Obstetrics

NEW YORK — As more women delay pregnancy into their 30s and 40s, physicians are seeing more pregnancy-associated breast cancers, experts noted at a New York University cancer symposium.

This trend may particularly impact women who carry BRCA1 and BRCA2 genetic mutations, since cancers develop in these women at significantly younger ages than in noncarriers, and some studies have indicated that mutation carriers are more likely to develop cancer during pregnancy.

“This underscores the importance of obstetricians' taking a good family history in their patients who are pregnant or planning to become pregnant,” said Ellen Warner, M.D., of the University of Toronto, who participated in a panel discussion.

“Women who carry a genetic mutation may need a baseline MRI to screen them for occult or early cancer prior to becoming pregnant, along with very close follow-up,” Dr. Warner said during the meeting, which was also sponsored by the Lynne Cohen Foundation for Ovarian Cancer Research.

“We can't say that we're going to save lives with certainty. Just as with other types of surveillance, this is based mostly on expert opinion,” said Elsa Reich, a genetic counselor at the university. “But I feel really strongly that obstetricians should be vigilant about evaluating family history. If a young woman has a mother who died of breast cancer at age 40, she should at least be advised of her increased risk and given the option of consulting a genetic counselor prior to pregnancy.”

Breast cancer is the most common cancer in pregnant and postpartum women, occurring in 1 in 3,000 women. The American College of Obstetricians and Gynecologists hasn't issued recommendations about screening in women with BRCA1 and BRCA2 mutations who plan to become pregnant, although it has noted that women whose first pregnancies occur after age 30 are at some degree of increased risk.

NEW YORK — As more women delay pregnancy into their 30s and 40s, physicians are seeing more pregnancy-associated breast cancers, experts noted at a New York University cancer symposium.

This trend may particularly impact women who carry BRCA1 and BRCA2 genetic mutations, since cancers develop in these women at significantly younger ages than in noncarriers, and some studies have indicated that mutation carriers are more likely to develop cancer during pregnancy.

“This underscores the importance of obstetricians' taking a good family history in their patients who are pregnant or planning to become pregnant,” said Ellen Warner, M.D., of the University of Toronto, who participated in a panel discussion.

“Women who carry a genetic mutation may need a baseline MRI to screen them for occult or early cancer prior to becoming pregnant, along with very close follow-up,” Dr. Warner said during the meeting, which was also sponsored by the Lynne Cohen Foundation for Ovarian Cancer Research.

“We can't say that we're going to save lives with certainty. Just as with other types of surveillance, this is based mostly on expert opinion,” said Elsa Reich, a genetic counselor at the university. “But I feel really strongly that obstetricians should be vigilant about evaluating family history. If a young woman has a mother who died of breast cancer at age 40, she should at least be advised of her increased risk and given the option of consulting a genetic counselor prior to pregnancy.”

Breast cancer is the most common cancer in pregnant and postpartum women, occurring in 1 in 3,000 women. The American College of Obstetricians and Gynecologists hasn't issued recommendations about screening in women with BRCA1 and BRCA2 mutations who plan to become pregnant, although it has noted that women whose first pregnancies occur after age 30 are at some degree of increased risk.

NEW YORK — As more women delay pregnancy into their 30s and 40s, physicians are seeing more pregnancy-associated breast cancers, experts noted at a New York University cancer symposium.

This trend may particularly impact women who carry BRCA1 and BRCA2 genetic mutations, since cancers develop in these women at significantly younger ages than in noncarriers, and some studies have indicated that mutation carriers are more likely to develop cancer during pregnancy.

“This underscores the importance of obstetricians' taking a good family history in their patients who are pregnant or planning to become pregnant,” said Ellen Warner, M.D., of the University of Toronto, who participated in a panel discussion.

“Women who carry a genetic mutation may need a baseline MRI to screen them for occult or early cancer prior to becoming pregnant, along with very close follow-up,” Dr. Warner said during the meeting, which was also sponsored by the Lynne Cohen Foundation for Ovarian Cancer Research.

“We can't say that we're going to save lives with certainty. Just as with other types of surveillance, this is based mostly on expert opinion,” said Elsa Reich, a genetic counselor at the university. “But I feel really strongly that obstetricians should be vigilant about evaluating family history. If a young woman has a mother who died of breast cancer at age 40, she should at least be advised of her increased risk and given the option of consulting a genetic counselor prior to pregnancy.”

Breast cancer is the most common cancer in pregnant and postpartum women, occurring in 1 in 3,000 women. The American College of Obstetricians and Gynecologists hasn't issued recommendations about screening in women with BRCA1 and BRCA2 mutations who plan to become pregnant, although it has noted that women whose first pregnancies occur after age 30 are at some degree of increased risk.

Acupuncture and stabilizing exercises are effective adjuncts to standard treatment for pelvic girdle pain in pregnancy, Swedish researchers reported.

When combined with standard therapy, both acupuncture and stabilizing exercises provided more pain relief than standard therapy alone. Acupuncture combined with standard therapy produced the best pain relief, said Helen Elden, a midwife at East Hospital, Sahlgrenska Academy, Gothenburg, Sweden, and her associates.

“This study shows that methods other than structured physiotherapy may be effective in treating pelvic pain in pregnancy and that acupuncture presents an effective alternative,” the researchers said (BMJ 2005;330:761).

The study included 386 pregnant women with pelvic girdle pain. The average age was 30 years, and all were singleton pregnancies. About 54% said they had previously experienced low back pain.

The women were randomized to 6 weeks of standard treatment (education, pelvic belt, and abdominal and gluteal strengthening exercises); standard therapy plus 30-minute acupuncture treatments twice a week; or standard therapy plus 6 hours/week of exercises for stabilizing pelvis and back and increasing hip rotator circulation and massage and stretching of hip extensors.

