincial perinatal database may be applicable to the general population, as they represent every birth in Nova Scotia for 1988–2001. “Researchers or clinicians in the field, particularly of preterm birth, would not be surprised by these results, but it adds substantially to the information that already is available and what might have been our best guess,” said Dr. Young, now head of the department of obstetrics and gynecology at Dalhousie University's IWK Health Centre in Halifax.

Although “we don't have a proven, effective method of intervention,” Dr. Young said, the study may shed light on the controversy surrounding intramuscular progesterone, which was the subject of several studies, including a randomized, controlled trial (N. Engl. J. Med 2003;348:2379–85). Since then, a more recent review has been published on the prevention of preterm delivery using the same medication (Obstet. Gynecol. 2005;105:1128–35).

“It [progesterone] may be the closest thing that might be effective,” Dr. Young said.

The study results also provide evidence that women who have a prior preterm birth—particularly those who delivered earlier than 34 weeks—should be monitored more closely, noted Dr. Young. These patients may be considered for investigations such as cervical length surveillance through transvaginal ultrasound, for the treatment of prophylactic steroids for lung maturity, and for modification of activity.

ST. PETE BEACH, FLA. — Assisted reproductive techniques may be a risk factor for CHARGE association and Goldenhar's syndrome, a small study suggests.

Of 31 patients with CHARGE association and 20 patients with Goldenhar's syndrome, 7 (23%) were conceived via maternal use of an assisted fertilization technique, Kerstin Stromland, M.D., reported at the annual meeting of the Teratology Society.

Of those with CHARGE association, one boy and one girl were the product of intracytoplasmic sperm injection, and another boy was conceived after his mother's use of ovulation stimulating hormone.

Of those with Goldenhar's syndrome, two twin boys (who had a healthy sibling) and one girl, who had a healthy twin sister, were born following intracytoplasmic sperm injection, and another girl was born after standard in vitro fertilization, said Dr. Stromland of Sahlgrenska University Hospital, Gothenburg, Sweden.

The possible link was identified after mothers completed a questionnaire asking about medical history and use of drugs, alcohol, or tobacco, and following the collection of data from medical records and interviews with parents of the children.

While there are a few publications suggesting a link between CHARGE association and Goldenhar's syndrome and assisted reproduction techniques (ART) this is the first to suggest a specific link between CHARGE association and intracytoplasmic sperm injection, Dr. Stromland said, noting that one possible reason for the lack of reports on such cases is the multiple malformations that characterize these syndromes. That is, patients' deformities are often registered as separate malformations, rather than malformations occurring as part of a syndrome.

Further study is needed to elucidate any relationship between assisted fertilization and these conditions, she concluded.

CHARGE association is a constellation of congenital malformations. The acronym stands for some of the most common features:

▸ Coloboma of the eye and cranial nerve abnormalities.

▸ Heart malformation.

▸ Choanal atresia.

▸ Retardation of growth after birth and of development.

▸ Genital hypoplasia in males and urinary tract.

▸ Ear malformations and/or deafness.

ST. PETE BEACH, FLA. — Assisted reproductive techniques may be a risk factor for CHARGE association and Goldenhar's syndrome, a small study suggests.

Of 31 patients with CHARGE association and 20 patients with Goldenhar's syndrome, 7 (23%) were conceived via maternal use of an assisted fertilization technique, Kerstin Stromland, M.D., reported at the annual meeting of the Teratology Society.

Of those with CHARGE association, one boy and one girl were the product of intracytoplasmic sperm injection, and another boy was conceived after his mother's use of ovulation stimulating hormone.

Of those with Goldenhar's syndrome, two twin boys (who had a healthy sibling) and one girl, who had a healthy twin sister, were born following intracytoplasmic sperm injection, and another girl was born after standard in vitro fertilization, said Dr. Stromland of Sahlgrenska University Hospital, Gothenburg, Sweden.

The possible link was identified after mothers completed a questionnaire asking about medical history and use of drugs, alcohol, or tobacco, and following the collection of data from medical records and interviews with parents of the children.

While there are a few publications suggesting a link between CHARGE association and Goldenhar's syndrome and assisted reproduction techniques (ART) this is the first to suggest a specific link between CHARGE association and intracytoplasmic sperm injection, Dr. Stromland said, noting that one possible reason for the lack of reports on such cases is the multiple malformations that characterize these syndromes. That is, patients' deformities are often registered as separate malformations, rather than malformations occurring as part of a syndrome.

Further study is needed to elucidate any relationship between assisted fertilization and these conditions, she concluded.

CHARGE association is a constellation of congenital malformations. The acronym stands for some of the most common features:

▸ Coloboma of the eye and cranial nerve abnormalities.

▸ Heart malformation.

▸ Choanal atresia.

▸ Retardation of growth after birth and of development.

▸ Genital hypoplasia in males and urinary tract.

▸ Ear malformations and/or deafness.

ST. PETE BEACH, FLA. — Assisted reproductive techniques may be a risk factor for CHARGE association and Goldenhar's syndrome, a small study suggests.

Of 31 patients with CHARGE association and 20 patients with Goldenhar's syndrome, 7 (23%) were conceived via maternal use of an assisted fertilization technique, Kerstin Stromland, M.D., reported at the annual meeting of the Teratology Society.

Of those with CHARGE association, one boy and one girl were the product of intracytoplasmic sperm injection, and another boy was conceived after his mother's use of ovulation stimulating hormone.

