Obstetrics

LAS VEGAS — From a legal standpoint, your hospital guidelines for the preparation and administration of Pitocin are a double-edged sword in the case of a bad birth outcome, Stephen Crandall advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If you have a policy in place, you better have meant it,” said Mr. Crandall, a Mayfield Heights, Ohio-based plaintiff's attorney who specializes in health care law.

During court depositions in trials involving a bad birth outcome, he said, nurses frequently describe their hospital's Pitocin (oxytocin) policy as “just a guideline,” Mr. Crandall said. “We hear that all the time.” If a Pitocin policy is in place but not followed, “it's a difficult road” to say that there was no deviation from the standard of care, he added.

The other problem he sees is that nurses and other members of the labor and delivery team are unaware that a Pitocin policy exists in their institution. In some court cases, he said, “we take a nurse's deposition and we ask her things about the Pitocin policy in place. They don't even know what the policy is. That can't happen. Nine times out of 10, the nurses that we depose don't know what they should know. It's very difficult to defend a case like that.”

A second common area of medicolegal risk is poor charting and communication among members of the labor and delivery team, said James Kelley, a plaintiff's attorney who practices in the same firm as Mr. Crandall. “If you see potentially concerning signs or an absence of reassuring signs from a nursing standpoint or a physician standpoint, you have to take action,” Mr. Kelley said. “If you make a call, you have to document that call. Remember the context: Most states allow 19 years for a child to file a lawsuit. If it's not in the chart, you're not going to remember [that call by the time the case goes to trial]. And I can assure you that who you say you called and told about what went wrong isn't going to remember that call either, if it's not in the chart.”

If you're reading worrisome signs from the electronic fetal heart rate monitor, “document your interaction with that strip, whether you're writing on the strip or entering it on computer-generated strips,” he added. “Make a note that you looked, that you palpated the contractions, or [that the electronic fetal monitor] wasn't giving you a reassuring sign as an external monitor. Palpate [the contractions]. Tell us what you find. Were they mild? Moderate? What kind of relaxation was there?”

Mr. Crandall added that without documentation of your actions in a case of labor and delivery that resulted in a bad outcome, “you really have no plan [of care]. And if you have no plan, it's difficult for defense lawyers to defend you,” he noted. “The other problem with a lack of documentation that benefits the plaintiff's side is that it leads to finger-pointing” among physicians, nurses, nurse-midwives, and other members of the labor and delivery team.

A third key area of medicolegal risk involves chart alteration. The bottom line?

Don't do it. “If you alter the medical record after there's a bad outcome, you have just created what we like to call verdict accelerant,” Mr. Kelley said. Medical record alteration “takes a very noble profession and 'villanizes' it in a courtroom. Regardless of how bad or how good your care is, [changing medical records is] indefensible.”

Mr. Crandall warned that people who alter charts eventually get caught, because other areas of the medical record often conflict with what they wrote. Also, “there are very talented document analysts who can show when you wrote what,” he said.

He concluded that a good lawyer “can defend anybody who is attentive to the patient's need and has a clear medical record, regardless of the outcome. As long as they can show us the basis for that, we've never had a problem in a courtroom,” he said.

“It's when that chart is inconsistent, unclear, or absent that it becomes open season on the plaintiff's side.”

LAS VEGAS — From a legal standpoint, your hospital guidelines for the preparation and administration of Pitocin are a double-edged sword in the case of a bad birth outcome, Stephen Crandall advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If you have a policy in place, you better have meant it,” said Mr. Crandall, a Mayfield Heights, Ohio-based plaintiff's attorney who specializes in health care law.

During court depositions in trials involving a bad birth outcome, he said, nurses frequently describe their hospital's Pitocin (oxytocin) policy as “just a guideline,” Mr. Crandall said. “We hear that all the time.” If a Pitocin policy is in place but not followed, “it's a difficult road” to say that there was no deviation from the standard of care, he added.

The other problem he sees is that nurses and other members of the labor and delivery team are unaware that a Pitocin policy exists in their institution. In some court cases, he said, “we take a nurse's deposition and we ask her things about the Pitocin policy in place. They don't even know what the policy is. That can't happen. Nine times out of 10, the nurses that we depose don't know what they should know. It's very difficult to defend a case like that.”

A second common area of medicolegal risk is poor charting and communication among members of the labor and delivery team, said James Kelley, a plaintiff's attorney who practices in the same firm as Mr. Crandall. “If you see potentially concerning signs or an absence of reassuring signs from a nursing standpoint or a physician standpoint, you have to take action,” Mr. Kelley said. “If you make a call, you have to document that call. Remember the context: Most states allow 19 years for a child to file a lawsuit. If it's not in the chart, you're not going to remember [that call by the time the case goes to trial]. And I can assure you that who you say you called and told about what went wrong isn't going to remember that call either, if it's not in the chart.”

If you're reading worrisome signs from the electronic fetal heart rate monitor, “document your interaction with that strip, whether you're writing on the strip or entering it on computer-generated strips,” he added. “Make a note that you looked, that you palpated the contractions, or [that the electronic fetal monitor] wasn't giving you a reassuring sign as an external monitor. Palpate [the contractions]. Tell us what you find. Were they mild? Moderate? What kind of relaxation was there?”

Mr. Crandall added that without documentation of your actions in a case of labor and delivery that resulted in a bad outcome, “you really have no plan [of care]. And if you have no plan, it's difficult for defense lawyers to defend you,” he noted. “The other problem with a lack of documentation that benefits the plaintiff's side is that it leads to finger-pointing” among physicians, nurses, nurse-midwives, and other members of the labor and delivery team.

A third key area of medicolegal risk involves chart alteration. The bottom line?

Don't do it. “If you alter the medical record after there's a bad outcome, you have just created what we like to call verdict accelerant,” Mr. Kelley said. Medical record alteration “takes a very noble profession and 'villanizes' it in a courtroom. Regardless of how bad or how good your care is, [changing medical records is] indefensible.”

Mr. Crandall warned that people who alter charts eventually get caught, because other areas of the medical record often conflict with what they wrote. Also, “there are very talented document analysts who can show when you wrote what,” he said.

He concluded that a good lawyer “can defend anybody who is attentive to the patient's need and has a clear medical record, regardless of the outcome. As long as they can show us the basis for that, we've never had a problem in a courtroom,” he said.

“It's when that chart is inconsistent, unclear, or absent that it becomes open season on the plaintiff's side.”

LAS VEGAS — From a legal standpoint, your hospital guidelines for the preparation and administration of Pitocin are a double-edged sword in the case of a bad birth outcome, Stephen Crandall advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If you have a policy in place, you better have meant it,” said Mr. Crandall, a Mayfield Heights, Ohio-based plaintiff's attorney who specializes in health care law.

During court depositions in trials involving a bad birth outcome, he said, nurses frequently describe their hospital's Pitocin (oxytocin) policy as “just a guideline,” Mr. Crandall said. “We hear that all the time.” If a Pitocin policy is in place but not followed, “it's a difficult road” to say that there was no deviation from the standard of care, he added.

The other problem he sees is that nurses and other members of the labor and delivery team are unaware that a Pitocin policy exists in their institution. In some court cases, he said, “we take a nurse's deposition and we ask her things about the Pitocin policy in place. They don't even know what the policy is. That can't happen. Nine times out of 10, the nurses that we depose don't know what they should know. It's very difficult to defend a case like that.”

A second common area of medicolegal risk is poor charting and communication among members of the labor and delivery team, said James Kelley, a plaintiff's attorney who practices in the same firm as Mr. Crandall. “If you see potentially concerning signs or an absence of reassuring signs from a nursing standpoint or a physician standpoint, you have to take action,” Mr. Kelley said. “If you make a call, you have to document that call. Remember the context: Most states allow 19 years for a child to file a lawsuit. If it's not in the chart, you're not going to remember [that call by the time the case goes to trial]. And I can assure you that who you say you called and told about what went wrong isn't going to remember that call either, if it's not in the chart.”

If you're reading worrisome signs from the electronic fetal heart rate monitor, “document your interaction with that strip, whether you're writing on the strip or entering it on computer-generated strips,” he added. “Make a note that you looked, that you palpated the contractions, or [that the electronic fetal monitor] wasn't giving you a reassuring sign as an external monitor. Palpate [the contractions]. Tell us what you find. Were they mild? Moderate? What kind of relaxation was there?”

Mr. Crandall added that without documentation of your actions in a case of labor and delivery that resulted in a bad outcome, “you really have no plan [of care]. And if you have no plan, it's difficult for defense lawyers to defend you,” he noted. “The other problem with a lack of documentation that benefits the plaintiff's side is that it leads to finger-pointing” among physicians, nurses, nurse-midwives, and other members of the labor and delivery team.

A third key area of medicolegal risk involves chart alteration. The bottom line?

Don't do it. “If you alter the medical record after there's a bad outcome, you have just created what we like to call verdict accelerant,” Mr. Kelley said. Medical record alteration “takes a very noble profession and 'villanizes' it in a courtroom. Regardless of how bad or how good your care is, [changing medical records is] indefensible.”

