Obstetrics

PITTSBURGH — Pregnancy can trigger a relapse in women with bipolar disorder, especially if they stop their mood-stabilizing treatment.

Although data from several studies are conflicting, a prospective study showed that about two-thirds of women with a history of bipolar disorder had a relapse during pregnancy, Adele C. Viguera, M.D., said at the Sixth International Conference on Bipolar Disorder.

In that study, about half of the women had relapsed before their 18th week of pregnancy. Relapse was even more rapid in the postpartum period, with about half of the women studied having a return of their bipolar disorder within 6 weeks after delivery, said Dr. Viguera, of the department of psychiatry at Massachusetts General Hospital in Boston.

Results from a separate study, led by Dr. Viguera and reported 2 years ago, showed that the majority of bipolar recurrences during pregnancy or postpartum involve either major depressive episodes or mixed states.

A major factor linked with recurrences is discontinuation of mood-stabilizing treatment, especially an abrupt stop. In Dr. Viguera's study which involved 82 women, the relapse rate among the women who stopped their mood-stabilizing medication was 75%, compared with a 35% relapse rate among women who continued their treatment.

Another important determinant of relapse is whether affective illness occurs during pregnancy. In Dr. Viguera's study, a total of 61% of the studied women had a postpartum relapse. More than 80% of the women with relapses had affective illness during pregnancy. As a result of this observation, “we're very aggressive about maintaining euthymia” during pregnancy, Dr. Viguera said at the meeting, also sponsored by the University of Pittsburgh.

But data are limited on the safety of mood stabilizers during and after pregnancy. A study reported this year showed that in a North American registry, treatment of pregnant women with valproic acid was linked with 16 fetal anomalies among 149 women treated, an 11% rate that was “much higher than expected,” said Dr. Viguera. Additional findings from studies of valproic acid use in pregnant women with epilepsy also show a relatively high rate of major malformations, fetal death, and developmental delay.

Results from another registry showed that treatment with lamotrigine was associated with a 3% incidence of major malformations in a series of 414 treated women. Other studies have confirmed that lamotrigine treatment is linked with fewer serious effects during pregnancy than other anticonvulsants.

Results from a prospective study published this year showed a single major malformation among 151 women treated with an atypical antipsychotic in pregnancy. The drugs included in this study were olanzapine, risperidone, quetiapine, and clozapine. Although the low rate of fetal damage was reassuring, the number of women studied was too small to produce a definitive conclusion about safety, Dr. Viguera said.

PITTSBURGH — Pregnancy can trigger a relapse in women with bipolar disorder, especially if they stop their mood-stabilizing treatment.

Although data from several studies are conflicting, a prospective study showed that about two-thirds of women with a history of bipolar disorder had a relapse during pregnancy, Adele C. Viguera, M.D., said at the Sixth International Conference on Bipolar Disorder.

In that study, about half of the women had relapsed before their 18th week of pregnancy. Relapse was even more rapid in the postpartum period, with about half of the women studied having a return of their bipolar disorder within 6 weeks after delivery, said Dr. Viguera, of the department of psychiatry at Massachusetts General Hospital in Boston.

Results from a separate study, led by Dr. Viguera and reported 2 years ago, showed that the majority of bipolar recurrences during pregnancy or postpartum involve either major depressive episodes or mixed states.

A major factor linked with recurrences is discontinuation of mood-stabilizing treatment, especially an abrupt stop. In Dr. Viguera's study which involved 82 women, the relapse rate among the women who stopped their mood-stabilizing medication was 75%, compared with a 35% relapse rate among women who continued their treatment.

Another important determinant of relapse is whether affective illness occurs during pregnancy. In Dr. Viguera's study, a total of 61% of the studied women had a postpartum relapse. More than 80% of the women with relapses had affective illness during pregnancy. As a result of this observation, “we're very aggressive about maintaining euthymia” during pregnancy, Dr. Viguera said at the meeting, also sponsored by the University of Pittsburgh.

But data are limited on the safety of mood stabilizers during and after pregnancy. A study reported this year showed that in a North American registry, treatment of pregnant women with valproic acid was linked with 16 fetal anomalies among 149 women treated, an 11% rate that was “much higher than expected,” said Dr. Viguera. Additional findings from studies of valproic acid use in pregnant women with epilepsy also show a relatively high rate of major malformations, fetal death, and developmental delay.

Results from another registry showed that treatment with lamotrigine was associated with a 3% incidence of major malformations in a series of 414 treated women. Other studies have confirmed that lamotrigine treatment is linked with fewer serious effects during pregnancy than other anticonvulsants.

Results from a prospective study published this year showed a single major malformation among 151 women treated with an atypical antipsychotic in pregnancy. The drugs included in this study were olanzapine, risperidone, quetiapine, and clozapine. Although the low rate of fetal damage was reassuring, the number of women studied was too small to produce a definitive conclusion about safety, Dr. Viguera said.

PITTSBURGH — Pregnancy can trigger a relapse in women with bipolar disorder, especially if they stop their mood-stabilizing treatment.

Although data from several studies are conflicting, a prospective study showed that about two-thirds of women with a history of bipolar disorder had a relapse during pregnancy, Adele C. Viguera, M.D., said at the Sixth International Conference on Bipolar Disorder.

In that study, about half of the women had relapsed before their 18th week of pregnancy. Relapse was even more rapid in the postpartum period, with about half of the women studied having a return of their bipolar disorder within 6 weeks after delivery, said Dr. Viguera, of the department of psychiatry at Massachusetts General Hospital in Boston.

Results from a separate study, led by Dr. Viguera and reported 2 years ago, showed that the majority of bipolar recurrences during pregnancy or postpartum involve either major depressive episodes or mixed states.

A major factor linked with recurrences is discontinuation of mood-stabilizing treatment, especially an abrupt stop. In Dr. Viguera's study which involved 82 women, the relapse rate among the women who stopped their mood-stabilizing medication was 75%, compared with a 35% relapse rate among women who continued their treatment.

Another important determinant of relapse is whether affective illness occurs during pregnancy. In Dr. Viguera's study, a total of 61% of the studied women had a postpartum relapse. More than 80% of the women with relapses had affective illness during pregnancy. As a result of this observation, “we're very aggressive about maintaining euthymia” during pregnancy, Dr. Viguera said at the meeting, also sponsored by the University of Pittsburgh.

But data are limited on the safety of mood stabilizers during and after pregnancy. A study reported this year showed that in a North American registry, treatment of pregnant women with valproic acid was linked with 16 fetal anomalies among 149 women treated, an 11% rate that was “much higher than expected,” said Dr. Viguera. Additional findings from studies of valproic acid use in pregnant women with epilepsy also show a relatively high rate of major malformations, fetal death, and developmental delay.

Results from another registry showed that treatment with lamotrigine was associated with a 3% incidence of major malformations in a series of 414 treated women. Other studies have confirmed that lamotrigine treatment is linked with fewer serious effects during pregnancy than other anticonvulsants.

Results from a prospective study published this year showed a single major malformation among 151 women treated with an atypical antipsychotic in pregnancy. The drugs included in this study were olanzapine, risperidone, quetiapine, and clozapine. Although the low rate of fetal damage was reassuring, the number of women studied was too small to produce a definitive conclusion about safety, Dr. Viguera said.

VIENNA — Prolonged intrauterine exposure to high-dose dexamethasone appears to be largely devoid of clinically significant adverse effects on normal T-cell development when evaluated up to a dozen years later, Paolo Airo, M.D., said at the annual European congress of rheumatology.

This has been a controversial issue. Some physicians are concerned that prolonged intrauterine exposure to corticosteroids might steer T-cell differentiation within the fetal thymus in a direction that predisposes to clinical immune dysfunction. They point to an increased rate of hospitalizations for infectious diseases during the first years of life in children with a history of prenatal steroid therapy for prematurity. But a corticosteroid effect is only one of a number of plausible explanations for such an association, said Dr. Airo of the University of Brescia (Italy).

To examine the effect of prenatal high-dose steroids on the T-cell component of the immune system, he and his coinvestigators studied eight children with a history of such therapy given after they were diagnosed in utero with neonatal lupus.

Neonatal lupus, he explained, is a serious condition occurring in children whose mothers have anti-Rho/SSA antibodies, which can cross the placenta. The most important clinical manifestation is congenital heart block; it is associated with significant mortality and permanent morbidity.

When affected fetuses are identified they are typically treated with several weeks of a high-dose steroid given to the woman. Dexamethasone is the agent used most widely. Since it is a fluorinated corticosteroid, it is not inactivated by placental enzymes, so it can reach the fetus in its active form. The purpose of this therapy is to slow the inflammatory process to prevent progression of incomplete to complete congenital heart block, as well as to treat fetal hydrops and/or myocarditis.

The mean age of the children was 6.6 years, with a range of 2–12 years. All had a pacemaker. None had clinical or laboratory indications of autoimmune disease. A total of 31 age-matched healthy children served as controls, he said at the congress, sponsored by the European League Against Rheumatism.

The results showed that the children with a history of in utero steroid therapy had no abnormalities in the various measures of T-cell number or function having the most clear-cut potential clinical consequences. Thymic output—a key study end point—was normal in children with prolonged fetal exposure to steroids; this was shown by the number of T-cell receptor excision circles (TRECs) in their peripheral blood mononuclear cells, which were measured by real-time polymerase chain reaction. The total number of T cells circulating in peripheral blood was similar to that of controls, as was T-cell subset diversity. Nor did the patients' lymphocyte proliferative response to mitogens differ from that seen in control subjects. Peripheral blood mononuclear cell interferon-γ production and apoptotic response were also similar to that in controls.