Of those with Goldenhar's syndrome, two twin boys (who had a healthy sibling) and one girl, who had a healthy twin sister, were born following intracytoplasmic sperm injection, and another girl was born after standard in vitro fertilization, said Dr. Stromland of Sahlgrenska University Hospital, Gothenburg, Sweden.

The possible link was identified after mothers completed a questionnaire asking about medical history and use of drugs, alcohol, or tobacco, and following the collection of data from medical records and interviews with parents of the children.

While there are a few publications suggesting a link between CHARGE association and Goldenhar's syndrome and assisted reproduction techniques (ART) this is the first to suggest a specific link between CHARGE association and intracytoplasmic sperm injection, Dr. Stromland said, noting that one possible reason for the lack of reports on such cases is the multiple malformations that characterize these syndromes. That is, patients' deformities are often registered as separate malformations, rather than malformations occurring as part of a syndrome.

Further study is needed to elucidate any relationship between assisted fertilization and these conditions, she concluded.

CHARGE association is a constellation of congenital malformations. The acronym stands for some of the most common features:

▸ Coloboma of the eye and cranial nerve abnormalities.

▸ Heart malformation.

▸ Choanal atresia.

▸ Retardation of growth after birth and of development.

▸ Genital hypoplasia in males and urinary tract.

▸ Ear malformations and/or deafness.

COPENHAGEN — An investigational prenatal diagnostic test that uses fetal cells taken from maternal endocervical mucus could offer all the advantages of chorionic villus sampling, according to a study sponsored by Biocept Inc., the San Diego company that's developing the test.

“This is a completely noninvasive diagnostic test that you can do in the first trimester. It's not just a screening test, which is what the other noninvasive tests are,” said study investigator Farideh Bischoff, Ph.D., of Baylor College of Medicine in Houston.

The idea of analyzing trophoblast cells taken from maternal blood or cervical mucus has been pursued for some time. However, inefficient endocervical sampling procedures and the scarcity of trophoblasts in maternal blood have hampered attempts to develop a reliable prenatal test.

The Biocept test involves collecting maternal endocervical mucus with a brush similar to that used to collect samples for Pap smears. A cell capture device is used to isolate fetal trophoblasts from the mucus. Next, an antibody-based purification system filters out the maternal cells.

In a study she presented at the annual meeting of the European Society of Human Reproduction and Embryology, Dr. Bischoff described immunohistochemical staining and fluorescence in situ hybridization testing on purified cells from 100 women.

The initial endocervical mucus sample contains very small numbers of trophoblasts and following the purification technique can strengthen the concentration to a purity of 85%–95%.

Diagnostic testing of the remaining trophoblast cells is then possible to detect chromosomal aneuploidies, she said.

“If you run a panel of probes you can detect trisomies. Alternatively, you can do DNA testing on the cells to screen for mutations. It basically allows you to do the same tests that investigators are doing with preimplantation embryos,” she said.

Dr. Bischoff said Biocept is running a clinical evaluation study at centers nationwide to compare the results of the test with those of standard chorionic villus sampling in a group of pregnant women.

COPENHAGEN — An investigational prenatal diagnostic test that uses fetal cells taken from maternal endocervical mucus could offer all the advantages of chorionic villus sampling, according to a study sponsored by Biocept Inc., the San Diego company that's developing the test.

“This is a completely noninvasive diagnostic test that you can do in the first trimester. It's not just a screening test, which is what the other noninvasive tests are,” said study investigator Farideh Bischoff, Ph.D., of Baylor College of Medicine in Houston.

The idea of analyzing trophoblast cells taken from maternal blood or cervical mucus has been pursued for some time. However, inefficient endocervical sampling procedures and the scarcity of trophoblasts in maternal blood have hampered attempts to develop a reliable prenatal test.

The Biocept test involves collecting maternal endocervical mucus with a brush similar to that used to collect samples for Pap smears. A cell capture device is used to isolate fetal trophoblasts from the mucus. Next, an antibody-based purification system filters out the maternal cells.

In a study she presented at the annual meeting of the European Society of Human Reproduction and Embryology, Dr. Bischoff described immunohistochemical staining and fluorescence in situ hybridization testing on purified cells from 100 women.

The initial endocervical mucus sample contains very small numbers of trophoblasts and following the purification technique can strengthen the concentration to a purity of 85%–95%.

Diagnostic testing of the remaining trophoblast cells is then possible to detect chromosomal aneuploidies, she said.

“If you run a panel of probes you can detect trisomies. Alternatively, you can do DNA testing on the cells to screen for mutations. It basically allows you to do the same tests that investigators are doing with preimplantation embryos,” she said.

Dr. Bischoff said Biocept is running a clinical evaluation study at centers nationwide to compare the results of the test with those of standard chorionic villus sampling in a group of pregnant women.

COPENHAGEN — An investigational prenatal diagnostic test that uses fetal cells taken from maternal endocervical mucus could offer all the advantages of chorionic villus sampling, according to a study sponsored by Biocept Inc., the San Diego company that's developing the test.

“This is a completely noninvasive diagnostic test that you can do in the first trimester. It's not just a screening test, which is what the other noninvasive tests are,” said study investigator Farideh Bischoff, Ph.D., of Baylor College of Medicine in Houston.

The idea of analyzing trophoblast cells taken from maternal blood or cervical mucus has been pursued for some time. However, inefficient endocervical sampling procedures and the scarcity of trophoblasts in maternal blood have hampered attempts to develop a reliable prenatal test.