Mr. Crandall warned that people who alter charts eventually get caught, because other areas of the medical record often conflict with what they wrote. Also, “there are very talented document analysts who can show when you wrote what,” he said.

He concluded that a good lawyer “can defend anybody who is attentive to the patient's need and has a clear medical record, regardless of the outcome. As long as they can show us the basis for that, we've never had a problem in a courtroom,” he said.

“It's when that chart is inconsistent, unclear, or absent that it becomes open season on the plaintiff's side.”

LAS VEGAS — Take adequate precautions when fetal monitoring is requested in a nonobstetric setting, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

First, ask yourself: Do we have the capability in this setting to do more than initiate intrauterine resuscitation measures? “In most nonobstetric settings we don't,” noted Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics. “That's going to lead to criticism if we identify nonreassuring fetal heart rate patterns that should have been acted upon from a delivery standpoint. If we don't have a plan in place to deliver that patient, we are going to assume a great vulnerability.”

Many times, she said, operating room personnel make a request for fetal monitoring without informing the obstetrician. That situation should be avoided because once you put on a fetal monitor, you need to be prepared to intervene based on the information you receive, she added. This means “going beyond intrauterine resuscitation measures toward delivery and necessary care,” Ms. Witcher explained.

“If she's 24 weeks and we're concerned about viability and we're not going to intervene on behalf of the fetus anyway, we don't need to collect that information. We don't need to monitor anymore,” she said.

To limit your vulnerability from a legal and clinical standpoint, make it hospital policy to have the request for fetal monitoring in a nonobstetric setting come from an obstetrician only. “The order needs to come from an obstetrician. I guarantee you that the [fetal] monitoring in the ORs is going to go down [if you do this], because most obstetricians are going to say no. If you are going to monitor in the OR, a nurse who's capable of interpreting [the tracings] must go with that monitor, and that nurse needs to stay in the OR.”

In that scenario, she added, the obstetric nurse should tell the surgeon, “You need to know that it's my responsibility to maintain a technically adequate tracing.”

Above all, have a plan for delivery, Ms. Witcher emphasized. Ask yourself: Where are we going to deliver? Here in the OR? In the ICU? Are we going to send the patient back to labor and delivery?

“Have this discussion with the obstetric and nonobstetric providers,” Ms. Witcher said. “It has to be communicated.”

Ms. Witcher said that there are times when it's useful to do fetal monitoring in a nonobstetric setting. She gave the example of a woman who is 32 weeks pregnant. She's in the ICU, has respiratory distress syndrome, and is on a mechanical ventilator.

“I think there is value in monitoring that patient, because you would intervene on behalf of the fetus,” Ms. Witcher said. “But if you're going to monitor that patient in the ICU, there has to be a labor and delivery attendant at the bedside.”

Pitocin augmentation and induction is another area fraught with liability. She recommended that hospitals adopt Pitocin policies and procedures that allow for nursing and medical judgment.

“Be as general as possible in your policy,” she said.

For example, in the component of your policy that discusses patients receiving Pitocin infusion, consider this wording: “Monitor fetal heart rate with electronic fetal monitoring unless otherwise ordered by provider.”

In the component of your policy about decreasing or stopping Pitocin, consider this wording: “Decrease/discontinue Pitocin for excessive uterine contractions or when fetal heart rate pattern warrants discontinuation. Notify provider.”

She recommended adding the following phrase to the bottom of your policy: “This policy is a guideline for Pitocin administration and should be superseded by medical or nursing judgment.”

LAS VEGAS — Take adequate precautions when fetal monitoring is requested in a nonobstetric setting, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

First, ask yourself: Do we have the capability in this setting to do more than initiate intrauterine resuscitation measures? “In most nonobstetric settings we don't,” noted Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics. “That's going to lead to criticism if we identify nonreassuring fetal heart rate patterns that should have been acted upon from a delivery standpoint. If we don't have a plan in place to deliver that patient, we are going to assume a great vulnerability.”

Many times, she said, operating room personnel make a request for fetal monitoring without informing the obstetrician. That situation should be avoided because once you put on a fetal monitor, you need to be prepared to intervene based on the information you receive, she added. This means “going beyond intrauterine resuscitation measures toward delivery and necessary care,” Ms. Witcher explained.

“If she's 24 weeks and we're concerned about viability and we're not going to intervene on behalf of the fetus anyway, we don't need to collect that information. We don't need to monitor anymore,” she said.

To limit your vulnerability from a legal and clinical standpoint, make it hospital policy to have the request for fetal monitoring in a nonobstetric setting come from an obstetrician only. “The order needs to come from an obstetrician. I guarantee you that the [fetal] monitoring in the ORs is going to go down [if you do this], because most obstetricians are going to say no. If you are going to monitor in the OR, a nurse who's capable of interpreting [the tracings] must go with that monitor, and that nurse needs to stay in the OR.”

In that scenario, she added, the obstetric nurse should tell the surgeon, “You need to know that it's my responsibility to maintain a technically adequate tracing.”

Above all, have a plan for delivery, Ms. Witcher emphasized. Ask yourself: Where are we going to deliver? Here in the OR? In the ICU? Are we going to send the patient back to labor and delivery?

“Have this discussion with the obstetric and nonobstetric providers,” Ms. Witcher said. “It has to be communicated.”

Ms. Witcher said that there are times when it's useful to do fetal monitoring in a nonobstetric setting. She gave the example of a woman who is 32 weeks pregnant. She's in the ICU, has respiratory distress syndrome, and is on a mechanical ventilator.

“I think there is value in monitoring that patient, because you would intervene on behalf of the fetus,” Ms. Witcher said. “But if you're going to monitor that patient in the ICU, there has to be a labor and delivery attendant at the bedside.”

Pitocin augmentation and induction is another area fraught with liability. She recommended that hospitals adopt Pitocin policies and procedures that allow for nursing and medical judgment.

“Be as general as possible in your policy,” she said.

For example, in the component of your policy that discusses patients receiving Pitocin infusion, consider this wording: “Monitor fetal heart rate with electronic fetal monitoring unless otherwise ordered by provider.”

In the component of your policy about decreasing or stopping Pitocin, consider this wording: “Decrease/discontinue Pitocin for excessive uterine contractions or when fetal heart rate pattern warrants discontinuation. Notify provider.”

She recommended adding the following phrase to the bottom of your policy: “This policy is a guideline for Pitocin administration and should be superseded by medical or nursing judgment.”

LAS VEGAS — Take adequate precautions when fetal monitoring is requested in a nonobstetric setting, Patricia M. Witcher, a registered nurse clinician, advised at a conference on fetal monitoring sponsored by Symposia Medicus.

First, ask yourself: Do we have the capability in this setting to do more than initiate intrauterine resuscitation measures? “In most nonobstetric settings we don't,” noted Ms. Witcher, a nurse at Northside Hospital in Atlanta who specializes in labor and delivery and high-risk obstetrics. “That's going to lead to criticism if we identify nonreassuring fetal heart rate patterns that should have been acted upon from a delivery standpoint. If we don't have a plan in place to deliver that patient, we are going to assume a great vulnerability.”

Many times, she said, operating room personnel make a request for fetal monitoring without informing the obstetrician. That situation should be avoided because once you put on a fetal monitor, you need to be prepared to intervene based on the information you receive, she added. This means “going beyond intrauterine resuscitation measures toward delivery and necessary care,” Ms. Witcher explained.

“If she's 24 weeks and we're concerned about viability and we're not going to intervene on behalf of the fetus anyway, we don't need to collect that information. We don't need to monitor anymore,” she said.

To limit your vulnerability from a legal and clinical standpoint, make it hospital policy to have the request for fetal monitoring in a nonobstetric setting come from an obstetrician only. “The order needs to come from an obstetrician. I guarantee you that the [fetal] monitoring in the ORs is going to go down [if you do this], because most obstetricians are going to say no. If you are going to monitor in the OR, a nurse who's capable of interpreting [the tracings] must go with that monitor, and that nurse needs to stay in the OR.”

In that scenario, she added, the obstetric nurse should tell the surgeon, “You need to know that it's my responsibility to maintain a technically adequate tracing.”

Above all, have a plan for delivery, Ms. Witcher emphasized. Ask yourself: Where are we going to deliver? Here in the OR? In the ICU? Are we going to send the patient back to labor and delivery?

“Have this discussion with the obstetric and nonobstetric providers,” Ms. Witcher said. “It has to be communicated.”

Ms. Witcher said that there are times when it's useful to do fetal monitoring in a nonobstetric setting. She gave the example of a woman who is 32 weeks pregnant. She's in the ICU, has respiratory distress syndrome, and is on a mechanical ventilator.

“I think there is value in monitoring that patient, because you would intervene on behalf of the fetus,” Ms. Witcher said. “But if you're going to monitor that patient in the ICU, there has to be a labor and delivery attendant at the bedside.”

Pitocin augmentation and induction is another area fraught with liability. She recommended that hospitals adopt Pitocin policies and procedures that allow for nursing and medical judgment.

“Be as general as possible in your policy,” she said.

