Obstetrics

LOS ANGELES — Pregnancies complicated by type 1 or type 2 diabetes mellitus can have good outcomes with new strategies for glucose control, Steven G. Gabbe, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

At less than 5%, the perinatal mortality of children whose mothers have diabetes is comparable with the rate in children of women without diabetes, according to Dr. Gabbe, dean of Vanderbilt University School of Medicine in Nashville, Tenn.

Nonetheless, preventing congenital malformations and overly large babies remains a challenge. “We have to develop individualized programs of insulin for our patients,” he said, offering strategies for patient education and self-management.

Glucose control goals change with pregnancy, said Dr. Gabbe. Physicians should counsel diabetic women before conception to bring their glycosylated hemoglobin (HbA_1c) levels to no more than 1% above the normal range. Targeted plasma glucose levels should be 80–110 mg/dL before meals and less than 155 mg/dL after meals.

During pregnancy, target plasma glucose levels should be 60–90 mg/dL before breakfast; 60–105 mg/dL before lunch, supper, or a bedtime snack; less than 120 mg/dL 2 hours after meals; and above 60 mg/dL between 2 a.m. and 6 a.m. The mean capillary glucose level should be maintained below 100 mg/dL.

To help patients use HbA_1c levels to approximate mean glucose levels, he suggested teaching them “the rule of eights”: An HbA_1c of 8% equals 180 mg/dL, and each 1% change equals ±30 mg/dL.

Pregnant patients need to understand that there is a “lag time” between an injection of insulin and a meal (N. Engl. J. Med. 2005;352:174–83), he continued. Physicians should also warn them against “insulin stacking” in which a correction dose of insulin is given before the prior dose of prandial insulin has reached its peak effect (JAMA 2003;289:2254–64).

Insulin stacking leads to hypoglycemia, he warned. “You have to remember and remind patients about overcorrecting with too much insulin too soon before the insulin they have taken has played out.”

Dr. Gabbe said insulin levels increase in pregnancy, but changes can vary for each woman. To help with the adjustment, he advised teaching the patient that:

▸ One unit of short-acting insulin will lower her blood glucose level by approximately 30 mg/dL.

▸ Ten grams of carbohydrate will elevate her blood glucose by about 30 mg/dL.

▸ One unit of short-acting insulin will cover approximately 10 g of carbohydrates.

He recommended the short-acting insulins lispro and aspart for pregnant patients; these can be injected or used with an insulin pump. He said there are concerns but not much experience with the long-acting insulin glargine in pregnancy.

Insulin pumps offer many advantages. Along with eliminating the need for multiple injections, they provide a continuous basal rate, which reduces the risk of mean glucose excursions and hypoglycemia. They also allow a more flexible lifestyle.

But the pumps also have disadvantages. They require excellent compliance, intensive glucose monitoring, and can produce hypo- or hyperglycemia if mechanical problems occur. Pump failure increases the risk of ketoacidosis, and there is the potential for infection at the insertion site. It also “costs $140 more per month to use a pump vs. multiple injections,” he said.

Whatever method is used, Dr. Gabbe said diet is critical as well. Patients should have three meals and three snacks each day.

Another concern is hypoglycemia unawareness, which could be exacerbated by intensive insulin therapy during pregnancy. Determine if the patient has hypoglycemia unawareness; review and adjust her diet, insulin, and exercise; and teach family members to treat hypoglycemia, Dr. Gabbe said.

“Does all of this really make a difference?” he asked rhetorically. “Yes, it does—in having a baby that grows normally and behaves normally in the nursery.”

LOS ANGELES — Pregnancies complicated by type 1 or type 2 diabetes mellitus can have good outcomes with new strategies for glucose control, Steven G. Gabbe, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

At less than 5%, the perinatal mortality of children whose mothers have diabetes is comparable with the rate in children of women without diabetes, according to Dr. Gabbe, dean of Vanderbilt University School of Medicine in Nashville, Tenn.

Nonetheless, preventing congenital malformations and overly large babies remains a challenge. “We have to develop individualized programs of insulin for our patients,” he said, offering strategies for patient education and self-management.

Glucose control goals change with pregnancy, said Dr. Gabbe. Physicians should counsel diabetic women before conception to bring their glycosylated hemoglobin (HbA_1c) levels to no more than 1% above the normal range. Targeted plasma glucose levels should be 80–110 mg/dL before meals and less than 155 mg/dL after meals.

During pregnancy, target plasma glucose levels should be 60–90 mg/dL before breakfast; 60–105 mg/dL before lunch, supper, or a bedtime snack; less than 120 mg/dL 2 hours after meals; and above 60 mg/dL between 2 a.m. and 6 a.m. The mean capillary glucose level should be maintained below 100 mg/dL.

To help patients use HbA_1c levels to approximate mean glucose levels, he suggested teaching them “the rule of eights”: An HbA_1c of 8% equals 180 mg/dL, and each 1% change equals ±30 mg/dL.

Pregnant patients need to understand that there is a “lag time” between an injection of insulin and a meal (N. Engl. J. Med. 2005;352:174–83), he continued. Physicians should also warn them against “insulin stacking” in which a correction dose of insulin is given before the prior dose of prandial insulin has reached its peak effect (JAMA 2003;289:2254–64).

Insulin stacking leads to hypoglycemia, he warned. “You have to remember and remind patients about overcorrecting with too much insulin too soon before the insulin they have taken has played out.”

Dr. Gabbe said insulin levels increase in pregnancy, but changes can vary for each woman. To help with the adjustment, he advised teaching the patient that:

▸ One unit of short-acting insulin will lower her blood glucose level by approximately 30 mg/dL.

▸ Ten grams of carbohydrate will elevate her blood glucose by about 30 mg/dL.

▸ One unit of short-acting insulin will cover approximately 10 g of carbohydrates.

He recommended the short-acting insulins lispro and aspart for pregnant patients; these can be injected or used with an insulin pump. He said there are concerns but not much experience with the long-acting insulin glargine in pregnancy.

Insulin pumps offer many advantages. Along with eliminating the need for multiple injections, they provide a continuous basal rate, which reduces the risk of mean glucose excursions and hypoglycemia. They also allow a more flexible lifestyle.

But the pumps also have disadvantages. They require excellent compliance, intensive glucose monitoring, and can produce hypo- or hyperglycemia if mechanical problems occur. Pump failure increases the risk of ketoacidosis, and there is the potential for infection at the insertion site. It also “costs $140 more per month to use a pump vs. multiple injections,” he said.

Whatever method is used, Dr. Gabbe said diet is critical as well. Patients should have three meals and three snacks each day.

Another concern is hypoglycemia unawareness, which could be exacerbated by intensive insulin therapy during pregnancy. Determine if the patient has hypoglycemia unawareness; review and adjust her diet, insulin, and exercise; and teach family members to treat hypoglycemia, Dr. Gabbe said.

“Does all of this really make a difference?” he asked rhetorically. “Yes, it does—in having a baby that grows normally and behaves normally in the nursery.”

LOS ANGELES — Pregnancies complicated by type 1 or type 2 diabetes mellitus can have good outcomes with new strategies for glucose control, Steven G. Gabbe, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

At less than 5%, the perinatal mortality of children whose mothers have diabetes is comparable with the rate in children of women without diabetes, according to Dr. Gabbe, dean of Vanderbilt University School of Medicine in Nashville, Tenn.

Nonetheless, preventing congenital malformations and overly large babies remains a challenge. “We have to develop individualized programs of insulin for our patients,” he said, offering strategies for patient education and self-management.

Glucose control goals change with pregnancy, said Dr. Gabbe. Physicians should counsel diabetic women before conception to bring their glycosylated hemoglobin (HbA_1c) levels to no more than 1% above the normal range. Targeted plasma glucose levels should be 80–110 mg/dL before meals and less than 155 mg/dL after meals.

During pregnancy, target plasma glucose levels should be 60–90 mg/dL before breakfast; 60–105 mg/dL before lunch, supper, or a bedtime snack; less than 120 mg/dL 2 hours after meals; and above 60 mg/dL between 2 a.m. and 6 a.m. The mean capillary glucose level should be maintained below 100 mg/dL.

To help patients use HbA_1c levels to approximate mean glucose levels, he suggested teaching them “the rule of eights”: An HbA_1c of 8% equals 180 mg/dL, and each 1% change equals ±30 mg/dL.