The Biocept test involves collecting maternal endocervical mucus with a brush similar to that used to collect samples for Pap smears. A cell capture device is used to isolate fetal trophoblasts from the mucus. Next, an antibody-based purification system filters out the maternal cells.

In a study she presented at the annual meeting of the European Society of Human Reproduction and Embryology, Dr. Bischoff described immunohistochemical staining and fluorescence in situ hybridization testing on purified cells from 100 women.

The initial endocervical mucus sample contains very small numbers of trophoblasts and following the purification technique can strengthen the concentration to a purity of 85%–95%.

Diagnostic testing of the remaining trophoblast cells is then possible to detect chromosomal aneuploidies, she said.

“If you run a panel of probes you can detect trisomies. Alternatively, you can do DNA testing on the cells to screen for mutations. It basically allows you to do the same tests that investigators are doing with preimplantation embryos,” she said.

Dr. Bischoff said Biocept is running a clinical evaluation study at centers nationwide to compare the results of the test with those of standard chorionic villus sampling in a group of pregnant women.

ST. PETE BEACH, FLA. — Typical primary effects of parvovirus B19 infection during pregnancy include hydrops fetalis, fetal death, and spontaneous abortion, but a recent case and a review of the literature suggest that central nervous system abnormalities are a rare but possible effect of such infection, Dr. Kenneth Lyon Jones reported at the annual meeting of the Teratology Society.

Dr. Jones' case involved an 11-year-old boy whose mother had documented parvovirus B19 infection early in her first trimester. The child had severe brain development defects secondary to the prenatal exposure. Mental retardation was severe; he had not learned to speak and had been diagnosed with hypertonic cerebral palsy.

Diagnosis of maternal infection was made during the first trimester. An ultrasound at 20.5 weeks' gestation indicated fetal ventricular enlargement, and at birth the boy weighed 2,898 g. At day 5 he received a blood transfusion because he had severe anemia, said Dr. Jones of the University of California, San Diego.

During the newborn period, ultrasound showed severe cerebral atrophy.

At age 11 his height was 122 cm (below the 3rd percentile), and his weight was 27.3 kg (10th percentile).

The child was markedly hirsute and had a frontal hair upsweep, a large hemangioma over the helix of his right ear, a large space between his upper central incisors, and clinodactyly of the index and fifth fingers of his left hand, Dr. Jones noted.

His inner canthal distance was 2.7 cm (25th percentile), and his palpebral fissure was 2.3 cm (below the 2nd percentile).

Valproic acid and carbamazepine treatment failed to control seizures, which he began having at birth.

A search of the literature revealed three publications documenting CNS abnormalities after maternal parvovirus B19 infection, Dr. Jones said. The first, which was published as an abstract, involved three cases. In one case, the fetus died, and in the other two cases the fetuses survived but had severe mental retardation.

Neuropathology at the time of death in the nonsurviving fetus, which was exposed to infection at 24 weeks' gestation, showed brain atrophy with widespread dysplasia and focal destruction of spinal cord and piriform cells, among other abnormal findings.

One of the survivors was exposed to infection at 18 weeks' gestation. The child had cerebral palsy, developmental delay, and infantile spasms. Neuroimaging revealed enlarged ventricles with small periventricular calcifications, cortical dysplasia with polymicrogyria, and periventricular hypodensity.

The final case in that report involved a fetus exposed at 23 weeks' gestation. A CT scan of the brain revealed periventricular calcifications.

The second publication was a case report involving a fetus that was exposed at 15 weeks' gestation and died 7 hours after birth. Neuropathology showed multinucleated giant cells, macrophages, microglia, and many small calcifications around the vessels, predominantly in the cerebral white matter. Polymerase chain reaction amplification showed that parvovirus DNA was present in the nuclei of the multinucleated giant cells and endothelial cells, Dr. Jones said.

The final publication involved a series of 92 consecutive singleton pregnancies with serologic evidence of parvovirus B19 infection. There were 3 therapeutic abortions, 64 fetal deaths, 10 premature births (8 of the babies subsequently died), and 15 term births (1 baby subsequently died).

Of the 73 fetal or neonatal deaths, 21 had adequate histologic evaluation of the brain, and 9 of these showed CNS abnormalities. Of the 16 surviving babies, 5 had CNS abnormalities.

One of the 14 with CNS abnormalities had trisomy 13 syndrome; no etiology was determined in the remaining cases, but the findings suggested anemia might be an important mechanism for CNS abnormalities, Dr. Jones noted.

Based on the findings of the published reports, it appears three patterns of abnormalities are associated with maternal parvovirus B19 infection: positional limb deformities, radiographic evidence of intercranial calcifications, and dysplastic changes, including agyria, macrogyria, polymicrogyria, and dysgenesis of the corpus callosum, he said.

“CNS involvement is a rare occurrence following maternal parvovirus infection, but it clearly occurs, and when it does, it's clearly significant,” Dr. Jones said, noting that the mechanism of action most likely includes both infection of cells in the central nervous system and hypoxia secondary to severe anemia.

It is possible that subtle neurobehavioral effects in otherwise normal children result from a mild case of maternal parvovirus B19 infection, he added.

ST. PETE BEACH, FLA. — Typical primary effects of parvovirus B19 infection during pregnancy include hydrops fetalis, fetal death, and spontaneous abortion, but a recent case and a review of the literature suggest that central nervous system abnormalities are a rare but possible effect of such infection, Dr. Kenneth Lyon Jones reported at the annual meeting of the Teratology Society.

