Obstetrics

COPENHAGEN — The higher rate of obstetric complications documented in donor oocyte pregnancies is confined to those pregnancies in which the oocyte donor is not related to the recipient, according to Korean researchers.

In fact, pregnancies achieved through in vitro fertilization procedures involving oocytes donated by a sibling have a complication rate similar to that of in vitro fertilization pregnancies that do not involve donor oocytes, reported S.H. Cha, M.D., in a study that was directed by M.K. Koong, M.D., from Samsung Cheil Hospital, Sungkyunkwan University, Seoul.

This is the first report linking different degrees of oocyte allogenicity to obstetric complications, suggesting that this phenomenon could be due to immunologic factors, Dr. Cha said during the annual meeting of the European Society for Human Reproduction and Embryology.

It has been well documented that pregnancies achieved using donor oocytes demonstrate increased rates of pregnancy-induced hypertension and first-trimester bleeding, Dr. Cha said. Possible explanations for these findings include primiparity, the higher rate of multiple pregnancies, and the increased maternal age of this obstetric population.

Dr. Cha's study compared 61 pregnancies resulting from oocyte donation and 127 pregnancies from standard, nondonor in vitro fertilization (controls). Of the donor pregnancies, 36 involved oocytes from siblings and 25 involved oocytes from nonsiblings.

As expected, the donor group had a much higher rate of early pregnancy loss (34% vs. 13%), second-trimester bleeding (13% vs. 1%), and pregnancy-induced hypertension (12.5% vs. 4%), compared with the controls.

But when the donor group was subdivided into sibling and nonsibling donors, the complications were largely concentrated in the nonsibling donor group. The sibling donor group showed a complication rate that was only slightly (and not statistically significantly) higher than that of the controls, Dr. Cha said. (See table.)

“These data suggest that PIH [pregnancy-induced hypertension] appears to occur more often in pregnancies following oocyte donation from immunologically unrelated donors. Therefore, women who become pregnant after oocyte donation from immunologically unrelated donors should be considered as high risk,” she noted.

COPENHAGEN — The higher rate of obstetric complications documented in donor oocyte pregnancies is confined to those pregnancies in which the oocyte donor is not related to the recipient, according to Korean researchers.

In fact, pregnancies achieved through in vitro fertilization procedures involving oocytes donated by a sibling have a complication rate similar to that of in vitro fertilization pregnancies that do not involve donor oocytes, reported S.H. Cha, M.D., in a study that was directed by M.K. Koong, M.D., from Samsung Cheil Hospital, Sungkyunkwan University, Seoul.

This is the first report linking different degrees of oocyte allogenicity to obstetric complications, suggesting that this phenomenon could be due to immunologic factors, Dr. Cha said during the annual meeting of the European Society for Human Reproduction and Embryology.

It has been well documented that pregnancies achieved using donor oocytes demonstrate increased rates of pregnancy-induced hypertension and first-trimester bleeding, Dr. Cha said. Possible explanations for these findings include primiparity, the higher rate of multiple pregnancies, and the increased maternal age of this obstetric population.

Dr. Cha's study compared 61 pregnancies resulting from oocyte donation and 127 pregnancies from standard, nondonor in vitro fertilization (controls). Of the donor pregnancies, 36 involved oocytes from siblings and 25 involved oocytes from nonsiblings.

As expected, the donor group had a much higher rate of early pregnancy loss (34% vs. 13%), second-trimester bleeding (13% vs. 1%), and pregnancy-induced hypertension (12.5% vs. 4%), compared with the controls.

But when the donor group was subdivided into sibling and nonsibling donors, the complications were largely concentrated in the nonsibling donor group. The sibling donor group showed a complication rate that was only slightly (and not statistically significantly) higher than that of the controls, Dr. Cha said. (See table.)

“These data suggest that PIH [pregnancy-induced hypertension] appears to occur more often in pregnancies following oocyte donation from immunologically unrelated donors. Therefore, women who become pregnant after oocyte donation from immunologically unrelated donors should be considered as high risk,” she noted.

COPENHAGEN — The higher rate of obstetric complications documented in donor oocyte pregnancies is confined to those pregnancies in which the oocyte donor is not related to the recipient, according to Korean researchers.

In fact, pregnancies achieved through in vitro fertilization procedures involving oocytes donated by a sibling have a complication rate similar to that of in vitro fertilization pregnancies that do not involve donor oocytes, reported S.H. Cha, M.D., in a study that was directed by M.K. Koong, M.D., from Samsung Cheil Hospital, Sungkyunkwan University, Seoul.

This is the first report linking different degrees of oocyte allogenicity to obstetric complications, suggesting that this phenomenon could be due to immunologic factors, Dr. Cha said during the annual meeting of the European Society for Human Reproduction and Embryology.

It has been well documented that pregnancies achieved using donor oocytes demonstrate increased rates of pregnancy-induced hypertension and first-trimester bleeding, Dr. Cha said. Possible explanations for these findings include primiparity, the higher rate of multiple pregnancies, and the increased maternal age of this obstetric population.

Dr. Cha's study compared 61 pregnancies resulting from oocyte donation and 127 pregnancies from standard, nondonor in vitro fertilization (controls). Of the donor pregnancies, 36 involved oocytes from siblings and 25 involved oocytes from nonsiblings.

As expected, the donor group had a much higher rate of early pregnancy loss (34% vs. 13%), second-trimester bleeding (13% vs. 1%), and pregnancy-induced hypertension (12.5% vs. 4%), compared with the controls.

But when the donor group was subdivided into sibling and nonsibling donors, the complications were largely concentrated in the nonsibling donor group. The sibling donor group showed a complication rate that was only slightly (and not statistically significantly) higher than that of the controls, Dr. Cha said. (See table.)

“These data suggest that PIH [pregnancy-induced hypertension] appears to occur more often in pregnancies following oocyte donation from immunologically unrelated donors. Therefore, women who become pregnant after oocyte donation from immunologically unrelated donors should be considered as high risk,” she noted.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of their most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury.

The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One-third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day during pregnancy. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102 degrees) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102 degrees after 15 minutes of soaking in 102-degree water or 10 minutes in 106-degree water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of their most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury.

The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One-third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day during pregnancy. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102 degrees) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102 degrees after 15 minutes of soaking in 102-degree water or 10 minutes in 106-degree water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — In the general ob.gyn. practice of Amy Meg Autry, M.D., visits with pregnant patients have evolved from giving equal time to examination and counseling to about 2% to examination and 98% to counseling.

Dr. Autry of the University of California, San Francisco, researched answers to some of their most common safety concerns regarding pregnancy and offered an overview of her findings at a meeting on antepartum and intrapartum management sponsored by the university:

▸ Fish. While eating fish can be good for maternal cardiovascular health and fetal growth and development, fish accumulate methyl mercury in their muscles from industrial pollution, which may cause neurotoxic symptoms in neonates that resemble cerebral palsy.