For example, in the component of your policy that discusses patients receiving Pitocin infusion, consider this wording: “Monitor fetal heart rate with electronic fetal monitoring unless otherwise ordered by provider.”

In the component of your policy about decreasing or stopping Pitocin, consider this wording: “Decrease/discontinue Pitocin for excessive uterine contractions or when fetal heart rate pattern warrants discontinuation. Notify provider.”

She recommended adding the following phrase to the bottom of your policy: “This policy is a guideline for Pitocin administration and should be superseded by medical or nursing judgment.”

LOS ANGELES — Scientists have developed a noninvasive “genetic Pap” test to screen for Down syndrome and other chromosomal abnormalities early in pregnancy.

The test analyzes trophoblast cells shed by the fetus and scraped from the cervix, investigator Moshe D. Fejgin, M.D., reported in an oral presentation at the annual meeting of the Society for Gynecologic Investigation.

Researchers found fetal cells in about 87% of nearly 500 samples from two studies. The test identified two cases of trisomy 21 and one case each of Turner's syndrome and Klinefelter's syndrome in 110 pregnancies, according to Dr. Fejgin of the Meir Medical Center in Kfar Saba, Israel.

Gender predictions were correct in 92% of samples, he said, with accuracy ranging from 89% in samples from women planning to complete their pregnancies and 94% from a group that chose termination. Dr. Fejgin described the test as 100% accurate in determining male gender.

“When you are running 80%–90% accuracy, it can be used as a diagnostic,” Dr. Fejgin said.

He and his coinvestigators concluded that the “genetic Pap” has the potential to replace other noninvasive screening techniques for Down syndrome.

Their announced goal is to find an alternative to invasive procedures such as amniocentesis and chorionic villi sampling, which can be risky as well as costly.

The concept is not entirely new. Scientists have long attempted to isolate fetal cells from maternal blood for this purpose without success, according to Dr. Fejgin.

Fetal cells are shed into the cervix between 5 and 12 weeks of gestation, Dr. Fejgin said, describing the time frame as a window of opportunity for the “genetic Pap.”

After the cells are obtained with a cytobrush, the screening process includes immunohistochemistry and fluorescence in situ hybridization (FISH) analysis for gender and for chromosomal abnormalities.

The investigators have formed a company to commercialize the test, Dr. Fejgin added during an interview.

He said they plan to start clinical trials in Europe and the United States and plan to submit the test to the Food and Drug Administration for approval.

LOS ANGELES — Scientists have developed a noninvasive “genetic Pap” test to screen for Down syndrome and other chromosomal abnormalities early in pregnancy.

The test analyzes trophoblast cells shed by the fetus and scraped from the cervix, investigator Moshe D. Fejgin, M.D., reported in an oral presentation at the annual meeting of the Society for Gynecologic Investigation.

Researchers found fetal cells in about 87% of nearly 500 samples from two studies. The test identified two cases of trisomy 21 and one case each of Turner's syndrome and Klinefelter's syndrome in 110 pregnancies, according to Dr. Fejgin of the Meir Medical Center in Kfar Saba, Israel.

Gender predictions were correct in 92% of samples, he said, with accuracy ranging from 89% in samples from women planning to complete their pregnancies and 94% from a group that chose termination. Dr. Fejgin described the test as 100% accurate in determining male gender.

“When you are running 80%–90% accuracy, it can be used as a diagnostic,” Dr. Fejgin said.

He and his coinvestigators concluded that the “genetic Pap” has the potential to replace other noninvasive screening techniques for Down syndrome.

Their announced goal is to find an alternative to invasive procedures such as amniocentesis and chorionic villi sampling, which can be risky as well as costly.

The concept is not entirely new. Scientists have long attempted to isolate fetal cells from maternal blood for this purpose without success, according to Dr. Fejgin.

Fetal cells are shed into the cervix between 5 and 12 weeks of gestation, Dr. Fejgin said, describing the time frame as a window of opportunity for the “genetic Pap.”

After the cells are obtained with a cytobrush, the screening process includes immunohistochemistry and fluorescence in situ hybridization (FISH) analysis for gender and for chromosomal abnormalities.

The investigators have formed a company to commercialize the test, Dr. Fejgin added during an interview.

He said they plan to start clinical trials in Europe and the United States and plan to submit the test to the Food and Drug Administration for approval.

LOS ANGELES — Scientists have developed a noninvasive “genetic Pap” test to screen for Down syndrome and other chromosomal abnormalities early in pregnancy.

The test analyzes trophoblast cells shed by the fetus and scraped from the cervix, investigator Moshe D. Fejgin, M.D., reported in an oral presentation at the annual meeting of the Society for Gynecologic Investigation.

Researchers found fetal cells in about 87% of nearly 500 samples from two studies. The test identified two cases of trisomy 21 and one case each of Turner's syndrome and Klinefelter's syndrome in 110 pregnancies, according to Dr. Fejgin of the Meir Medical Center in Kfar Saba, Israel.

Gender predictions were correct in 92% of samples, he said, with accuracy ranging from 89% in samples from women planning to complete their pregnancies and 94% from a group that chose termination. Dr. Fejgin described the test as 100% accurate in determining male gender.

“When you are running 80%–90% accuracy, it can be used as a diagnostic,” Dr. Fejgin said.

He and his coinvestigators concluded that the “genetic Pap” has the potential to replace other noninvasive screening techniques for Down syndrome.

Their announced goal is to find an alternative to invasive procedures such as amniocentesis and chorionic villi sampling, which can be risky as well as costly.

The concept is not entirely new. Scientists have long attempted to isolate fetal cells from maternal blood for this purpose without success, according to Dr. Fejgin.

Fetal cells are shed into the cervix between 5 and 12 weeks of gestation, Dr. Fejgin said, describing the time frame as a window of opportunity for the “genetic Pap.”

After the cells are obtained with a cytobrush, the screening process includes immunohistochemistry and fluorescence in situ hybridization (FISH) analysis for gender and for chromosomal abnormalities.

The investigators have formed a company to commercialize the test, Dr. Fejgin added during an interview.

He said they plan to start clinical trials in Europe and the United States and plan to submit the test to the Food and Drug Administration for approval.

GRAPEVINE, TEX. — The behavioral and cognitive defects in children with fetal alcohol effects may be partly due to genetic psychiatric disorders, researchers reported in a poster presentation at a meeting sponsored by the American College of Medical Genetics.

“Physicians need to ask about psychiatric and behavioral illnesses in families when diagnosing children with fetal alcohol effects [FAE],” said Helga V. Toriello, Ph.D., director of genetics services, Spectrum Health, Grand Rapids, Mich. “Acquiring a family history is important, because they suddenly may be dealing with genetic factors rather than alcohol.”

While the diagnostic criteria for fetal alcohol syndrome are firm, the criteria for fetal alcohol effects are less clear and may overlap with other psychiatric and behavioral disorders, she said.

Researchers at Spectrum and DeVos Children's Hospital, also in Grand Rapids, found that 95% of children thought to have fetal alcohol effects also had psychiatric or behavioral disorders and that 89% had a first-degree relative with a psychiatric or behavioral disorder.

The study included 100 children aged 3–19 years who had been seen to determine whether they had fetal alcohol syndrome. None of the children fit the criteria for fetal alcohol syndrome and thus could be considered to have FAE.

But after conducting family histories, the researchers found a high rate of psychiatric and behavioral illnesses such as bipolar depression and attention-deficit disorder, not only in the children but in first-degree relatives.

“This raises the question of how much of the behavioral problems are due to psychiatric illness or alcohol exposure,” she asked. “A genetic condition might be contributing to the child's behavior.”

Psychiatric and behavioral problems such as depression, anxiety, bipolar disorder, and attention-deficit hyperactivity disorder are known to be highly heritable.

Additionally, there appears to be a comorbidity of alcoholism and mental illness. For example, at least 20% of those with mood or anxiety disorders also have substance abuse disorder. And at least 20% of those with substance abuse problems also have mood or anxiety disorders.

The researchers found that children with bipolar depression had split verbal and performance IQ, executive dysfunction, and attention problems—all common features also reported in children exposed to alcohol.

Also, some individuals with psychiatric and behavioral illnesses have similar characteristics as those exposed to alcohol prenatally. For example, in bipolar depression, there is sexually inappropriate behavior, anger, hyperactivity, and learning disabilities, features also found in alcohol exposure.

Dr. Toriello said the researchers are not saying that alcohol does not have an effect, but it may not be the only reason for the child's behavior. “When we did a family history there was a high frequency of one or both parents having a mental illness or behavioral disorder. It might be that a genetic condition is contributing to the child's behavior rather than strictly alcohol exposure.”

GRAPEVINE, TEX. — The behavioral and cognitive defects in children with fetal alcohol effects may be partly due to genetic psychiatric disorders, researchers reported in a poster presentation at a meeting sponsored by the American College of Medical Genetics.

“Physicians need to ask about psychiatric and behavioral illnesses in families when diagnosing children with fetal alcohol effects [FAE],” said Helga V. Toriello, Ph.D., director of genetics services, Spectrum Health, Grand Rapids, Mich. “Acquiring a family history is important, because they suddenly may be dealing with genetic factors rather than alcohol.”