Dr. Jones' case involved an 11-year-old boy whose mother had documented parvovirus B19 infection early in her first trimester. The child had severe brain development defects secondary to the prenatal exposure. Mental retardation was severe; he had not learned to speak and had been diagnosed with hypertonic cerebral palsy.

Diagnosis of maternal infection was made during the first trimester. An ultrasound at 20.5 weeks' gestation indicated fetal ventricular enlargement, and at birth the boy weighed 2,898 g. At day 5 he received a blood transfusion because he had severe anemia, said Dr. Jones of the University of California, San Diego.

During the newborn period, ultrasound showed severe cerebral atrophy.

At age 11 his height was 122 cm (below the 3rd percentile), and his weight was 27.3 kg (10th percentile).

The child was markedly hirsute and had a frontal hair upsweep, a large hemangioma over the helix of his right ear, a large space between his upper central incisors, and clinodactyly of the index and fifth fingers of his left hand, Dr. Jones noted.

His inner canthal distance was 2.7 cm (25th percentile), and his palpebral fissure was 2.3 cm (below the 2nd percentile).

Valproic acid and carbamazepine treatment failed to control seizures, which he began having at birth.

A search of the literature revealed three publications documenting CNS abnormalities after maternal parvovirus B19 infection, Dr. Jones said. The first, which was published as an abstract, involved three cases. In one case, the fetus died, and in the other two cases the fetuses survived but had severe mental retardation.

Neuropathology at the time of death in the nonsurviving fetus, which was exposed to infection at 24 weeks' gestation, showed brain atrophy with widespread dysplasia and focal destruction of spinal cord and piriform cells, among other abnormal findings.

One of the survivors was exposed to infection at 18 weeks' gestation. The child had cerebral palsy, developmental delay, and infantile spasms. Neuroimaging revealed enlarged ventricles with small periventricular calcifications, cortical dysplasia with polymicrogyria, and periventricular hypodensity.

The final case in that report involved a fetus exposed at 23 weeks' gestation. A CT scan of the brain revealed periventricular calcifications.

The second publication was a case report involving a fetus that was exposed at 15 weeks' gestation and died 7 hours after birth. Neuropathology showed multinucleated giant cells, macrophages, microglia, and many small calcifications around the vessels, predominantly in the cerebral white matter. Polymerase chain reaction amplification showed that parvovirus DNA was present in the nuclei of the multinucleated giant cells and endothelial cells, Dr. Jones said.

The final publication involved a series of 92 consecutive singleton pregnancies with serologic evidence of parvovirus B19 infection. There were 3 therapeutic abortions, 64 fetal deaths, 10 premature births (8 of the babies subsequently died), and 15 term births (1 baby subsequently died).

Of the 73 fetal or neonatal deaths, 21 had adequate histologic evaluation of the brain, and 9 of these showed CNS abnormalities. Of the 16 surviving babies, 5 had CNS abnormalities.

One of the 14 with CNS abnormalities had trisomy 13 syndrome; no etiology was determined in the remaining cases, but the findings suggested anemia might be an important mechanism for CNS abnormalities, Dr. Jones noted.

Based on the findings of the published reports, it appears three patterns of abnormalities are associated with maternal parvovirus B19 infection: positional limb deformities, radiographic evidence of intercranial calcifications, and dysplastic changes, including agyria, macrogyria, polymicrogyria, and dysgenesis of the corpus callosum, he said.

“CNS involvement is a rare occurrence following maternal parvovirus infection, but it clearly occurs, and when it does, it's clearly significant,” Dr. Jones said, noting that the mechanism of action most likely includes both infection of cells in the central nervous system and hypoxia secondary to severe anemia.

It is possible that subtle neurobehavioral effects in otherwise normal children result from a mild case of maternal parvovirus B19 infection, he added.

ST. PETE BEACH, FLA. — Typical primary effects of parvovirus B19 infection during pregnancy include hydrops fetalis, fetal death, and spontaneous abortion, but a recent case and a review of the literature suggest that central nervous system abnormalities are a rare but possible effect of such infection, Dr. Kenneth Lyon Jones reported at the annual meeting of the Teratology Society.

Dr. Jones' case involved an 11-year-old boy whose mother had documented parvovirus B19 infection early in her first trimester. The child had severe brain development defects secondary to the prenatal exposure. Mental retardation was severe; he had not learned to speak and had been diagnosed with hypertonic cerebral palsy.

Diagnosis of maternal infection was made during the first trimester. An ultrasound at 20.5 weeks' gestation indicated fetal ventricular enlargement, and at birth the boy weighed 2,898 g. At day 5 he received a blood transfusion because he had severe anemia, said Dr. Jones of the University of California, San Diego.

During the newborn period, ultrasound showed severe cerebral atrophy.

At age 11 his height was 122 cm (below the 3rd percentile), and his weight was 27.3 kg (10th percentile).

The child was markedly hirsute and had a frontal hair upsweep, a large hemangioma over the helix of his right ear, a large space between his upper central incisors, and clinodactyly of the index and fifth fingers of his left hand, Dr. Jones noted.

His inner canthal distance was 2.7 cm (25th percentile), and his palpebral fissure was 2.3 cm (below the 2nd percentile).

Valproic acid and carbamazepine treatment failed to control seizures, which he began having at birth.

A search of the literature revealed three publications documenting CNS abnormalities after maternal parvovirus B19 infection, Dr. Jones said. The first, which was published as an abstract, involved three cases. In one case, the fetus died, and in the other two cases the fetuses survived but had severe mental retardation.