Only one retrospective study has found severe neurotoxic effects in children born to Japanese women who ate a steady diet of fish with high levels of mercury, even though the mothers showed minimal or no effects of mercury ingestion. Three other studies found neurologic effects in Japanese adults who ate a similar toxic-fish diet or Iraqi adults who ate grain that had been pretreated with mercury.

Two prospective studies produced conflicting results. In one, a diet high in whale blubber was associated with delays in attention, memory, and small-motor function in serial testing of children through age 6 in the Faeroe Islands of Norway. A separate study of residents of the Seychelles Islands who ate 12 meals of fish per week found that they had mercury levels 10–20 times higher than average levels in U.S. residents, yet this exposure produced no long-term neurologic effects. Other prospective studies are ongoing.

A 2004 joint advisory for consumers issued by the Environmental Protection Agency and the Food and Drug Administration recommended that pregnant women not eat shark, swordfish, king mackerel, or tilefish, because they are high in mercury.

The advisory emphasized the positive benefits of fish and stated that pregnant women may eat up to 12 ounces (two average meals) per week of fish low in mercury, such as salmon, shrimp, pollack, and catfish. Canned light tuna has less mercury than albacore tuna. For local fish, consult local and tribal advisories that apply to your area, or limit ingestion to 6 ounces per week.

▸ Cheese and hot dogs. One-third of an estimated 1,500 cases of listeriosis each year in the United States are in pregnant women. They are more susceptible to the infection due to compromised immune systems. One in five pregnant women with listeriosis experiences a spontaneous abortion or stillbirth.

Although cases of listeriosis in pregnancy are rare and sporadic, it's prudent to avoid high-risk foods such as hot dogs or luncheon meats, unless they've been reheated to steaming. Avoid soft cheeses, refrigerated patés or meat spreads, unpasteurized milk, and raw or undercooked meats.

▸ Caffeine. No data substantiate concerns about adverse pregnancy effects caused by light to moderate caffeine consumption.

Many studies that suggested caffeine may raise the risk for low birth weight, spontaneous abortion, congenital anomalies, or conception delays are poorly designed and demonstrate study bias, she said. Most of these studies were confounded by an association between caffeine intake and cigarette smoking.

▸ Alcohol. Multiple small studies show deleterious effects of drinking even small amounts of alcohol during pregnancy. A 2002 study that followed children from birth to age 6, for example, found persistently smaller head circumferences, height, and weight in children of women who had less than one drink per day during pregnancy. A 2001 study found more aggressive behavior in children of mothers who had one drink per week during pregnancy.

▸ Hot tubs. Animal data suggest that maternal hyperthermia (a body temperature of 102 degrees) may lead to first-trimester spontaneous abortion or neural tube defects. A very poorly designed study in human subjects, which was published in 2003, found a higher rate of first-trimester losses in women who used a hot tub more than weekly within 4 weeks of their last menstrual period. A 2005 metaanalysis of 42 studies suggested an 86% increase in risk for neural tube defects if the mother used a hot tub, sauna, or electric blanket and developed a fever.

On average, a pregnant woman's core body temperature will reach 102 degrees after 15 minutes of soaking in 102-degree water or 10 minutes in 106-degree water.

Skip hot tubs in the first trimester, and limit soaking times or water temperature after that, Dr. Autry advised.

▸ Exercise. Getting hot from exercise is okay; there's no evidence that hyperthermia from exercise is teratogenic, she said. Even exercise at high altitudes appears safe.

Exercise helps prevent gestational diabetes and decreases the risk for postpartum depression. Avoid standing still, supine activities, sports that cause falling or heavy contact, and scuba diving, which can cause decompression sickness in the fetus.

▸ Hair dye. All attempts to find an association between hair dye and teratogenic effects or cancer have washed out. Dye if you want to, Dr. Autry said.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said during a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

The tool should be ready for clinical use in 2006, said Dr. Kuppermann of the university.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures that the state requires clinicians to give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures during three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” she said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

This difference in knowledge between groups also persisted 2 weeks later, she said.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study very inclined to undergo invasive testing were more likely to change their minds during the study and not be tested, Dr. Kupperman said.

Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by prenatal testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome. They also are creating a low-literacy version of the tool that relies less on text.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said during a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

The tool should be ready for clinical use in 2006, said Dr. Kuppermann of the university.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures that the state requires clinicians to give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures during three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” she said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

This difference in knowledge between groups also persisted 2 weeks later, she said.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study very inclined to undergo invasive testing were more likely to change their minds during the study and not be tested, Dr. Kupperman said.

Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by prenatal testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome. They also are creating a low-literacy version of the tool that relies less on text.

SAN FRANCISCO — A new computerized tool helps pregnant women decide whether they want invasive prenatal testing, Miriam Kuppermann, Ph.D., said during a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

The tool should be ready for clinical use in 2006, said Dr. Kuppermann of the university.

In a randomized, controlled trial, 496 pregnant women seen at three institutions in the San Francisco Bay area used the computerized decision-assistance tool or viewed a computer version of age-appropriate brochures that the state requires clinicians to give to all pregnant women. Both were available in English and Spanish. Investigators assessed the impact of the tool or the brochures during three follow-up interviews.

“We do emphasize throughout that the goal of our program is neither to get women to test nor to get them not to test. The goal is to help them make an informed decision that is consistent with their own preferences and values,” she said.

Immediately after the computer session, 75% of women using the decision-assistance tool correctly estimated their risk for having a baby with Down syndrome, compared with 5% of women in the control group. A significant difference in knowledge persisted in the second follow-up interview 2 weeks later.

The state pamphlets do not provide an individual's risk for Down syndrome, so the difference in knowledge between groups is not too surprising, but it's nevertheless encouraging to see that a high percentage of women understood their risk for trisomy 21 after using the computerized tool, Dr. Kuppermann said.

Immediately after the computer session, about 50% of women in the intervention group correctly estimated their risk for miscarriage related to prenatal testing, compared with 20% of women in the control group.

This difference in knowledge between groups also persisted 2 weeks later, she said.

The third follow-up interview, conducted at 30 weeks' gestation after any decisions about prenatal testing were made, found that women in the intervention group had less uncertainty about their decisions, reported fewer factors contributing to uncertainty, and had less decisional conflict, meaning they were more comfortable with their decisions.

Women in the intervention group were more likely to undergo invasive prenatal testing, compared with the control group. Women in this group who entered the study very inclined to undergo invasive testing were more likely to change their minds during the study and not be tested, Dr. Kupperman said.

Women who came in with little inclination to be tested were more likely to change their minds and undergo testing.

“So it's working in both directions, which makes me feel good that it's not a biased tool,” she said. “We believe that our tool does lead to more informed decisions that better reflect underlying preferences.”