While the diagnostic criteria for fetal alcohol syndrome are firm, the criteria for fetal alcohol effects are less clear and may overlap with other psychiatric and behavioral disorders, she said.

Researchers at Spectrum and DeVos Children's Hospital, also in Grand Rapids, found that 95% of children thought to have fetal alcohol effects also had psychiatric or behavioral disorders and that 89% had a first-degree relative with a psychiatric or behavioral disorder.

The study included 100 children aged 3–19 years who had been seen to determine whether they had fetal alcohol syndrome. None of the children fit the criteria for fetal alcohol syndrome and thus could be considered to have FAE.

But after conducting family histories, the researchers found a high rate of psychiatric and behavioral illnesses such as bipolar depression and attention-deficit disorder, not only in the children but in first-degree relatives.

“This raises the question of how much of the behavioral problems are due to psychiatric illness or alcohol exposure,” she asked. “A genetic condition might be contributing to the child's behavior.”

Psychiatric and behavioral problems such as depression, anxiety, bipolar disorder, and attention-deficit hyperactivity disorder are known to be highly heritable.

Additionally, there appears to be a comorbidity of alcoholism and mental illness. For example, at least 20% of those with mood or anxiety disorders also have substance abuse disorder. And at least 20% of those with substance abuse problems also have mood or anxiety disorders.

The researchers found that children with bipolar depression had split verbal and performance IQ, executive dysfunction, and attention problems—all common features also reported in children exposed to alcohol.

Also, some individuals with psychiatric and behavioral illnesses have similar characteristics as those exposed to alcohol prenatally. For example, in bipolar depression, there is sexually inappropriate behavior, anger, hyperactivity, and learning disabilities, features also found in alcohol exposure.

Dr. Toriello said the researchers are not saying that alcohol does not have an effect, but it may not be the only reason for the child's behavior. “When we did a family history there was a high frequency of one or both parents having a mental illness or behavioral disorder. It might be that a genetic condition is contributing to the child's behavior rather than strictly alcohol exposure.”

GRAPEVINE, TEX. — The behavioral and cognitive defects in children with fetal alcohol effects may be partly due to genetic psychiatric disorders, researchers reported in a poster presentation at a meeting sponsored by the American College of Medical Genetics.

“Physicians need to ask about psychiatric and behavioral illnesses in families when diagnosing children with fetal alcohol effects [FAE],” said Helga V. Toriello, Ph.D., director of genetics services, Spectrum Health, Grand Rapids, Mich. “Acquiring a family history is important, because they suddenly may be dealing with genetic factors rather than alcohol.”

While the diagnostic criteria for fetal alcohol syndrome are firm, the criteria for fetal alcohol effects are less clear and may overlap with other psychiatric and behavioral disorders, she said.

Researchers at Spectrum and DeVos Children's Hospital, also in Grand Rapids, found that 95% of children thought to have fetal alcohol effects also had psychiatric or behavioral disorders and that 89% had a first-degree relative with a psychiatric or behavioral disorder.

The study included 100 children aged 3–19 years who had been seen to determine whether they had fetal alcohol syndrome. None of the children fit the criteria for fetal alcohol syndrome and thus could be considered to have FAE.

But after conducting family histories, the researchers found a high rate of psychiatric and behavioral illnesses such as bipolar depression and attention-deficit disorder, not only in the children but in first-degree relatives.

“This raises the question of how much of the behavioral problems are due to psychiatric illness or alcohol exposure,” she asked. “A genetic condition might be contributing to the child's behavior.”

Psychiatric and behavioral problems such as depression, anxiety, bipolar disorder, and attention-deficit hyperactivity disorder are known to be highly heritable.

Additionally, there appears to be a comorbidity of alcoholism and mental illness. For example, at least 20% of those with mood or anxiety disorders also have substance abuse disorder. And at least 20% of those with substance abuse problems also have mood or anxiety disorders.

The researchers found that children with bipolar depression had split verbal and performance IQ, executive dysfunction, and attention problems—all common features also reported in children exposed to alcohol.

Also, some individuals with psychiatric and behavioral illnesses have similar characteristics as those exposed to alcohol prenatally. For example, in bipolar depression, there is sexually inappropriate behavior, anger, hyperactivity, and learning disabilities, features also found in alcohol exposure.

Dr. Toriello said the researchers are not saying that alcohol does not have an effect, but it may not be the only reason for the child's behavior. “When we did a family history there was a high frequency of one or both parents having a mental illness or behavioral disorder. It might be that a genetic condition is contributing to the child's behavior rather than strictly alcohol exposure.”

PALM DESERT, CALIF. — Women with a common genetic variant on the μ-opioid receptor had a markedly reduced need for intrathecal fentanyl during labor, raising the strong possibility that genes influence analgesic response to the drug.

An international research team that was led by Ruth Landau, M.D., of the University Hospital of Geneva, announced their findings at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Genetic polymorphism of the μ-opioid receptor is very common, found in roughly 10%–28% of the world's population.

When Dr. Landau and her associates genotyped the DNA of 113 nulliparous Swiss women at less than 35 weeks' gestation, the A118G variant was discovered in 32%.

Patients who went into spontaneous early labor and requested analgesia all received a starting dose of 18 mcg of fentanyl with a testing interval between patients of 2 mcg.

After that point, their fentanyl dose was allocated in a blinded fashion according to an up-down allocation protocol until anesthesia success was reached, defined as a visual analog score of 1 or less for at least 60 minutes.

Failure was defined as a patient not reaching that degree of pain relief within 20 minutes, or analgesia wearing off before 60 minutes.

Anesthesiologists and parturients were blinded as to genotype and total fentanyl doses required for successful anesthesia success.

Among 37 patients who have thus far met the study criteria, adequate pain relief was obtained at a dosage of 16 mcg in patients with the genetic A118G variant and 26.8 mcg in patients with the more typical gene receptor.

The difference between the two patient groups was very highly significant.

“We have demonstrated a highly significant 1.68-fold potentiation of intrathecal fentanyl effect by μ-opioid receptor A118 polymorphism,” said Dr. Landau, who is chief of the anesthesiology clinic at the university.

“We were very impressed. We were expecting—I guess hoping for—a difference, but we didn't think it would be this big,” she said.

Results of the study are preliminary, and enrollment continues.

Nonetheless, a number of other intriguing findings have already begun to emerge.

In a separate analysis of 52 patients whose labor was induced, fentanyl was administered in small to high doses in a random fashion until successful anesthesia was achieved. In that group, three women with the genetic variant achieved success at less than 10 mcg of fentanyl, a strikingly low dose.

Another five patients from the original genotyped cohort had such rapid cervical dilation they could not be included in the medication analysis. Interestingly, four of the five had the genetic variant although they represented a much smaller number of total patients in the cohort.

Dr. Landau posed a number of possible explanations for the differences between patients with and without the gene variant.

The intrathecal fentanyl may have an enhanced effect on individuals with the polymorphism: These patients may have altered pain perception, or their labor progress may be different from individuals without the genetic variant.

“We are continuing to investigate this [difference],” she said.

Since its cloning in 1993, the μ-opioid receptor polymorphism has been the subject of numerous studies by investigators curious about its potential link to opiate addiction and alcoholism, according to Dr. Landau.

In vitro studies have shown that the variant greatly increases the binding affinity and potency of β-endorphins, but not morphine, and that it may alter the toxicity profile of morphine 6 glucuronide response.

Carriers of the polymorphism have been shown to have an increased pain threshold when exposed to pressure pain. she said.

PALM DESERT, CALIF. — Women with a common genetic variant on the μ-opioid receptor had a markedly reduced need for intrathecal fentanyl during labor, raising the strong possibility that genes influence analgesic response to the drug.

An international research team that was led by Ruth Landau, M.D., of the University Hospital of Geneva, announced their findings at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Genetic polymorphism of the μ-opioid receptor is very common, found in roughly 10%–28% of the world's population.

When Dr. Landau and her associates genotyped the DNA of 113 nulliparous Swiss women at less than 35 weeks' gestation, the A118G variant was discovered in 32%.

Patients who went into spontaneous early labor and requested analgesia all received a starting dose of 18 mcg of fentanyl with a testing interval between patients of 2 mcg.

After that point, their fentanyl dose was allocated in a blinded fashion according to an up-down allocation protocol until anesthesia success was reached, defined as a visual analog score of 1 or less for at least 60 minutes.

Failure was defined as a patient not reaching that degree of pain relief within 20 minutes, or analgesia wearing off before 60 minutes.

Anesthesiologists and parturients were blinded as to genotype and total fentanyl doses required for successful anesthesia success.

Among 37 patients who have thus far met the study criteria, adequate pain relief was obtained at a dosage of 16 mcg in patients with the genetic A118G variant and 26.8 mcg in patients with the more typical gene receptor.

The difference between the two patient groups was very highly significant.