Neuropathology at the time of death in the nonsurviving fetus, which was exposed to infection at 24 weeks' gestation, showed brain atrophy with widespread dysplasia and focal destruction of spinal cord and piriform cells, among other abnormal findings.

One of the survivors was exposed to infection at 18 weeks' gestation. The child had cerebral palsy, developmental delay, and infantile spasms. Neuroimaging revealed enlarged ventricles with small periventricular calcifications, cortical dysplasia with polymicrogyria, and periventricular hypodensity.

The final case in that report involved a fetus exposed at 23 weeks' gestation. A CT scan of the brain revealed periventricular calcifications.

The second publication was a case report involving a fetus that was exposed at 15 weeks' gestation and died 7 hours after birth. Neuropathology showed multinucleated giant cells, macrophages, microglia, and many small calcifications around the vessels, predominantly in the cerebral white matter. Polymerase chain reaction amplification showed that parvovirus DNA was present in the nuclei of the multinucleated giant cells and endothelial cells, Dr. Jones said.

The final publication involved a series of 92 consecutive singleton pregnancies with serologic evidence of parvovirus B19 infection. There were 3 therapeutic abortions, 64 fetal deaths, 10 premature births (8 of the babies subsequently died), and 15 term births (1 baby subsequently died).

Of the 73 fetal or neonatal deaths, 21 had adequate histologic evaluation of the brain, and 9 of these showed CNS abnormalities. Of the 16 surviving babies, 5 had CNS abnormalities.

One of the 14 with CNS abnormalities had trisomy 13 syndrome; no etiology was determined in the remaining cases, but the findings suggested anemia might be an important mechanism for CNS abnormalities, Dr. Jones noted.

Based on the findings of the published reports, it appears three patterns of abnormalities are associated with maternal parvovirus B19 infection: positional limb deformities, radiographic evidence of intercranial calcifications, and dysplastic changes, including agyria, macrogyria, polymicrogyria, and dysgenesis of the corpus callosum, he said.

“CNS involvement is a rare occurrence following maternal parvovirus infection, but it clearly occurs, and when it does, it's clearly significant,” Dr. Jones said, noting that the mechanism of action most likely includes both infection of cells in the central nervous system and hypoxia secondary to severe anemia.

It is possible that subtle neurobehavioral effects in otherwise normal children result from a mild case of maternal parvovirus B19 infection, he added.

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16.

The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison said. “Empowerment is the key.”

Sitting in a circle, the group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed. Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care—see box—it is not an easy one to implement. Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group. The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

A Comparison of Two Care Models

Traditional care

▸ Physical assessment is primary.

▸ Education is mostly one-on-one.

▸ Communication is didactic.

▸ Process of care is disempowering.

▸ Psychosocial support is incidental.

CenteringPregnancy care

▸ Physical assessment is just one aspect of care.

▸ Education is group-based and interactive.

▸ Communication is interactive and facilitated.

▸ Process of care is empowering.

▸ Psychosocial support and community-building are primary.

Source: Ms. Hutchison

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16.

The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison said. “Empowerment is the key.”

Sitting in a circle, the group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed. Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care—see box—it is not an easy one to implement. Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group. The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

A Comparison of Two Care Models

Traditional care

▸ Physical assessment is primary.

▸ Education is mostly one-on-one.

▸ Communication is didactic.

▸ Process of care is disempowering.

▸ Psychosocial support is incidental.

CenteringPregnancy care

▸ Physical assessment is just one aspect of care.

▸ Education is group-based and interactive.

▸ Communication is interactive and facilitated.

▸ Process of care is empowering.

▸ Psychosocial support and community-building are primary.

Source: Ms. Hutchison

SAN FRANCISCO — A group prenatal care program designed to empower pregnant women is spreading across the United States, Margaret Hutchison said at a meeting on antepartum and intrapartum management.

More than 60 sites offering prenatal care in 28 states have started CenteringPregnancy programs—mostly in public clinics, with some in HMOs and military clinics, said Ms. Hutchison, a certified nurse-midwife at San Francisco General Hospital, a teaching hospital of the University of California, which also sponsored the meeting.

Developed by a certified nurse-midwife and pilot-tested in 1993, the CenteringPregnancy model groups 8–12 women of similar gestational age for 10 facilitated 2-hour meetings starting at gestational weeks 12–16.

The groups usually meet monthly for the first 4 months and twice monthly after that. The women do self-care activities, such as measuring weight, taking blood pressure readings, and charting.

“This is an important part. It's not a group to just sit and talk,” Ms. Hutchison said. “Empowerment is the key.”

Sitting in a circle, the group discusses specific topics related to pregnancy and parenting, guided by “self-assessment sheets,” with the emphasis varying among core topics, such as smoking cessation or community building.

Ms. Hutchison said she started a CenteringPregnancy program at San Francisco General Hospital to help the many immigrant Hispanic females seen at her institution who seemed socially isolated. “I wanted them to have someone to call after we've sent them home with a baby,” she said.

Ms. Hutchison said she has no financial relationship with the nonprofit group that owns the program trademark, the Centering Pregnancy & Parenting Association Inc.

During group time, the women take turns having “mat time” with a health provider who conducts pregnancy risk assessments within the group space, sometimes on a floor mat that can be behind a screen if privacy is needed. Staying in the room to conduct assessments is important, she explained. Moving a woman into a separate room interrupts the group process and reasserts the traditional hierarchical relationship between providers and patients.

Because the program, which demands change from health care providers, is so different from traditional care—see box—it is not an easy one to implement. Billing has not been an issue, because the program fits into standard reimbursement systems, she said.