The one abnormality seen in children with a history of fetal exposure to steroids involved evidence of oligoclonal T-cell expansion. Similar changes have been reported in animals with in utero exposure to high-dose steroids. However, such changes also can be readily observed in humans after a viral infection. And the clinical significance of this sort of alteration in T-cell repertoire remains unclear, Dr. Airo said.

“We don't know if there is a link between these kinds of changes in PCR repertoire and autoimmunity, but we know that this kind of restriction is frequently detected in patients with rheumatoid arthritis and other autoimmune disorders. And it has been reported that children with neonatal lupus are at increased risk of developing autoimmune disorders in their first years,” according to the rheumatologist.

Putting aside the question of the effects on T cells of intrauterine steroid exposure, other adverse consequences have been reported by various investigators. These include increased rates of obstetric complications, adrenal insufficiency, hypertension, and neuropsychiatric impairment.

“We didn't observe any signs of neuropsychiatric impairment in a series of nine children treated with dexamethasone in utero for neonatal lupus in our hospital,” the physician said.

VIENNA — Prolonged intrauterine exposure to high-dose dexamethasone appears to be largely devoid of clinically significant adverse effects on normal T-cell development when evaluated up to a dozen years later, Paolo Airo, M.D., said at the annual European congress of rheumatology.

This has been a controversial issue. Some physicians are concerned that prolonged intrauterine exposure to corticosteroids might steer T-cell differentiation within the fetal thymus in a direction that predisposes to clinical immune dysfunction. They point to an increased rate of hospitalizations for infectious diseases during the first years of life in children with a history of prenatal steroid therapy for prematurity. But a corticosteroid effect is only one of a number of plausible explanations for such an association, said Dr. Airo of the University of Brescia (Italy).

To examine the effect of prenatal high-dose steroids on the T-cell component of the immune system, he and his coinvestigators studied eight children with a history of such therapy given after they were diagnosed in utero with neonatal lupus.

Neonatal lupus, he explained, is a serious condition occurring in children whose mothers have anti-Rho/SSA antibodies, which can cross the placenta. The most important clinical manifestation is congenital heart block; it is associated with significant mortality and permanent morbidity.

When affected fetuses are identified they are typically treated with several weeks of a high-dose steroid given to the woman. Dexamethasone is the agent used most widely. Since it is a fluorinated corticosteroid, it is not inactivated by placental enzymes, so it can reach the fetus in its active form. The purpose of this therapy is to slow the inflammatory process to prevent progression of incomplete to complete congenital heart block, as well as to treat fetal hydrops and/or myocarditis.

The mean age of the children was 6.6 years, with a range of 2–12 years. All had a pacemaker. None had clinical or laboratory indications of autoimmune disease. A total of 31 age-matched healthy children served as controls, he said at the congress, sponsored by the European League Against Rheumatism.

The results showed that the children with a history of in utero steroid therapy had no abnormalities in the various measures of T-cell number or function having the most clear-cut potential clinical consequences. Thymic output—a key study end point—was normal in children with prolonged fetal exposure to steroids; this was shown by the number of T-cell receptor excision circles (TRECs) in their peripheral blood mononuclear cells, which were measured by real-time polymerase chain reaction. The total number of T cells circulating in peripheral blood was similar to that of controls, as was T-cell subset diversity. Nor did the patients' lymphocyte proliferative response to mitogens differ from that seen in control subjects. Peripheral blood mononuclear cell interferon-γ production and apoptotic response were also similar to that in controls.

The one abnormality seen in children with a history of fetal exposure to steroids involved evidence of oligoclonal T-cell expansion. Similar changes have been reported in animals with in utero exposure to high-dose steroids. However, such changes also can be readily observed in humans after a viral infection. And the clinical significance of this sort of alteration in T-cell repertoire remains unclear, Dr. Airo said.

“We don't know if there is a link between these kinds of changes in PCR repertoire and autoimmunity, but we know that this kind of restriction is frequently detected in patients with rheumatoid arthritis and other autoimmune disorders. And it has been reported that children with neonatal lupus are at increased risk of developing autoimmune disorders in their first years,” according to the rheumatologist.

Putting aside the question of the effects on T cells of intrauterine steroid exposure, other adverse consequences have been reported by various investigators. These include increased rates of obstetric complications, adrenal insufficiency, hypertension, and neuropsychiatric impairment.

“We didn't observe any signs of neuropsychiatric impairment in a series of nine children treated with dexamethasone in utero for neonatal lupus in our hospital,” the physician said.

VIENNA — Prolonged intrauterine exposure to high-dose dexamethasone appears to be largely devoid of clinically significant adverse effects on normal T-cell development when evaluated up to a dozen years later, Paolo Airo, M.D., said at the annual European congress of rheumatology.

This has been a controversial issue. Some physicians are concerned that prolonged intrauterine exposure to corticosteroids might steer T-cell differentiation within the fetal thymus in a direction that predisposes to clinical immune dysfunction. They point to an increased rate of hospitalizations for infectious diseases during the first years of life in children with a history of prenatal steroid therapy for prematurity. But a corticosteroid effect is only one of a number of plausible explanations for such an association, said Dr. Airo of the University of Brescia (Italy).

To examine the effect of prenatal high-dose steroids on the T-cell component of the immune system, he and his coinvestigators studied eight children with a history of such therapy given after they were diagnosed in utero with neonatal lupus.

Neonatal lupus, he explained, is a serious condition occurring in children whose mothers have anti-Rho/SSA antibodies, which can cross the placenta. The most important clinical manifestation is congenital heart block; it is associated with significant mortality and permanent morbidity.

When affected fetuses are identified they are typically treated with several weeks of a high-dose steroid given to the woman. Dexamethasone is the agent used most widely. Since it is a fluorinated corticosteroid, it is not inactivated by placental enzymes, so it can reach the fetus in its active form. The purpose of this therapy is to slow the inflammatory process to prevent progression of incomplete to complete congenital heart block, as well as to treat fetal hydrops and/or myocarditis.

The mean age of the children was 6.6 years, with a range of 2–12 years. All had a pacemaker. None had clinical or laboratory indications of autoimmune disease. A total of 31 age-matched healthy children served as controls, he said at the congress, sponsored by the European League Against Rheumatism.

The results showed that the children with a history of in utero steroid therapy had no abnormalities in the various measures of T-cell number or function having the most clear-cut potential clinical consequences. Thymic output—a key study end point—was normal in children with prolonged fetal exposure to steroids; this was shown by the number of T-cell receptor excision circles (TRECs) in their peripheral blood mononuclear cells, which were measured by real-time polymerase chain reaction. The total number of T cells circulating in peripheral blood was similar to that of controls, as was T-cell subset diversity. Nor did the patients' lymphocyte proliferative response to mitogens differ from that seen in control subjects. Peripheral blood mononuclear cell interferon-γ production and apoptotic response were also similar to that in controls.

The one abnormality seen in children with a history of fetal exposure to steroids involved evidence of oligoclonal T-cell expansion. Similar changes have been reported in animals with in utero exposure to high-dose steroids. However, such changes also can be readily observed in humans after a viral infection. And the clinical significance of this sort of alteration in T-cell repertoire remains unclear, Dr. Airo said.

“We don't know if there is a link between these kinds of changes in PCR repertoire and autoimmunity, but we know that this kind of restriction is frequently detected in patients with rheumatoid arthritis and other autoimmune disorders. And it has been reported that children with neonatal lupus are at increased risk of developing autoimmune disorders in their first years,” according to the rheumatologist.

Putting aside the question of the effects on T cells of intrauterine steroid exposure, other adverse consequences have been reported by various investigators. These include increased rates of obstetric complications, adrenal insufficiency, hypertension, and neuropsychiatric impairment.

“We didn't observe any signs of neuropsychiatric impairment in a series of nine children treated with dexamethasone in utero for neonatal lupus in our hospital,” the physician said.

Treatment of gestational diabetes reduces serious perinatal morbidity, Caroline A. Crowther, M.D., of the University of Adelaide (Australia) and her associates reported.

Although the risks associated with gestational diabetes mellitus (GDM) are well recognized, it has been uncertain whether screening and treatment to reduce maternal glucose levels reduces these risks. Given this uncertainty, professional groups disagree on which patients should be screened, the investigators said (N. Engl. J. Med. 2005;352:2477–86).

Now, new investigation findings in favor of screening come from the 18-center Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) in which serious perinatal complications occurred in just 1% of the infants of 490 women with GDM who were randomized to intensive glucose management, compared with 4% of 510 women who received routine care.

In an accompanying editorial, Michael F. Greene, M.D., and Caren G. Solomon, M.D., wrote that “this study provides critical evidence that identifying and treating [GDM] can substantially reduce the risk of adverse perinatal outcomes without, at least in this trial, increasing the rate of cesarean delivery.”

However, Dr. Greene and Dr. Solomon, both on the editorial board of the New England Journal of Medicine, noted that the study leaves unanswered the question of what level of blood glucose warrants routine intervention (N. Engl. J. Med. 2005;352:2544–6).

The study included women with a singleton or twin pregnancy between 16 and 30 weeks' gestation who had at least one risk factor for GDM on selective screening or a positive 50-g oral glucose challenge test, with a 1-hour postchallenge glucose level of at least 140 mg/dL followed by a 75-g oral glucose tolerance test at 24–34 weeks' gestation in which venous plasma glucose was less than 140 mg/dL after an overnight fast and 140–198 mg/dL at 2 hours.

When the study began, these women had been classified as having glucose intolerance of pregnancy by the World Health Organization, but during the course of the study (in 1998) WHO began classifying any glucose level above normal as being GDM. Women whose glucose values exceeded these cutoffs were not included in the study.

The women randomized to intensive intervention were informed of their diagnosis. They received dietary counseling and were taught how to perform self-blood glucose monitoring, with targets of no more than 99 mg/dL premeal and 126 mg/dL 2 hours after eating. Twenty percent received insulin therapy. The women randomized to routine care were told they did not have GDM, according to Dr. Crowther and her associates.