Pregnant patients need to understand that there is a “lag time” between an injection of insulin and a meal (N. Engl. J. Med. 2005;352:174–83), he continued. Physicians should also warn them against “insulin stacking” in which a correction dose of insulin is given before the prior dose of prandial insulin has reached its peak effect (JAMA 2003;289:2254–64).

Insulin stacking leads to hypoglycemia, he warned. “You have to remember and remind patients about overcorrecting with too much insulin too soon before the insulin they have taken has played out.”

Dr. Gabbe said insulin levels increase in pregnancy, but changes can vary for each woman. To help with the adjustment, he advised teaching the patient that:

▸ One unit of short-acting insulin will lower her blood glucose level by approximately 30 mg/dL.

▸ Ten grams of carbohydrate will elevate her blood glucose by about 30 mg/dL.

▸ One unit of short-acting insulin will cover approximately 10 g of carbohydrates.

He recommended the short-acting insulins lispro and aspart for pregnant patients; these can be injected or used with an insulin pump. He said there are concerns but not much experience with the long-acting insulin glargine in pregnancy.

Insulin pumps offer many advantages. Along with eliminating the need for multiple injections, they provide a continuous basal rate, which reduces the risk of mean glucose excursions and hypoglycemia. They also allow a more flexible lifestyle.

But the pumps also have disadvantages. They require excellent compliance, intensive glucose monitoring, and can produce hypo- or hyperglycemia if mechanical problems occur. Pump failure increases the risk of ketoacidosis, and there is the potential for infection at the insertion site. It also “costs $140 more per month to use a pump vs. multiple injections,” he said.

Whatever method is used, Dr. Gabbe said diet is critical as well. Patients should have three meals and three snacks each day.

Another concern is hypoglycemia unawareness, which could be exacerbated by intensive insulin therapy during pregnancy. Determine if the patient has hypoglycemia unawareness; review and adjust her diet, insulin, and exercise; and teach family members to treat hypoglycemia, Dr. Gabbe said.

“Does all of this really make a difference?” he asked rhetorically. “Yes, it does—in having a baby that grows normally and behaves normally in the nursery.”

SAN FRANCISCO — Newborns with a 5-minute Apgar score of 7 or less have a high risk of developing respiratory distress syndrome, according to Linda R. Chambliss, M.D., associate director of maternal fetal medicine at the Maricopa Integrated Health System in Phoenix, Ariz.

The recent findings should help alert physicians to high-risk infants who should be monitored more intensively or given therapies to reduce the incidence or severity of respiratory distress syndrome (RDS), she reported at the annual meeting of the American College of Obstetricians and Gynecologists.

“What is surprising is that many people, including myself, have felt that as long as the 5-minute Apgar hits 7, the baby will be fine, but this is not necessarily the case,” she told this newspaper. “Clinicians who deliver an infant with such a score should counsel the families and the nursery that RDS is very likely. These infants have to be watched very closely.”

Her study analyzed more than 26,000 births from a statewide registry and identified 657 admissions to neonatal intensive care with a diagnosis of RDS.

Of these admissions, 540 infants had an Apgar score of 7 or less, compared with 3,803 infants who had the same Apgar score but no RDS.

After controlling for education level, marital status, race, parity, smoking, prenatal care, diabetes, hypertension, preeclampsia, induction/augmentation of labor, intrapartum fever, prolonged rupture of membranes, abruption, nonreassuring fetal heart rate, delivery by cesarean, infant's gender and gestational age, the 5-minute Apgar score of 7 or less was an independent risk factor for RDS, with an adjusted odds ratio of 25, Dr. Chambliss said.

When the infant's birth weight was substituted for gestational age, the risk remained similar (odds ratio 22).

Low birth weight and prematurity are well-recognized risk factors for the development of RDS, even when Apgar scores are normal, Dr. Chambliss said.

But her findings suggest that regardless of birth weight or prematurity, or any of the other variables that the researcher measured, the 5-minute Apgar score of 7 or less remains a high risk factor for RDS.

“People may not have realized how strongly this predicts future problems with RDS. While the Apgar score may not be the best way to predict some complications, such as neurological injury, we feel it has a great deal of utility to predict the risk RDS even when controlled for a number of other variables,” she said.

SAN FRANCISCO — Newborns with a 5-minute Apgar score of 7 or less have a high risk of developing respiratory distress syndrome, according to Linda R. Chambliss, M.D., associate director of maternal fetal medicine at the Maricopa Integrated Health System in Phoenix, Ariz.

The recent findings should help alert physicians to high-risk infants who should be monitored more intensively or given therapies to reduce the incidence or severity of respiratory distress syndrome (RDS), she reported at the annual meeting of the American College of Obstetricians and Gynecologists.

“What is surprising is that many people, including myself, have felt that as long as the 5-minute Apgar hits 7, the baby will be fine, but this is not necessarily the case,” she told this newspaper. “Clinicians who deliver an infant with such a score should counsel the families and the nursery that RDS is very likely. These infants have to be watched very closely.”

Her study analyzed more than 26,000 births from a statewide registry and identified 657 admissions to neonatal intensive care with a diagnosis of RDS.

Of these admissions, 540 infants had an Apgar score of 7 or less, compared with 3,803 infants who had the same Apgar score but no RDS.

After controlling for education level, marital status, race, parity, smoking, prenatal care, diabetes, hypertension, preeclampsia, induction/augmentation of labor, intrapartum fever, prolonged rupture of membranes, abruption, nonreassuring fetal heart rate, delivery by cesarean, infant's gender and gestational age, the 5-minute Apgar score of 7 or less was an independent risk factor for RDS, with an adjusted odds ratio of 25, Dr. Chambliss said.

When the infant's birth weight was substituted for gestational age, the risk remained similar (odds ratio 22).

Low birth weight and prematurity are well-recognized risk factors for the development of RDS, even when Apgar scores are normal, Dr. Chambliss said.

But her findings suggest that regardless of birth weight or prematurity, or any of the other variables that the researcher measured, the 5-minute Apgar score of 7 or less remains a high risk factor for RDS.

“People may not have realized how strongly this predicts future problems with RDS. While the Apgar score may not be the best way to predict some complications, such as neurological injury, we feel it has a great deal of utility to predict the risk RDS even when controlled for a number of other variables,” she said.

SAN FRANCISCO — Newborns with a 5-minute Apgar score of 7 or less have a high risk of developing respiratory distress syndrome, according to Linda R. Chambliss, M.D., associate director of maternal fetal medicine at the Maricopa Integrated Health System in Phoenix, Ariz.

The recent findings should help alert physicians to high-risk infants who should be monitored more intensively or given therapies to reduce the incidence or severity of respiratory distress syndrome (RDS), she reported at the annual meeting of the American College of Obstetricians and Gynecologists.

“What is surprising is that many people, including myself, have felt that as long as the 5-minute Apgar hits 7, the baby will be fine, but this is not necessarily the case,” she told this newspaper. “Clinicians who deliver an infant with such a score should counsel the families and the nursery that RDS is very likely. These infants have to be watched very closely.”

Her study analyzed more than 26,000 births from a statewide registry and identified 657 admissions to neonatal intensive care with a diagnosis of RDS.

Of these admissions, 540 infants had an Apgar score of 7 or less, compared with 3,803 infants who had the same Apgar score but no RDS.

After controlling for education level, marital status, race, parity, smoking, prenatal care, diabetes, hypertension, preeclampsia, induction/augmentation of labor, intrapartum fever, prolonged rupture of membranes, abruption, nonreassuring fetal heart rate, delivery by cesarean, infant's gender and gestational age, the 5-minute Apgar score of 7 or less was an independent risk factor for RDS, with an adjusted odds ratio of 25, Dr. Chambliss said.

When the infant's birth weight was substituted for gestational age, the risk remained similar (odds ratio 22).

Low birth weight and prematurity are well-recognized risk factors for the development of RDS, even when Apgar scores are normal, Dr. Chambliss said.

But her findings suggest that regardless of birth weight or prematurity, or any of the other variables that the researcher measured, the 5-minute Apgar score of 7 or less remains a high risk factor for RDS.

“People may not have realized how strongly this predicts future problems with RDS. While the Apgar score may not be the best way to predict some complications, such as neurological injury, we feel it has a great deal of utility to predict the risk RDS even when controlled for a number of other variables,” she said.