The program improved birth weights in a nonrandomized trial of 458 low-income women at two institutions. The women either participated in a CenteringPregnancy group or received traditional care, with the groups matched by age, race, parity, and date of delivery.

Average birth weight in the CenteringPregnancy group was 3,228 g—significantly higher than the average of 3,159 g in the control group. The CenteringPregnancy group showed a nonsignificant trend toward fewer low-birth-weight babies. In that study, 7% of babies born to the CenteringPregnancy group and 10% in the control group had low birth weights, defined as less than 500 g (Obstet. Gynecol. 2003;102[pt. 1]:1051–7).

A Comparison of Two Care Models

Traditional care

▸ Physical assessment is primary.

▸ Education is mostly one-on-one.

▸ Communication is didactic.

▸ Process of care is disempowering.

▸ Psychosocial support is incidental.

CenteringPregnancy care

▸ Physical assessment is just one aspect of care.

▸ Education is group-based and interactive.

▸ Communication is interactive and facilitated.

▸ Process of care is empowering.

▸ Psychosocial support and community-building are primary.

Source: Ms. Hutchison

COPENHAGEN — Roughly 20% of pregnancies currently regarded as failing intrauterine pregnancies may actually be viable, results of a prospective, observational study suggest.

Serum HCG guidelines for recognizing intrauterine pregnancy viability should be revised to reflect this information, Emma Kirk, M.D., said at the annual meeting of the European Society of Human Reproduction and Embryology.

Evidence suggests that about one-third of pregnancies of unknown location (PUL) are actually intrauterine pregnancies that are too small to visualize on transvaginal ultrasound. Guidelines issued by the American Society for Reproductive Medicine advise that in such cases a suboptimal rise in the β-HCG level—defined as a rise of less than 66% over 48 hours or an HCG ratio (HCG at 48 hours to HCG at 0 hours) of less than 1.66—is predictive of nonviability, Dr. Kirk said.

In many cases, such HCG findings would prompt an intervention, such as laparoscopy, to look for a possible ectopic pregnancy, but clinicians should be aware that in some cases this could interrupt a viable pregnancy, said Dr. Kirk of the early pregnancy unit at St. George's Hospital, London.

In a prospective, observational study of 985 PULs in her unit between June 2001 and October 2004, Dr. Kirk's team documented 115 (12%) with suboptimally rising HCG. Of these 115 pregnancies, 31% were eventually identified as intrauterine pregnancies, 43% were ectopics, and 26% were “failing,” that is, HCG levels had begun to decrease.

The mean HCG ratio in the intrauterine pregnancy group was 1.46. While most of these pregnancies (81%) eventually failed, 19% remained viable. Among these viable pregnancies, the lowest HCG ratio was 1.33 and the mean was 1.56.

“PULs with suboptimally rising HCG should be managed conservatively because interventions when the HCG ratio is as low as 1.33 could interrupt a viable pregnancy,” Dr. Kirk said.

She said the pregnancy unit she works in attempts interventions in such pregnancies only if the patient has symptoms.

COPENHAGEN — Roughly 20% of pregnancies currently regarded as failing intrauterine pregnancies may actually be viable, results of a prospective, observational study suggest.

Serum HCG guidelines for recognizing intrauterine pregnancy viability should be revised to reflect this information, Emma Kirk, M.D., said at the annual meeting of the European Society of Human Reproduction and Embryology.

Evidence suggests that about one-third of pregnancies of unknown location (PUL) are actually intrauterine pregnancies that are too small to visualize on transvaginal ultrasound. Guidelines issued by the American Society for Reproductive Medicine advise that in such cases a suboptimal rise in the β-HCG level—defined as a rise of less than 66% over 48 hours or an HCG ratio (HCG at 48 hours to HCG at 0 hours) of less than 1.66—is predictive of nonviability, Dr. Kirk said.

In many cases, such HCG findings would prompt an intervention, such as laparoscopy, to look for a possible ectopic pregnancy, but clinicians should be aware that in some cases this could interrupt a viable pregnancy, said Dr. Kirk of the early pregnancy unit at St. George's Hospital, London.

In a prospective, observational study of 985 PULs in her unit between June 2001 and October 2004, Dr. Kirk's team documented 115 (12%) with suboptimally rising HCG. Of these 115 pregnancies, 31% were eventually identified as intrauterine pregnancies, 43% were ectopics, and 26% were “failing,” that is, HCG levels had begun to decrease.

The mean HCG ratio in the intrauterine pregnancy group was 1.46. While most of these pregnancies (81%) eventually failed, 19% remained viable. Among these viable pregnancies, the lowest HCG ratio was 1.33 and the mean was 1.56.

“PULs with suboptimally rising HCG should be managed conservatively because interventions when the HCG ratio is as low as 1.33 could interrupt a viable pregnancy,” Dr. Kirk said.

She said the pregnancy unit she works in attempts interventions in such pregnancies only if the patient has symptoms.

COPENHAGEN — Roughly 20% of pregnancies currently regarded as failing intrauterine pregnancies may actually be viable, results of a prospective, observational study suggest.

Serum HCG guidelines for recognizing intrauterine pregnancy viability should be revised to reflect this information, Emma Kirk, M.D., said at the annual meeting of the European Society of Human Reproduction and Embryology.