Serious perinatal outcomes, including death, shoulder dystocia, bone fracture, and nerve palsy, occurred in 1% of the intervention group vs. 4% of the routine care group after adjustment for maternal age, race/ethnicity, and parity. Thus, 34 mothers would need to be treated to prevent one serious outcome in an infant, they said.

Women in the intervention group were significantly more likely to have induction of labor (39% vs. 29%), but the rates of cesarean delivery were similar (31% vs. 32%), as were the reasons for it. Infants in the intervention group also had fewer admissions to the neonatal nursery (71% vs. 61%). At 3 months' post partum, fewer women in the intervention group had a score on the Edinburgh Postnatal Depression Scale suggestive of depression (8% vs. 17%); anxiety scores were similar.

Among the secondary outcomes, there were no perinatal deaths among the infants from the intervention group, but three stillbirths and two neonatal deaths occurred among infants in the routine care group. There were no differences in the rates of shoulder dystocia between the two groups. No bone fractures or nerve palsies occurred in the intervention group; the routine care group had one of the former and three of the latter.

Birth weights were significantly lower among the infants born to women in the intervention group (3,335 g vs. 3,482 g), and they were also born at an earlier gestational age, which makes sense given their higher rate of induction of labor. Significantly fewer infants in the intervention group were large for gestational age (13% vs. 22%), and fewer had macrosomia, defined by a birth weight of 4 kg or greater (10% vs. 21%).

Women in the intervention group made fewer prenatal clinic visits after enrollment than did the routine care group, but they made more visits to the physician. Weight gain was less in the intervention group, and fewer women were diagnosed with preeclampsia. The rates of prenatal hospital admissions were similar.

Dr. Greene and Dr. Solomon agreed with the authors' justification for having randomized one group of women to no treatment—that before this study there were no conclusive data regarding the effects of treating GDM, even after the WHO definition was revised.

Treatment of gestational diabetes reduces serious perinatal morbidity, Caroline A. Crowther, M.D., of the University of Adelaide (Australia) and her associates reported.

Although the risks associated with gestational diabetes mellitus (GDM) are well recognized, it has been uncertain whether screening and treatment to reduce maternal glucose levels reduces these risks. Given this uncertainty, professional groups disagree on which patients should be screened, the investigators said (N. Engl. J. Med. 2005;352:2477–86).

Now, new investigation findings in favor of screening come from the 18-center Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) in which serious perinatal complications occurred in just 1% of the infants of 490 women with GDM who were randomized to intensive glucose management, compared with 4% of 510 women who received routine care.

In an accompanying editorial, Michael F. Greene, M.D., and Caren G. Solomon, M.D., wrote that “this study provides critical evidence that identifying and treating [GDM] can substantially reduce the risk of adverse perinatal outcomes without, at least in this trial, increasing the rate of cesarean delivery.”

However, Dr. Greene and Dr. Solomon, both on the editorial board of the New England Journal of Medicine, noted that the study leaves unanswered the question of what level of blood glucose warrants routine intervention (N. Engl. J. Med. 2005;352:2544–6).

The study included women with a singleton or twin pregnancy between 16 and 30 weeks' gestation who had at least one risk factor for GDM on selective screening or a positive 50-g oral glucose challenge test, with a 1-hour postchallenge glucose level of at least 140 mg/dL followed by a 75-g oral glucose tolerance test at 24–34 weeks' gestation in which venous plasma glucose was less than 140 mg/dL after an overnight fast and 140–198 mg/dL at 2 hours.

When the study began, these women had been classified as having glucose intolerance of pregnancy by the World Health Organization, but during the course of the study (in 1998) WHO began classifying any glucose level above normal as being GDM. Women whose glucose values exceeded these cutoffs were not included in the study.

The women randomized to intensive intervention were informed of their diagnosis. They received dietary counseling and were taught how to perform self-blood glucose monitoring, with targets of no more than 99 mg/dL premeal and 126 mg/dL 2 hours after eating. Twenty percent received insulin therapy. The women randomized to routine care were told they did not have GDM, according to Dr. Crowther and her associates.

Serious perinatal outcomes, including death, shoulder dystocia, bone fracture, and nerve palsy, occurred in 1% of the intervention group vs. 4% of the routine care group after adjustment for maternal age, race/ethnicity, and parity. Thus, 34 mothers would need to be treated to prevent one serious outcome in an infant, they said.

Women in the intervention group were significantly more likely to have induction of labor (39% vs. 29%), but the rates of cesarean delivery were similar (31% vs. 32%), as were the reasons for it. Infants in the intervention group also had fewer admissions to the neonatal nursery (71% vs. 61%). At 3 months' post partum, fewer women in the intervention group had a score on the Edinburgh Postnatal Depression Scale suggestive of depression (8% vs. 17%); anxiety scores were similar.

Among the secondary outcomes, there were no perinatal deaths among the infants from the intervention group, but three stillbirths and two neonatal deaths occurred among infants in the routine care group. There were no differences in the rates of shoulder dystocia between the two groups. No bone fractures or nerve palsies occurred in the intervention group; the routine care group had one of the former and three of the latter.

Birth weights were significantly lower among the infants born to women in the intervention group (3,335 g vs. 3,482 g), and they were also born at an earlier gestational age, which makes sense given their higher rate of induction of labor. Significantly fewer infants in the intervention group were large for gestational age (13% vs. 22%), and fewer had macrosomia, defined by a birth weight of 4 kg or greater (10% vs. 21%).

Women in the intervention group made fewer prenatal clinic visits after enrollment than did the routine care group, but they made more visits to the physician. Weight gain was less in the intervention group, and fewer women were diagnosed with preeclampsia. The rates of prenatal hospital admissions were similar.

Dr. Greene and Dr. Solomon agreed with the authors' justification for having randomized one group of women to no treatment—that before this study there were no conclusive data regarding the effects of treating GDM, even after the WHO definition was revised.

Treatment of gestational diabetes reduces serious perinatal morbidity, Caroline A. Crowther, M.D., of the University of Adelaide (Australia) and her associates reported.

Although the risks associated with gestational diabetes mellitus (GDM) are well recognized, it has been uncertain whether screening and treatment to reduce maternal glucose levels reduces these risks. Given this uncertainty, professional groups disagree on which patients should be screened, the investigators said (N. Engl. J. Med. 2005;352:2477–86).

Now, new investigation findings in favor of screening come from the 18-center Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) in which serious perinatal complications occurred in just 1% of the infants of 490 women with GDM who were randomized to intensive glucose management, compared with 4% of 510 women who received routine care.

In an accompanying editorial, Michael F. Greene, M.D., and Caren G. Solomon, M.D., wrote that “this study provides critical evidence that identifying and treating [GDM] can substantially reduce the risk of adverse perinatal outcomes without, at least in this trial, increasing the rate of cesarean delivery.”

However, Dr. Greene and Dr. Solomon, both on the editorial board of the New England Journal of Medicine, noted that the study leaves unanswered the question of what level of blood glucose warrants routine intervention (N. Engl. J. Med. 2005;352:2544–6).

The study included women with a singleton or twin pregnancy between 16 and 30 weeks' gestation who had at least one risk factor for GDM on selective screening or a positive 50-g oral glucose challenge test, with a 1-hour postchallenge glucose level of at least 140 mg/dL followed by a 75-g oral glucose tolerance test at 24–34 weeks' gestation in which venous plasma glucose was less than 140 mg/dL after an overnight fast and 140–198 mg/dL at 2 hours.

When the study began, these women had been classified as having glucose intolerance of pregnancy by the World Health Organization, but during the course of the study (in 1998) WHO began classifying any glucose level above normal as being GDM. Women whose glucose values exceeded these cutoffs were not included in the study.

The women randomized to intensive intervention were informed of their diagnosis. They received dietary counseling and were taught how to perform self-blood glucose monitoring, with targets of no more than 99 mg/dL premeal and 126 mg/dL 2 hours after eating. Twenty percent received insulin therapy. The women randomized to routine care were told they did not have GDM, according to Dr. Crowther and her associates.

Serious perinatal outcomes, including death, shoulder dystocia, bone fracture, and nerve palsy, occurred in 1% of the intervention group vs. 4% of the routine care group after adjustment for maternal age, race/ethnicity, and parity. Thus, 34 mothers would need to be treated to prevent one serious outcome in an infant, they said.

Women in the intervention group were significantly more likely to have induction of labor (39% vs. 29%), but the rates of cesarean delivery were similar (31% vs. 32%), as were the reasons for it. Infants in the intervention group also had fewer admissions to the neonatal nursery (71% vs. 61%). At 3 months' post partum, fewer women in the intervention group had a score on the Edinburgh Postnatal Depression Scale suggestive of depression (8% vs. 17%); anxiety scores were similar.

Among the secondary outcomes, there were no perinatal deaths among the infants from the intervention group, but three stillbirths and two neonatal deaths occurred among infants in the routine care group. There were no differences in the rates of shoulder dystocia between the two groups. No bone fractures or nerve palsies occurred in the intervention group; the routine care group had one of the former and three of the latter.

Birth weights were significantly lower among the infants born to women in the intervention group (3,335 g vs. 3,482 g), and they were also born at an earlier gestational age, which makes sense given their higher rate of induction of labor. Significantly fewer infants in the intervention group were large for gestational age (13% vs. 22%), and fewer had macrosomia, defined by a birth weight of 4 kg or greater (10% vs. 21%).

Women in the intervention group made fewer prenatal clinic visits after enrollment than did the routine care group, but they made more visits to the physician. Weight gain was less in the intervention group, and fewer women were diagnosed with preeclampsia. The rates of prenatal hospital admissions were similar.