WASHINGTON — Isolated intrapartum fever and chorioamnionitis are independent risk factors for neonatal encephalopathy, Heidi Blume, M.D., said at the annual meeting of the Pediatric Academic Societies.

“It remains unclear if fever is the cause of injury, exacerbates injury, or is a sign of some other noxious process,” said Dr. Blume of the University of Washington, Seattle.

Neonatal encephalopathy, which affects up to 6 in 1,000 term infants annually, is a clinically defined syndrome of disturbed neurologic function during the infant's earliest days of life. Symptoms include difficulty initiating and maintaining respiration; depressed tone and reflexes; subnormal level of consciousness; and, sometimes, seizures.

Dr. Blume undertook a population-based, case-control study of infants born in Washington from 1994 to 2002. She used data from the Washington State Birth Registry; this information is linked to the state's Comprehensive Hospital Abstract Reporting System. The system includes discharge diagnoses, diagnosis and procedure codes, and dates of hospitalization.

The 1,114 cases were singleton term infants whose ICD-9 discharge diagnoses included birth asphyxia, newborn convulsions, central nervous system dysfunction, or other cerebral irritability.

These cases were matched with 6,046 control infants. Exposure to isolated fever was defined as maternal intrapartum fever of 38° C or greater, or ICD-9 diagnosis of maternal intrapartum pyrexia without chorioamnionitis.

Exposure to chorioamnionitis was defined by ICD-9 diagnosis of chorioamnionitis or infection of the amnion.

Mothers of encephalopathy cases were more likely to be of low socioeconomic status, to be nulliparous, and to have had preeclampsia.

Case infants were more likely to have received late prenatal care and to be of low birth weight, and slightly more likely to be male, according to the researcher.

Both isolated maternal fever and chorioamnionitis were more common in encephalopathy cases than in controls. Exposure to maternal fever reportedly occurred in 2.5% of the controls and 8% of cases, for an adjusted odds ratio of 3.2. Chorioamnionitis was present in 1.2% of controls and 6% of cases, for an adjusted odds ratio of 5.7.

“These relationships persisted in subgroups of cases who were diagnosed with seizures and birth asphyxia,” Dr. Blume said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediactric Association, and the American Academy of Pediatrics.

Infants exposed to intrapartum maternal fever had a threefold increase in the risk of being diagnosed with seizure and a 3.5-fold increased risk of being diagnosed with birth asphyxia.

Infants exposed to chorioamnionitis had a fivefold increased risk of being diagnosed with seizure and almost a sevenfold increased risk of being diagnosed with birth asphyxia.

Dr. Blume noted some limitations in the study. She was not able to review charts, so it was impossible to determine what symptoms led to the diagnosis and discharge codes. However, she felt certain that few of the infants had meningitis, since the cases were limited to infants who were diagnosed during their newborn hospitalization, or who were admitted within 2 days of birth.

WASHINGTON — Isolated intrapartum fever and chorioamnionitis are independent risk factors for neonatal encephalopathy, Heidi Blume, M.D., said at the annual meeting of the Pediatric Academic Societies.

“It remains unclear if fever is the cause of injury, exacerbates injury, or is a sign of some other noxious process,” said Dr. Blume of the University of Washington, Seattle.

Neonatal encephalopathy, which affects up to 6 in 1,000 term infants annually, is a clinically defined syndrome of disturbed neurologic function during the infant's earliest days of life. Symptoms include difficulty initiating and maintaining respiration; depressed tone and reflexes; subnormal level of consciousness; and, sometimes, seizures.

Dr. Blume undertook a population-based, case-control study of infants born in Washington from 1994 to 2002. She used data from the Washington State Birth Registry; this information is linked to the state's Comprehensive Hospital Abstract Reporting System. The system includes discharge diagnoses, diagnosis and procedure codes, and dates of hospitalization.

The 1,114 cases were singleton term infants whose ICD-9 discharge diagnoses included birth asphyxia, newborn convulsions, central nervous system dysfunction, or other cerebral irritability.

These cases were matched with 6,046 control infants. Exposure to isolated fever was defined as maternal intrapartum fever of 38° C or greater, or ICD-9 diagnosis of maternal intrapartum pyrexia without chorioamnionitis.

Exposure to chorioamnionitis was defined by ICD-9 diagnosis of chorioamnionitis or infection of the amnion.

Mothers of encephalopathy cases were more likely to be of low socioeconomic status, to be nulliparous, and to have had preeclampsia.

Case infants were more likely to have received late prenatal care and to be of low birth weight, and slightly more likely to be male, according to the researcher.

Both isolated maternal fever and chorioamnionitis were more common in encephalopathy cases than in controls. Exposure to maternal fever reportedly occurred in 2.5% of the controls and 8% of cases, for an adjusted odds ratio of 3.2. Chorioamnionitis was present in 1.2% of controls and 6% of cases, for an adjusted odds ratio of 5.7.

“These relationships persisted in subgroups of cases who were diagnosed with seizures and birth asphyxia,” Dr. Blume said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediactric Association, and the American Academy of Pediatrics.

Infants exposed to intrapartum maternal fever had a threefold increase in the risk of being diagnosed with seizure and a 3.5-fold increased risk of being diagnosed with birth asphyxia.

Infants exposed to chorioamnionitis had a fivefold increased risk of being diagnosed with seizure and almost a sevenfold increased risk of being diagnosed with birth asphyxia.

Dr. Blume noted some limitations in the study. She was not able to review charts, so it was impossible to determine what symptoms led to the diagnosis and discharge codes. However, she felt certain that few of the infants had meningitis, since the cases were limited to infants who were diagnosed during their newborn hospitalization, or who were admitted within 2 days of birth.

WASHINGTON — Isolated intrapartum fever and chorioamnionitis are independent risk factors for neonatal encephalopathy, Heidi Blume, M.D., said at the annual meeting of the Pediatric Academic Societies.

“It remains unclear if fever is the cause of injury, exacerbates injury, or is a sign of some other noxious process,” said Dr. Blume of the University of Washington, Seattle.

Neonatal encephalopathy, which affects up to 6 in 1,000 term infants annually, is a clinically defined syndrome of disturbed neurologic function during the infant's earliest days of life. Symptoms include difficulty initiating and maintaining respiration; depressed tone and reflexes; subnormal level of consciousness; and, sometimes, seizures.

Dr. Blume undertook a population-based, case-control study of infants born in Washington from 1994 to 2002. She used data from the Washington State Birth Registry; this information is linked to the state's Comprehensive Hospital Abstract Reporting System. The system includes discharge diagnoses, diagnosis and procedure codes, and dates of hospitalization.

The 1,114 cases were singleton term infants whose ICD-9 discharge diagnoses included birth asphyxia, newborn convulsions, central nervous system dysfunction, or other cerebral irritability.

These cases were matched with 6,046 control infants. Exposure to isolated fever was defined as maternal intrapartum fever of 38° C or greater, or ICD-9 diagnosis of maternal intrapartum pyrexia without chorioamnionitis.

Exposure to chorioamnionitis was defined by ICD-9 diagnosis of chorioamnionitis or infection of the amnion.

Mothers of encephalopathy cases were more likely to be of low socioeconomic status, to be nulliparous, and to have had preeclampsia.

Case infants were more likely to have received late prenatal care and to be of low birth weight, and slightly more likely to be male, according to the researcher.

Both isolated maternal fever and chorioamnionitis were more common in encephalopathy cases than in controls. Exposure to maternal fever reportedly occurred in 2.5% of the controls and 8% of cases, for an adjusted odds ratio of 3.2. Chorioamnionitis was present in 1.2% of controls and 6% of cases, for an adjusted odds ratio of 5.7.

“These relationships persisted in subgroups of cases who were diagnosed with seizures and birth asphyxia,” Dr. Blume said at the meeting, sponsored by the American Pediatric Society, the Society for Pediatric Research, the Ambulatory Pediactric Association, and the American Academy of Pediatrics.

Infants exposed to intrapartum maternal fever had a threefold increase in the risk of being diagnosed with seizure and a 3.5-fold increased risk of being diagnosed with birth asphyxia.

Infants exposed to chorioamnionitis had a fivefold increased risk of being diagnosed with seizure and almost a sevenfold increased risk of being diagnosed with birth asphyxia.