The computerized tool first reassures women that most babies are born healthy, but it notes that 3%–4% will have a birth defect and that Down syndrome is one of the defects that can be detected by prenatal testing.

The woman enters her age, answers questions about other risk factors, and then receives an individualized risk presentation. For example, a 36-year-old woman's mid-trimester risk for carrying a fetus affected by trisomy 21 is about 4 in 1,000, so the computer might show her a photo of 1,000 balls, 4 of which are highlighted yellow to represent the risk.

In a “values clarification exercise,” the woman answers questions about various aspects of testing scenarios to elicit their value to her, ranging from “absolutely critical” to “not at all important.” Based on the woman's responses, the program suggests testing strategies that might fit her values and risks, and it gives summaries of strategies she chooses. “Again, there's no absolute recommendation,” Dr. Kuppermann said.

She and her associates now are modifying the tool to include first-trimester screening and testing strategies and models for other genetic tests for prenatal disorders besides Down syndrome. They also are creating a low-literacy version of the tool that relies less on text.

Physicians should screen all pregnant women for HIV infection, according to updated recommendations from the U.S. Preventive Services Task Force.

The task force—an independent panel of experts in prevention and primary care—recommended in 1996 that physicians routinely screen and counsel pregnant women at high risk for HIV and those living in communities with high rates of HIV-infected newborns.

At that time, the task force did not find sufficient evidence to recommend for or against routine screening for pregnant women without identified risk factors for HIV.

The updated recommendation is based on “good evidence” that both standard and rapid screening tests can accurately detect HIV infection in pregnant women and “fair evidence” that the universal prenatal counseling and voluntary testing increases the proportion of HIV-infected women who are diagnosed and treated before delivery (Ann. Intern. Med. 2005;143:32–7).

The task force also determined that there is “good evidence” that treatments such as highly active antiretroviral therapy (HAART) can lead to significantly reduced rates of HIV transmission from mother to child.

“Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother-to-child transmission, allows providers to avoid obstetric practices that may increase the risk for transmission, and allows an opportunity to counsel the mother against breast-feeding,” the task force said.

About 40,000 people are infected with HIV each year in the United States; this number includes about 300 cases of mother-to-child transmission, the task force reported.

The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention all recommend that HIV testing be part of a routine battery of prenatal blood tests unless declined by the patient.

The CDC and ACOG also recommend that women in their third trimester be retested if they are known to be at high risk for acquiring HIV and that rapid HIV testing be done during labor in women whose HIV status is undocumented.

A system in which women are informed of the screening and given the chance to opt out has been shown to produce higher screening rates than opt-in approaches for which specific informed consent is required, according to ACOG.

“Given the enormous advances in HIV prophylaxis for pregnant women and newborns, it is clear that early identification and treatment of all pregnant women with HIV is the best way to prevent neonatal disease,” ACOG's Committee on Obstetric Practice wrote in a November 2004 committee opinion.

The USPSTF also recommended that physicians screen all adolescents and adults at increased risk for HIV infection. Patients are considered to be at increased risk for HIV if they have one or more individual risk factors or receive health care in a high-prevalence or high-risk clinical setting such as an STD clinic or correctional facility.

The task force did not make a recommendation for routine screening for HIV among adolescents and adults who are not at increased risk.

The task force recommendations are available online at www.ahrq.gov/clinic/uspstf/uspshivi.htm

Physicians should screen all pregnant women for HIV infection, according to updated recommendations from the U.S. Preventive Services Task Force.

The task force—an independent panel of experts in prevention and primary care—recommended in 1996 that physicians routinely screen and counsel pregnant women at high risk for HIV and those living in communities with high rates of HIV-infected newborns.

At that time, the task force did not find sufficient evidence to recommend for or against routine screening for pregnant women without identified risk factors for HIV.

The updated recommendation is based on “good evidence” that both standard and rapid screening tests can accurately detect HIV infection in pregnant women and “fair evidence” that the universal prenatal counseling and voluntary testing increases the proportion of HIV-infected women who are diagnosed and treated before delivery (Ann. Intern. Med. 2005;143:32–7).

The task force also determined that there is “good evidence” that treatments such as highly active antiretroviral therapy (HAART) can lead to significantly reduced rates of HIV transmission from mother to child.

“Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother-to-child transmission, allows providers to avoid obstetric practices that may increase the risk for transmission, and allows an opportunity to counsel the mother against breast-feeding,” the task force said.

About 40,000 people are infected with HIV each year in the United States; this number includes about 300 cases of mother-to-child transmission, the task force reported.

The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention all recommend that HIV testing be part of a routine battery of prenatal blood tests unless declined by the patient.

The CDC and ACOG also recommend that women in their third trimester be retested if they are known to be at high risk for acquiring HIV and that rapid HIV testing be done during labor in women whose HIV status is undocumented.

A system in which women are informed of the screening and given the chance to opt out has been shown to produce higher screening rates than opt-in approaches for which specific informed consent is required, according to ACOG.

“Given the enormous advances in HIV prophylaxis for pregnant women and newborns, it is clear that early identification and treatment of all pregnant women with HIV is the best way to prevent neonatal disease,” ACOG's Committee on Obstetric Practice wrote in a November 2004 committee opinion.

The USPSTF also recommended that physicians screen all adolescents and adults at increased risk for HIV infection. Patients are considered to be at increased risk for HIV if they have one or more individual risk factors or receive health care in a high-prevalence or high-risk clinical setting such as an STD clinic or correctional facility.

The task force did not make a recommendation for routine screening for HIV among adolescents and adults who are not at increased risk.

The task force recommendations are available online at www.ahrq.gov/clinic/uspstf/uspshivi.htm

Physicians should screen all pregnant women for HIV infection, according to updated recommendations from the U.S. Preventive Services Task Force.

The task force—an independent panel of experts in prevention and primary care—recommended in 1996 that physicians routinely screen and counsel pregnant women at high risk for HIV and those living in communities with high rates of HIV-infected newborns.

At that time, the task force did not find sufficient evidence to recommend for or against routine screening for pregnant women without identified risk factors for HIV.

The updated recommendation is based on “good evidence” that both standard and rapid screening tests can accurately detect HIV infection in pregnant women and “fair evidence” that the universal prenatal counseling and voluntary testing increases the proportion of HIV-infected women who are diagnosed and treated before delivery (Ann. Intern. Med. 2005;143:32–7).

The task force also determined that there is “good evidence” that treatments such as highly active antiretroviral therapy (HAART) can lead to significantly reduced rates of HIV transmission from mother to child.

“Early identification of maternal HIV seropositivity allows early antiretroviral treatment to prevent mother-to-child transmission, allows providers to avoid obstetric practices that may increase the risk for transmission, and allows an opportunity to counsel the mother against breast-feeding,” the task force said.