Pain was assessed by a visual analog scale at baseline at 1 week following the conclusion of therapy.

Those on standard therapy plus acupuncture had the biggest decrease in pain; morning pain scores fell from 23 to 15, and evening scores fell from 65 to 31.

The group on standard therapy plus stabilizing exercises improved, but not as much; morning scores fell from 22 to 18. Evening scores fell from 60 to 45.

In the standard-therapy group, morning scores rose from 23 to 27. Evening scores fell from 63 to 58.

It's not clear how stabilizing exercises reduce pelvic pain, but research has shown that contraction of the transversus abdominis decreases laxity of the sacroiliac joint. Massage and stretching also may have contributed to relief, they noted.

They speculated that acupuncture relieved pain by activating the segmental pain inhibitory system and boosting secretion of endogenous opioids.

Acupuncture and stabilizing exercises are effective adjuncts to standard treatment for pelvic girdle pain in pregnancy, Swedish researchers reported.

When combined with standard therapy, both acupuncture and stabilizing exercises provided more pain relief than standard therapy alone. Acupuncture combined with standard therapy produced the best pain relief, said Helen Elden, a midwife at East Hospital, Sahlgrenska Academy, Gothenburg, Sweden, and her associates.

“This study shows that methods other than structured physiotherapy may be effective in treating pelvic pain in pregnancy and that acupuncture presents an effective alternative,” the researchers said (BMJ 2005;330:761).

The study included 386 pregnant women with pelvic girdle pain. The average age was 30 years, and all were singleton pregnancies. About 54% said they had previously experienced low back pain.

The women were randomized to 6 weeks of standard treatment (education, pelvic belt, and abdominal and gluteal strengthening exercises); standard therapy plus 30-minute acupuncture treatments twice a week; or standard therapy plus 6 hours/week of exercises for stabilizing pelvis and back and increasing hip rotator circulation and massage and stretching of hip extensors.

Pain was assessed by a visual analog scale at baseline at 1 week following the conclusion of therapy.

Those on standard therapy plus acupuncture had the biggest decrease in pain; morning pain scores fell from 23 to 15, and evening scores fell from 65 to 31.

The group on standard therapy plus stabilizing exercises improved, but not as much; morning scores fell from 22 to 18. Evening scores fell from 60 to 45.

In the standard-therapy group, morning scores rose from 23 to 27. Evening scores fell from 63 to 58.

It's not clear how stabilizing exercises reduce pelvic pain, but research has shown that contraction of the transversus abdominis decreases laxity of the sacroiliac joint. Massage and stretching also may have contributed to relief, they noted.

They speculated that acupuncture relieved pain by activating the segmental pain inhibitory system and boosting secretion of endogenous opioids.

Acupuncture and stabilizing exercises are effective adjuncts to standard treatment for pelvic girdle pain in pregnancy, Swedish researchers reported.

When combined with standard therapy, both acupuncture and stabilizing exercises provided more pain relief than standard therapy alone. Acupuncture combined with standard therapy produced the best pain relief, said Helen Elden, a midwife at East Hospital, Sahlgrenska Academy, Gothenburg, Sweden, and her associates.

“This study shows that methods other than structured physiotherapy may be effective in treating pelvic pain in pregnancy and that acupuncture presents an effective alternative,” the researchers said (BMJ 2005;330:761).

The study included 386 pregnant women with pelvic girdle pain. The average age was 30 years, and all were singleton pregnancies. About 54% said they had previously experienced low back pain.

The women were randomized to 6 weeks of standard treatment (education, pelvic belt, and abdominal and gluteal strengthening exercises); standard therapy plus 30-minute acupuncture treatments twice a week; or standard therapy plus 6 hours/week of exercises for stabilizing pelvis and back and increasing hip rotator circulation and massage and stretching of hip extensors.

Pain was assessed by a visual analog scale at baseline at 1 week following the conclusion of therapy.

Those on standard therapy plus acupuncture had the biggest decrease in pain; morning pain scores fell from 23 to 15, and evening scores fell from 65 to 31.

The group on standard therapy plus stabilizing exercises improved, but not as much; morning scores fell from 22 to 18. Evening scores fell from 60 to 45.

In the standard-therapy group, morning scores rose from 23 to 27. Evening scores fell from 63 to 58.

It's not clear how stabilizing exercises reduce pelvic pain, but research has shown that contraction of the transversus abdominis decreases laxity of the sacroiliac joint. Massage and stretching also may have contributed to relief, they noted.

They speculated that acupuncture relieved pain by activating the segmental pain inhibitory system and boosting secretion of endogenous opioids.

ORLANDO, FLA. — Pregnancy and postpartum are not especially high-risk periods for cardiac events in women with long QT syndrome, G. Michael Vincent, M.D., reported at the annual meeting of the American College of Cardiology.

Indeed, cardiac event rates—sudden death, syncope, and aborted cardiac arrest—are highest in women with long QT syndrome (LQTS) in the periods prior to first pregnancy and during the nonpregnant portion of the childbearing years, according to Dr. Vincent of LDS Hospital and the University of Utah, Salt Lake City.

These findings from a unique database housed at LDS Hospital are at odds with an earlier report by other investigators, who reported that the postpartum period in women with LQTS was associated with a 41-fold increased rate of cardiac events (Circulation 1998;97:451ndash;6).

That report was based on data from nongenotyped probands in the International LQTS Registry. Probands are almost always the most symptomatic members of LQTS families, and they are not representative of the LQTS population as a whole, he argued.