Dr. Greene and Dr. Solomon agreed with the authors' justification for having randomized one group of women to no treatment—that before this study there were no conclusive data regarding the effects of treating GDM, even after the WHO definition was revised.

PITTSBURGH — Women with a history of bipolar disorder have an increased risk of developing depression during and after pregnancy, based on a review of more than 2,000 pregnant women.

A history of unipolar depression also predisposed women to develop depression during the peripartum and postpartum periods, although unipolar depression was not as potent a risk factor as bipolar disorder. The findings suggest “an urgent need” for better screening and detection of bipolar-spectrum disorders in pregnant women, Adele C. Viguera, M.D., said while presenting a poster at the Sixth International Conference on Bipolar Disorders.

The results show that pregnant women with a history of bipolar disorder or unipolar depression are “ticking time bombs” for the development of peripartum or postpartum depression, Dr. Viguera, associate director of perinatal and reproductive psychiatry at Massachusetts General Hospital, Boston, told this newspaper.

Women with bipolar disorder who are treated with lithium while breast-feeding transfer a modest amount of lithium to their infant children. “Adverse clinical effects in infants exposed to lithium through breast milk were rare and clinically insignificant” in a study with 10 mother-infant pairs, Dr. Viguera reported in a second poster at the conference, which was sponsored by the University of Pittsburgh.

The prevalence of bipolar depression in pregnant women and its association with peripartum and postpartum depression was assessed in 2,340 consecutive women who sought prenatal care at the Massachusetts General Hospital during 1996–1999.

A mood-disorder questionnaire was completed by 1,814 of the study participants during their second trimester, and 526 women completed a second questionnaire when they were seen at the clinic 6 weeks after delivery.

Bipolar disorder was diagnosed in women with a self-reported history of mania with or without a history of depression. Depression during pregnancy or the postpartum period was diagnosed when women scored at least 16 on the Center for Epidemiologic Studies Depression Scale.

The average age of the entire group of 2,340 women was 32.5 years, and 61% did not have children before the index pregnancy.

The women who finished their pregnancy questionnaires had a 3.2% overall prevalence of probable bipolar disorder at some time during their lives.

In the second trimester, the prevalence of depression was about 52% among women with a history of bipolar disorder, about 34% among those with a history of unipolar depression, and about 8% among women with no history of a mood disorder. The differences between the bipolar and unipolar groups and the women with no mood disorders were statistically significant, Dr. Viguera reported.

At the sixth week post partum, the prevalence of depression was 50% among women with a history of bipolar disorder, about 32% among women with a history of unipolar depression, and about 6% among women with no history of mood disorders. Again, the prevalence of depression was significantly greater among women with a history of bipolar disorder or unipolar depression, compared with those who did not have this history.

During and after pregnancy, depression should be closely monitored, especially in women with a history of depression or bipolar disorder. These women can be treated like any other patients with these disorders, Dr. Viguera said. Patients with bipolar disorder should receive a mood stabilizer, while those with unipolar depression should get an antidepressant.

The passage of lithium from mother to child via breast milk was examined in a separate study that involved 10 mother-infant pairs. Serum and breast milk samples were obtained from both the mothers and infants at 4–12 weeks' post partum, both before a dose of lithium was administered and within 12 hours after a dose. Repeat samples were collected from five subjects.

The average maternal dose of lithium was 850 mg/day, which led to an average serum concentration of 0.76 mEq/L. The average lithium concentration in milk was 0.35 mEq/L, and the average serum level in the infants was 0.16 mEq/L.

The findings suggest a “rule of halves” for lithium: Breast milk contains about half the lithium concentration as maternal serum, and infant serum contains about half of the concentration in breast milk, Dr. Viguera said. (This means that infant serum contains about one-fourth the concentration in maternal serum.)

Nine of the 10 infants in the study showed no adverse effects from lithium exposure. One infant had an elevated level of TSH, but the level normalized within 2 weeks after lithium was stopped. All of the other nine infants had TSH levels that were within the normal range. Renal function was normal for all 10 infants, and there were no other acute effects seen. Follow-up observations and reports also showed no late developmental abnormalities.

In routine practice, infants who are nursed by mothers treated with lithium should be monitored by serum assays of TSH, blood urea nitrogen, and serum creatinine every 6–8 weeks during breast-feeding, Dr. Viguera said.

PITTSBURGH — Women with a history of bipolar disorder have an increased risk of developing depression during and after pregnancy, based on a review of more than 2,000 pregnant women.

A history of unipolar depression also predisposed women to develop depression during the peripartum and postpartum periods, although unipolar depression was not as potent a risk factor as bipolar disorder. The findings suggest “an urgent need” for better screening and detection of bipolar-spectrum disorders in pregnant women, Adele C. Viguera, M.D., said while presenting a poster at the Sixth International Conference on Bipolar Disorders.

The results show that pregnant women with a history of bipolar disorder or unipolar depression are “ticking time bombs” for the development of peripartum or postpartum depression, Dr. Viguera, associate director of perinatal and reproductive psychiatry at Massachusetts General Hospital, Boston, told this newspaper.

Women with bipolar disorder who are treated with lithium while breast-feeding transfer a modest amount of lithium to their infant children. “Adverse clinical effects in infants exposed to lithium through breast milk were rare and clinically insignificant” in a study with 10 mother-infant pairs, Dr. Viguera reported in a second poster at the conference, which was sponsored by the University of Pittsburgh.

The prevalence of bipolar depression in pregnant women and its association with peripartum and postpartum depression was assessed in 2,340 consecutive women who sought prenatal care at the Massachusetts General Hospital during 1996–1999.

A mood-disorder questionnaire was completed by 1,814 of the study participants during their second trimester, and 526 women completed a second questionnaire when they were seen at the clinic 6 weeks after delivery.

Bipolar disorder was diagnosed in women with a self-reported history of mania with or without a history of depression. Depression during pregnancy or the postpartum period was diagnosed when women scored at least 16 on the Center for Epidemiologic Studies Depression Scale.

The average age of the entire group of 2,340 women was 32.5 years, and 61% did not have children before the index pregnancy.

The women who finished their pregnancy questionnaires had a 3.2% overall prevalence of probable bipolar disorder at some time during their lives.

In the second trimester, the prevalence of depression was about 52% among women with a history of bipolar disorder, about 34% among those with a history of unipolar depression, and about 8% among women with no history of a mood disorder. The differences between the bipolar and unipolar groups and the women with no mood disorders were statistically significant, Dr. Viguera reported.

At the sixth week post partum, the prevalence of depression was 50% among women with a history of bipolar disorder, about 32% among women with a history of unipolar depression, and about 6% among women with no history of mood disorders. Again, the prevalence of depression was significantly greater among women with a history of bipolar disorder or unipolar depression, compared with those who did not have this history.

During and after pregnancy, depression should be closely monitored, especially in women with a history of depression or bipolar disorder. These women can be treated like any other patients with these disorders, Dr. Viguera said. Patients with bipolar disorder should receive a mood stabilizer, while those with unipolar depression should get an antidepressant.

The passage of lithium from mother to child via breast milk was examined in a separate study that involved 10 mother-infant pairs. Serum and breast milk samples were obtained from both the mothers and infants at 4–12 weeks' post partum, both before a dose of lithium was administered and within 12 hours after a dose. Repeat samples were collected from five subjects.

The average maternal dose of lithium was 850 mg/day, which led to an average serum concentration of 0.76 mEq/L. The average lithium concentration in milk was 0.35 mEq/L, and the average serum level in the infants was 0.16 mEq/L.

The findings suggest a “rule of halves” for lithium: Breast milk contains about half the lithium concentration as maternal serum, and infant serum contains about half of the concentration in breast milk, Dr. Viguera said. (This means that infant serum contains about one-fourth the concentration in maternal serum.)

Nine of the 10 infants in the study showed no adverse effects from lithium exposure. One infant had an elevated level of TSH, but the level normalized within 2 weeks after lithium was stopped. All of the other nine infants had TSH levels that were within the normal range. Renal function was normal for all 10 infants, and there were no other acute effects seen. Follow-up observations and reports also showed no late developmental abnormalities.

In routine practice, infants who are nursed by mothers treated with lithium should be monitored by serum assays of TSH, blood urea nitrogen, and serum creatinine every 6–8 weeks during breast-feeding, Dr. Viguera said.

PITTSBURGH — Women with a history of bipolar disorder have an increased risk of developing depression during and after pregnancy, based on a review of more than 2,000 pregnant women.

A history of unipolar depression also predisposed women to develop depression during the peripartum and postpartum periods, although unipolar depression was not as potent a risk factor as bipolar disorder. The findings suggest “an urgent need” for better screening and detection of bipolar-spectrum disorders in pregnant women, Adele C. Viguera, M.D., said while presenting a poster at the Sixth International Conference on Bipolar Disorders.

The results show that pregnant women with a history of bipolar disorder or unipolar depression are “ticking time bombs” for the development of peripartum or postpartum depression, Dr. Viguera, associate director of perinatal and reproductive psychiatry at Massachusetts General Hospital, Boston, told this newspaper.

Women with bipolar disorder who are treated with lithium while breast-feeding transfer a modest amount of lithium to their infant children. “Adverse clinical effects in infants exposed to lithium through breast milk were rare and clinically insignificant” in a study with 10 mother-infant pairs, Dr. Viguera reported in a second poster at the conference, which was sponsored by the University of Pittsburgh.

The prevalence of bipolar depression in pregnant women and its association with peripartum and postpartum depression was assessed in 2,340 consecutive women who sought prenatal care at the Massachusetts General Hospital during 1996–1999.

A mood-disorder questionnaire was completed by 1,814 of the study participants during their second trimester, and 526 women completed a second questionnaire when they were seen at the clinic 6 weeks after delivery.