About 40,000 people are infected with HIV each year in the United States; this number includes about 300 cases of mother-to-child transmission, the task force reported.

The American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the Centers for Disease Control and Prevention all recommend that HIV testing be part of a routine battery of prenatal blood tests unless declined by the patient.

The CDC and ACOG also recommend that women in their third trimester be retested if they are known to be at high risk for acquiring HIV and that rapid HIV testing be done during labor in women whose HIV status is undocumented.

A system in which women are informed of the screening and given the chance to opt out has been shown to produce higher screening rates than opt-in approaches for which specific informed consent is required, according to ACOG.

“Given the enormous advances in HIV prophylaxis for pregnant women and newborns, it is clear that early identification and treatment of all pregnant women with HIV is the best way to prevent neonatal disease,” ACOG's Committee on Obstetric Practice wrote in a November 2004 committee opinion.

The USPSTF also recommended that physicians screen all adolescents and adults at increased risk for HIV infection. Patients are considered to be at increased risk for HIV if they have one or more individual risk factors or receive health care in a high-prevalence or high-risk clinical setting such as an STD clinic or correctional facility.

The task force did not make a recommendation for routine screening for HIV among adolescents and adults who are not at increased risk.

The task force recommendations are available online at www.ahrq.gov/clinic/uspstf/uspshivi.htm

WASHINGTON — High parity has replaced preterm delivery as the greatest risk factor for SIDS, according to a study of national data, presented at the annual meeting of the Pediatric Academic Societies.

“Our highest single risk factor was high parity,” said Donna R. Halloran, M.D., of the University of Alabama, Birmingham. Mothers with a parity of five or greater were 3.6 times more likely to have an infant die of SIDS.

The shift follows an epidemiologic shift in SIDS deaths that occurred in the mid-1990s. In 1991, 1.2 cases of SIDS occurred for every 1,000 live births in the United States. By 1996, the number had dropped dramatically, to 0.7 cases for every 1,000 live births. In 2002, there were 0.6 cases for every 1,000 live births.

The decrease in SIDS deaths has been attributed to the National Institute of Child Health and Human Development's “Back to Sleep” educational campaign initiated in 1994. The number of parents putting their infants in a prone sleep position dropped dramatically. In 1992, 70% of infants were sleeping in a prone position, compared with 18% in 1996.

The study population included all singleton live births in the United States from 1996 to 1998. These data came from the National Center for Health Statistics birth cohort (with linked birth and death files). Infants were excluded if their gestation was less than 22 weeks or greater than 44 weeks. Multiple gestations also were excluded, as were infants of nonresident mothers.

The multivariate analysis model included maternal variables—race/ethnicity, education, age, marital status, smoking, alcohol use, diabetes, hypertension, and parity. The model also included infant gender, region of birth, fetal growth, and gestation. Fetal growth was defined as birth weight given the length of gestation: small (lower-10th percentile), appropriate, and large (upper-10th percentile).

A total of 8,199 deaths due to SIDS were identified for a rate of 0.72 deaths per 1,000 live births. High parity may have replaced preterm delivery as the greatest risk factor, but preterm birth still is a strong predictor of SIDS risk. Infants less than 32 weeks gestational age were three times more likely to die of SIDS, compared with those born at the gestational age of 40–41 weeks. The odds ratio for SIDS death increased as gestational age decreased.

This may be especially important because the preterm delivery rate has risen in the last 15 years. In 1990, 10.6% of infants born in the United States were preterm. In 2002, 12.1% of infants were born preterm—almost a half million infants per year.

“We found that preterm birth and fetal growth are actually independent risk factors for SIDS. This is a new finding in the United States,” said Dr. Halloran. Infants small for their gestational age were 1.7 times more likely to die of SIDS. Large size seemed to have a protective effect, with infants large for their gestational age 30% less likely to die of SIDS.

Hispanic infants were 50% less likely to die of SIDS, compared with non-Hispanic white infants. Non-Hispanic black and American Indian infants had a greater risk (OR 1.3 and 1.4, respectively). “Native Americans and non-Hispanic blacks actually have increasing odds ratios,” she said. It appears this may be due to the rate of SIDS deaths having dropped among non-Hispanic whites, resulting from the success of the “Back to Sleep” educational campaign.

Other traditional risk factors for SIDS are unchanged following this epidemiologic transition. Male infants were 1.5 times more likely to die of SIDS than females. Infants born to mothers with low education were 1.3 times more likely to die of SIDS; those born to mothers with higher education levels were 20% less likely to die of SIDS.

Infants born to mothers younger than 20 years of age were 1.7 times more likely to die of SIDS than those born to mothers in their 20s, and infants born to mothers older than 30 and older than 35 were both 50% less likely to die of SIDS. Infants born to unmarried mothers were 1.6 times more likely to die of SIDS than those born to married mothers. Infants born to women who smoked were 2.4 times more likely to die of SIDS than those born to nonsmokers.

The meeting also was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

WASHINGTON — High parity has replaced preterm delivery as the greatest risk factor for SIDS, according to a study of national data, presented at the annual meeting of the Pediatric Academic Societies.

“Our highest single risk factor was high parity,” said Donna R. Halloran, M.D., of the University of Alabama, Birmingham. Mothers with a parity of five or greater were 3.6 times more likely to have an infant die of SIDS.

The shift follows an epidemiologic shift in SIDS deaths that occurred in the mid-1990s. In 1991, 1.2 cases of SIDS occurred for every 1,000 live births in the United States. By 1996, the number had dropped dramatically, to 0.7 cases for every 1,000 live births. In 2002, there were 0.6 cases for every 1,000 live births.

The decrease in SIDS deaths has been attributed to the National Institute of Child Health and Human Development's “Back to Sleep” educational campaign initiated in 1994. The number of parents putting their infants in a prone sleep position dropped dramatically. In 1992, 70% of infants were sleeping in a prone position, compared with 18% in 1996.

The study population included all singleton live births in the United States from 1996 to 1998. These data came from the National Center for Health Statistics birth cohort (with linked birth and death files). Infants were excluded if their gestation was less than 22 weeks or greater than 44 weeks. Multiple gestations also were excluded, as were infants of nonresident mothers.

The multivariate analysis model included maternal variables—race/ethnicity, education, age, marital status, smoking, alcohol use, diabetes, hypertension, and parity. The model also included infant gender, region of birth, fetal growth, and gestation. Fetal growth was defined as birth weight given the length of gestation: small (lower-10th percentile), appropriate, and large (upper-10th percentile).

A total of 8,199 deaths due to SIDS were identified for a rate of 0.72 deaths per 1,000 live births. High parity may have replaced preterm delivery as the greatest risk factor, but preterm birth still is a strong predictor of SIDS risk. Infants less than 32 weeks gestational age were three times more likely to die of SIDS, compared with those born at the gestational age of 40–41 weeks. The odds ratio for SIDS death increased as gestational age decreased.