In contrast, the 32-year-old LDS Hospital database contains 367 LQTS families whose pedigrees have been expanded to include 6,268 members. Most have been systematically screened for LQTS, and since 1992, many have been genotyped. This database thus includes unaffected family members, as well as others encompassing the spectrum of the LQTS phenotype, rendering the Utah data singularly applicable to the broad population of LQTS women.

For this analysis Dr. Vincent reported on 255 women with 747 term pregnancies. They came from 120 LQTS families. The combined cardiac event rate during pregnancy was 3.1%. The event rate in the postpartum period—defined as the 9 months after delivery—was 3.5%. In contrast, 23.9% of the women experienced a cardiac event while not pregnant but in their childbearing years, as defined by the interval from their first pregnancy to last postpartum period.

Prior to their first pregnancy, 23.5% of subjects experienced a cardiac event, as did 2.4% after their final postpartum period.

No sudden cardiac deaths occurred during pregnancy. There were four post partum: three among 46 women with the LQT2 genotype, compared with just one of 101 LQT1 women. Most cardiac events in LQT1 women occurred prior to the childbearing years.

ORLANDO, FLA. — Pregnancy and postpartum are not especially high-risk periods for cardiac events in women with long QT syndrome, G. Michael Vincent, M.D., reported at the annual meeting of the American College of Cardiology.

Indeed, cardiac event rates—sudden death, syncope, and aborted cardiac arrest—are highest in women with long QT syndrome (LQTS) in the periods prior to first pregnancy and during the nonpregnant portion of the childbearing years, according to Dr. Vincent of LDS Hospital and the University of Utah, Salt Lake City.

These findings from a unique database housed at LDS Hospital are at odds with an earlier report by other investigators, who reported that the postpartum period in women with LQTS was associated with a 41-fold increased rate of cardiac events (Circulation 1998;97:451ndash;6).

That report was based on data from nongenotyped probands in the International LQTS Registry. Probands are almost always the most symptomatic members of LQTS families, and they are not representative of the LQTS population as a whole, he argued.

In contrast, the 32-year-old LDS Hospital database contains 367 LQTS families whose pedigrees have been expanded to include 6,268 members. Most have been systematically screened for LQTS, and since 1992, many have been genotyped. This database thus includes unaffected family members, as well as others encompassing the spectrum of the LQTS phenotype, rendering the Utah data singularly applicable to the broad population of LQTS women.

For this analysis Dr. Vincent reported on 255 women with 747 term pregnancies. They came from 120 LQTS families. The combined cardiac event rate during pregnancy was 3.1%. The event rate in the postpartum period—defined as the 9 months after delivery—was 3.5%. In contrast, 23.9% of the women experienced a cardiac event while not pregnant but in their childbearing years, as defined by the interval from their first pregnancy to last postpartum period.

Prior to their first pregnancy, 23.5% of subjects experienced a cardiac event, as did 2.4% after their final postpartum period.

No sudden cardiac deaths occurred during pregnancy. There were four post partum: three among 46 women with the LQT2 genotype, compared with just one of 101 LQT1 women. Most cardiac events in LQT1 women occurred prior to the childbearing years.

ORLANDO, FLA. — Pregnancy and postpartum are not especially high-risk periods for cardiac events in women with long QT syndrome, G. Michael Vincent, M.D., reported at the annual meeting of the American College of Cardiology.

Indeed, cardiac event rates—sudden death, syncope, and aborted cardiac arrest—are highest in women with long QT syndrome (LQTS) in the periods prior to first pregnancy and during the nonpregnant portion of the childbearing years, according to Dr. Vincent of LDS Hospital and the University of Utah, Salt Lake City.

These findings from a unique database housed at LDS Hospital are at odds with an earlier report by other investigators, who reported that the postpartum period in women with LQTS was associated with a 41-fold increased rate of cardiac events (Circulation 1998;97:451ndash;6).

That report was based on data from nongenotyped probands in the International LQTS Registry. Probands are almost always the most symptomatic members of LQTS families, and they are not representative of the LQTS population as a whole, he argued.

In contrast, the 32-year-old LDS Hospital database contains 367 LQTS families whose pedigrees have been expanded to include 6,268 members. Most have been systematically screened for LQTS, and since 1992, many have been genotyped. This database thus includes unaffected family members, as well as others encompassing the spectrum of the LQTS phenotype, rendering the Utah data singularly applicable to the broad population of LQTS women.

For this analysis Dr. Vincent reported on 255 women with 747 term pregnancies. They came from 120 LQTS families. The combined cardiac event rate during pregnancy was 3.1%. The event rate in the postpartum period—defined as the 9 months after delivery—was 3.5%. In contrast, 23.9% of the women experienced a cardiac event while not pregnant but in their childbearing years, as defined by the interval from their first pregnancy to last postpartum period.

Prior to their first pregnancy, 23.5% of subjects experienced a cardiac event, as did 2.4% after their final postpartum period.

No sudden cardiac deaths occurred during pregnancy. There were four post partum: three among 46 women with the LQT2 genotype, compared with just one of 101 LQT1 women. Most cardiac events in LQT1 women occurred prior to the childbearing years.

NEW YORK — Vaginal misoprostol is an effective alternative to surgical intervention for management of early pregnancy failure, with a high degree of patient acceptability, according to a study reported at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

The more tissue present, the higher the success rate; surgical intervention is less often needed for embryonic or fetal demise and incomplete abortion than for anembryonic gestations.

Failed pregnancy in the first trimester is followed by spontaneous uterine expulsion of the products of conception in up to 80% of cases, but this may take 2 months, and many women don't want to wait. “About 60% prefer treatment to expectant management,” Carolyn Westhoff, M.D., professor of obstetrics and gynecology, epidemiology and population and family health at the university, said at the meeting.