“We have demonstrated a highly significant 1.68-fold potentiation of intrathecal fentanyl effect by μ-opioid receptor A118 polymorphism,” said Dr. Landau, who is chief of the anesthesiology clinic at the university.

“We were very impressed. We were expecting—I guess hoping for—a difference, but we didn't think it would be this big,” she said.

Results of the study are preliminary, and enrollment continues.

Nonetheless, a number of other intriguing findings have already begun to emerge.

In a separate analysis of 52 patients whose labor was induced, fentanyl was administered in small to high doses in a random fashion until successful anesthesia was achieved. In that group, three women with the genetic variant achieved success at less than 10 mcg of fentanyl, a strikingly low dose.

Another five patients from the original genotyped cohort had such rapid cervical dilation they could not be included in the medication analysis. Interestingly, four of the five had the genetic variant although they represented a much smaller number of total patients in the cohort.

Dr. Landau posed a number of possible explanations for the differences between patients with and without the gene variant.

The intrathecal fentanyl may have an enhanced effect on individuals with the polymorphism: These patients may have altered pain perception, or their labor progress may be different from individuals without the genetic variant.

“We are continuing to investigate this [difference],” she said.

Since its cloning in 1993, the μ-opioid receptor polymorphism has been the subject of numerous studies by investigators curious about its potential link to opiate addiction and alcoholism, according to Dr. Landau.

In vitro studies have shown that the variant greatly increases the binding affinity and potency of β-endorphins, but not morphine, and that it may alter the toxicity profile of morphine 6 glucuronide response.

Carriers of the polymorphism have been shown to have an increased pain threshold when exposed to pressure pain. she said.

PALM DESERT, CALIF. — Women with a common genetic variant on the μ-opioid receptor had a markedly reduced need for intrathecal fentanyl during labor, raising the strong possibility that genes influence analgesic response to the drug.

An international research team that was led by Ruth Landau, M.D., of the University Hospital of Geneva, announced their findings at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Genetic polymorphism of the μ-opioid receptor is very common, found in roughly 10%–28% of the world's population.

When Dr. Landau and her associates genotyped the DNA of 113 nulliparous Swiss women at less than 35 weeks' gestation, the A118G variant was discovered in 32%.

Patients who went into spontaneous early labor and requested analgesia all received a starting dose of 18 mcg of fentanyl with a testing interval between patients of 2 mcg.

After that point, their fentanyl dose was allocated in a blinded fashion according to an up-down allocation protocol until anesthesia success was reached, defined as a visual analog score of 1 or less for at least 60 minutes.

Failure was defined as a patient not reaching that degree of pain relief within 20 minutes, or analgesia wearing off before 60 minutes.

Anesthesiologists and parturients were blinded as to genotype and total fentanyl doses required for successful anesthesia success.

Among 37 patients who have thus far met the study criteria, adequate pain relief was obtained at a dosage of 16 mcg in patients with the genetic A118G variant and 26.8 mcg in patients with the more typical gene receptor.

The difference between the two patient groups was very highly significant.

“We have demonstrated a highly significant 1.68-fold potentiation of intrathecal fentanyl effect by μ-opioid receptor A118 polymorphism,” said Dr. Landau, who is chief of the anesthesiology clinic at the university.

“We were very impressed. We were expecting—I guess hoping for—a difference, but we didn't think it would be this big,” she said.

Results of the study are preliminary, and enrollment continues.

Nonetheless, a number of other intriguing findings have already begun to emerge.

In a separate analysis of 52 patients whose labor was induced, fentanyl was administered in small to high doses in a random fashion until successful anesthesia was achieved. In that group, three women with the genetic variant achieved success at less than 10 mcg of fentanyl, a strikingly low dose.

Another five patients from the original genotyped cohort had such rapid cervical dilation they could not be included in the medication analysis. Interestingly, four of the five had the genetic variant although they represented a much smaller number of total patients in the cohort.

Dr. Landau posed a number of possible explanations for the differences between patients with and without the gene variant.

The intrathecal fentanyl may have an enhanced effect on individuals with the polymorphism: These patients may have altered pain perception, or their labor progress may be different from individuals without the genetic variant.

“We are continuing to investigate this [difference],” she said.

Since its cloning in 1993, the μ-opioid receptor polymorphism has been the subject of numerous studies by investigators curious about its potential link to opiate addiction and alcoholism, according to Dr. Landau.

In vitro studies have shown that the variant greatly increases the binding affinity and potency of β-endorphins, but not morphine, and that it may alter the toxicity profile of morphine 6 glucuronide response.

Carriers of the polymorphism have been shown to have an increased pain threshold when exposed to pressure pain. she said.

RANCHO MIRAGE, CALIF. — Genital trauma during delivery was common but did not lead to postpartum urinary incontinence in a prospective study of 455 midwifery patients with low-risk pregnancies.

The findings of the study counter a common reason that is often cited for performing episiotomies: to prevent anterior genital trauma in hopes of avoiding future incontinence.

As episiotomy rates decreased from 55% of deliveries in 1991 to 29% in 2001, the rate of anterior lacerations increased, leading investigators in the current study to analyze whether the increase in lacerations was associated with urinary incontinence.

Only 20% of the 455 women had no lacerations after delivery. An additional 35% had anterior lacerations to the clitoral, labial, or periurethral tissues; 18% developed posterior (perineal) lacerations, and 25% had both anterior and posterior trauma, Rebecca Rogers, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 2% of women were excluded from analysis because their vaginal lacerations did not extend to external genitalia. Only two of these nine patients required sutures.

Most of the trauma included in the analyses was minor. Only 1% of patients developed a posterior third- or fourth-degree laceration, according to Dr. Rogers of the University of New Mexico, Albuquerque.

Urinary incontinence was reported by 27% of women 6 weeks after delivery and by 29% 3 months after delivery. These women answered “yes” to the question, “Since the birth of your baby, have you leaked urine when you did not mean to?”

Fewer women, however, felt that the incontinence significantly affected their social functioning. Postpartum, 16% of women at 6 weeks and 13% at 3 months scored greater than 0 on the Incontinence Impact Questionnaire-7 (IIQ-7), which defined significant impact.

The urinary incontinence was not associated with the presence of genital trauma or any of a number of other factors analyzed. On the contrary, women with anterior lacerations were less likely to have urinary incontinence at 3 months post partum, compared with all other women combined.

“This is a little surprising to us because, if anything, we thought we would find that anterior trauma was linked to complaints of incontinence,” Dr. Rogers said. “Isolated anterior trauma may serve as a marker for preservation of the continence mechanism in some way that I can't really explain at this point.”

In formal commentary after Dr. Rogers' presentation, Charles Nager, M.D., said, “The important part of this study is that it dispels a commonly held belief by many obstetricians that episiotomy, which does reduce the risk of anterior genital tract trauma, can be justified because it helps prevent incontinence.”

The results are consistent with a Cochrane Review of other studies on episiotomy at vaginal birth, which found that a “restricted episiotomy” protocol increased the relative risk of anterior trauma by 79%, compared with routine episiotomy—but this difference reportedly did not increase the risk for urinary incontinence or dyspareunia, said Dr. Nager of the University of California, San Diego.

“The authors [of the current study] should be commended for a well-done, prospective, clinically relevant and clinically important study,” he said.

Participants in the study agreed to mapping of genital trauma at birth and two postpartum assessments of perineal anatomy, urinary continence, and incontinence-related social functioning.

The study excluded women who underwent episiotomy or operative delivery, he said.

The participants were an average 25 years of age, and 40% were nulliparous. For delivery, 41% had epidural anesthesia and 23% received oxytocin.

The investigators will analyze data on sexual function and anal incontinence, Dr. Rogers said. In a preliminary review, genital trauma did not seem to be linked to either of these.

“Anterior genital tract trauma is not something that we need to be extremely concerned about preventing,” Dr. Rogers explained.

RANCHO MIRAGE, CALIF. — Genital trauma during delivery was common but did not lead to postpartum urinary incontinence in a prospective study of 455 midwifery patients with low-risk pregnancies.

The findings of the study counter a common reason that is often cited for performing episiotomies: to prevent anterior genital trauma in hopes of avoiding future incontinence.

As episiotomy rates decreased from 55% of deliveries in 1991 to 29% in 2001, the rate of anterior lacerations increased, leading investigators in the current study to analyze whether the increase in lacerations was associated with urinary incontinence.

Only 20% of the 455 women had no lacerations after delivery. An additional 35% had anterior lacerations to the clitoral, labial, or periurethral tissues; 18% developed posterior (perineal) lacerations, and 25% had both anterior and posterior trauma, Rebecca Rogers, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 2% of women were excluded from analysis because their vaginal lacerations did not extend to external genitalia. Only two of these nine patients required sutures.

Most of the trauma included in the analyses was minor. Only 1% of patients developed a posterior third- or fourth-degree laceration, according to Dr. Rogers of the University of New Mexico, Albuquerque.

Urinary incontinence was reported by 27% of women 6 weeks after delivery and by 29% 3 months after delivery. These women answered “yes” to the question, “Since the birth of your baby, have you leaked urine when you did not mean to?”