Bipolar disorder was diagnosed in women with a self-reported history of mania with or without a history of depression. Depression during pregnancy or the postpartum period was diagnosed when women scored at least 16 on the Center for Epidemiologic Studies Depression Scale.

The average age of the entire group of 2,340 women was 32.5 years, and 61% did not have children before the index pregnancy.

The women who finished their pregnancy questionnaires had a 3.2% overall prevalence of probable bipolar disorder at some time during their lives.

In the second trimester, the prevalence of depression was about 52% among women with a history of bipolar disorder, about 34% among those with a history of unipolar depression, and about 8% among women with no history of a mood disorder. The differences between the bipolar and unipolar groups and the women with no mood disorders were statistically significant, Dr. Viguera reported.

At the sixth week post partum, the prevalence of depression was 50% among women with a history of bipolar disorder, about 32% among women with a history of unipolar depression, and about 6% among women with no history of mood disorders. Again, the prevalence of depression was significantly greater among women with a history of bipolar disorder or unipolar depression, compared with those who did not have this history.

During and after pregnancy, depression should be closely monitored, especially in women with a history of depression or bipolar disorder. These women can be treated like any other patients with these disorders, Dr. Viguera said. Patients with bipolar disorder should receive a mood stabilizer, while those with unipolar depression should get an antidepressant.

The passage of lithium from mother to child via breast milk was examined in a separate study that involved 10 mother-infant pairs. Serum and breast milk samples were obtained from both the mothers and infants at 4–12 weeks' post partum, both before a dose of lithium was administered and within 12 hours after a dose. Repeat samples were collected from five subjects.

The average maternal dose of lithium was 850 mg/day, which led to an average serum concentration of 0.76 mEq/L. The average lithium concentration in milk was 0.35 mEq/L, and the average serum level in the infants was 0.16 mEq/L.

The findings suggest a “rule of halves” for lithium: Breast milk contains about half the lithium concentration as maternal serum, and infant serum contains about half of the concentration in breast milk, Dr. Viguera said. (This means that infant serum contains about one-fourth the concentration in maternal serum.)

Nine of the 10 infants in the study showed no adverse effects from lithium exposure. One infant had an elevated level of TSH, but the level normalized within 2 weeks after lithium was stopped. All of the other nine infants had TSH levels that were within the normal range. Renal function was normal for all 10 infants, and there were no other acute effects seen. Follow-up observations and reports also showed no late developmental abnormalities.

In routine practice, infants who are nursed by mothers treated with lithium should be monitored by serum assays of TSH, blood urea nitrogen, and serum creatinine every 6–8 weeks during breast-feeding, Dr. Viguera said.

INDIAN WELLS, CALIF. — Women who conceive through in vitro fertilization and have a “vanishing twin” are still at risk of having the remaining twin born at a low birth weight for gestational age, Mohamed Mitwally, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a review of 945 live-birth deliveries of infants conceived through in vitro fertilization (IVF), 40 patients experienced spontaneous reduction of fetuses in a multiple gestation and then gave birth to one infant.

Those infants weighed a mean 2,842 g at a mean 271 days' gestation. That compared with a mean birth weight of 3,206 g in 514 women who gave birth to singletons and had not experienced fetal reduction, either spontaneous or selective, and a mean birth weight of 3,166 g in 15 patients who delivered singleton infants after selective fetal reductions.

The finding was somewhat unexpected; the main purpose of the study was to investigate if selective fetal reduction really improved birth weight and risk of preterm delivery, said Dr. Mitwally of the division of reproductive endocrinology and infertility at Wayne State University, Detroit.

The study showed that selective fetal reduction did result in better birth weight and less risk of preterm birth, without increased pregnancy loss, except perhaps when twins were reduced to singletons. The reason the study observed no benefit from selectively reducing twins may have been that there were only a few cases in which twins were reduced, Dr. Mitwally said.

The rest of the literature on fetal reduction, including a recent metaanalysis, “supports the findings of this study,” said Sae Sohn, M.D., a fertility specialist who practices in Greenbrae, Calif., and who commented on the study at the meeting.

INDIAN WELLS, CALIF. — Women who conceive through in vitro fertilization and have a “vanishing twin” are still at risk of having the remaining twin born at a low birth weight for gestational age, Mohamed Mitwally, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a review of 945 live-birth deliveries of infants conceived through in vitro fertilization (IVF), 40 patients experienced spontaneous reduction of fetuses in a multiple gestation and then gave birth to one infant.

Those infants weighed a mean 2,842 g at a mean 271 days' gestation. That compared with a mean birth weight of 3,206 g in 514 women who gave birth to singletons and had not experienced fetal reduction, either spontaneous or selective, and a mean birth weight of 3,166 g in 15 patients who delivered singleton infants after selective fetal reductions.

The finding was somewhat unexpected; the main purpose of the study was to investigate if selective fetal reduction really improved birth weight and risk of preterm delivery, said Dr. Mitwally of the division of reproductive endocrinology and infertility at Wayne State University, Detroit.

The study showed that selective fetal reduction did result in better birth weight and less risk of preterm birth, without increased pregnancy loss, except perhaps when twins were reduced to singletons. The reason the study observed no benefit from selectively reducing twins may have been that there were only a few cases in which twins were reduced, Dr. Mitwally said.

The rest of the literature on fetal reduction, including a recent metaanalysis, “supports the findings of this study,” said Sae Sohn, M.D., a fertility specialist who practices in Greenbrae, Calif., and who commented on the study at the meeting.

INDIAN WELLS, CALIF. — Women who conceive through in vitro fertilization and have a “vanishing twin” are still at risk of having the remaining twin born at a low birth weight for gestational age, Mohamed Mitwally, M.D., said at the annual meeting of the Pacific Coast Reproductive Society.

In a review of 945 live-birth deliveries of infants conceived through in vitro fertilization (IVF), 40 patients experienced spontaneous reduction of fetuses in a multiple gestation and then gave birth to one infant.

Those infants weighed a mean 2,842 g at a mean 271 days' gestation. That compared with a mean birth weight of 3,206 g in 514 women who gave birth to singletons and had not experienced fetal reduction, either spontaneous or selective, and a mean birth weight of 3,166 g in 15 patients who delivered singleton infants after selective fetal reductions.

The finding was somewhat unexpected; the main purpose of the study was to investigate if selective fetal reduction really improved birth weight and risk of preterm delivery, said Dr. Mitwally of the division of reproductive endocrinology and infertility at Wayne State University, Detroit.

The study showed that selective fetal reduction did result in better birth weight and less risk of preterm birth, without increased pregnancy loss, except perhaps when twins were reduced to singletons. The reason the study observed no benefit from selectively reducing twins may have been that there were only a few cases in which twins were reduced, Dr. Mitwally said.

The rest of the literature on fetal reduction, including a recent metaanalysis, “supports the findings of this study,” said Sae Sohn, M.D., a fertility specialist who practices in Greenbrae, Calif., and who commented on the study at the meeting.

WASHINGTON — The hypofibrinolytic plasminogen activator inhibitor was an independent predictor of miscarriage in a cohort of 441 women with polycystic ovary syndrome who had previous pregnancies, Charles J. Glueck, M.D., reported at the Clinical Research 2005 meeting.

PAI-Fx is highly correlated with fasting serum insulin resistance, and Glucophage (metformin) (2.25–2.5 g/day) sharply lowers both insulin and PAI-Fx levels, significantly improving the odds of live births for women with PCOS, said Dr. Glueck, director of the Jewish Hospital Cholesterol Center in Cincinnati.

The 441 women were part of a larger cohort of 968 women with PCOS. Of these 441 women, 206 had only live births, 118 had at least one live birth and one miscarriage, and 75 had only miscarriages.

In addition, of 926 women with PCOS for whom genetic data were available, 727 (79%) had the 4G5G or 4G4G genotype vs. 87 of 126 (69%) healthy female controls.

This PAI-1 genetic mutation was significantly associated with miscarriage, in part through its gene product, PAI-Fx, and appears to be more common in women with PCOS than in healthy women, Dr. Glueck said at the meeting, sponsored by the American Federation for Medical Research.

The overall frequency of the 4G allele was 53% among PCOS women, compared with 46% of the controls.

Dr. Glueck and his associates also evaluated 30 women who took metformin during pregnancy and had live births and 23 women who took it and had first-trimester miscarriages. The PAI-Fx level fell by approximately 44% among the women who had live births, but it rose approximately 19% among the women who had early miscarriages. Among the women who had live births, PAI-Fx fell consistently from pre-pregnancy treatment through the first trimester, from 16.8 to 6.7 units/mL.

Left untreated, approximately 50% of pregnant women with PCOS experience first-trimester miscarriages; treatment with metformin, combined with dietary changes, reduces this figure to approximately 15% (the national average in the United States).

PCOS-associated obesity, hyperinsulinemia, and hypertriglyceridemia can contribute to the high PAI-Fx levels that promote miscarriage in women with PCOS, Dr. Glueck noted.

Physicians can optimize pregnancy outcomes by prescribing metformin and diet, which has been shown to reduce obesity, hyperinsulinemia, hypertriglyceridemia, and PAI-Fx levels.

WASHINGTON — The hypofibrinolytic plasminogen activator inhibitor was an independent predictor of miscarriage in a cohort of 441 women with polycystic ovary syndrome who had previous pregnancies, Charles J. Glueck, M.D., reported at the Clinical Research 2005 meeting.

PAI-Fx is highly correlated with fasting serum insulin resistance, and Glucophage (metformin) (2.25–2.5 g/day) sharply lowers both insulin and PAI-Fx levels, significantly improving the odds of live births for women with PCOS, said Dr. Glueck, director of the Jewish Hospital Cholesterol Center in Cincinnati.