Dr. Blume noted some limitations in the study. She was not able to review charts, so it was impossible to determine what symptoms led to the diagnosis and discharge codes. However, she felt certain that few of the infants had meningitis, since the cases were limited to infants who were diagnosed during their newborn hospitalization, or who were admitted within 2 days of birth.

SAN FRANCISCO — Anticonvulsants are known to cause birth defects when taken during pregnancy, but physicians should weigh the benefits and risks before discontinuing anticonvulsant therapy, Jennifer R. Niebyl, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The risks are not all that large, said Dr. Niebyl of the University of Iowa, Iowa City. Only 5%–10% of women taking anticonvulsants during pregnancy develop fetal hydantoin syndrome.

Women taking a single anticonvulsant medication have about 2.5 times the risk of having this embryopathy as do epileptic women not taking anticonvulsants. Those taking at least two anticonvulsants have a significantly higher risk: 3.7 times as high as epileptics not taking anticonvulsants. This suggests it is the drug, not the epilepsy itself, that causes the syndrome.

Children with fetal hydantoin syndrome typically show multiple symptoms, including disorders of growth and of mental development, dysmorphic craniofacial features, and hypoplasia of the nails and distal phalanges.

Dr. Niebyl said it's becoming clear that it's desirable to wean women planning a pregnancy from their anticonvulsant medications if possible. This is more likely to be successful in women whose epilepsy is idiopathic, rather than caused by a head injury.

Other factors that bode well for getting women off anticonvulsants include a lack of neurologic abnormalities, a normal EEG, onset of epilepsy in childhood, seizures controlled by a single drug, and being seizure free for at least 2 years.

About 75% of these women will remain seizure free after discontinuing medication. But since 25% will have a seizure—and it's impossible to predict who will fall into that group—these women should be instructed not to drive during the time they're off the drug.

“If you don't see the patient until they're already pregnant, the benefits of continuing therapy usually outweigh the risks,” Dr. Niebyl said.

Anticonvulsants can interfere with folate metabolism, so Dr. Niebyl recommended being especially vigilant about folic acid supplementation. And some of these drugs—particularly phenytoin, primidone (Mysoline), and phenobarbital—inhibit the transfer of vitamin K across the placenta. This results in a decrease in fetal clotting factors and an increase in the risk of fetal hemorrhage. For this reason, many physicians will put patients on vitamin K supplementation (20 mg/day) for the final month or two of pregnancy, although there's no definitive evidence that this has a beneficial effect.

Some of the newer anticonvulsant medications, such as lamotrigine (Lamictal), may confer a smaller risk of birth defects than the older drugs, Dr. Niebyl said, but once again definitive evidence is lacking.

Dr. Niebyl said she had no financial conflicts of interest relevant to her presentation.

SAN FRANCISCO — Anticonvulsants are known to cause birth defects when taken during pregnancy, but physicians should weigh the benefits and risks before discontinuing anticonvulsant therapy, Jennifer R. Niebyl, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The risks are not all that large, said Dr. Niebyl of the University of Iowa, Iowa City. Only 5%–10% of women taking anticonvulsants during pregnancy develop fetal hydantoin syndrome.

Women taking a single anticonvulsant medication have about 2.5 times the risk of having this embryopathy as do epileptic women not taking anticonvulsants. Those taking at least two anticonvulsants have a significantly higher risk: 3.7 times as high as epileptics not taking anticonvulsants. This suggests it is the drug, not the epilepsy itself, that causes the syndrome.

Children with fetal hydantoin syndrome typically show multiple symptoms, including disorders of growth and of mental development, dysmorphic craniofacial features, and hypoplasia of the nails and distal phalanges.

Dr. Niebyl said it's becoming clear that it's desirable to wean women planning a pregnancy from their anticonvulsant medications if possible. This is more likely to be successful in women whose epilepsy is idiopathic, rather than caused by a head injury.

Other factors that bode well for getting women off anticonvulsants include a lack of neurologic abnormalities, a normal EEG, onset of epilepsy in childhood, seizures controlled by a single drug, and being seizure free for at least 2 years.

About 75% of these women will remain seizure free after discontinuing medication. But since 25% will have a seizure—and it's impossible to predict who will fall into that group—these women should be instructed not to drive during the time they're off the drug.

“If you don't see the patient until they're already pregnant, the benefits of continuing therapy usually outweigh the risks,” Dr. Niebyl said.

Anticonvulsants can interfere with folate metabolism, so Dr. Niebyl recommended being especially vigilant about folic acid supplementation. And some of these drugs—particularly phenytoin, primidone (Mysoline), and phenobarbital—inhibit the transfer of vitamin K across the placenta. This results in a decrease in fetal clotting factors and an increase in the risk of fetal hemorrhage. For this reason, many physicians will put patients on vitamin K supplementation (20 mg/day) for the final month or two of pregnancy, although there's no definitive evidence that this has a beneficial effect.

Some of the newer anticonvulsant medications, such as lamotrigine (Lamictal), may confer a smaller risk of birth defects than the older drugs, Dr. Niebyl said, but once again definitive evidence is lacking.

Dr. Niebyl said she had no financial conflicts of interest relevant to her presentation.

SAN FRANCISCO — Anticonvulsants are known to cause birth defects when taken during pregnancy, but physicians should weigh the benefits and risks before discontinuing anticonvulsant therapy, Jennifer R. Niebyl, M.D., said at the annual meeting of the American College of Obstetricians and Gynecologists.

The risks are not all that large, said Dr. Niebyl of the University of Iowa, Iowa City. Only 5%–10% of women taking anticonvulsants during pregnancy develop fetal hydantoin syndrome.

Women taking a single anticonvulsant medication have about 2.5 times the risk of having this embryopathy as do epileptic women not taking anticonvulsants. Those taking at least two anticonvulsants have a significantly higher risk: 3.7 times as high as epileptics not taking anticonvulsants. This suggests it is the drug, not the epilepsy itself, that causes the syndrome.

Children with fetal hydantoin syndrome typically show multiple symptoms, including disorders of growth and of mental development, dysmorphic craniofacial features, and hypoplasia of the nails and distal phalanges.

Dr. Niebyl said it's becoming clear that it's desirable to wean women planning a pregnancy from their anticonvulsant medications if possible. This is more likely to be successful in women whose epilepsy is idiopathic, rather than caused by a head injury.

Other factors that bode well for getting women off anticonvulsants include a lack of neurologic abnormalities, a normal EEG, onset of epilepsy in childhood, seizures controlled by a single drug, and being seizure free for at least 2 years.

About 75% of these women will remain seizure free after discontinuing medication. But since 25% will have a seizure—and it's impossible to predict who will fall into that group—these women should be instructed not to drive during the time they're off the drug.

“If you don't see the patient until they're already pregnant, the benefits of continuing therapy usually outweigh the risks,” Dr. Niebyl said.

Anticonvulsants can interfere with folate metabolism, so Dr. Niebyl recommended being especially vigilant about folic acid supplementation. And some of these drugs—particularly phenytoin, primidone (Mysoline), and phenobarbital—inhibit the transfer of vitamin K across the placenta. This results in a decrease in fetal clotting factors and an increase in the risk of fetal hemorrhage. For this reason, many physicians will put patients on vitamin K supplementation (20 mg/day) for the final month or two of pregnancy, although there's no definitive evidence that this has a beneficial effect.

Some of the newer anticonvulsant medications, such as lamotrigine (Lamictal), may confer a smaller risk of birth defects than the older drugs, Dr. Niebyl said, but once again definitive evidence is lacking.

Dr. Niebyl said she had no financial conflicts of interest relevant to her presentation.

PALM DESERT, CALIF. — The degree to which women expected postoperative pain was highly correlated with actual postcesarean section pain scores, James C. Eisenach, M.D., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

He and his associates prospectively studied 31 healthy women scheduled for elective C-section. They conducted psychological and pain studies from 1 to 10 days before surgery and then monitored pain scores and analgesia use after surgery.

Preoperative testing included ratings of unpleasantness and pain during a 5-second application of heat stimuli to the forearm and lower back; administration of a state anxiety and trait anxiety questionnaire; and questions about how much pain the women expected to experience postoperatively and whether they expected to require pain medication.