The standard of care has become dilatation and curettage (D&C), increasingly done as an office procedure using vacuum aspiration.

Use of the synthetic prostaglandin analog misoprostol for early pregnancy failure has been reported since 1983, usually involving hospital admission and repeated administration by various routes. Definitions of success have varied (depending on time allowed for effect), and few have involved comparison groups.

It appears that vaginal administration is most effective; in four trials involving a total of 123 women, the drug in this form resulted in expulsion of 60%-90% of embryos of up to 13-week size, Dr. Westhoff said.

In a 2004 NIH pilot trial of vaginal misoprostol for anembryonic gestation and fetal/embryonic demise, a single application (repeated if necessary, after 48 hours) was successful (expulsion by 1 week, without the need for D&C) in 94% of 51 cases of embryonic/fetal demise, and in 69% of 29 anembryonic gestations.

Dr. Westhoff reported findings of a randomized multicenter trial conducted under the auspices of the National Institutes of Child and Maternal Health, which enrolled 652 women with early pregnancy failure (at less than 12 weeks' gestation or size).

Two-thirds of the women were given a single 800-mcg dose of vaginal misoprostol—the other women had D&C—with a second administration if a sac or lining of more than 30 mm was still present on transvaginal ultrasound examination at day 2. Vacuum aspiration was provided on request for medical indications such as heavy bleeding, or when expulsion had not occurred within 1 week.

Expulsion was most likely to be complete by day 3 among the 30 women who had had incomplete or inevitable abortion, a pattern that held on day 8, when 93% in this group had successfully expelled the products of conception, compared with 87% of the 281 women with embryonic or fetal demise and 81% of the 177 women with anembryonic gestation.

“Women with incomplete/inevitable abortion and intrauterine fetal demise did very well with misoprostol alone; most required only one dose. The results were less impressive for anembryonic gestation,” Dr. Westhoff said.

More than 80% of participants in every category said they would recommend the procedure to a friend, if the need arose, and more than 75% said they would opt for it themselves. “Acceptance was highest in the incomplete-abortion group,” she said.

One lesson from the trial was the clinical importance of a follow-up visit 2 days after misoprostol insertion. “A number of patients had tissue in the internal os, with attendant bleeding. It needed just ring forceps for removal, but if this had not been done, some [cases] would have turned into an emergency,” Dr. Westhoff said.

Only 28% of women telephoned their medical providers during the trial, perhaps reflecting the value of counseling on what symptoms to expect, she said.

NEW YORK — Vaginal misoprostol is an effective alternative to surgical intervention for management of early pregnancy failure, with a high degree of patient acceptability, according to a study reported at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

The more tissue present, the higher the success rate; surgical intervention is less often needed for embryonic or fetal demise and incomplete abortion than for anembryonic gestations.

Failed pregnancy in the first trimester is followed by spontaneous uterine expulsion of the products of conception in up to 80% of cases, but this may take 2 months, and many women don't want to wait. “About 60% prefer treatment to expectant management,” Carolyn Westhoff, M.D., professor of obstetrics and gynecology, epidemiology and population and family health at the university, said at the meeting.

The standard of care has become dilatation and curettage (D&C), increasingly done as an office procedure using vacuum aspiration.

Use of the synthetic prostaglandin analog misoprostol for early pregnancy failure has been reported since 1983, usually involving hospital admission and repeated administration by various routes. Definitions of success have varied (depending on time allowed for effect), and few have involved comparison groups.

It appears that vaginal administration is most effective; in four trials involving a total of 123 women, the drug in this form resulted in expulsion of 60%-90% of embryos of up to 13-week size, Dr. Westhoff said.

In a 2004 NIH pilot trial of vaginal misoprostol for anembryonic gestation and fetal/embryonic demise, a single application (repeated if necessary, after 48 hours) was successful (expulsion by 1 week, without the need for D&C) in 94% of 51 cases of embryonic/fetal demise, and in 69% of 29 anembryonic gestations.

Dr. Westhoff reported findings of a randomized multicenter trial conducted under the auspices of the National Institutes of Child and Maternal Health, which enrolled 652 women with early pregnancy failure (at less than 12 weeks' gestation or size).

Two-thirds of the women were given a single 800-mcg dose of vaginal misoprostol—the other women had D&C—with a second administration if a sac or lining of more than 30 mm was still present on transvaginal ultrasound examination at day 2. Vacuum aspiration was provided on request for medical indications such as heavy bleeding, or when expulsion had not occurred within 1 week.

Expulsion was most likely to be complete by day 3 among the 30 women who had had incomplete or inevitable abortion, a pattern that held on day 8, when 93% in this group had successfully expelled the products of conception, compared with 87% of the 281 women with embryonic or fetal demise and 81% of the 177 women with anembryonic gestation.

“Women with incomplete/inevitable abortion and intrauterine fetal demise did very well with misoprostol alone; most required only one dose. The results were less impressive for anembryonic gestation,” Dr. Westhoff said.

More than 80% of participants in every category said they would recommend the procedure to a friend, if the need arose, and more than 75% said they would opt for it themselves. “Acceptance was highest in the incomplete-abortion group,” she said.

One lesson from the trial was the clinical importance of a follow-up visit 2 days after misoprostol insertion. “A number of patients had tissue in the internal os, with attendant bleeding. It needed just ring forceps for removal, but if this had not been done, some [cases] would have turned into an emergency,” Dr. Westhoff said.

Only 28% of women telephoned their medical providers during the trial, perhaps reflecting the value of counseling on what symptoms to expect, she said.

NEW YORK — Vaginal misoprostol is an effective alternative to surgical intervention for management of early pregnancy failure, with a high degree of patient acceptability, according to a study reported at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

The more tissue present, the higher the success rate; surgical intervention is less often needed for embryonic or fetal demise and incomplete abortion than for anembryonic gestations.