This may be especially important because the preterm delivery rate has risen in the last 15 years. In 1990, 10.6% of infants born in the United States were preterm. In 2002, 12.1% of infants were born preterm—almost a half million infants per year.

“We found that preterm birth and fetal growth are actually independent risk factors for SIDS. This is a new finding in the United States,” said Dr. Halloran. Infants small for their gestational age were 1.7 times more likely to die of SIDS. Large size seemed to have a protective effect, with infants large for their gestational age 30% less likely to die of SIDS.

Hispanic infants were 50% less likely to die of SIDS, compared with non-Hispanic white infants. Non-Hispanic black and American Indian infants had a greater risk (OR 1.3 and 1.4, respectively). “Native Americans and non-Hispanic blacks actually have increasing odds ratios,” she said. It appears this may be due to the rate of SIDS deaths having dropped among non-Hispanic whites, resulting from the success of the “Back to Sleep” educational campaign.

Other traditional risk factors for SIDS are unchanged following this epidemiologic transition. Male infants were 1.5 times more likely to die of SIDS than females. Infants born to mothers with low education were 1.3 times more likely to die of SIDS; those born to mothers with higher education levels were 20% less likely to die of SIDS.

Infants born to mothers younger than 20 years of age were 1.7 times more likely to die of SIDS than those born to mothers in their 20s, and infants born to mothers older than 30 and older than 35 were both 50% less likely to die of SIDS. Infants born to unmarried mothers were 1.6 times more likely to die of SIDS than those born to married mothers. Infants born to women who smoked were 2.4 times more likely to die of SIDS than those born to nonsmokers.

The meeting also was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

WASHINGTON — High parity has replaced preterm delivery as the greatest risk factor for SIDS, according to a study of national data, presented at the annual meeting of the Pediatric Academic Societies.

“Our highest single risk factor was high parity,” said Donna R. Halloran, M.D., of the University of Alabama, Birmingham. Mothers with a parity of five or greater were 3.6 times more likely to have an infant die of SIDS.

The shift follows an epidemiologic shift in SIDS deaths that occurred in the mid-1990s. In 1991, 1.2 cases of SIDS occurred for every 1,000 live births in the United States. By 1996, the number had dropped dramatically, to 0.7 cases for every 1,000 live births. In 2002, there were 0.6 cases for every 1,000 live births.

The decrease in SIDS deaths has been attributed to the National Institute of Child Health and Human Development's “Back to Sleep” educational campaign initiated in 1994. The number of parents putting their infants in a prone sleep position dropped dramatically. In 1992, 70% of infants were sleeping in a prone position, compared with 18% in 1996.

The study population included all singleton live births in the United States from 1996 to 1998. These data came from the National Center for Health Statistics birth cohort (with linked birth and death files). Infants were excluded if their gestation was less than 22 weeks or greater than 44 weeks. Multiple gestations also were excluded, as were infants of nonresident mothers.

The multivariate analysis model included maternal variables—race/ethnicity, education, age, marital status, smoking, alcohol use, diabetes, hypertension, and parity. The model also included infant gender, region of birth, fetal growth, and gestation. Fetal growth was defined as birth weight given the length of gestation: small (lower-10th percentile), appropriate, and large (upper-10th percentile).

A total of 8,199 deaths due to SIDS were identified for a rate of 0.72 deaths per 1,000 live births. High parity may have replaced preterm delivery as the greatest risk factor, but preterm birth still is a strong predictor of SIDS risk. Infants less than 32 weeks gestational age were three times more likely to die of SIDS, compared with those born at the gestational age of 40–41 weeks. The odds ratio for SIDS death increased as gestational age decreased.

This may be especially important because the preterm delivery rate has risen in the last 15 years. In 1990, 10.6% of infants born in the United States were preterm. In 2002, 12.1% of infants were born preterm—almost a half million infants per year.

“We found that preterm birth and fetal growth are actually independent risk factors for SIDS. This is a new finding in the United States,” said Dr. Halloran. Infants small for their gestational age were 1.7 times more likely to die of SIDS. Large size seemed to have a protective effect, with infants large for their gestational age 30% less likely to die of SIDS.

Hispanic infants were 50% less likely to die of SIDS, compared with non-Hispanic white infants. Non-Hispanic black and American Indian infants had a greater risk (OR 1.3 and 1.4, respectively). “Native Americans and non-Hispanic blacks actually have increasing odds ratios,” she said. It appears this may be due to the rate of SIDS deaths having dropped among non-Hispanic whites, resulting from the success of the “Back to Sleep” educational campaign.

Other traditional risk factors for SIDS are unchanged following this epidemiologic transition. Male infants were 1.5 times more likely to die of SIDS than females. Infants born to mothers with low education were 1.3 times more likely to die of SIDS; those born to mothers with higher education levels were 20% less likely to die of SIDS.

Infants born to mothers younger than 20 years of age were 1.7 times more likely to die of SIDS than those born to mothers in their 20s, and infants born to mothers older than 30 and older than 35 were both 50% less likely to die of SIDS. Infants born to unmarried mothers were 1.6 times more likely to die of SIDS than those born to married mothers. Infants born to women who smoked were 2.4 times more likely to die of SIDS than those born to nonsmokers.

The meeting also was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into prenatal practice in the United States, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies now have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in every ob.gyn.'s office, he said.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk.

Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said during the meeting.

“I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier, Dr. Ball added.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into prenatal practice in the United States, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies now have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in every ob.gyn.'s office, he said.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk.

Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said during the meeting.

“I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier, Dr. Ball added.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — First-trimester screening for aneuploidy may soon become the standard of care, Robert H. Ball, M.D., predicted at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

There is sufficient evidence to support the incorporation of first-trimester testing into prenatal practice in the United States, and the focus now should be on the most effective way to implement this, according to a consensus statement produced at a workshop sponsored by the National Institute of Child Health and Human Development in December 2004.

At least seven studies now have shown that detection of aneuploidy can be improved by analyzing a combination of risk factors in the first trimester: maternal age, nuchal translucency measured on ultrasound, and serum testing for β-HCG and PAPP-A.

Women at risk may be offered more definitive testing earlier in pregnancy with this approach, or results of negative first-trimester screens can be integrated with second-trimester serum screening for improved aneuploidy detection in the second trimester.

“This is a big deal, no doubt about it,” said Dr. Ball, a perinatologist at UCSF Children's Hospital. Most nuchal translucency screens will be done in prenatal diagnostic centers, not in every ob.gyn.'s office, he said.

Dr. Ball presented data at the meeting from the First and Second Trimester Evaluation of Risk for Aneuploidy (FASTER) trial, in which he was an investigator. The results have been accepted for publication in the New England Journal of Medicine.