State anxiety reflects one's self-assessment tension associated with a specific experience, while trait anxiety reflects one's assessment of how much he or she is generally prone to anxiety.

“What we see is what everyone sees. That is, there is a tremendous variability in pain scores at rest and with movement 24 hours after C-section,” said Dr. Eisenach, professor of anesthesiology and vice chair of research at Wake Forest University, Winston-Salem, N.C.

Pain scores indeed varied widely even though all patients received spinal anesthesia, nurse-administered intravenous opioids in the recovery room, and patient-controlled intravenous analgesia once they left the recovery room.

The subjects rated overall postoperative pain from 0.5 to 9.5 on a 10-point visual analog scale. Average pain at rest scores ranged from 0 to 7 and pain with movement from 0.2 to 9.2; morphine use in the first 10 postoperative hours ranged from 0 to 81 mg. Positive associations varied depending on the type of pain assessed.

Regression analysis identified three variables associated with postoperative pain at rest: trait anxiety, expected postoperative pain, and the sensory level at the time the incision was made.

Movement pain was associated with results of suprathreshold pain testing on the forearm (but not the lower back), state anxiety, expected pain, and the duration of surgery.

Analgesic drug use was associated with pain threshold in the forearm test, trait anxiety, expected pain, and the duration of surgery. Only expected pain was associated with all postoperative pain measures.

Dr. Eisenach theorized that duration of surgery was related to the degree of adhesions that were present from previous C-sections, since all of the procedures were performed by experienced obstetricians from a private obstetric practice in Winston-Salem.

A number of intriguing findings emerged, beyond associations with specific measures of pain.

As part of the work-up before the surgery, women were asked to listen to tones of different decibels, and these test results were compared with their scores on a visual analog pain scale during the application of a heated stimulus on the forearm and lower back. There was a high degree of correlation, Dr. Eisenach said.

He also found that women at term do not have the same type of responses to pain stimuli as men or nonpregnant women. Term women have an initially intense response to increasing temperatures, but then a marked decline in the degree of response even as temperatures rise—a phenomenon known as offset analgesia.

In the study, pain thresholds of women at term did not vary widely, but the majority could not tolerate this at all, he said. “There is clearly something very different about the ability to recruit endogenous analgesic systems” at term, he said.

The investigators were unable to find correlations between subjects' pain thresholds at different anatomic sites (the lower back versus the forearm) and postoperative pain.

PALM DESERT, CALIF. — The degree to which women expected postoperative pain was highly correlated with actual postcesarean section pain scores, James C. Eisenach, M.D., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

He and his associates prospectively studied 31 healthy women scheduled for elective C-section. They conducted psychological and pain studies from 1 to 10 days before surgery and then monitored pain scores and analgesia use after surgery.

Preoperative testing included ratings of unpleasantness and pain during a 5-second application of heat stimuli to the forearm and lower back; administration of a state anxiety and trait anxiety questionnaire; and questions about how much pain the women expected to experience postoperatively and whether they expected to require pain medication.

State anxiety reflects one's self-assessment tension associated with a specific experience, while trait anxiety reflects one's assessment of how much he or she is generally prone to anxiety.

“What we see is what everyone sees. That is, there is a tremendous variability in pain scores at rest and with movement 24 hours after C-section,” said Dr. Eisenach, professor of anesthesiology and vice chair of research at Wake Forest University, Winston-Salem, N.C.

Pain scores indeed varied widely even though all patients received spinal anesthesia, nurse-administered intravenous opioids in the recovery room, and patient-controlled intravenous analgesia once they left the recovery room.

The subjects rated overall postoperative pain from 0.5 to 9.5 on a 10-point visual analog scale. Average pain at rest scores ranged from 0 to 7 and pain with movement from 0.2 to 9.2; morphine use in the first 10 postoperative hours ranged from 0 to 81 mg. Positive associations varied depending on the type of pain assessed.

Regression analysis identified three variables associated with postoperative pain at rest: trait anxiety, expected postoperative pain, and the sensory level at the time the incision was made.

Movement pain was associated with results of suprathreshold pain testing on the forearm (but not the lower back), state anxiety, expected pain, and the duration of surgery.

Analgesic drug use was associated with pain threshold in the forearm test, trait anxiety, expected pain, and the duration of surgery. Only expected pain was associated with all postoperative pain measures.

Dr. Eisenach theorized that duration of surgery was related to the degree of adhesions that were present from previous C-sections, since all of the procedures were performed by experienced obstetricians from a private obstetric practice in Winston-Salem.

A number of intriguing findings emerged, beyond associations with specific measures of pain.

As part of the work-up before the surgery, women were asked to listen to tones of different decibels, and these test results were compared with their scores on a visual analog pain scale during the application of a heated stimulus on the forearm and lower back. There was a high degree of correlation, Dr. Eisenach said.

He also found that women at term do not have the same type of responses to pain stimuli as men or nonpregnant women. Term women have an initially intense response to increasing temperatures, but then a marked decline in the degree of response even as temperatures rise—a phenomenon known as offset analgesia.

In the study, pain thresholds of women at term did not vary widely, but the majority could not tolerate this at all, he said. “There is clearly something very different about the ability to recruit endogenous analgesic systems” at term, he said.

The investigators were unable to find correlations between subjects' pain thresholds at different anatomic sites (the lower back versus the forearm) and postoperative pain.

PALM DESERT, CALIF. — The degree to which women expected postoperative pain was highly correlated with actual postcesarean section pain scores, James C. Eisenach, M.D., reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

He and his associates prospectively studied 31 healthy women scheduled for elective C-section. They conducted psychological and pain studies from 1 to 10 days before surgery and then monitored pain scores and analgesia use after surgery.

Preoperative testing included ratings of unpleasantness and pain during a 5-second application of heat stimuli to the forearm and lower back; administration of a state anxiety and trait anxiety questionnaire; and questions about how much pain the women expected to experience postoperatively and whether they expected to require pain medication.

State anxiety reflects one's self-assessment tension associated with a specific experience, while trait anxiety reflects one's assessment of how much he or she is generally prone to anxiety.

“What we see is what everyone sees. That is, there is a tremendous variability in pain scores at rest and with movement 24 hours after C-section,” said Dr. Eisenach, professor of anesthesiology and vice chair of research at Wake Forest University, Winston-Salem, N.C.

Pain scores indeed varied widely even though all patients received spinal anesthesia, nurse-administered intravenous opioids in the recovery room, and patient-controlled intravenous analgesia once they left the recovery room.

The subjects rated overall postoperative pain from 0.5 to 9.5 on a 10-point visual analog scale. Average pain at rest scores ranged from 0 to 7 and pain with movement from 0.2 to 9.2; morphine use in the first 10 postoperative hours ranged from 0 to 81 mg. Positive associations varied depending on the type of pain assessed.

Regression analysis identified three variables associated with postoperative pain at rest: trait anxiety, expected postoperative pain, and the sensory level at the time the incision was made.

Movement pain was associated with results of suprathreshold pain testing on the forearm (but not the lower back), state anxiety, expected pain, and the duration of surgery.

Analgesic drug use was associated with pain threshold in the forearm test, trait anxiety, expected pain, and the duration of surgery. Only expected pain was associated with all postoperative pain measures.

Dr. Eisenach theorized that duration of surgery was related to the degree of adhesions that were present from previous C-sections, since all of the procedures were performed by experienced obstetricians from a private obstetric practice in Winston-Salem.

A number of intriguing findings emerged, beyond associations with specific measures of pain.

As part of the work-up before the surgery, women were asked to listen to tones of different decibels, and these test results were compared with their scores on a visual analog pain scale during the application of a heated stimulus on the forearm and lower back. There was a high degree of correlation, Dr. Eisenach said.

He also found that women at term do not have the same type of responses to pain stimuli as men or nonpregnant women. Term women have an initially intense response to increasing temperatures, but then a marked decline in the degree of response even as temperatures rise—a phenomenon known as offset analgesia.

In the study, pain thresholds of women at term did not vary widely, but the majority could not tolerate this at all, he said. “There is clearly something very different about the ability to recruit endogenous analgesic systems” at term, he said.

The investigators were unable to find correlations between subjects' pain thresholds at different anatomic sites (the lower back versus the forearm) and postoperative pain.