Failed pregnancy in the first trimester is followed by spontaneous uterine expulsion of the products of conception in up to 80% of cases, but this may take 2 months, and many women don't want to wait. “About 60% prefer treatment to expectant management,” Carolyn Westhoff, M.D., professor of obstetrics and gynecology, epidemiology and population and family health at the university, said at the meeting.

The standard of care has become dilatation and curettage (D&C), increasingly done as an office procedure using vacuum aspiration.

Use of the synthetic prostaglandin analog misoprostol for early pregnancy failure has been reported since 1983, usually involving hospital admission and repeated administration by various routes. Definitions of success have varied (depending on time allowed for effect), and few have involved comparison groups.

It appears that vaginal administration is most effective; in four trials involving a total of 123 women, the drug in this form resulted in expulsion of 60%-90% of embryos of up to 13-week size, Dr. Westhoff said.

In a 2004 NIH pilot trial of vaginal misoprostol for anembryonic gestation and fetal/embryonic demise, a single application (repeated if necessary, after 48 hours) was successful (expulsion by 1 week, without the need for D&C) in 94% of 51 cases of embryonic/fetal demise, and in 69% of 29 anembryonic gestations.

Dr. Westhoff reported findings of a randomized multicenter trial conducted under the auspices of the National Institutes of Child and Maternal Health, which enrolled 652 women with early pregnancy failure (at less than 12 weeks' gestation or size).

Two-thirds of the women were given a single 800-mcg dose of vaginal misoprostol—the other women had D&C—with a second administration if a sac or lining of more than 30 mm was still present on transvaginal ultrasound examination at day 2. Vacuum aspiration was provided on request for medical indications such as heavy bleeding, or when expulsion had not occurred within 1 week.

Expulsion was most likely to be complete by day 3 among the 30 women who had had incomplete or inevitable abortion, a pattern that held on day 8, when 93% in this group had successfully expelled the products of conception, compared with 87% of the 281 women with embryonic or fetal demise and 81% of the 177 women with anembryonic gestation.

“Women with incomplete/inevitable abortion and intrauterine fetal demise did very well with misoprostol alone; most required only one dose. The results were less impressive for anembryonic gestation,” Dr. Westhoff said.

More than 80% of participants in every category said they would recommend the procedure to a friend, if the need arose, and more than 75% said they would opt for it themselves. “Acceptance was highest in the incomplete-abortion group,” she said.

One lesson from the trial was the clinical importance of a follow-up visit 2 days after misoprostol insertion. “A number of patients had tissue in the internal os, with attendant bleeding. It needed just ring forceps for removal, but if this had not been done, some [cases] would have turned into an emergency,” Dr. Westhoff said.

Only 28% of women telephoned their medical providers during the trial, perhaps reflecting the value of counseling on what symptoms to expect, she said.

LAS VEGAS — When it comes to effective risk management in electronic fetal monitoring, step No. 1 is to adopt a set of uniform definitions for fetal heart-rate tracings, Lisa A. Miller advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If we are not speaking the same language in electronic fetal monitoring, we are not going to be able to effectively communicate,” said Ms. Miller, a certified nurse-midwife, lawyer, and perinatal risk management educator/consultant in Chicago.

Detailed guidelines for the interpretation of fetal heart-rate tracings were published 8 years ago by a panel of experts convened by the National Institute of Child Health and Human Development (Am. J. Obstet. Gynecol. 1997;177:1385ndash;90). The purpose of the effort was to develop “standardized and unambiguous definitions” for visual reading of fetal heart-rate tracings.

The panel included 16 physicians who specialized in maternal/fetal medicine or obstetrics, 1 epidemiologist, 1 NICHD physician, and 1 nursing expert.

Even though the panel clearly defined terms like baseline “variability,” “sinusoidal baseline,” and “prolonged acceleration” for use in clinical practice, Ms. Miller said that adoption of the NICHD nomenclature by clinicians during the last 8 years has been inconsistent. “It's all over the map,” she said. “In some [obstetrics] residency [programs], it's didactic. In some, it's hands-on. In some, it's a combination. In some residencies, they test for it; in some, they don't.”

She called the NICHD guidelines “the best that we have,” because they are easily teachable, they come from a panel of experts, and they're the most widely accepted in the literature.

“If you want to increase education, you want to decrease liability, and you want to make the world a better place, move to the NICHD nomenclature,” she said. “Standardization of terms can improve communication. Therefore, it should improve clinical management. We still need research on the clinical helpfulness of electronic fetal monitoring. But, she said, “meaningful research” requires that everyone use the same language.

She also advised physicians, nurses, and midwives to get their electronic fetal monitoring education together. “It is ridiculous to have the nurses going to one program and doctors going to another,” she said. “It makes absolutely no sense.”

According to the Centers for Disease Control and Prevention, 80% of American women have had some amount of electronic fetal monitoring during labor and delivery, making it the most common obstetric procedure in the United States.

LAS VEGAS — When it comes to effective risk management in electronic fetal monitoring, step No. 1 is to adopt a set of uniform definitions for fetal heart-rate tracings, Lisa A. Miller advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If we are not speaking the same language in electronic fetal monitoring, we are not going to be able to effectively communicate,” said Ms. Miller, a certified nurse-midwife, lawyer, and perinatal risk management educator/consultant in Chicago.

Detailed guidelines for the interpretation of fetal heart-rate tracings were published 8 years ago by a panel of experts convened by the National Institute of Child Health and Human Development (Am. J. Obstet. Gynecol. 1997;177:1385ndash;90). The purpose of the effort was to develop “standardized and unambiguous definitions” for visual reading of fetal heart-rate tracings.