The 441 women were part of a larger cohort of 968 women with PCOS. Of these 441 women, 206 had only live births, 118 had at least one live birth and one miscarriage, and 75 had only miscarriages.

In addition, of 926 women with PCOS for whom genetic data were available, 727 (79%) had the 4G5G or 4G4G genotype vs. 87 of 126 (69%) healthy female controls.

This PAI-1 genetic mutation was significantly associated with miscarriage, in part through its gene product, PAI-Fx, and appears to be more common in women with PCOS than in healthy women, Dr. Glueck said at the meeting, sponsored by the American Federation for Medical Research.

The overall frequency of the 4G allele was 53% among PCOS women, compared with 46% of the controls.

Dr. Glueck and his associates also evaluated 30 women who took metformin during pregnancy and had live births and 23 women who took it and had first-trimester miscarriages. The PAI-Fx level fell by approximately 44% among the women who had live births, but it rose approximately 19% among the women who had early miscarriages. Among the women who had live births, PAI-Fx fell consistently from pre-pregnancy treatment through the first trimester, from 16.8 to 6.7 units/mL.

Left untreated, approximately 50% of pregnant women with PCOS experience first-trimester miscarriages; treatment with metformin, combined with dietary changes, reduces this figure to approximately 15% (the national average in the United States).

PCOS-associated obesity, hyperinsulinemia, and hypertriglyceridemia can contribute to the high PAI-Fx levels that promote miscarriage in women with PCOS, Dr. Glueck noted.

Physicians can optimize pregnancy outcomes by prescribing metformin and diet, which has been shown to reduce obesity, hyperinsulinemia, hypertriglyceridemia, and PAI-Fx levels.

WASHINGTON — The hypofibrinolytic plasminogen activator inhibitor was an independent predictor of miscarriage in a cohort of 441 women with polycystic ovary syndrome who had previous pregnancies, Charles J. Glueck, M.D., reported at the Clinical Research 2005 meeting.

PAI-Fx is highly correlated with fasting serum insulin resistance, and Glucophage (metformin) (2.25–2.5 g/day) sharply lowers both insulin and PAI-Fx levels, significantly improving the odds of live births for women with PCOS, said Dr. Glueck, director of the Jewish Hospital Cholesterol Center in Cincinnati.

The 441 women were part of a larger cohort of 968 women with PCOS. Of these 441 women, 206 had only live births, 118 had at least one live birth and one miscarriage, and 75 had only miscarriages.

In addition, of 926 women with PCOS for whom genetic data were available, 727 (79%) had the 4G5G or 4G4G genotype vs. 87 of 126 (69%) healthy female controls.

This PAI-1 genetic mutation was significantly associated with miscarriage, in part through its gene product, PAI-Fx, and appears to be more common in women with PCOS than in healthy women, Dr. Glueck said at the meeting, sponsored by the American Federation for Medical Research.

The overall frequency of the 4G allele was 53% among PCOS women, compared with 46% of the controls.

Dr. Glueck and his associates also evaluated 30 women who took metformin during pregnancy and had live births and 23 women who took it and had first-trimester miscarriages. The PAI-Fx level fell by approximately 44% among the women who had live births, but it rose approximately 19% among the women who had early miscarriages. Among the women who had live births, PAI-Fx fell consistently from pre-pregnancy treatment through the first trimester, from 16.8 to 6.7 units/mL.

Left untreated, approximately 50% of pregnant women with PCOS experience first-trimester miscarriages; treatment with metformin, combined with dietary changes, reduces this figure to approximately 15% (the national average in the United States).

PCOS-associated obesity, hyperinsulinemia, and hypertriglyceridemia can contribute to the high PAI-Fx levels that promote miscarriage in women with PCOS, Dr. Glueck noted.

Physicians can optimize pregnancy outcomes by prescribing metformin and diet, which has been shown to reduce obesity, hyperinsulinemia, hypertriglyceridemia, and PAI-Fx levels.

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

Not only are planned home births in North America safe for mother and baby, they are associated with a lower rate of medical intervention than are low-risk hospital births in the United States, results of the largest prospective analysis of such births suggest.

“Our study of certified professional midwives suggests they achieve good outcomes among low-risk women without routine use of expensive hospital intervention,” said study authors Kenneth C. Johnson, M.D., senior epidemiologist for the Public Health Agency of Canada, and Betty-Anne Daviss, a certified professional midwife from Canada.

“A high degree of safety and maternal satisfaction were reported, and more than 87% of mothers and neonates did not require transfer to hospital,” the study authors said.

The cohort included information from 5,418 women whose births during the year 2000 were attended by 409 of the 534 registered professional midwives in the United States and Canada (BMJ 2005;330:1416–9).

The researchers compared outcomes in that group with outcomes among more than 3.3 million term, singleton vertex hospital births the same year in the United States.

There were no maternal deaths in the home-birth group. Three infants died from fatal birth defects. There were five intrapartum fetal deaths and six neonatal deaths.

There were no deaths among the 80 planned home-delivered breeches, nor among the 13 sets of twins.

When the researchers excluded planned breech deliveries and twins (not considered low-risk), the rate of intrapartum and neonatal death was 1.7/1,000 planned low-risk home births.

About 12% of the mothers were transferred to a hospital either intrapartum or post partum.

Five of every six who went to a hospital did so before delivery: 51% went for failure to progress, pain relief, and/or exhaustion, according to the investigators.

After delivery, 1.3% of mothers and 0.7% of newborns were transferred. The most common reasons mentioned were maternal hemorrhage (0.6% of total births), retained placenta (0.5% of total births), or respiratory problems in the infant (0.5% of total births).

The midwives reportedly considered transfers urgent in 3.4% of cases. Transfers were four times more common among primiparous women (25%) than multiparous women (6%).

Compared with low-risk hospital births, planned home births had a significantly lower rate of induction of labor (9.6% vs. 21%), stimulation of labor (9.2% vs. 18.9%), episiotomy (2.1% vs. 33%), forceps (1% vs. 2.2%), and vacuum extractions (0.6% vs. 5.2%).

The rate of cesarean section for women transferred to a hospital also was lower than the rate among low-risk hospital births (3.7% vs. 18%).

Not only are planned home births in North America safe for mother and baby, they are associated with a lower rate of medical intervention than are low-risk hospital births in the United States, results of the largest prospective analysis of such births suggest.

“Our study of certified professional midwives suggests they achieve good outcomes among low-risk women without routine use of expensive hospital intervention,” said study authors Kenneth C. Johnson, M.D., senior epidemiologist for the Public Health Agency of Canada, and Betty-Anne Daviss, a certified professional midwife from Canada.

“A high degree of safety and maternal satisfaction were reported, and more than 87% of mothers and neonates did not require transfer to hospital,” the study authors said.

The cohort included information from 5,418 women whose births during the year 2000 were attended by 409 of the 534 registered professional midwives in the United States and Canada (BMJ 2005;330:1416–9).

The researchers compared outcomes in that group with outcomes among more than 3.3 million term, singleton vertex hospital births the same year in the United States.

There were no maternal deaths in the home-birth group. Three infants died from fatal birth defects. There were five intrapartum fetal deaths and six neonatal deaths.

There were no deaths among the 80 planned home-delivered breeches, nor among the 13 sets of twins.

When the researchers excluded planned breech deliveries and twins (not considered low-risk), the rate of intrapartum and neonatal death was 1.7/1,000 planned low-risk home births.

About 12% of the mothers were transferred to a hospital either intrapartum or post partum.

Five of every six who went to a hospital did so before delivery: 51% went for failure to progress, pain relief, and/or exhaustion, according to the investigators.

After delivery, 1.3% of mothers and 0.7% of newborns were transferred. The most common reasons mentioned were maternal hemorrhage (0.6% of total births), retained placenta (0.5% of total births), or respiratory problems in the infant (0.5% of total births).

The midwives reportedly considered transfers urgent in 3.4% of cases. Transfers were four times more common among primiparous women (25%) than multiparous women (6%).

Compared with low-risk hospital births, planned home births had a significantly lower rate of induction of labor (9.6% vs. 21%), stimulation of labor (9.2% vs. 18.9%), episiotomy (2.1% vs. 33%), forceps (1% vs. 2.2%), and vacuum extractions (0.6% vs. 5.2%).

The rate of cesarean section for women transferred to a hospital also was lower than the rate among low-risk hospital births (3.7% vs. 18%).

Not only are planned home births in North America safe for mother and baby, they are associated with a lower rate of medical intervention than are low-risk hospital births in the United States, results of the largest prospective analysis of such births suggest.

“Our study of certified professional midwives suggests they achieve good outcomes among low-risk women without routine use of expensive hospital intervention,” said study authors Kenneth C. Johnson, M.D., senior epidemiologist for the Public Health Agency of Canada, and Betty-Anne Daviss, a certified professional midwife from Canada.

“A high degree of safety and maternal satisfaction were reported, and more than 87% of mothers and neonates did not require transfer to hospital,” the study authors said.

The cohort included information from 5,418 women whose births during the year 2000 were attended by 409 of the 534 registered professional midwives in the United States and Canada (BMJ 2005;330:1416–9).

The researchers compared outcomes in that group with outcomes among more than 3.3 million term, singleton vertex hospital births the same year in the United States.

There were no maternal deaths in the home-birth group. Three infants died from fatal birth defects. There were five intrapartum fetal deaths and six neonatal deaths.

There were no deaths among the 80 planned home-delivered breeches, nor among the 13 sets of twins.

When the researchers excluded planned breech deliveries and twins (not considered low-risk), the rate of intrapartum and neonatal death was 1.7/1,000 planned low-risk home births.

About 12% of the mothers were transferred to a hospital either intrapartum or post partum.

Five of every six who went to a hospital did so before delivery: 51% went for failure to progress, pain relief, and/or exhaustion, according to the investigators.