Evidence suggests that about one-third of pregnancies of unknown location (PUL) are actually intrauterine pregnancies that are too small to visualize on transvaginal ultrasound. Guidelines issued by the American Society for Reproductive Medicine advise that in such cases a suboptimal rise in the β-HCG level—defined as a rise of less than 66% over 48 hours or an HCG ratio (HCG at 48 hours to HCG at 0 hours) of less than 1.66—is predictive of nonviability, Dr. Kirk said.

In many cases, such HCG findings would prompt an intervention, such as laparoscopy, to look for a possible ectopic pregnancy, but clinicians should be aware that in some cases this could interrupt a viable pregnancy, said Dr. Kirk of the early pregnancy unit at St. George's Hospital, London.

In a prospective, observational study of 985 PULs in her unit between June 2001 and October 2004, Dr. Kirk's team documented 115 (12%) with suboptimally rising HCG. Of these 115 pregnancies, 31% were eventually identified as intrauterine pregnancies, 43% were ectopics, and 26% were “failing,” that is, HCG levels had begun to decrease.

The mean HCG ratio in the intrauterine pregnancy group was 1.46. While most of these pregnancies (81%) eventually failed, 19% remained viable. Among these viable pregnancies, the lowest HCG ratio was 1.33 and the mean was 1.56.

“PULs with suboptimally rising HCG should be managed conservatively because interventions when the HCG ratio is as low as 1.33 could interrupt a viable pregnancy,” Dr. Kirk said.

She said the pregnancy unit she works in attempts interventions in such pregnancies only if the patient has symptoms.

COPENHAGEN — The chances of having a healthy newborn are similar among patients with a history of recurrent miscarriage, regardless of whether they have chromosomal abnormalities, Maureen T.M. Franssen, M.D., reported during the annual meeting of the European Society of Human Reproduction and Embryology.

But carriers of chromosomal abnormalities have a higher risk of repeat miscarriage before eventually achieving their successful pregnancies.

Dr. Franssen of the Center for Reproductive Medicine, Academic Medical Center, Amsterdam, and her associates analyzed 705 couples who had experienced recurrent miscarriage and had been tested for chromosome abnormalities.

A total of 278 couples were identified as carriers, meaning that they had chromosome abnormalities. In carrier couples, products of conception can sometimes have an unbalanced karyotype, resulting in miscarriage, stillbirth, or the birth of a child with major congenital handicaps, she explained.

The study compared the reproductive outcomes of carrier couples with those of the 427 noncarrier couples (controls) over a mean follow-up period of 5.8 years.

A significantly greater percentage of the carrier couples than controls (16% vs. 6%) decided to stop trying to get pregnant. The main reason given by carriers was their risk of giving birth to a viable but unhealthy child. Among controls, the main reason was advanced maternal age.

Both groups had similar rates of successful reproductive outcomes, meaning the birth of a healthy child (83% for carriers and 84% for controls), but the carrier group had a significantly higher rate of miscarriage before a successful pregnancy (49% vs. 30%).

Both groups had similar rates of ectopic pregnancy, stillbirth, and neonatal death. In the carrier group these adverse outcomes were sometimes, but not always, the result of chromosomal abnormalities.

Both groups also had similar rates of pregnancy termination (2%), and in carrier couples two pregnancies were terminated because of an unbalanced structural chromosome abnormality.

Finally, in the 550 pregnancies in the carrier group two children (0.2%) with an unbalanced structural chromosome abnormality and major congenital abnormalities were born. One of these children died immediately after birth.

“In carrier couples … the risk of viable unbalanced offspring is very low,” Dr. Franssen said. “These couples have a good prognosis toward successful reproductive outcome, which is similar to noncarrier couples, even though their risk of miscarriage is higher.”

But a North American expert in miscarriage said she is concerned that the researchers grouped together all carriers without identifying the causes of miscarriage in each couple.

“We need to address each couple individually because there are couples whose specific chromosome abnormalities increase the likelihood of their pregnancy being unbalanced. But there are also many couples [with chromosome abnormalities] who are having miscarriages for other reasons,” she said during an interview.

In a study that she presented last year at the American Society for Reproductive Medicine's annual meeting, Dr. Stephenson showed that among carrier couples, only one-third of miscarriages are due to fetal chromosomal abnormalities, while two-thirds are not. To counsel recurrent miscarriage patients using only parental chromosome analysis without analyzing their products of conception is to disregard a big piece of the puzzle, she said.

For example, in the subgroup of carrier couples whose adverse reproductive outcomes are directly linked to their chromosome abnormalities, the chances of a successful outcome are much lower than in the group as a whole.

“The important part is to send the miscarriage specimen for cytogenetic analysis to try to get as much information as to why the miscarriage occurred. Then we can counsel the couple appropriately,” Dr. Stephenson said.

COPENHAGEN — The chances of having a healthy newborn are similar among patients with a history of recurrent miscarriage, regardless of whether they have chromosomal abnormalities, Maureen T.M. Franssen, M.D., reported during the annual meeting of the European Society of Human Reproduction and Embryology.

But carriers of chromosomal abnormalities have a higher risk of repeat miscarriage before eventually achieving their successful pregnancies.

Dr. Franssen of the Center for Reproductive Medicine, Academic Medical Center, Amsterdam, and her associates analyzed 705 couples who had experienced recurrent miscarriage and had been tested for chromosome abnormalities.

A total of 278 couples were identified as carriers, meaning that they had chromosome abnormalities. In carrier couples, products of conception can sometimes have an unbalanced karyotype, resulting in miscarriage, stillbirth, or the birth of a child with major congenital handicaps, she explained.

The study compared the reproductive outcomes of carrier couples with those of the 427 noncarrier couples (controls) over a mean follow-up period of 5.8 years.