The panel included 16 physicians who specialized in maternal/fetal medicine or obstetrics, 1 epidemiologist, 1 NICHD physician, and 1 nursing expert.

Even though the panel clearly defined terms like baseline “variability,” “sinusoidal baseline,” and “prolonged acceleration” for use in clinical practice, Ms. Miller said that adoption of the NICHD nomenclature by clinicians during the last 8 years has been inconsistent. “It's all over the map,” she said. “In some [obstetrics] residency [programs], it's didactic. In some, it's hands-on. In some, it's a combination. In some residencies, they test for it; in some, they don't.”

She called the NICHD guidelines “the best that we have,” because they are easily teachable, they come from a panel of experts, and they're the most widely accepted in the literature.

“If you want to increase education, you want to decrease liability, and you want to make the world a better place, move to the NICHD nomenclature,” she said. “Standardization of terms can improve communication. Therefore, it should improve clinical management. We still need research on the clinical helpfulness of electronic fetal monitoring. But, she said, “meaningful research” requires that everyone use the same language.

She also advised physicians, nurses, and midwives to get their electronic fetal monitoring education together. “It is ridiculous to have the nurses going to one program and doctors going to another,” she said. “It makes absolutely no sense.”

According to the Centers for Disease Control and Prevention, 80% of American women have had some amount of electronic fetal monitoring during labor and delivery, making it the most common obstetric procedure in the United States.

LAS VEGAS — When it comes to effective risk management in electronic fetal monitoring, step No. 1 is to adopt a set of uniform definitions for fetal heart-rate tracings, Lisa A. Miller advised at a conference on fetal monitoring sponsored by Symposia Medicus.

“If we are not speaking the same language in electronic fetal monitoring, we are not going to be able to effectively communicate,” said Ms. Miller, a certified nurse-midwife, lawyer, and perinatal risk management educator/consultant in Chicago.

Detailed guidelines for the interpretation of fetal heart-rate tracings were published 8 years ago by a panel of experts convened by the National Institute of Child Health and Human Development (Am. J. Obstet. Gynecol. 1997;177:1385ndash;90). The purpose of the effort was to develop “standardized and unambiguous definitions” for visual reading of fetal heart-rate tracings.

The panel included 16 physicians who specialized in maternal/fetal medicine or obstetrics, 1 epidemiologist, 1 NICHD physician, and 1 nursing expert.

Even though the panel clearly defined terms like baseline “variability,” “sinusoidal baseline,” and “prolonged acceleration” for use in clinical practice, Ms. Miller said that adoption of the NICHD nomenclature by clinicians during the last 8 years has been inconsistent. “It's all over the map,” she said. “In some [obstetrics] residency [programs], it's didactic. In some, it's hands-on. In some, it's a combination. In some residencies, they test for it; in some, they don't.”

She called the NICHD guidelines “the best that we have,” because they are easily teachable, they come from a panel of experts, and they're the most widely accepted in the literature.

“If you want to increase education, you want to decrease liability, and you want to make the world a better place, move to the NICHD nomenclature,” she said. “Standardization of terms can improve communication. Therefore, it should improve clinical management. We still need research on the clinical helpfulness of electronic fetal monitoring. But, she said, “meaningful research” requires that everyone use the same language.

She also advised physicians, nurses, and midwives to get their electronic fetal monitoring education together. “It is ridiculous to have the nurses going to one program and doctors going to another,” she said. “It makes absolutely no sense.”

According to the Centers for Disease Control and Prevention, 80% of American women have had some amount of electronic fetal monitoring during labor and delivery, making it the most common obstetric procedure in the United States.

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

“In obstetrics we have lots of information that should be recorded, but we're about 10 years behind in the health care field in our use of information technology to make us more efficient and better clinicians,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Shopping for the right perinatal computer system for your practice can be a daunting task because “all the systems are different, and you have to do a careful assessment,” Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to. It's a waste of our time,” Ms. Miller said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display with adequate size for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display” is adequate.

▸ Drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to decrease possibility of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said. “The computer should do the math for me.”

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative, whatever system you're using,” she said.

▸ Safeguard features against incomplete records. These kinds of systems provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome. For example, you should be able to generate a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group. This not-for-profit group provides forums and support for those buying perinatal computer systems. Visit www.pisug.org

Documentation Errors to Avoid

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document

▸ Incomplete charting

▸ Late entries

▸ Poor grammar and/or spelling

▸ Improper error correction

▸ Lack of standardized abbreviations

▸ Illegibility

Source: Lisa A. Miller

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

“In obstetrics we have lots of information that should be recorded, but we're about 10 years behind in the health care field in our use of information technology to make us more efficient and better clinicians,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Shopping for the right perinatal computer system for your practice can be a daunting task because “all the systems are different, and you have to do a careful assessment,” Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to. It's a waste of our time,” Ms. Miller said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display with adequate size for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display” is adequate.

▸ Drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to decrease possibility of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said. “The computer should do the math for me.”

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative, whatever system you're using,” she said.

▸ Safeguard features against incomplete records. These kinds of systems provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome. For example, you should be able to generate a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group. This not-for-profit group provides forums and support for those buying perinatal computer systems. Visit www.pisug.org

Documentation Errors to Avoid

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document

▸ Incomplete charting

▸ Late entries

▸ Poor grammar and/or spelling

▸ Improper error correction

▸ Lack of standardized abbreviations

▸ Illegibility

Source: Lisa A. Miller

LAS VEGAS — Electronic perinatal medical record keeping “has great potential for reducing errors and making our lives easier, whether you're a physician, midwife, or nurse,” Lisa A. Miller said at a conference on fetal monitoring sponsored by Symposia Medicus.