The study obtained follow-up information for 37,002 births, from an impressive 97% of the women who enrolled and underwent first- and second-trimester screening. Aneuploidy detection rates improved when first-trimester serum screening was added to nuchal translucency measurement, compared with using nuchal translucency alone to assess risk.

Detection improved further when these first-trimester results were integrated with second-trimester serum screening.

The study's size provided the power to analyze subgroups, including results based on the gestational week of screening. The best time for first-trimester screening was week 11: When screening was performed at that time, detection rates were 73% with nuchal translucency alone and 93% with the combined nuchal translucency/serum screen. After integrating the combined first-trimester screen with second-trimester screening, the detection rate was 98%.

First trimester screening may pose scheduling problems, he predicted. “That's sort of a logistical nightmare, if you think about it,” because physicians will be scrambling to get patients into prenatal diagnostic centers before the 11-week window passes, he said during the meeting.

“I can imagine people suing because they didn't get in for their nuchal translucency screening and they have a Down syndrome kid” that might have been detected earlier, Dr. Ball added.

In hopes that the integrated first- and second-trimester screening strategies might obviate the need for genetic sonograms, investigators analyzed the FASTER data with and without genetic sonogram results. They found that the likelihood of aneuploidy greatly increased with identification of at least one genetic marker on ultrasound. Genetic ultrasound results improved the overall 84% detection rate for aneuploidy using first-trimester screening alone and decreased the false-positive rate.

“Much to my chagrin, having a genetic sonogram after you've had a bucket load of other tests is actually going to be useful,” Dr. Ball said.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists in 2003 recommended that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm labor by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant., said Dr. Caritis, who is professor and chief of maternal-fetal medicine at the University of Pittsburgh.

Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered.

“I think this is still the best study we have” on preventing preterm birth with progesterones, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial.

Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said. His institution offers only 17-OHPC to women with previous spontaneous preterm birth. For now, they do not give this treatment to women who have a short cervix, threatened preterm labor, or multifetal gestation.

Studies are underway in the maternal-fetal medicine units network evaluating 17-OHPC treatment for those indications.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists in 2003 recommended that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm labor by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant., said Dr. Caritis, who is professor and chief of maternal-fetal medicine at the University of Pittsburgh.

Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered.

“I think this is still the best study we have” on preventing preterm birth with progesterones, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial.

Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said. His institution offers only 17-OHPC to women with previous spontaneous preterm birth. For now, they do not give this treatment to women who have a short cervix, threatened preterm labor, or multifetal gestation.

Studies are underway in the maternal-fetal medicine units network evaluating 17-OHPC treatment for those indications.

SAN FRANCISCO — Recent studies provide some guidance in applying recommendations from the American College of Obstetricians and Gynecologists on the use of progesterone to prevent preterm birth, Steve Caritis, M.D., said at a meeting on antepartum and intrapartum management, sponsored by the University of California, San Francisco.

Only intramuscular injections of 17-hydroxyprogesterone caproate (17-OHPC) have been shown convincingly to prevent recurrent preterm birth, he said.

The American College of Obstetricians and Gynecologists in 2003 recommended that progesterone may be used to help prevent preterm birth but should be restricted to pregnant women with a documented history of spontaneous preterm birth before 37 weeks' gestation. The statement noted that “the ideal progesterone formulation remains unknown until further research is done.”

A 1990 metaanalysis of studies using 17-OHPC found that this agent dramatically lowered the risks for preterm labor and preterm birth.

Although some individual studies had shown a benefit, most were too small to detect significant changes in benefit. When combined in the metaanalysis, they provided the power to show a dramatic impact of 17-OHPC, which reduced the overall odds of preterm labor by 43%, and the odds of preterm birth in women at high risk for preterm birth by 50%, he said.

A separate study conducted for the National Institutes of Child Health and Human Development Maternal-Fetal Medicine Units Network randomized 459 pregnant women who had at least one previous preterm birth to receive weekly injections of 17-OHPC or placebo starting between gestational weeks 16 and 20. The study was stopped early when it became evident that 17-OHPC decreased the risk for preterm birth before 37 weeks by 34%.

Critics of that study noted that the control group had a very high rate of preterm birth and that castor oil (in which 17-OHPC is dissolved) is a uterine stimulant., said Dr. Caritis, who is professor and chief of maternal-fetal medicine at the University of Pittsburgh.

Both the treatment and control groups received castor oil, so it is hard to argue that this created a methodologic problem, he added. The preterm birth rate among controls was similar, however, to rates seen in two other studies and was not unexpected, he said.

Critics also noted a higher rate of spontaneous abortions at less than 20 weeks in the 17-OHPC group. The five spontaneous abortions in that group were counted as preterm births, so there would have been a more significant benefit in the 17-OHPC group, compared with placebo, if these losses had been excluded, he countered.

“I think this is still the best study we have” on preventing preterm birth with progesterones, Dr. Caritis said.

A third study randomized 142 women with singleton gestations and a history of preterm birth to vaginal suppositories of 100 mg of progesterone or placebo starting at 24–34 weeks' gestation, later than the 16–20 weeks' initiation in the 17-OHPC trial.

Results showed a 50% reduction in preterm birth before 37 weeks of gestation with the progesterone suppositories and an 85% reduction in preterm births before 34 weeks' gestation. The latter result “makes me a little suspicious,” he said.

The vaginal suppository trial excluded patients with preterm premature rupture of the membranes (PPROM). “We don't think that's appropriate. It's hard to differentiate preterm labor with or without PPROM,” Dr. Caritis said. His institution offers only 17-OHPC to women with previous spontaneous preterm birth. For now, they do not give this treatment to women who have a short cervix, threatened preterm labor, or multifetal gestation.

Studies are underway in the maternal-fetal medicine units network evaluating 17-OHPC treatment for those indications.

WASHINGTON — Infants born to women treated for infertility—particularly those treated with clomiphene citrate around the time of conception—have a significantly increased risk of neural tube defects, according to results of a study presented at the annual meeting of the Pediatric Academic Societies.

In the study, singleton infants with neural tube defects were almost five times (OR 4.8) as likely as were those in a healthy control group to have a mother with a history of infertility. Singletons with neural tube defects were 11.7 times more likely to have been exposed to clomiphene around the time of conception than were those in the control group, said Yvonne Wu, M.D., of the University of California, San Francisco.

Clomiphene citrate has been used to treat infertility since the 1960s. Beginning in the 1970s, some case reports suggested that the drug might be a risk factor for neural tube defects in offspring. Several observational studies conducted in the 1980s produced conflicting results. Animal studies have shown that clomiphene administration before ovulation leads to an increased risk of exencephaly in offspring.

The current case-control study was nested within the population of 110,624 singleton live births delivered at 36 weeks' gestation or later from 1994 to 1997. The data came from the Kaiser Permanente database for Northern California.