After delivery, 1.3% of mothers and 0.7% of newborns were transferred. The most common reasons mentioned were maternal hemorrhage (0.6% of total births), retained placenta (0.5% of total births), or respiratory problems in the infant (0.5% of total births).

The midwives reportedly considered transfers urgent in 3.4% of cases. Transfers were four times more common among primiparous women (25%) than multiparous women (6%).

Compared with low-risk hospital births, planned home births had a significantly lower rate of induction of labor (9.6% vs. 21%), stimulation of labor (9.2% vs. 18.9%), episiotomy (2.1% vs. 33%), forceps (1% vs. 2.2%), and vacuum extractions (0.6% vs. 5.2%).

The rate of cesarean section for women transferred to a hospital also was lower than the rate among low-risk hospital births (3.7% vs. 18%).

SAN FRANCISCO — Three randomized, controlled trials now show evidence of beneficial effects from a limited number of repeat courses of prenatal corticosteroids for fetuses at risk of preterm delivery, according to Julian T. Parer, M.D.

Those aren't necessarily the official conclusions of the studies, however, he acknowledged at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Two of the three studies found no overall benefit from repeat prenatal steroids but reported significantly less respiratory distress and morbidity in babies born at younger gestational ages if they got more than one course of betamethasone prenatally.

The third study showed a benefit from repeat prenatal steroids, but the investigators will not draw conclusions about the results until after a 2-year follow-up period, said Dr. Parer, who is professor of ob.gyn. at the university.

Dr. Parer said he has no financial relationships with companies that make corticosteroids.

A consensus statement issued in 2000 by the National Institutes of Health says that repeat courses of corticosteroids should not be used routinely due to insufficient data from randomized clinical trials.

Data from these three more recent studies, however, support the administration of more than one course of prenatal corticosteroids for women who are at at high risk of delivering before 28 weeks, Dr. Parer said.

“It is possible to justify repeating at least a single course in those patients, particularly if given at a 2-week interval,” he said.

Dr. Parer relayed results of the third, and most recent, study that he heard presented at a conference in Australia earlier this year. That study included 982 pregnant women at risk for preterm delivery who had received one course of prenatal corticosteroids.

The women were randomized to weekly corticosteroids or placebo; treatment continued until 32 weeks' gestation only if the risk for preterm delivery continued.

The study included singletons, twins, and triplets for a total of 1,100 fetuses that were a mean of 28 weeks' gestation at enrollment. The risk factors for preterm birth were similar between groups.

Results showed significantly lower rates of respiratory distress syndrome (RDS) and severe RDS in the weekly corticosteroid group. With weekly corticosteroids, 33% developed RDS, and 12% had severe RDS, compared with 41% and 20%, respectively, in the placebo group.

The need for oxygen or mechanical ventilation fell less dramatically in the weekly corticosteroids group, compared with placebo, but it was not clear whether these differences were significant.

There were no significant differences between groups in the need for intensive care, duration of intensive care, rates of chronic lung disease or severe intraventricular hemorrhage, or maternal outcomes.

Although birth weights were somewhat lower in the steroid group, the weight differences between groups resolved by the time of hospital discharge, he said. Average neonatal length and head circumference did not differ between groups.

No harmful effects of repeat corticosteroids were noted. Of those women who received repeat courses, 24% received at least four courses. The investigators declined to present a conclusion until they've completed 2 years of neurodevelopmental follow-up, he said at the meeting.

A separate study, which was reported at the Society of Maternal and Fetal Medicine meeting in 2004, randomized 495 women after an initial course of prenatal corticosteroids to weekly courses or placebo.

The study was stopped prematurely at 23% of its expected enrollment due to concerns about birth weights, and no signs of a substantial reduction in overall morbidity in the steroid group.

The investigators concluded that there was no benefit to repeated courses of corticosteroids, but Dr. Parer highlighted the “much more impressive” results in infants delivered at less than 32 weeks. These babies had significantly less bronchopulmonary dysplasia and less need for mechanical ventilation or continuous positive airway pressure if they had received repeat corticosteroids, he noted. Birth weights were lower only in infants who had been exposed to more than four courses of corticosteroids.

A third study that randomized 502 women to a single course or weekly courses of corticosteroids also was stopped early and reported no benefit from weekly prenatal steroids (JAMA 2001;286:1581–7).

That study also reported a significantly lower incidence of RDS in babies born before 28 weeks whose mothers received repeated courses of corticosteroids, Dr. Parer noted.

Critics contend that both of these studies were too small and too short to detect significant differences in their primary end point of composite morbidity.

SAN FRANCISCO — Three randomized, controlled trials now show evidence of beneficial effects from a limited number of repeat courses of prenatal corticosteroids for fetuses at risk of preterm delivery, according to Julian T. Parer, M.D.

Those aren't necessarily the official conclusions of the studies, however, he acknowledged at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Two of the three studies found no overall benefit from repeat prenatal steroids but reported significantly less respiratory distress and morbidity in babies born at younger gestational ages if they got more than one course of betamethasone prenatally.

The third study showed a benefit from repeat prenatal steroids, but the investigators will not draw conclusions about the results until after a 2-year follow-up period, said Dr. Parer, who is professor of ob.gyn. at the university.

Dr. Parer said he has no financial relationships with companies that make corticosteroids.

A consensus statement issued in 2000 by the National Institutes of Health says that repeat courses of corticosteroids should not be used routinely due to insufficient data from randomized clinical trials.

Data from these three more recent studies, however, support the administration of more than one course of prenatal corticosteroids for women who are at at high risk of delivering before 28 weeks, Dr. Parer said.

“It is possible to justify repeating at least a single course in those patients, particularly if given at a 2-week interval,” he said.

Dr. Parer relayed results of the third, and most recent, study that he heard presented at a conference in Australia earlier this year. That study included 982 pregnant women at risk for preterm delivery who had received one course of prenatal corticosteroids.

The women were randomized to weekly corticosteroids or placebo; treatment continued until 32 weeks' gestation only if the risk for preterm delivery continued.

The study included singletons, twins, and triplets for a total of 1,100 fetuses that were a mean of 28 weeks' gestation at enrollment. The risk factors for preterm birth were similar between groups.

Results showed significantly lower rates of respiratory distress syndrome (RDS) and severe RDS in the weekly corticosteroid group. With weekly corticosteroids, 33% developed RDS, and 12% had severe RDS, compared with 41% and 20%, respectively, in the placebo group.

The need for oxygen or mechanical ventilation fell less dramatically in the weekly corticosteroids group, compared with placebo, but it was not clear whether these differences were significant.

There were no significant differences between groups in the need for intensive care, duration of intensive care, rates of chronic lung disease or severe intraventricular hemorrhage, or maternal outcomes.

Although birth weights were somewhat lower in the steroid group, the weight differences between groups resolved by the time of hospital discharge, he said. Average neonatal length and head circumference did not differ between groups.

No harmful effects of repeat corticosteroids were noted. Of those women who received repeat courses, 24% received at least four courses. The investigators declined to present a conclusion until they've completed 2 years of neurodevelopmental follow-up, he said at the meeting.

A separate study, which was reported at the Society of Maternal and Fetal Medicine meeting in 2004, randomized 495 women after an initial course of prenatal corticosteroids to weekly courses or placebo.

The study was stopped prematurely at 23% of its expected enrollment due to concerns about birth weights, and no signs of a substantial reduction in overall morbidity in the steroid group.

The investigators concluded that there was no benefit to repeated courses of corticosteroids, but Dr. Parer highlighted the “much more impressive” results in infants delivered at less than 32 weeks. These babies had significantly less bronchopulmonary dysplasia and less need for mechanical ventilation or continuous positive airway pressure if they had received repeat corticosteroids, he noted. Birth weights were lower only in infants who had been exposed to more than four courses of corticosteroids.

A third study that randomized 502 women to a single course or weekly courses of corticosteroids also was stopped early and reported no benefit from weekly prenatal steroids (JAMA 2001;286:1581–7).

That study also reported a significantly lower incidence of RDS in babies born before 28 weeks whose mothers received repeated courses of corticosteroids, Dr. Parer noted.

Critics contend that both of these studies were too small and too short to detect significant differences in their primary end point of composite morbidity.

SAN FRANCISCO — Three randomized, controlled trials now show evidence of beneficial effects from a limited number of repeat courses of prenatal corticosteroids for fetuses at risk of preterm delivery, according to Julian T. Parer, M.D.

Those aren't necessarily the official conclusions of the studies, however, he acknowledged at a meeting on antepartum and intrapartum management sponsored by the University of California, San Francisco.

Two of the three studies found no overall benefit from repeat prenatal steroids but reported significantly less respiratory distress and morbidity in babies born at younger gestational ages if they got more than one course of betamethasone prenatally.

The third study showed a benefit from repeat prenatal steroids, but the investigators will not draw conclusions about the results until after a 2-year follow-up period, said Dr. Parer, who is professor of ob.gyn. at the university.

Dr. Parer said he has no financial relationships with companies that make corticosteroids.

A consensus statement issued in 2000 by the National Institutes of Health says that repeat courses of corticosteroids should not be used routinely due to insufficient data from randomized clinical trials.

Data from these three more recent studies, however, support the administration of more than one course of prenatal corticosteroids for women who are at at high risk of delivering before 28 weeks, Dr. Parer said.

“It is possible to justify repeating at least a single course in those patients, particularly if given at a 2-week interval,” he said.

Dr. Parer relayed results of the third, and most recent, study that he heard presented at a conference in Australia earlier this year. That study included 982 pregnant women at risk for preterm delivery who had received one course of prenatal corticosteroids.

The women were randomized to weekly corticosteroids or placebo; treatment continued until 32 weeks' gestation only if the risk for preterm delivery continued.