PALM DESERT, CALIF. — More than one in seven healthy parturients report residual pain 6 months after undergoing an elective cesarean section, a Belgian research group reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Three characteristics distinguished patients suffering chronic postoperative pain from those who reported no pain at 6 months: higher pain scores 24 hours after surgery; a greater likelihood of reporting wound hyperalgesia at 24 and 48 hours; and a previous history of a genitourinary infection.

Patricia M. Lavand'homme, M.D., said her 100-subject study is one of the first to address the issue, despite the rising rate of elective C-sections and the importance of identifying risk factors that may point to preventive strategies.

“I think we really, really need to have more studies,” she remarked.

One previous study included all C-sections, including emergency procedures, and found that 12% of patients still suffered residual pain and discomfort after an average of 10 months, and among these patients, 6% had daily pain. General anesthesia appeared to induce more residual pain and discomfort than did spinal anesthesia (Acta Anaesthesiol. Scand. 2004;48:111–6).

She and her associates at the Université Catholique de Louvain in Brussels prospectively followed 100 healthy women who had undergone elective C-section.

At 6 months, 15 reported chronic pain around the scar. In four women, the pain was intense enough to require analgesics, including codeine and NSAIDs, at least three times a week. The pain was associated with a visceral component in two of the subjects with chronic pain.

No significant differences were found in women with or without chronic pain in terms of previous C-sections or other abdominal surgeries, age, number of pregnancies, endometriosis, or obstetric procedures.

Eight of 15 patients who had chronic pain reported previous genitourinary infections, compared with just 14 of 85 patients with no pain at 6 months. This difference was statistically significant.

At 24 hours, patients who would go on to experience chronic pain rated their pain at rest as a 30 and with movement as a 72 on a 100-point visual analog scale. Patients whose pain resolved before 6 months averaged visual pain scores of 17 at rest and 46 with movement. These differences between groups were also significant.

Chronic pain patients also experienced postoperative wound hyperalgesia at far higher rates than other patients (10 of 15 patients at 24 hours, compared with 20 of 85 in the no chronic pain group, and 8 of 15 patients at 48 hours, compared with 12 of 85 patients).

In response to a question from an audience member, Dr. Lavand'homme said the type of C-section incision used might play a role in rates of residual pain. All patients in the study received a Pfannenstiel incision with peritoneal layer closure. This incision is more comparable with the incision for an inguinal hernia repair—a surgery linked to high rates of residual pain—than is a vertical incision, she said.

However, much more study is needed to determine what specific factors contribute to chronic post-C-section pain and discomfort, Dr. Lavand'homme stressed.

PALM DESERT, CALIF. — More than one in seven healthy parturients report residual pain 6 months after undergoing an elective cesarean section, a Belgian research group reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Three characteristics distinguished patients suffering chronic postoperative pain from those who reported no pain at 6 months: higher pain scores 24 hours after surgery; a greater likelihood of reporting wound hyperalgesia at 24 and 48 hours; and a previous history of a genitourinary infection.

Patricia M. Lavand'homme, M.D., said her 100-subject study is one of the first to address the issue, despite the rising rate of elective C-sections and the importance of identifying risk factors that may point to preventive strategies.

“I think we really, really need to have more studies,” she remarked.

One previous study included all C-sections, including emergency procedures, and found that 12% of patients still suffered residual pain and discomfort after an average of 10 months, and among these patients, 6% had daily pain. General anesthesia appeared to induce more residual pain and discomfort than did spinal anesthesia (Acta Anaesthesiol. Scand. 2004;48:111–6).

She and her associates at the Université Catholique de Louvain in Brussels prospectively followed 100 healthy women who had undergone elective C-section.

At 6 months, 15 reported chronic pain around the scar. In four women, the pain was intense enough to require analgesics, including codeine and NSAIDs, at least three times a week. The pain was associated with a visceral component in two of the subjects with chronic pain.

No significant differences were found in women with or without chronic pain in terms of previous C-sections or other abdominal surgeries, age, number of pregnancies, endometriosis, or obstetric procedures.

Eight of 15 patients who had chronic pain reported previous genitourinary infections, compared with just 14 of 85 patients with no pain at 6 months. This difference was statistically significant.

At 24 hours, patients who would go on to experience chronic pain rated their pain at rest as a 30 and with movement as a 72 on a 100-point visual analog scale. Patients whose pain resolved before 6 months averaged visual pain scores of 17 at rest and 46 with movement. These differences between groups were also significant.

Chronic pain patients also experienced postoperative wound hyperalgesia at far higher rates than other patients (10 of 15 patients at 24 hours, compared with 20 of 85 in the no chronic pain group, and 8 of 15 patients at 48 hours, compared with 12 of 85 patients).

In response to a question from an audience member, Dr. Lavand'homme said the type of C-section incision used might play a role in rates of residual pain. All patients in the study received a Pfannenstiel incision with peritoneal layer closure. This incision is more comparable with the incision for an inguinal hernia repair—a surgery linked to high rates of residual pain—than is a vertical incision, she said.

However, much more study is needed to determine what specific factors contribute to chronic post-C-section pain and discomfort, Dr. Lavand'homme stressed.

PALM DESERT, CALIF. — More than one in seven healthy parturients report residual pain 6 months after undergoing an elective cesarean section, a Belgian research group reported at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Three characteristics distinguished patients suffering chronic postoperative pain from those who reported no pain at 6 months: higher pain scores 24 hours after surgery; a greater likelihood of reporting wound hyperalgesia at 24 and 48 hours; and a previous history of a genitourinary infection.

Patricia M. Lavand'homme, M.D., said her 100-subject study is one of the first to address the issue, despite the rising rate of elective C-sections and the importance of identifying risk factors that may point to preventive strategies.

“I think we really, really need to have more studies,” she remarked.

One previous study included all C-sections, including emergency procedures, and found that 12% of patients still suffered residual pain and discomfort after an average of 10 months, and among these patients, 6% had daily pain. General anesthesia appeared to induce more residual pain and discomfort than did spinal anesthesia (Acta Anaesthesiol. Scand. 2004;48:111–6).

She and her associates at the Université Catholique de Louvain in Brussels prospectively followed 100 healthy women who had undergone elective C-section.

At 6 months, 15 reported chronic pain around the scar. In four women, the pain was intense enough to require analgesics, including codeine and NSAIDs, at least three times a week. The pain was associated with a visceral component in two of the subjects with chronic pain.

No significant differences were found in women with or without chronic pain in terms of previous C-sections or other abdominal surgeries, age, number of pregnancies, endometriosis, or obstetric procedures.

Eight of 15 patients who had chronic pain reported previous genitourinary infections, compared with just 14 of 85 patients with no pain at 6 months. This difference was statistically significant.

At 24 hours, patients who would go on to experience chronic pain rated their pain at rest as a 30 and with movement as a 72 on a 100-point visual analog scale. Patients whose pain resolved before 6 months averaged visual pain scores of 17 at rest and 46 with movement. These differences between groups were also significant.

Chronic pain patients also experienced postoperative wound hyperalgesia at far higher rates than other patients (10 of 15 patients at 24 hours, compared with 20 of 85 in the no chronic pain group, and 8 of 15 patients at 48 hours, compared with 12 of 85 patients).

In response to a question from an audience member, Dr. Lavand'homme said the type of C-section incision used might play a role in rates of residual pain. All patients in the study received a Pfannenstiel incision with peritoneal layer closure. This incision is more comparable with the incision for an inguinal hernia repair—a surgery linked to high rates of residual pain—than is a vertical incision, she said.

However, much more study is needed to determine what specific factors contribute to chronic post-C-section pain and discomfort, Dr. Lavand'homme stressed.

KEVIN FOLEY, RESEARCH/ELIZABETH B. LOBDELL, DESIGN

KEVIN FOLEY, RESEARCH/ELIZABETH B. LOBDELL, DESIGN

KEVIN FOLEY, RESEARCH/ELIZABETH B. LOBDELL, DESIGN

SAN FRANCISCO — Birth trauma occurs at the same rate in vaginal and cesarean deliveries, but the nature of the trauma is different, according to data presented at the annual meeting of the American College of Obstetricians and Gynecologists.

Study investigators were not able to distinguish between planned cesarean deliveries and cesarean deliveries that resulted from a failed trial of labor, however.