“In obstetrics we have lots of information that should be recorded, but we're about 10 years behind in the health care field in our use of information technology to make us more efficient and better clinicians,” added Ms. Miller, a Chicago-based certified nurse-midwife and lawyer who is a perinatal risk management educator and consultant.

Shopping for the right perinatal computer system for your practice can be a daunting task because “all the systems are different, and you have to do a careful assessment,” Ms. Miller said.

She listed the following features to look for when selecting a system:

▸ Secure sign-on and access.

▸ Complete record keeping from the prenatal period through hospital course of mother and baby.

▸ Integration of prenatal data into the hospital record without reentry by clinician. “How much time do you spend reentering data from a paper prenatal record into your system? There's no reason to. It's a waste of our time,” Ms. Miller said.

▸ Checklists as forced functions to avoid reliance on memory.

▸ Detailed and complete assessment data tailored to standardized definitions. “If you are going to use the National Institute of Child Health and Human Development [guidelines for fetal heart rate monitoring], you need to make sure that your system can adapt and be edited so that the terminology can be used,” she said.

▸ Display with adequate size for on-screen reading of fetal heart rate data. “You have to be able to see 10 minutes of data at real [paper strip] size or larger,” Ms. Miller said. “The small screens are fine for keeping an eye on things, but if you're reading [strips] and you've gone paperless, you need to make sure your display” is adequate.

▸ Drop-down menus with point-and-click capability that force inclusive charting.

▸ Ability to view data in multiple formats, such as timeline vs. graphic.

▸ Accurate and contemporaneous charting, with safeguards against falsification of records and accurate reflection of entry times. The record should be easy to read both on screen and when the records are printed out, Ms. Miller said.

▸ Automatic calculations to decrease possibility of error and save clinician time. “I shouldn't have to do math when I've been up for 24 hours or when I'm working a double” shift, she said. “The computer should do the math for me.”

▸ Visual cues to complete summaries with all pertinent information in the least amount of time and effort.

▸ Accurate and detailed listing of complications for labor and delivery and placenta and cord.

▸ Automatic record of newborn resuscitation for every delivery.

▸ Detailed and complete record of birth attendants and room for narrative comments. “You should always be able to pull up a box and type in a narrative, whatever system you're using,” she said.

▸ Safeguard features against incomplete records. These kinds of systems provide you with a warning sign or error message that informs you what fields you need to fill out before you can complete the record.

▸ Ability to produce statistics on any outcome. For example, you should be able to generate a report that shows how you've handled patients in the past 6 months who are positive for group B strep.

For additional information, Ms. Miller recommended contacting the Perinatal Information Systems User Group. This not-for-profit group provides forums and support for those buying perinatal computer systems. Visit www.pisug.org

Documentation Errors to Avoid

The following common documentation errors can be avoided if you choose the right electronic medical records system for your practice:

▸ Failure to document

▸ Incomplete charting

▸ Late entries

▸ Poor grammar and/or spelling

▸ Improper error correction

▸ Lack of standardized abbreviations

▸ Illegibility

Source: Lisa A. Miller

RENO, NEV. — The risk of preterm birth is not increased by occupational factors, including hours worked outside the home and jobs requiring physical exertion, Patricia C. Santiago-Munoz, M.D., and colleagues reported in a poster presentation.

These conclusions were based on a large, prospective cohort study involving 1,434 women with prior preterm births who were referred to a specialty clinic, said the researchers from the University of Texas Southwestern Medical Center in Dallas. There, the women participated in a structured interview regarding their obstetric history, their socioeconomic background, and their work outside the home. The findings were presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Other studies have reached conflicting conclusions regarding the risk of outside employment. Some studies have found associations between physically demanding work and preterm birth, while others have found no such associations.

Of the 1,434 women who participated in the study, 25% worked outside the home, and 14% experienced a recurrent preterm birth, defined as a birth at 35 weeks' gestation or less.

There was no significant difference in the risk of preterm birth among women who worked outside the home and those who did not. Among those women who worked outside the home, there was no significant difference in the risk of preterm birth among the women who had physically demanding jobs and those who did not. Nor was there a significant relationship between the number of hours worked and the likelihood of preterm birth.

Furthermore, the lack of help inside the home did not increase a patient's risk, and that risk did not vary along with the number of children cared for in the home.

RENO, NEV. — The risk of preterm birth is not increased by occupational factors, including hours worked outside the home and jobs requiring physical exertion, Patricia C. Santiago-Munoz, M.D., and colleagues reported in a poster presentation.

These conclusions were based on a large, prospective cohort study involving 1,434 women with prior preterm births who were referred to a specialty clinic, said the researchers from the University of Texas Southwestern Medical Center in Dallas. There, the women participated in a structured interview regarding their obstetric history, their socioeconomic background, and their work outside the home. The findings were presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Other studies have reached conflicting conclusions regarding the risk of outside employment. Some studies have found associations between physically demanding work and preterm birth, while others have found no such associations.

Of the 1,434 women who participated in the study, 25% worked outside the home, and 14% experienced a recurrent preterm birth, defined as a birth at 35 weeks' gestation or less.

There was no significant difference in the risk of preterm birth among women who worked outside the home and those who did not. Among those women who worked outside the home, there was no significant difference in the risk of preterm birth among the women who had physically demanding jobs and those who did not. Nor was there a significant relationship between the number of hours worked and the likelihood of preterm birth.

Furthermore, the lack of help inside the home did not increase a patient's risk, and that risk did not vary along with the number of children cared for in the home.