The researchers identified all infants in this group with a physician diagnosis of spina bifida, other spinal cord anomalies, or spinal cerebellar disease. Reviewers were blinded to maternal infertility.

In all, 18 cases of neural tube defects were identified, resulting in a birth prevalence of 1.6 per 10,000. These included 13 cases of spina bifida aperta (myelomeningocele and meningocele) and 5 cases of spina bifida occulta. A total of 1,608 control infants also were identified. These infants were free of cerebral palsy, genetic abnormalities, or congenital anomalies.

Univariate and multivariate odds ratios were calculated and adjusted for infant gender, maternal age, and maternal race. There were no demographic differences between the infants in the case and control groups.

A maternal history of infertility and clomiphene use were both independent predictors of neural tube defects.

Among the infants with neural tube defects, 22% of the mothers had a history of infertility, compared with only 6% of mothers of infants in the control group. Maternal history of infertility was determined from an infertility diagnosis in the Kaiser database, use of one of 23 infertility drugs documented in the Kaiser system, or evaluation at one of 11 infertility clinics in Northern California.

Seventeen percent of the infants with neural tube defects were exposed to clomiphene around the time of conception, compared with 2% of the infants in the control group. The periconceptional window was defined as 60 days before the date of conception to 15 days after. The date of conception was defined as the date of birth minus seven times the gestational age in weeks.

Eighty percent of the women who had been given clomiphene around the time of conception had received multiple courses of the drug before conception. Previous research has shown that the active component of clomiphene is present in the bloodstream for more than a month, meaning that clomiphene is still present for 3–4 weeks after conception—the period when the neural tube closes.

Three of the mothers of infants with neural tube defects had received an average of 5.7 courses of clomiphene, compared with 2.7 courses for the mothers of infants in the control group exposed to the drug. This difference was significant, suggesting that there may be a dose response.

The meeting was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

WASHINGTON — Infants born to women treated for infertility—particularly those treated with clomiphene citrate around the time of conception—have a significantly increased risk of neural tube defects, according to results of a study presented at the annual meeting of the Pediatric Academic Societies.

In the study, singleton infants with neural tube defects were almost five times (OR 4.8) as likely as were those in a healthy control group to have a mother with a history of infertility. Singletons with neural tube defects were 11.7 times more likely to have been exposed to clomiphene around the time of conception than were those in the control group, said Yvonne Wu, M.D., of the University of California, San Francisco.

Clomiphene citrate has been used to treat infertility since the 1960s. Beginning in the 1970s, some case reports suggested that the drug might be a risk factor for neural tube defects in offspring. Several observational studies conducted in the 1980s produced conflicting results. Animal studies have shown that clomiphene administration before ovulation leads to an increased risk of exencephaly in offspring.

The current case-control study was nested within the population of 110,624 singleton live births delivered at 36 weeks' gestation or later from 1994 to 1997. The data came from the Kaiser Permanente database for Northern California.

The researchers identified all infants in this group with a physician diagnosis of spina bifida, other spinal cord anomalies, or spinal cerebellar disease. Reviewers were blinded to maternal infertility.

In all, 18 cases of neural tube defects were identified, resulting in a birth prevalence of 1.6 per 10,000. These included 13 cases of spina bifida aperta (myelomeningocele and meningocele) and 5 cases of spina bifida occulta. A total of 1,608 control infants also were identified. These infants were free of cerebral palsy, genetic abnormalities, or congenital anomalies.

Univariate and multivariate odds ratios were calculated and adjusted for infant gender, maternal age, and maternal race. There were no demographic differences between the infants in the case and control groups.

A maternal history of infertility and clomiphene use were both independent predictors of neural tube defects.

Among the infants with neural tube defects, 22% of the mothers had a history of infertility, compared with only 6% of mothers of infants in the control group. Maternal history of infertility was determined from an infertility diagnosis in the Kaiser database, use of one of 23 infertility drugs documented in the Kaiser system, or evaluation at one of 11 infertility clinics in Northern California.

Seventeen percent of the infants with neural tube defects were exposed to clomiphene around the time of conception, compared with 2% of the infants in the control group. The periconceptional window was defined as 60 days before the date of conception to 15 days after. The date of conception was defined as the date of birth minus seven times the gestational age in weeks.

Eighty percent of the women who had been given clomiphene around the time of conception had received multiple courses of the drug before conception. Previous research has shown that the active component of clomiphene is present in the bloodstream for more than a month, meaning that clomiphene is still present for 3–4 weeks after conception—the period when the neural tube closes.

Three of the mothers of infants with neural tube defects had received an average of 5.7 courses of clomiphene, compared with 2.7 courses for the mothers of infants in the control group exposed to the drug. This difference was significant, suggesting that there may be a dose response.

The meeting was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

WASHINGTON — Infants born to women treated for infertility—particularly those treated with clomiphene citrate around the time of conception—have a significantly increased risk of neural tube defects, according to results of a study presented at the annual meeting of the Pediatric Academic Societies.

In the study, singleton infants with neural tube defects were almost five times (OR 4.8) as likely as were those in a healthy control group to have a mother with a history of infertility. Singletons with neural tube defects were 11.7 times more likely to have been exposed to clomiphene around the time of conception than were those in the control group, said Yvonne Wu, M.D., of the University of California, San Francisco.

Clomiphene citrate has been used to treat infertility since the 1960s. Beginning in the 1970s, some case reports suggested that the drug might be a risk factor for neural tube defects in offspring. Several observational studies conducted in the 1980s produced conflicting results. Animal studies have shown that clomiphene administration before ovulation leads to an increased risk of exencephaly in offspring.

The current case-control study was nested within the population of 110,624 singleton live births delivered at 36 weeks' gestation or later from 1994 to 1997. The data came from the Kaiser Permanente database for Northern California.

The researchers identified all infants in this group with a physician diagnosis of spina bifida, other spinal cord anomalies, or spinal cerebellar disease. Reviewers were blinded to maternal infertility.

In all, 18 cases of neural tube defects were identified, resulting in a birth prevalence of 1.6 per 10,000. These included 13 cases of spina bifida aperta (myelomeningocele and meningocele) and 5 cases of spina bifida occulta. A total of 1,608 control infants also were identified. These infants were free of cerebral palsy, genetic abnormalities, or congenital anomalies.

Univariate and multivariate odds ratios were calculated and adjusted for infant gender, maternal age, and maternal race. There were no demographic differences between the infants in the case and control groups.

A maternal history of infertility and clomiphene use were both independent predictors of neural tube defects.

Among the infants with neural tube defects, 22% of the mothers had a history of infertility, compared with only 6% of mothers of infants in the control group. Maternal history of infertility was determined from an infertility diagnosis in the Kaiser database, use of one of 23 infertility drugs documented in the Kaiser system, or evaluation at one of 11 infertility clinics in Northern California.