“The group we have to pay particular attention to is women who had a failed attempt at delivery and then had a C-section. That's probably the highest risk group and may actually be contributing to the trauma in the C-section group. But we couldn't look at this, so we can't tell the whole story with this research,” said Susan Meikle, M.D., who is lead investigator of the study and works at the Agency for Healthcare Research and Quality (AHRQ), located in Rockville, Md.

The AHRQ is mandated by Congress to produce an annual National Healthcare Quality Report that compiles health care data on patient safety. The report also defines adverse events that could be preventable. This portion of the report focuses on the risks for birth trauma.

Birth trauma data were identified using discharge data from 995 nonfederal hospitals located in 35 states and were then compared with data on infants without birth trauma. The data were analyzed by mode of delivery, clinical characteristics, demographics, and hospital characteristics.

The rate of birth trauma among more than 4,000,000 neonates was about 7 per 1,000 live singleton births, Dr. Meikle said.

When analyzed according to mode of delivery, the unadjusted rate of birth trauma was the same for both vaginal and cesarean deliveries. In addition, male infants and preterm infants were were found to be at higher risk for birth trauma regardless of the mode of delivery.

After adjustment for delivery mode, vaginal delivery of infants that were large for gestational age had a higher risk of skeletal, spinal, clavicular, and brachial plexus injuries, with an odds ratio (OR) of 1.5.

Cesarean delivery was associated with a higher risk of subdural or cerebral hemorrhage (OR 1.6) and other peripheral or cranial nerve or unspecified trauma (OR 2.1).

“Birth trauma is a heterogeneous group of injuries, and it was not possible to determine whether mode of delivery was a precipitating factor,” Dr. Meikle concluded.

“Trauma occurs with both types of delivery. There's a certain element we can't predict, and you need to be careful in deciding whether you do a C-section or a vaginal delivery,” she said in an interview. “It's hard for us to predict how big babies [will be], and if we had some tools to give us better predictive ability, that would help.”

Dr. Meikle said she also recommended that neonatal birth trauma data specify the type of injury, as well as include the attempts at vaginal delivery before a cesarean section should be accounted for in an effort to facilitate research in this field.

SAN FRANCISCO — Birth trauma occurs at the same rate in vaginal and cesarean deliveries, but the nature of the trauma is different, according to data presented at the annual meeting of the American College of Obstetricians and Gynecologists.

Study investigators were not able to distinguish between planned cesarean deliveries and cesarean deliveries that resulted from a failed trial of labor, however.

“The group we have to pay particular attention to is women who had a failed attempt at delivery and then had a C-section. That's probably the highest risk group and may actually be contributing to the trauma in the C-section group. But we couldn't look at this, so we can't tell the whole story with this research,” said Susan Meikle, M.D., who is lead investigator of the study and works at the Agency for Healthcare Research and Quality (AHRQ), located in Rockville, Md.

The AHRQ is mandated by Congress to produce an annual National Healthcare Quality Report that compiles health care data on patient safety. The report also defines adverse events that could be preventable. This portion of the report focuses on the risks for birth trauma.

Birth trauma data were identified using discharge data from 995 nonfederal hospitals located in 35 states and were then compared with data on infants without birth trauma. The data were analyzed by mode of delivery, clinical characteristics, demographics, and hospital characteristics.

The rate of birth trauma among more than 4,000,000 neonates was about 7 per 1,000 live singleton births, Dr. Meikle said.

When analyzed according to mode of delivery, the unadjusted rate of birth trauma was the same for both vaginal and cesarean deliveries. In addition, male infants and preterm infants were were found to be at higher risk for birth trauma regardless of the mode of delivery.

After adjustment for delivery mode, vaginal delivery of infants that were large for gestational age had a higher risk of skeletal, spinal, clavicular, and brachial plexus injuries, with an odds ratio (OR) of 1.5.

Cesarean delivery was associated with a higher risk of subdural or cerebral hemorrhage (OR 1.6) and other peripheral or cranial nerve or unspecified trauma (OR 2.1).

“Birth trauma is a heterogeneous group of injuries, and it was not possible to determine whether mode of delivery was a precipitating factor,” Dr. Meikle concluded.

“Trauma occurs with both types of delivery. There's a certain element we can't predict, and you need to be careful in deciding whether you do a C-section or a vaginal delivery,” she said in an interview. “It's hard for us to predict how big babies [will be], and if we had some tools to give us better predictive ability, that would help.”

Dr. Meikle said she also recommended that neonatal birth trauma data specify the type of injury, as well as include the attempts at vaginal delivery before a cesarean section should be accounted for in an effort to facilitate research in this field.

SAN FRANCISCO — Birth trauma occurs at the same rate in vaginal and cesarean deliveries, but the nature of the trauma is different, according to data presented at the annual meeting of the American College of Obstetricians and Gynecologists.

Study investigators were not able to distinguish between planned cesarean deliveries and cesarean deliveries that resulted from a failed trial of labor, however.

“The group we have to pay particular attention to is women who had a failed attempt at delivery and then had a C-section. That's probably the highest risk group and may actually be contributing to the trauma in the C-section group. But we couldn't look at this, so we can't tell the whole story with this research,” said Susan Meikle, M.D., who is lead investigator of the study and works at the Agency for Healthcare Research and Quality (AHRQ), located in Rockville, Md.

The AHRQ is mandated by Congress to produce an annual National Healthcare Quality Report that compiles health care data on patient safety. The report also defines adverse events that could be preventable. This portion of the report focuses on the risks for birth trauma.

Birth trauma data were identified using discharge data from 995 nonfederal hospitals located in 35 states and were then compared with data on infants without birth trauma. The data were analyzed by mode of delivery, clinical characteristics, demographics, and hospital characteristics.

The rate of birth trauma among more than 4,000,000 neonates was about 7 per 1,000 live singleton births, Dr. Meikle said.

When analyzed according to mode of delivery, the unadjusted rate of birth trauma was the same for both vaginal and cesarean deliveries. In addition, male infants and preterm infants were were found to be at higher risk for birth trauma regardless of the mode of delivery.

After adjustment for delivery mode, vaginal delivery of infants that were large for gestational age had a higher risk of skeletal, spinal, clavicular, and brachial plexus injuries, with an odds ratio (OR) of 1.5.

Cesarean delivery was associated with a higher risk of subdural or cerebral hemorrhage (OR 1.6) and other peripheral or cranial nerve or unspecified trauma (OR 2.1).

“Birth trauma is a heterogeneous group of injuries, and it was not possible to determine whether mode of delivery was a precipitating factor,” Dr. Meikle concluded.

“Trauma occurs with both types of delivery. There's a certain element we can't predict, and you need to be careful in deciding whether you do a C-section or a vaginal delivery,” she said in an interview. “It's hard for us to predict how big babies [will be], and if we had some tools to give us better predictive ability, that would help.”

Dr. Meikle said she also recommended that neonatal birth trauma data specify the type of injury, as well as include the attempts at vaginal delivery before a cesarean section should be accounted for in an effort to facilitate research in this field.

PALM DESERT, CALIF. — Just 9% of obstetric patients who required transfusions had no identifiable risk factors for hemorrhage in a study presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A review of medical records from 2002 and 2003 revealed that 27 of 14,813 patients who delivered vaginally and 44 of 3,844 patients who delivered by cesarean section required blood products, resulting in transfusion rates of 0.18% and 1.1% in vaginal and cesarean deliveries, respectively.

Among those obstetric patients who received a transfusion, more than a third of them had one risk factor, a third had two risk factors, and one in five of the patients had three risk factors, according to John T. Ratliff, M.D., a fellow in anesthesiology at Northwestern University, Chicago.

According to the study findings, the most common risk factor was chorioamnionitis, discovered in 17 of the patients. Some of the other risk factors included multiple gestation (12 patients), a prior uterine scar with no labor (9 patients), placenta previa (8 patients), placental abruption (8 patients), and accreta/percreta (9 patients).

Remaining risk factors included magnesium therapy, prior C-section after a vaginal trial of labor, intrauterine fetal demise, and pregnancy-induced hypertension.

“These data suggest that it might be possible to predict those obstetric patients at risk, and to establish criteria for crossmatching in this population,” wrote Dr. Ratliff in a poster that was presented at the meeting.