Fewer women, however, felt that the incontinence significantly affected their social functioning. Postpartum, 16% of women at 6 weeks and 13% at 3 months scored greater than 0 on the Incontinence Impact Questionnaire-7 (IIQ-7), which defined significant impact.

The urinary incontinence was not associated with the presence of genital trauma or any of a number of other factors analyzed. On the contrary, women with anterior lacerations were less likely to have urinary incontinence at 3 months post partum, compared with all other women combined.

“This is a little surprising to us because, if anything, we thought we would find that anterior trauma was linked to complaints of incontinence,” Dr. Rogers said. “Isolated anterior trauma may serve as a marker for preservation of the continence mechanism in some way that I can't really explain at this point.”

In formal commentary after Dr. Rogers' presentation, Charles Nager, M.D., said, “The important part of this study is that it dispels a commonly held belief by many obstetricians that episiotomy, which does reduce the risk of anterior genital tract trauma, can be justified because it helps prevent incontinence.”

The results are consistent with a Cochrane Review of other studies on episiotomy at vaginal birth, which found that a “restricted episiotomy” protocol increased the relative risk of anterior trauma by 79%, compared with routine episiotomy—but this difference reportedly did not increase the risk for urinary incontinence or dyspareunia, said Dr. Nager of the University of California, San Diego.

“The authors [of the current study] should be commended for a well-done, prospective, clinically relevant and clinically important study,” he said.

Participants in the study agreed to mapping of genital trauma at birth and two postpartum assessments of perineal anatomy, urinary continence, and incontinence-related social functioning.

The study excluded women who underwent episiotomy or operative delivery, he said.

The participants were an average 25 years of age, and 40% were nulliparous. For delivery, 41% had epidural anesthesia and 23% received oxytocin.

The investigators will analyze data on sexual function and anal incontinence, Dr. Rogers said. In a preliminary review, genital trauma did not seem to be linked to either of these.

“Anterior genital tract trauma is not something that we need to be extremely concerned about preventing,” Dr. Rogers explained.

RANCHO MIRAGE, CALIF. — Genital trauma during delivery was common but did not lead to postpartum urinary incontinence in a prospective study of 455 midwifery patients with low-risk pregnancies.

The findings of the study counter a common reason that is often cited for performing episiotomies: to prevent anterior genital trauma in hopes of avoiding future incontinence.

As episiotomy rates decreased from 55% of deliveries in 1991 to 29% in 2001, the rate of anterior lacerations increased, leading investigators in the current study to analyze whether the increase in lacerations was associated with urinary incontinence.

Only 20% of the 455 women had no lacerations after delivery. An additional 35% had anterior lacerations to the clitoral, labial, or periurethral tissues; 18% developed posterior (perineal) lacerations, and 25% had both anterior and posterior trauma, Rebecca Rogers, M.D., said at the annual meeting of the Society of Gynecologic Surgeons.

The remaining 2% of women were excluded from analysis because their vaginal lacerations did not extend to external genitalia. Only two of these nine patients required sutures.

Most of the trauma included in the analyses was minor. Only 1% of patients developed a posterior third- or fourth-degree laceration, according to Dr. Rogers of the University of New Mexico, Albuquerque.

Urinary incontinence was reported by 27% of women 6 weeks after delivery and by 29% 3 months after delivery. These women answered “yes” to the question, “Since the birth of your baby, have you leaked urine when you did not mean to?”

Fewer women, however, felt that the incontinence significantly affected their social functioning. Postpartum, 16% of women at 6 weeks and 13% at 3 months scored greater than 0 on the Incontinence Impact Questionnaire-7 (IIQ-7), which defined significant impact.

The urinary incontinence was not associated with the presence of genital trauma or any of a number of other factors analyzed. On the contrary, women with anterior lacerations were less likely to have urinary incontinence at 3 months post partum, compared with all other women combined.

“This is a little surprising to us because, if anything, we thought we would find that anterior trauma was linked to complaints of incontinence,” Dr. Rogers said. “Isolated anterior trauma may serve as a marker for preservation of the continence mechanism in some way that I can't really explain at this point.”

In formal commentary after Dr. Rogers' presentation, Charles Nager, M.D., said, “The important part of this study is that it dispels a commonly held belief by many obstetricians that episiotomy, which does reduce the risk of anterior genital tract trauma, can be justified because it helps prevent incontinence.”

The results are consistent with a Cochrane Review of other studies on episiotomy at vaginal birth, which found that a “restricted episiotomy” protocol increased the relative risk of anterior trauma by 79%, compared with routine episiotomy—but this difference reportedly did not increase the risk for urinary incontinence or dyspareunia, said Dr. Nager of the University of California, San Diego.

“The authors [of the current study] should be commended for a well-done, prospective, clinically relevant and clinically important study,” he said.

Participants in the study agreed to mapping of genital trauma at birth and two postpartum assessments of perineal anatomy, urinary continence, and incontinence-related social functioning.

The study excluded women who underwent episiotomy or operative delivery, he said.

The participants were an average 25 years of age, and 40% were nulliparous. For delivery, 41% had epidural anesthesia and 23% received oxytocin.

The investigators will analyze data on sexual function and anal incontinence, Dr. Rogers said. In a preliminary review, genital trauma did not seem to be linked to either of these.

“Anterior genital tract trauma is not something that we need to be extremely concerned about preventing,” Dr. Rogers explained.

LOS ANGELES — A small study adds to the growing body of evidence implicating periodontal disease in poor pregnancy outcomes.

Twelve percent of women with periodontal disease had low-birth-weight babies in a 277-patient observational study. In comparison, only 2% of women with healthy gums had small babies, a statistically significant difference.

The data were presented in poster form at the annual meeting of the Society for Gynecologic Investigation.

The women with periodontal disease also had a higher incidence of preterm births (7% vs. 3%) but Alexis L. Shub, M.D., an investigator in the study, said this difference was not statistically significant. About 15% of women in the study had periodontal disease.

An updated analysis completed just before the meeting also found higher rates of tumor necrosis factor-α in the cord blood of women with periodontal disease, Dr. Shub, an obstetrician at the University of Western Australia in Perth, said in an interview.

These data were not included in the poster presentation, she noted, adding that the findings suggest an ongoing inflammatory process in these women and their fetuses.

John P. Newnham, M.D., who is the study's lead author and director of the Women and Infants Research Foundation at King Edward Memorial Hospital in Perth, said in an interview that he is also working on a large, randomized controlled trial to study this issue. The investigators have begun to divide 1,000 pregnant women with periodontal disease into two cohorts: one given periodontal care during pregnancy and the other afterward. The trial's primary outcomes will be preterm birth, fetal growth, and preeclampsia.

He said the investigators are concerned that heightened awareness of possible harm from periodontal disease could skew outcomes. They suspect screening patients for periodontal disease in the observational study led to better dental care. The preterm birth rates were expected to be about 11%, according to Dr. Newnham, who also plans to monitor pregnancy outcomes and prenatal care in a region-wide medical database.

“The exciting thing is that it is possible that a simple community-based public health intervention could have a profound impact on the need for expensive high-tech hospital resources,” he said.

LOS ANGELES — A small study adds to the growing body of evidence implicating periodontal disease in poor pregnancy outcomes.

Twelve percent of women with periodontal disease had low-birth-weight babies in a 277-patient observational study. In comparison, only 2% of women with healthy gums had small babies, a statistically significant difference.

The data were presented in poster form at the annual meeting of the Society for Gynecologic Investigation.

The women with periodontal disease also had a higher incidence of preterm births (7% vs. 3%) but Alexis L. Shub, M.D., an investigator in the study, said this difference was not statistically significant. About 15% of women in the study had periodontal disease.

An updated analysis completed just before the meeting also found higher rates of tumor necrosis factor-α in the cord blood of women with periodontal disease, Dr. Shub, an obstetrician at the University of Western Australia in Perth, said in an interview.

These data were not included in the poster presentation, she noted, adding that the findings suggest an ongoing inflammatory process in these women and their fetuses.

John P. Newnham, M.D., who is the study's lead author and director of the Women and Infants Research Foundation at King Edward Memorial Hospital in Perth, said in an interview that he is also working on a large, randomized controlled trial to study this issue. The investigators have begun to divide 1,000 pregnant women with periodontal disease into two cohorts: one given periodontal care during pregnancy and the other afterward. The trial's primary outcomes will be preterm birth, fetal growth, and preeclampsia.

He said the investigators are concerned that heightened awareness of possible harm from periodontal disease could skew outcomes. They suspect screening patients for periodontal disease in the observational study led to better dental care. The preterm birth rates were expected to be about 11%, according to Dr. Newnham, who also plans to monitor pregnancy outcomes and prenatal care in a region-wide medical database.

“The exciting thing is that it is possible that a simple community-based public health intervention could have a profound impact on the need for expensive high-tech hospital resources,” he said.

LOS ANGELES — A small study adds to the growing body of evidence implicating periodontal disease in poor pregnancy outcomes.

Twelve percent of women with periodontal disease had low-birth-weight babies in a 277-patient observational study. In comparison, only 2% of women with healthy gums had small babies, a statistically significant difference.