A significantly greater percentage of the carrier couples than controls (16% vs. 6%) decided to stop trying to get pregnant. The main reason given by carriers was their risk of giving birth to a viable but unhealthy child. Among controls, the main reason was advanced maternal age.

Both groups had similar rates of successful reproductive outcomes, meaning the birth of a healthy child (83% for carriers and 84% for controls), but the carrier group had a significantly higher rate of miscarriage before a successful pregnancy (49% vs. 30%).

Both groups had similar rates of ectopic pregnancy, stillbirth, and neonatal death. In the carrier group these adverse outcomes were sometimes, but not always, the result of chromosomal abnormalities.

Both groups also had similar rates of pregnancy termination (2%), and in carrier couples two pregnancies were terminated because of an unbalanced structural chromosome abnormality.

Finally, in the 550 pregnancies in the carrier group two children (0.2%) with an unbalanced structural chromosome abnormality and major congenital abnormalities were born. One of these children died immediately after birth.

“In carrier couples … the risk of viable unbalanced offspring is very low,” Dr. Franssen said. “These couples have a good prognosis toward successful reproductive outcome, which is similar to noncarrier couples, even though their risk of miscarriage is higher.”

But a North American expert in miscarriage said she is concerned that the researchers grouped together all carriers without identifying the causes of miscarriage in each couple.

“We need to address each couple individually because there are couples whose specific chromosome abnormalities increase the likelihood of their pregnancy being unbalanced. But there are also many couples [with chromosome abnormalities] who are having miscarriages for other reasons,” she said during an interview.

In a study that she presented last year at the American Society for Reproductive Medicine's annual meeting, Dr. Stephenson showed that among carrier couples, only one-third of miscarriages are due to fetal chromosomal abnormalities, while two-thirds are not. To counsel recurrent miscarriage patients using only parental chromosome analysis without analyzing their products of conception is to disregard a big piece of the puzzle, she said.

For example, in the subgroup of carrier couples whose adverse reproductive outcomes are directly linked to their chromosome abnormalities, the chances of a successful outcome are much lower than in the group as a whole.

“The important part is to send the miscarriage specimen for cytogenetic analysis to try to get as much information as to why the miscarriage occurred. Then we can counsel the couple appropriately,” Dr. Stephenson said.

COPENHAGEN — The chances of having a healthy newborn are similar among patients with a history of recurrent miscarriage, regardless of whether they have chromosomal abnormalities, Maureen T.M. Franssen, M.D., reported during the annual meeting of the European Society of Human Reproduction and Embryology.

But carriers of chromosomal abnormalities have a higher risk of repeat miscarriage before eventually achieving their successful pregnancies.

Dr. Franssen of the Center for Reproductive Medicine, Academic Medical Center, Amsterdam, and her associates analyzed 705 couples who had experienced recurrent miscarriage and had been tested for chromosome abnormalities.

A total of 278 couples were identified as carriers, meaning that they had chromosome abnormalities. In carrier couples, products of conception can sometimes have an unbalanced karyotype, resulting in miscarriage, stillbirth, or the birth of a child with major congenital handicaps, she explained.

The study compared the reproductive outcomes of carrier couples with those of the 427 noncarrier couples (controls) over a mean follow-up period of 5.8 years.

A significantly greater percentage of the carrier couples than controls (16% vs. 6%) decided to stop trying to get pregnant. The main reason given by carriers was their risk of giving birth to a viable but unhealthy child. Among controls, the main reason was advanced maternal age.

Both groups had similar rates of successful reproductive outcomes, meaning the birth of a healthy child (83% for carriers and 84% for controls), but the carrier group had a significantly higher rate of miscarriage before a successful pregnancy (49% vs. 30%).

Both groups had similar rates of ectopic pregnancy, stillbirth, and neonatal death. In the carrier group these adverse outcomes were sometimes, but not always, the result of chromosomal abnormalities.

Both groups also had similar rates of pregnancy termination (2%), and in carrier couples two pregnancies were terminated because of an unbalanced structural chromosome abnormality.

Finally, in the 550 pregnancies in the carrier group two children (0.2%) with an unbalanced structural chromosome abnormality and major congenital abnormalities were born. One of these children died immediately after birth.

“In carrier couples … the risk of viable unbalanced offspring is very low,” Dr. Franssen said. “These couples have a good prognosis toward successful reproductive outcome, which is similar to noncarrier couples, even though their risk of miscarriage is higher.”

But a North American expert in miscarriage said she is concerned that the researchers grouped together all carriers without identifying the causes of miscarriage in each couple.

“We need to address each couple individually because there are couples whose specific chromosome abnormalities increase the likelihood of their pregnancy being unbalanced. But there are also many couples [with chromosome abnormalities] who are having miscarriages for other reasons,” she said during an interview.

In a study that she presented last year at the American Society for Reproductive Medicine's annual meeting, Dr. Stephenson showed that among carrier couples, only one-third of miscarriages are due to fetal chromosomal abnormalities, while two-thirds are not. To counsel recurrent miscarriage patients using only parental chromosome analysis without analyzing their products of conception is to disregard a big piece of the puzzle, she said.

For example, in the subgroup of carrier couples whose adverse reproductive outcomes are directly linked to their chromosome abnormalities, the chances of a successful outcome are much lower than in the group as a whole.

“The important part is to send the miscarriage specimen for cytogenetic analysis to try to get as much information as to why the miscarriage occurred. Then we can counsel the couple appropriately,” Dr. Stephenson said.