PALM DESERT, CALIF. — Just 9% of obstetric patients who required transfusions had no identifiable risk factors for hemorrhage in a study presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A review of medical records from 2002 and 2003 revealed that 27 of 14,813 patients who delivered vaginally and 44 of 3,844 patients who delivered by cesarean section required blood products, resulting in transfusion rates of 0.18% and 1.1% in vaginal and cesarean deliveries, respectively.

Among those obstetric patients who received a transfusion, more than a third of them had one risk factor, a third had two risk factors, and one in five of the patients had three risk factors, according to John T. Ratliff, M.D., a fellow in anesthesiology at Northwestern University, Chicago.

According to the study findings, the most common risk factor was chorioamnionitis, discovered in 17 of the patients. Some of the other risk factors included multiple gestation (12 patients), a prior uterine scar with no labor (9 patients), placenta previa (8 patients), placental abruption (8 patients), and accreta/percreta (9 patients).

Remaining risk factors included magnesium therapy, prior C-section after a vaginal trial of labor, intrauterine fetal demise, and pregnancy-induced hypertension.

“These data suggest that it might be possible to predict those obstetric patients at risk, and to establish criteria for crossmatching in this population,” wrote Dr. Ratliff in a poster that was presented at the meeting.

PALM DESERT, CALIF. — Just 9% of obstetric patients who required transfusions had no identifiable risk factors for hemorrhage in a study presented at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

A review of medical records from 2002 and 2003 revealed that 27 of 14,813 patients who delivered vaginally and 44 of 3,844 patients who delivered by cesarean section required blood products, resulting in transfusion rates of 0.18% and 1.1% in vaginal and cesarean deliveries, respectively.

Among those obstetric patients who received a transfusion, more than a third of them had one risk factor, a third had two risk factors, and one in five of the patients had three risk factors, according to John T. Ratliff, M.D., a fellow in anesthesiology at Northwestern University, Chicago.

According to the study findings, the most common risk factor was chorioamnionitis, discovered in 17 of the patients. Some of the other risk factors included multiple gestation (12 patients), a prior uterine scar with no labor (9 patients), placenta previa (8 patients), placental abruption (8 patients), and accreta/percreta (9 patients).

Remaining risk factors included magnesium therapy, prior C-section after a vaginal trial of labor, intrauterine fetal demise, and pregnancy-induced hypertension.

“These data suggest that it might be possible to predict those obstetric patients at risk, and to establish criteria for crossmatching in this population,” wrote Dr. Ratliff in a poster that was presented at the meeting.

LAS VEGAS — When assessing variable decelerations in the second stage of labor, measure their depth and duration but also determine how those decelerations are affecting the baseline variability and baseline rate, Suzanne McMurtry Baird, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“How well is this baby tolerating those persistent variable decelerations?” asked Ms. Baird, a staff nurse in the labor and delivery unit at Vanderbilt University Medical Center, Nashville, Tenn. “Over a prolonged period of time, fetal oxygen reserves will decrease and variability will progressively decrease. Baseline rate will progressively rise if hypoxia begins. Make sure you are documenting and assessing for this and anticipating that this is a possibility. It will prolong the second stage of labor.”

Variable decelerations occur when the fetal heart rate decrease is greater than or equal to 15 beats per minute and last for longer than or equal to 15 seconds but less than 2 minutes from onset to return to baseline.

Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent.

Perform a cervical exam to rule out prolapsed cord and funic presentation and check for imminent delivery.

Depending on the position of the cord, amnioinfusion could be a good option. “Some health care providers like this option and use it,” Ms. Baird said. However, she noted that the consistent efficacy of this measure is “very up in the air.”

Nevertheless, communication with the patient is key during variable decelerations. “Notify this patient and let the family know,” said Ms. Baird, who also teaches at the Vanderbilt University School of Nursing. “They may get real excited and see a [fetal] heart rate of 60 [bpm]. Have you had the heart rate disappear during that time because you're [doing] an ultrasound? I've heard patients say that the baby's heart rate stopped with every contraction. It wasn't stopping. We just failed to tell them that we weren't tracing that heart rate at the end of a deceleration.”

Ms. Baird emphasized that “there is no place” for uterine hyperstimulation when a woman is experiencing persistent variable decelerations or persistent late decelerations.

“Oftentimes, I see nurses turning the Pitocin up, even in the presence of all of these patterns and we're at 1–2 minute uterine contractions,” Ms. Baird said at the conference.

LAS VEGAS — When assessing variable decelerations in the second stage of labor, measure their depth and duration but also determine how those decelerations are affecting the baseline variability and baseline rate, Suzanne McMurtry Baird, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“How well is this baby tolerating those persistent variable decelerations?” asked Ms. Baird, a staff nurse in the labor and delivery unit at Vanderbilt University Medical Center, Nashville, Tenn. “Over a prolonged period of time, fetal oxygen reserves will decrease and variability will progressively decrease. Baseline rate will progressively rise if hypoxia begins. Make sure you are documenting and assessing for this and anticipating that this is a possibility. It will prolong the second stage of labor.”

Variable decelerations occur when the fetal heart rate decrease is greater than or equal to 15 beats per minute and last for longer than or equal to 15 seconds but less than 2 minutes from onset to return to baseline.

Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent.

Perform a cervical exam to rule out prolapsed cord and funic presentation and check for imminent delivery.

Depending on the position of the cord, amnioinfusion could be a good option. “Some health care providers like this option and use it,” Ms. Baird said. However, she noted that the consistent efficacy of this measure is “very up in the air.”

Nevertheless, communication with the patient is key during variable decelerations. “Notify this patient and let the family know,” said Ms. Baird, who also teaches at the Vanderbilt University School of Nursing. “They may get real excited and see a [fetal] heart rate of 60 [bpm]. Have you had the heart rate disappear during that time because you're [doing] an ultrasound? I've heard patients say that the baby's heart rate stopped with every contraction. It wasn't stopping. We just failed to tell them that we weren't tracing that heart rate at the end of a deceleration.”

Ms. Baird emphasized that “there is no place” for uterine hyperstimulation when a woman is experiencing persistent variable decelerations or persistent late decelerations.

“Oftentimes, I see nurses turning the Pitocin up, even in the presence of all of these patterns and we're at 1–2 minute uterine contractions,” Ms. Baird said at the conference.

LAS VEGAS — When assessing variable decelerations in the second stage of labor, measure their depth and duration but also determine how those decelerations are affecting the baseline variability and baseline rate, Suzanne McMurtry Baird, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“How well is this baby tolerating those persistent variable decelerations?” asked Ms. Baird, a staff nurse in the labor and delivery unit at Vanderbilt University Medical Center, Nashville, Tenn. “Over a prolonged period of time, fetal oxygen reserves will decrease and variability will progressively decrease. Baseline rate will progressively rise if hypoxia begins. Make sure you are documenting and assessing for this and anticipating that this is a possibility. It will prolong the second stage of labor.”

Variable decelerations occur when the fetal heart rate decrease is greater than or equal to 15 beats per minute and last for longer than or equal to 15 seconds but less than 2 minutes from onset to return to baseline.

Common causes of variable decelerations include vagal reflex triggered by head compression during pushing and cord compression such as that caused by short cord, nuchal cord, body entanglement, prolapsed cord, decreased amniotic fluid, and fetal descent.

Perform a cervical exam to rule out prolapsed cord and funic presentation and check for imminent delivery.

Depending on the position of the cord, amnioinfusion could be a good option. “Some health care providers like this option and use it,” Ms. Baird said. However, she noted that the consistent efficacy of this measure is “very up in the air.”

Nevertheless, communication with the patient is key during variable decelerations. “Notify this patient and let the family know,” said Ms. Baird, who also teaches at the Vanderbilt University School of Nursing. “They may get real excited and see a [fetal] heart rate of 60 [bpm]. Have you had the heart rate disappear during that time because you're [doing] an ultrasound? I've heard patients say that the baby's heart rate stopped with every contraction. It wasn't stopping. We just failed to tell them that we weren't tracing that heart rate at the end of a deceleration.”

Ms. Baird emphasized that “there is no place” for uterine hyperstimulation when a woman is experiencing persistent variable decelerations or persistent late decelerations.

“Oftentimes, I see nurses turning the Pitocin up, even in the presence of all of these patterns and we're at 1–2 minute uterine contractions,” Ms. Baird said at the conference.