The study included singletons, twins, and triplets for a total of 1,100 fetuses that were a mean of 28 weeks' gestation at enrollment. The risk factors for preterm birth were similar between groups.

Results showed significantly lower rates of respiratory distress syndrome (RDS) and severe RDS in the weekly corticosteroid group. With weekly corticosteroids, 33% developed RDS, and 12% had severe RDS, compared with 41% and 20%, respectively, in the placebo group.

The need for oxygen or mechanical ventilation fell less dramatically in the weekly corticosteroids group, compared with placebo, but it was not clear whether these differences were significant.

There were no significant differences between groups in the need for intensive care, duration of intensive care, rates of chronic lung disease or severe intraventricular hemorrhage, or maternal outcomes.

Although birth weights were somewhat lower in the steroid group, the weight differences between groups resolved by the time of hospital discharge, he said. Average neonatal length and head circumference did not differ between groups.

No harmful effects of repeat corticosteroids were noted. Of those women who received repeat courses, 24% received at least four courses. The investigators declined to present a conclusion until they've completed 2 years of neurodevelopmental follow-up, he said at the meeting.

A separate study, which was reported at the Society of Maternal and Fetal Medicine meeting in 2004, randomized 495 women after an initial course of prenatal corticosteroids to weekly courses or placebo.

The study was stopped prematurely at 23% of its expected enrollment due to concerns about birth weights, and no signs of a substantial reduction in overall morbidity in the steroid group.

The investigators concluded that there was no benefit to repeated courses of corticosteroids, but Dr. Parer highlighted the “much more impressive” results in infants delivered at less than 32 weeks. These babies had significantly less bronchopulmonary dysplasia and less need for mechanical ventilation or continuous positive airway pressure if they had received repeat corticosteroids, he noted. Birth weights were lower only in infants who had been exposed to more than four courses of corticosteroids.

A third study that randomized 502 women to a single course or weekly courses of corticosteroids also was stopped early and reported no benefit from weekly prenatal steroids (JAMA 2001;286:1581–7).

That study also reported a significantly lower incidence of RDS in babies born before 28 weeks whose mothers received repeated courses of corticosteroids, Dr. Parer noted.

Critics contend that both of these studies were too small and too short to detect significant differences in their primary end point of composite morbidity.

WASHINGTON — The term “prenatal care” should be rethought to include much more of a woman's life cycle, Dawn Misra, Ph.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

“We have to go beyond the [typical] prenatal period” of a few months before pregnancy, said Dr. Misra of the University of Michigan, Ann Arbor. When it comes to chronic illnesses that may affect pregnancy, for example, “we have to plan strategies to address these matters across the life course; if we want to fix them, we can't wait until pregnancy to [address] them.”

Dr. Misra gave hypertension as an example. “There really is no good treatment for hypertension once you're pregnant,” she said. “You can do some things to try to moderate its effects and lessen its impact, but you can't fix it. So [instead] we could prevent women from having hypertension and entering pregnancy with hypertension.” This involves addressing such chronic health problems in the preconception period as well as between pregnancies.

She gave several reasons why providers haven't taken this approach. “Public health and medical professionals are wedded to the notion that prenatal care is fundamental,” she said. “There have been a lot of successes with prenatal care, but I would like to take a step back and think about how prenatal care is not the only answer.”

The health care financing system has encouraged this model of prenatal care by the way it reimburses for care, she continued. As a result, “very few women get no prenatal care, yet we haven't achieved much improvement in terms of infant outcomes.”

Changing this system of care would also mean increasing involvement by providers outside the specialty of ob.gyn., such as pediatricians, Dr. Misra said. “Pediatricians are taking care of future mothers. They could spend time from that perspective thinking about chronic illnesses, keeping [these patients] well, and thinking about what future concerns might be.”

Some of these changes might be fostered by improving medical school training. In addition, people from outside the medical profession such as coaches and personal trainers could be involved in these types of issues, she said.

Pediatricians could also help provide better record transfer, Dr. Misra noted. “We have young girls moving from the pediatrician to the ob.gyn. or the nurse-midwife. A lot is lost when young girls move to those providers, and we need to find better ways to relay their health history.” This is a challenge that needs to be met, especially in the wake of a study showing that 25% of pregnant women have a chronic health condition, Dr. Misra added.

On a broader level, public health officials need to rethink their method of separating chronic disease care from maternal and child health programming, Dr. Misra said. “This may require thinking about how future [pregnancy] outcomes are dependent on preventing these kinds of illnesses.”

One audience member commented that although she liked the speaker's message, “The women's health movement has been struggling for a long time to get away from thinking about women's health merely in terms of maternity and reproduction,” she said. “I think we need to reword language like 'preconceptional.' When we're sitting in this room, we know what we're talking about, but many people out there still think of women as reproductive machines.”

WASHINGTON — The term “prenatal care” should be rethought to include much more of a woman's life cycle, Dawn Misra, Ph.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

“We have to go beyond the [typical] prenatal period” of a few months before pregnancy, said Dr. Misra of the University of Michigan, Ann Arbor. When it comes to chronic illnesses that may affect pregnancy, for example, “we have to plan strategies to address these matters across the life course; if we want to fix them, we can't wait until pregnancy to [address] them.”

Dr. Misra gave hypertension as an example. “There really is no good treatment for hypertension once you're pregnant,” she said. “You can do some things to try to moderate its effects and lessen its impact, but you can't fix it. So [instead] we could prevent women from having hypertension and entering pregnancy with hypertension.” This involves addressing such chronic health problems in the preconception period as well as between pregnancies.

She gave several reasons why providers haven't taken this approach. “Public health and medical professionals are wedded to the notion that prenatal care is fundamental,” she said. “There have been a lot of successes with prenatal care, but I would like to take a step back and think about how prenatal care is not the only answer.”

The health care financing system has encouraged this model of prenatal care by the way it reimburses for care, she continued. As a result, “very few women get no prenatal care, yet we haven't achieved much improvement in terms of infant outcomes.”

Changing this system of care would also mean increasing involvement by providers outside the specialty of ob.gyn., such as pediatricians, Dr. Misra said. “Pediatricians are taking care of future mothers. They could spend time from that perspective thinking about chronic illnesses, keeping [these patients] well, and thinking about what future concerns might be.”

Some of these changes might be fostered by improving medical school training. In addition, people from outside the medical profession such as coaches and personal trainers could be involved in these types of issues, she said.

Pediatricians could also help provide better record transfer, Dr. Misra noted. “We have young girls moving from the pediatrician to the ob.gyn. or the nurse-midwife. A lot is lost when young girls move to those providers, and we need to find better ways to relay their health history.” This is a challenge that needs to be met, especially in the wake of a study showing that 25% of pregnant women have a chronic health condition, Dr. Misra added.

On a broader level, public health officials need to rethink their method of separating chronic disease care from maternal and child health programming, Dr. Misra said. “This may require thinking about how future [pregnancy] outcomes are dependent on preventing these kinds of illnesses.”

One audience member commented that although she liked the speaker's message, “The women's health movement has been struggling for a long time to get away from thinking about women's health merely in terms of maternity and reproduction,” she said. “I think we need to reword language like 'preconceptional.' When we're sitting in this room, we know what we're talking about, but many people out there still think of women as reproductive machines.”

WASHINGTON — The term “prenatal care” should be rethought to include much more of a woman's life cycle, Dawn Misra, Ph.D., said at a meeting sponsored by the Jacobs Institute of Women's Health.

“We have to go beyond the [typical] prenatal period” of a few months before pregnancy, said Dr. Misra of the University of Michigan, Ann Arbor. When it comes to chronic illnesses that may affect pregnancy, for example, “we have to plan strategies to address these matters across the life course; if we want to fix them, we can't wait until pregnancy to [address] them.”

Dr. Misra gave hypertension as an example. “There really is no good treatment for hypertension once you're pregnant,” she said. “You can do some things to try to moderate its effects and lessen its impact, but you can't fix it. So [instead] we could prevent women from having hypertension and entering pregnancy with hypertension.” This involves addressing such chronic health problems in the preconception period as well as between pregnancies.

She gave several reasons why providers haven't taken this approach. “Public health and medical professionals are wedded to the notion that prenatal care is fundamental,” she said. “There have been a lot of successes with prenatal care, but I would like to take a step back and think about how prenatal care is not the only answer.”

The health care financing system has encouraged this model of prenatal care by the way it reimburses for care, she continued. As a result, “very few women get no prenatal care, yet we haven't achieved much improvement in terms of infant outcomes.”

Changing this system of care would also mean increasing involvement by providers outside the specialty of ob.gyn., such as pediatricians, Dr. Misra said. “Pediatricians are taking care of future mothers. They could spend time from that perspective thinking about chronic illnesses, keeping [these patients] well, and thinking about what future concerns might be.”

Some of these changes might be fostered by improving medical school training. In addition, people from outside the medical profession such as coaches and personal trainers could be involved in these types of issues, she said.

Pediatricians could also help provide better record transfer, Dr. Misra noted. “We have young girls moving from the pediatrician to the ob.gyn. or the nurse-midwife. A lot is lost when young girls move to those providers, and we need to find better ways to relay their health history.” This is a challenge that needs to be met, especially in the wake of a study showing that 25% of pregnant women have a chronic health condition, Dr. Misra added.

On a broader level, public health officials need to rethink their method of separating chronic disease care from maternal and child health programming, Dr. Misra said. “This may require thinking about how future [pregnancy] outcomes are dependent on preventing these kinds of illnesses.”

One audience member commented that although she liked the speaker's message, “The women's health movement has been struggling for a long time to get away from thinking about women's health merely in terms of maternity and reproduction,” she said. “I think we need to reword language like 'preconceptional.' When we're sitting in this room, we know what we're talking about, but many people out there still think of women as reproductive machines.”