Seventeen percent of the infants with neural tube defects were exposed to clomiphene around the time of conception, compared with 2% of the infants in the control group. The periconceptional window was defined as 60 days before the date of conception to 15 days after. The date of conception was defined as the date of birth minus seven times the gestational age in weeks.

Eighty percent of the women who had been given clomiphene around the time of conception had received multiple courses of the drug before conception. Previous research has shown that the active component of clomiphene is present in the bloodstream for more than a month, meaning that clomiphene is still present for 3–4 weeks after conception—the period when the neural tube closes.

Three of the mothers of infants with neural tube defects had received an average of 5.7 courses of clomiphene, compared with 2.7 courses for the mothers of infants in the control group exposed to the drug. This difference was significant, suggesting that there may be a dose response.

The meeting was sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediatric Association, and the American Academy of Pediatrics.

Obese women are 30% more likely than women of normal weight to give birth to an infant with an orofacial cleft, investigators have reported.

“One possible explanation is undetected type 2 diabetes. Obese women, in the absence of overt diabetes, have been found to have an impaired glucose metabolism, which may be associated with an increased risk for orofacial clefts,” wrote Marie Cedergren, M.D., of the University of Linköping, and her coinvestigator, Bengt Kallen, M.D., of Tornblad Institute at the University of Lund (Cleft Palate Craniofac. J. 2005;42:367–71).

Of almost 1 million infants born in Sweden from 1992 to 2001, 1,686 infants were born with orofacial clefts; 84% of the clefts were not associated with another major congenital malformation. Compared with infants born of normal weight mothers, infants of obese mothers had their risk increase by 28% for cleft palate, 14% for cleft lip, and 31% for both abnormalities.

The risk of orofacial clefting among these infants was significantly higher (odds ratio 1.88) when associated with other congential defects, but still elevated (OR 1.20) when clefting was the only defect.

Obese women are 30% more likely than women of normal weight to give birth to an infant with an orofacial cleft, investigators have reported.

“One possible explanation is undetected type 2 diabetes. Obese women, in the absence of overt diabetes, have been found to have an impaired glucose metabolism, which may be associated with an increased risk for orofacial clefts,” wrote Marie Cedergren, M.D., of the University of Linköping, and her coinvestigator, Bengt Kallen, M.D., of Tornblad Institute at the University of Lund (Cleft Palate Craniofac. J. 2005;42:367–71).

Of almost 1 million infants born in Sweden from 1992 to 2001, 1,686 infants were born with orofacial clefts; 84% of the clefts were not associated with another major congenital malformation. Compared with infants born of normal weight mothers, infants of obese mothers had their risk increase by 28% for cleft palate, 14% for cleft lip, and 31% for both abnormalities.

The risk of orofacial clefting among these infants was significantly higher (odds ratio 1.88) when associated with other congential defects, but still elevated (OR 1.20) when clefting was the only defect.

Obese women are 30% more likely than women of normal weight to give birth to an infant with an orofacial cleft, investigators have reported.

“One possible explanation is undetected type 2 diabetes. Obese women, in the absence of overt diabetes, have been found to have an impaired glucose metabolism, which may be associated with an increased risk for orofacial clefts,” wrote Marie Cedergren, M.D., of the University of Linköping, and her coinvestigator, Bengt Kallen, M.D., of Tornblad Institute at the University of Lund (Cleft Palate Craniofac. J. 2005;42:367–71).

Of almost 1 million infants born in Sweden from 1992 to 2001, 1,686 infants were born with orofacial clefts; 84% of the clefts were not associated with another major congenital malformation. Compared with infants born of normal weight mothers, infants of obese mothers had their risk increase by 28% for cleft palate, 14% for cleft lip, and 31% for both abnormalities.

The risk of orofacial clefting among these infants was significantly higher (odds ratio 1.88) when associated with other congential defects, but still elevated (OR 1.20) when clefting was the only defect.

SAN DIEGO — Weight gain in the 5 years before pregnancy is associated with an increased risk for gestational diabetes, Monique Hedderson reported in a poster at the annual scientific sessions of the American Diabetes Association.

In a nested case-control study including 114 women with gestational diabetes mellitus (GDM) and 95 controls who were members of Kaiser Permanente of Northern California, those who had gained between 1.1 kg and 10.0 kg in the 5 years before their last menstrual period were nearly twice as likely (crude odds ratio 1.98) to have developed GDM during pregnancy than were those whose weight remained within 1 kg of baseline, said Ms. Hedderson, of Kaiser Permanente, Oakland, Calif., and her associates.

The women who developed GDM were older, more likely to be from an ethnic minority group, more likely to be overweight at baseline, and more likely to be primiparous or to have had at least two prior live births.

After adjustment for these factors, the relationship between prepregnancy weight gain and GDM was even stronger, with an odds ratio of 2.58. The relationship with weight loss was again insignificant (OR 0.9).

SAN DIEGO — Weight gain in the 5 years before pregnancy is associated with an increased risk for gestational diabetes, Monique Hedderson reported in a poster at the annual scientific sessions of the American Diabetes Association.

In a nested case-control study including 114 women with gestational diabetes mellitus (GDM) and 95 controls who were members of Kaiser Permanente of Northern California, those who had gained between 1.1 kg and 10.0 kg in the 5 years before their last menstrual period were nearly twice as likely (crude odds ratio 1.98) to have developed GDM during pregnancy than were those whose weight remained within 1 kg of baseline, said Ms. Hedderson, of Kaiser Permanente, Oakland, Calif., and her associates.

The women who developed GDM were older, more likely to be from an ethnic minority group, more likely to be overweight at baseline, and more likely to be primiparous or to have had at least two prior live births.

After adjustment for these factors, the relationship between prepregnancy weight gain and GDM was even stronger, with an odds ratio of 2.58. The relationship with weight loss was again insignificant (OR 0.9).

SAN DIEGO — Weight gain in the 5 years before pregnancy is associated with an increased risk for gestational diabetes, Monique Hedderson reported in a poster at the annual scientific sessions of the American Diabetes Association.

In a nested case-control study including 114 women with gestational diabetes mellitus (GDM) and 95 controls who were members of Kaiser Permanente of Northern California, those who had gained between 1.1 kg and 10.0 kg in the 5 years before their last menstrual period were nearly twice as likely (crude odds ratio 1.98) to have developed GDM during pregnancy than were those whose weight remained within 1 kg of baseline, said Ms. Hedderson, of Kaiser Permanente, Oakland, Calif., and her associates.

The women who developed GDM were older, more likely to be from an ethnic minority group, more likely to be overweight at baseline, and more likely to be primiparous or to have had at least two prior live births.

After adjustment for these factors, the relationship between prepregnancy weight gain and GDM was even stronger, with an odds ratio of 2.58. The relationship with weight loss was again insignificant (OR 0.9).