The data were presented in poster form at the annual meeting of the Society for Gynecologic Investigation.

The women with periodontal disease also had a higher incidence of preterm births (7% vs. 3%) but Alexis L. Shub, M.D., an investigator in the study, said this difference was not statistically significant. About 15% of women in the study had periodontal disease.

An updated analysis completed just before the meeting also found higher rates of tumor necrosis factor-α in the cord blood of women with periodontal disease, Dr. Shub, an obstetrician at the University of Western Australia in Perth, said in an interview.

These data were not included in the poster presentation, she noted, adding that the findings suggest an ongoing inflammatory process in these women and their fetuses.

John P. Newnham, M.D., who is the study's lead author and director of the Women and Infants Research Foundation at King Edward Memorial Hospital in Perth, said in an interview that he is also working on a large, randomized controlled trial to study this issue. The investigators have begun to divide 1,000 pregnant women with periodontal disease into two cohorts: one given periodontal care during pregnancy and the other afterward. The trial's primary outcomes will be preterm birth, fetal growth, and preeclampsia.

He said the investigators are concerned that heightened awareness of possible harm from periodontal disease could skew outcomes. They suspect screening patients for periodontal disease in the observational study led to better dental care. The preterm birth rates were expected to be about 11%, according to Dr. Newnham, who also plans to monitor pregnancy outcomes and prenatal care in a region-wide medical database.

“The exciting thing is that it is possible that a simple community-based public health intervention could have a profound impact on the need for expensive high-tech hospital resources,” he said.

PALM DESERT, CALIF. — There may be a threshold of morbid obesity associated with a sharply increased risk of nonelective cesarean delivery that is not shared by less obese women, according to results of a preliminary study presented at the annual meeting of the Society for Obstetric Anesthesiology and Perinatology.

The issue may have clinical implications for management of women at the lower ranges of morbid obesity who may wish to undergo labor without early and aggressive epidural management in anticipation of a probable cesarean section.

In their study, investigators at the University of Michigan, Ann Arbor, looked for a linear increase in cesarean deliveries as obesity increased, but instead found that nonelective cesarean deliveries did not significantly increase until body mass indexes rose above 46.

At the highest ranges of obesity, a very significant increase in nonelective C-sections was seen in the study of 226 parturients: 58% of those with a BMI of 47–88, compared with 39% for women with BMIs between 30 and 46.

Monica Riesner, M.D., of the department of anesthesiology at the University of Michigan, presented the findings on behalf of a colleague, Jill Mhyre, M.D., who could not attend the meeting.

Dr. Mhyre and associates studied the charts of obese parturients who delivered vaginally or by nonelective C-section at their institution between 1999 and 2002. Women undergoing elective C-sections were not included in the analysis.

Among the patients meeting study criteria, 62 had a BMI between 30 and 39.9 (defined as obese by the Institute of Medicine); 116 had a BMI between 40 and 49.9, and 48 had a BMI between 50 and 88. A BMI greater than 50 has been proposed by some authors to constitute a new category, the “super obese.”

The mean BMI in the cohort was 44.5. The mean age was 28 years.

Fourteen percent of the group had diabetes, 14% had preeclampsia, one-fifth had asthma, and a quarter smoked.

Slightly more than half of the women delivered vaginally.

The nonelective C-section rate was 42% in women with BMIs between 30 and 39, and 45.7% for those with BMIs between 40 and 88, a nonsignificant difference.

In fact, a statistically meaningful difference in C-section rates was not observed in women with BMIs lower than 46, although they were significant at every cut point of BMIs above that level.

The single-institution study was not sufficiently powered to determine an absolute threshold for increased cesarean risk, which investigators hypothesized “may be as high as 50 or even 55,” said Dr. Riesner.

Stepwise logistic regression analyses found that a BMI greater than 46 was independently associated with more than a twofold increase in the risk of C-section.

Parity appeared to be protective in less obese women, but not in those women with a BMI of 47 or higher.

A more comprehensive study is underway using a new electronic records system to capture more cases, with the aim of shedding more light on the findings of this preliminary study.

At this point, it appears to be reasonable to continue to encourage women with very high BMIs to allow early epidural analgesia, Dr. Riesner said.

If the findings are confirmed, less obese women may be safely managed without an epidural if they meet such criteria as a history of vaginal delivery at the same maternal weight; reassuring maternal airway findings upon examination; and good progression of labor and fetal status, she said.

An audience member praised the study and called for more research, since she recently learned that labor nurses at her institution were discouraging super-obese parturients from having epidural anesthesia during labor, since they are difficult to move following a motor block.

PALM DESERT, CALIF. — There may be a threshold of morbid obesity associated with a sharply increased risk of nonelective cesarean delivery that is not shared by less obese women, according to results of a preliminary study presented at the annual meeting of the Society for Obstetric Anesthesiology and Perinatology.

The issue may have clinical implications for management of women at the lower ranges of morbid obesity who may wish to undergo labor without early and aggressive epidural management in anticipation of a probable cesarean section.

In their study, investigators at the University of Michigan, Ann Arbor, looked for a linear increase in cesarean deliveries as obesity increased, but instead found that nonelective cesarean deliveries did not significantly increase until body mass indexes rose above 46.

At the highest ranges of obesity, a very significant increase in nonelective C-sections was seen in the study of 226 parturients: 58% of those with a BMI of 47–88, compared with 39% for women with BMIs between 30 and 46.

Monica Riesner, M.D., of the department of anesthesiology at the University of Michigan, presented the findings on behalf of a colleague, Jill Mhyre, M.D., who could not attend the meeting.

Dr. Mhyre and associates studied the charts of obese parturients who delivered vaginally or by nonelective C-section at their institution between 1999 and 2002. Women undergoing elective C-sections were not included in the analysis.

Among the patients meeting study criteria, 62 had a BMI between 30 and 39.9 (defined as obese by the Institute of Medicine); 116 had a BMI between 40 and 49.9, and 48 had a BMI between 50 and 88. A BMI greater than 50 has been proposed by some authors to constitute a new category, the “super obese.”

The mean BMI in the cohort was 44.5. The mean age was 28 years.

Fourteen percent of the group had diabetes, 14% had preeclampsia, one-fifth had asthma, and a quarter smoked.

Slightly more than half of the women delivered vaginally.

The nonelective C-section rate was 42% in women with BMIs between 30 and 39, and 45.7% for those with BMIs between 40 and 88, a nonsignificant difference.

In fact, a statistically meaningful difference in C-section rates was not observed in women with BMIs lower than 46, although they were significant at every cut point of BMIs above that level.

The single-institution study was not sufficiently powered to determine an absolute threshold for increased cesarean risk, which investigators hypothesized “may be as high as 50 or even 55,” said Dr. Riesner.

Stepwise logistic regression analyses found that a BMI greater than 46 was independently associated with more than a twofold increase in the risk of C-section.

Parity appeared to be protective in less obese women, but not in those women with a BMI of 47 or higher.

A more comprehensive study is underway using a new electronic records system to capture more cases, with the aim of shedding more light on the findings of this preliminary study.

At this point, it appears to be reasonable to continue to encourage women with very high BMIs to allow early epidural analgesia, Dr. Riesner said.

If the findings are confirmed, less obese women may be safely managed without an epidural if they meet such criteria as a history of vaginal delivery at the same maternal weight; reassuring maternal airway findings upon examination; and good progression of labor and fetal status, she said.

An audience member praised the study and called for more research, since she recently learned that labor nurses at her institution were discouraging super-obese parturients from having epidural anesthesia during labor, since they are difficult to move following a motor block.

PALM DESERT, CALIF. — There may be a threshold of morbid obesity associated with a sharply increased risk of nonelective cesarean delivery that is not shared by less obese women, according to results of a preliminary study presented at the annual meeting of the Society for Obstetric Anesthesiology and Perinatology.

The issue may have clinical implications for management of women at the lower ranges of morbid obesity who may wish to undergo labor without early and aggressive epidural management in anticipation of a probable cesarean section.

In their study, investigators at the University of Michigan, Ann Arbor, looked for a linear increase in cesarean deliveries as obesity increased, but instead found that nonelective cesarean deliveries did not significantly increase until body mass indexes rose above 46.

At the highest ranges of obesity, a very significant increase in nonelective C-sections was seen in the study of 226 parturients: 58% of those with a BMI of 47–88, compared with 39% for women with BMIs between 30 and 46.

Monica Riesner, M.D., of the department of anesthesiology at the University of Michigan, presented the findings on behalf of a colleague, Jill Mhyre, M.D., who could not attend the meeting.

Dr. Mhyre and associates studied the charts of obese parturients who delivered vaginally or by nonelective C-section at their institution between 1999 and 2002. Women undergoing elective C-sections were not included in the analysis.

Among the patients meeting study criteria, 62 had a BMI between 30 and 39.9 (defined as obese by the Institute of Medicine); 116 had a BMI between 40 and 49.9, and 48 had a BMI between 50 and 88. A BMI greater than 50 has been proposed by some authors to constitute a new category, the “super obese.”

The mean BMI in the cohort was 44.5. The mean age was 28 years.

Fourteen percent of the group had diabetes, 14% had preeclampsia, one-fifth had asthma, and a quarter smoked.

Slightly more than half of the women delivered vaginally.

The nonelective C-section rate was 42% in women with BMIs between 30 and 39, and 45.7% for those with BMIs between 40 and 88, a nonsignificant difference.

In fact, a statistically meaningful difference in C-section rates was not observed in women with BMIs lower than 46, although they were significant at every cut point of BMIs above that level.

The single-institution study was not sufficiently powered to determine an absolute threshold for increased cesarean risk, which investigators hypothesized “may be as high as 50 or even 55,” said Dr. Riesner.

Stepwise logistic regression analyses found that a BMI greater than 46 was independently associated with more than a twofold increase in the risk of C-section.

Parity appeared to be protective in less obese women, but not in those women with a BMI of 47 or higher.

A more comprehensive study is underway using a new electronic records system to capture more cases, with the aim of shedding more light on the findings of this preliminary study.

At this point, it appears to be reasonable to continue to encourage women with very high BMIs to allow early epidural analgesia, Dr. Riesner said.

If the findings are confirmed, less obese women may be safely managed without an epidural if they meet such criteria as a history of vaginal delivery at the same maternal weight; reassuring maternal airway findings upon examination; and good progression of labor and fetal status, she said.

An audience member praised the study and called for more research, since she recently learned that labor nurses at her institution were discouraging super-obese parturients from having epidural anesthesia during labor, since they are difficult to move following a motor block.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of parturients, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning parturient resuscitation after catastrophic events leading to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform cesarean section in parturients at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of parturients.

The issue may be of critical importance. Investigators pointed to findings in “Why Mothers Die 2000–2002,” a confidential analysis conducted in the United Kingdom that concluded some degree of substandard care was involved in more than 50% of maternal deaths and that most were preventable.

A lack of properly performed, timely resuscitation was implicated in some of those deaths.

“Catastrophic events leading to cardiorespiratory arrest may necessitate the resuscitation of pregnant women not only in labor and delivery suites, but also in other hospital locations,” Dr. Andes and her associates noted in the poster.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of parturients, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning parturient resuscitation after catastrophic events leading to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform cesarean section in parturients at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of parturients.

The issue may be of critical importance. Investigators pointed to findings in “Why Mothers Die 2000–2002,” a confidential analysis conducted in the United Kingdom that concluded some degree of substandard care was involved in more than 50% of maternal deaths and that most were preventable.

A lack of properly performed, timely resuscitation was implicated in some of those deaths.

“Catastrophic events leading to cardiorespiratory arrest may necessitate the resuscitation of pregnant women not only in labor and delivery suites, but also in other hospital locations,” Dr. Andes and her associates noted in the poster.

PALM DESERT, CALF. — Obstetricians, emergency physicians, and anesthesiologists may suffer significant knowledge gaps when it comes to resuscitation of parturients, suggest survey results presented in poster form at the annual meeting of the Society for Obstetric Anesthesia and Perinatology.

Faculty and residents in all three groups of specialists at Stanford (Calif.) University responded to an 11-question anonymous survey covering four critical knowledge areas concerning parturient resuscitation after catastrophic events leading to cardiorespiratory arrest:

▸ Awareness of the need for left uterine displacement.

▸ Recall of specific standard advanced cardiac life support (ACLS) algorithms.

▸ Knowledge of pertinent maternal physiology.

▸ Awareness of the recommendation to perform cesarean section in parturients at more than 20 weeks' gestation after 5 minutes of unsuccessful resuscitation for cardiac arrest.

Among 74 respondents, anesthesiologists answered the most questions correctly (average 76%). They were also better informed than other specialists about relevant maternal physiology.

Emergency physicians scored highest on questions regarding ACLS algorithms, averaging 93% correct responses.

All three groups earned similar scores on questions relating to left uterine displacement during resuscitation and the 5-minute cesarean rule. However, the rate of correct responses to those questions was low, at 60%–75%, said Leslie C. Andes, M.D., of the Stanford department of anesthesiology, and her associates.

They recommended that residents in all three specialties be required to complete ACLS certification, with an emphasis on the special resuscitation needs of parturients.

The issue may be of critical importance. Investigators pointed to findings in “Why Mothers Die 2000–2002,” a confidential analysis conducted in the United Kingdom that concluded some degree of substandard care was involved in more than 50% of maternal deaths and that most were preventable.

A lack of properly performed, timely resuscitation was implicated in some of those deaths.

“Catastrophic events leading to cardiorespiratory arrest may necessitate the resuscitation of pregnant women not only in labor and delivery suites, but also in other hospital locations,” Dr. Andes and her associates noted in the poster.

LONDON — Laparoscopic cystectomy during late pregnancy is a safe alternative to laparotomy or expectant management of large cysts, according to the results of a small case series presented at the annual congress of the International Society for Gynecologic Endoscopy.

“Although most (ovarian)cysts resolve spontaneously, large cysts can present a risk of torsion or rupture and also may cause malpresentation or labor dystocia,” commented Saurabh Phadnis, M.D., of Watford (England) General Hospital.

In addition, about 2%-5% of the cysts that appear during pregnancy are actually malignant, according to Dr. Phadnis.

He said that his surgical team performed laparoscopic cystectomy in six women whose pregnancies were between 21 and 30 weeks' gestation.

Each of the women had large cysts, measuring 8ndash;12 cm. Their surgical procedures were reported to have lasted no more than 40 minutes.

Three of the cysts were mature teratomas, two were mucinous cystadenomas, and one cyst was a serious cystadenoma.

There were no surgical complications reported, and all of the patients went home the following day except one who went home on the second day after the procedure.

Obstetric outcomes were considered normal for each of the patients, with spontaneous vaginal deliveries at term for every woman, except one patient who had requested to have a cesarean section delivery at 39 weeks' gestation.

This patient has an 8-cm ovarian cyst and 28-week gravid uterus.

The cyst is dissected off the ovarian tissue, using laparoscopic scissors.

Healthy tissue is left after the removal of the ovarian cyst. Photos courtesy Dr. Saurabh Phadnis

LONDON — Laparoscopic cystectomy during late pregnancy is a safe alternative to laparotomy or expectant management of large cysts, according to the results of a small case series presented at the annual congress of the International Society for Gynecologic Endoscopy.

“Although most (ovarian)cysts resolve spontaneously, large cysts can present a risk of torsion or rupture and also may cause malpresentation or labor dystocia,” commented Saurabh Phadnis, M.D., of Watford (England) General Hospital.

In addition, about 2%-5% of the cysts that appear during pregnancy are actually malignant, according to Dr. Phadnis.

He said that his surgical team performed laparoscopic cystectomy in six women whose pregnancies were between 21 and 30 weeks' gestation.

Each of the women had large cysts, measuring 8ndash;12 cm. Their surgical procedures were reported to have lasted no more than 40 minutes.

Three of the cysts were mature teratomas, two were mucinous cystadenomas, and one cyst was a serious cystadenoma.

There were no surgical complications reported, and all of the patients went home the following day except one who went home on the second day after the procedure.

Obstetric outcomes were considered normal for each of the patients, with spontaneous vaginal deliveries at term for every woman, except one patient who had requested to have a cesarean section delivery at 39 weeks' gestation.

This patient has an 8-cm ovarian cyst and 28-week gravid uterus.

The cyst is dissected off the ovarian tissue, using laparoscopic scissors.

Healthy tissue is left after the removal of the ovarian cyst. Photos courtesy Dr. Saurabh Phadnis

LONDON — Laparoscopic cystectomy during late pregnancy is a safe alternative to laparotomy or expectant management of large cysts, according to the results of a small case series presented at the annual congress of the International Society for Gynecologic Endoscopy.

“Although most (ovarian)cysts resolve spontaneously, large cysts can present a risk of torsion or rupture and also may cause malpresentation or labor dystocia,” commented Saurabh Phadnis, M.D., of Watford (England) General Hospital.

In addition, about 2%-5% of the cysts that appear during pregnancy are actually malignant, according to Dr. Phadnis.

He said that his surgical team performed laparoscopic cystectomy in six women whose pregnancies were between 21 and 30 weeks' gestation.

Each of the women had large cysts, measuring 8ndash;12 cm. Their surgical procedures were reported to have lasted no more than 40 minutes.

Three of the cysts were mature teratomas, two were mucinous cystadenomas, and one cyst was a serious cystadenoma.

There were no surgical complications reported, and all of the patients went home the following day except one who went home on the second day after the procedure.

Obstetric outcomes were considered normal for each of the patients, with spontaneous vaginal deliveries at term for every woman, except one patient who had requested to have a cesarean section delivery at 39 weeks' gestation.

This patient has an 8-cm ovarian cyst and 28-week gravid uterus.

The cyst is dissected off the ovarian tissue, using laparoscopic scissors.

Healthy tissue is left after the removal of the ovarian cyst. Photos courtesy Dr. Saurabh Phadnis