RENO, NEV. — The risk of preterm birth is not increased by occupational factors, including hours worked outside the home and jobs requiring physical exertion, Patricia C. Santiago-Munoz, M.D., and colleagues reported in a poster presentation.

These conclusions were based on a large, prospective cohort study involving 1,434 women with prior preterm births who were referred to a specialty clinic, said the researchers from the University of Texas Southwestern Medical Center in Dallas. There, the women participated in a structured interview regarding their obstetric history, their socioeconomic background, and their work outside the home. The findings were presented at the annual meeting of the Society for Maternal-Fetal Medicine.

Other studies have reached conflicting conclusions regarding the risk of outside employment. Some studies have found associations between physically demanding work and preterm birth, while others have found no such associations.

Of the 1,434 women who participated in the study, 25% worked outside the home, and 14% experienced a recurrent preterm birth, defined as a birth at 35 weeks' gestation or less.

There was no significant difference in the risk of preterm birth among women who worked outside the home and those who did not. Among those women who worked outside the home, there was no significant difference in the risk of preterm birth among the women who had physically demanding jobs and those who did not. Nor was there a significant relationship between the number of hours worked and the likelihood of preterm birth.

Furthermore, the lack of help inside the home did not increase a patient's risk, and that risk did not vary along with the number of children cared for in the home.

SAN ANTONIO — Pregnant women with asthma take less asthma medication than do nonpregnant women with asthma, according to a new study that did not measure the effect of the medication reduction.

“Whether they stopped taking their medications because their symptoms improved, or whether they were reluctant to take their medications, we don't know,” lead investigator Ami Degala, M.D., told this newspaper.

Research shows that among women with asthma, about one-third get better during pregnancy. In addition, asthma symptoms worsen in one-third and remain the same in another third. But physicians and pregnant women alike are often conservative with asthma medication during pregnancy to avoid overexposing the fetus, said Dr. Degala, a fellow in allergy and clinical immunology at Henry Ford Hospital in Detroit.

In her study, which was presented as a poster at the annual meeting of the American Academy of Asthma, Allergy, and Immunology, the asthma medication refill habits of 240 women with asthma were observed for a 1-year surveillance period.

After this time, the refill habits of 80 women who became pregnant were compared during the last two trimesters with the refill habits of 160 nonpregnant participants who were assigned matched delivery dates.

Among women who did not take their controller medication during the surveillance period, only 9% started taking the medication when they became pregnant, compared with 22% of the nonpregnant controls during this same period. And 25% of the pregnant women used their rescue medication, compared with 59% of controls.

A similar pattern was seen among women who did take their controller medication during the surveillance period, with only 33% of pregnant women continuing their controller medications, compared with 59% of controls, and 52% of pregnant women continuing their rescue medications, compared with 62% of controls.

Overall, there was a statistically significant difference between pregnant women and controls in the reduction in medication between the surveillance and pregnancy periods. Medication refills were reduced by 43% in pregnant women over this period, while they were reduced by 15% in controls.

Although there is evidence that oral corticosteroids can have adverse effects on the fetus, there is no such evidence for β-agonists, inhaled corticosteroids, or even theophylline, Dr. Degala said.

In contrast, there is evidence of both fetal and maternal risks in undertreating asthma.

“There's a risk of fetal and maternal hypoxia, and studies also show an increased risk of perinatal mortality and low birth weight,” she said.

SAN ANTONIO — Pregnant women with asthma take less asthma medication than do nonpregnant women with asthma, according to a new study that did not measure the effect of the medication reduction.

“Whether they stopped taking their medications because their symptoms improved, or whether they were reluctant to take their medications, we don't know,” lead investigator Ami Degala, M.D., told this newspaper.

Research shows that among women with asthma, about one-third get better during pregnancy. In addition, asthma symptoms worsen in one-third and remain the same in another third. But physicians and pregnant women alike are often conservative with asthma medication during pregnancy to avoid overexposing the fetus, said Dr. Degala, a fellow in allergy and clinical immunology at Henry Ford Hospital in Detroit.

In her study, which was presented as a poster at the annual meeting of the American Academy of Asthma, Allergy, and Immunology, the asthma medication refill habits of 240 women with asthma were observed for a 1-year surveillance period.

After this time, the refill habits of 80 women who became pregnant were compared during the last two trimesters with the refill habits of 160 nonpregnant participants who were assigned matched delivery dates.

Among women who did not take their controller medication during the surveillance period, only 9% started taking the medication when they became pregnant, compared with 22% of the nonpregnant controls during this same period. And 25% of the pregnant women used their rescue medication, compared with 59% of controls.

A similar pattern was seen among women who did take their controller medication during the surveillance period, with only 33% of pregnant women continuing their controller medications, compared with 59% of controls, and 52% of pregnant women continuing their rescue medications, compared with 62% of controls.

Overall, there was a statistically significant difference between pregnant women and controls in the reduction in medication between the surveillance and pregnancy periods. Medication refills were reduced by 43% in pregnant women over this period, while they were reduced by 15% in controls.

Although there is evidence that oral corticosteroids can have adverse effects on the fetus, there is no such evidence for β-agonists, inhaled corticosteroids, or even theophylline, Dr. Degala said.

In contrast, there is evidence of both fetal and maternal risks in undertreating asthma.

“There's a risk of fetal and maternal hypoxia, and studies also show an increased risk of perinatal mortality and low birth weight,” she said.

SAN ANTONIO — Pregnant women with asthma take less asthma medication than do nonpregnant women with asthma, according to a new study that did not measure the effect of the medication reduction.

“Whether they stopped taking their medications because their symptoms improved, or whether they were reluctant to take their medications, we don't know,” lead investigator Ami Degala, M.D., told this newspaper.

Research shows that among women with asthma, about one-third get better during pregnancy. In addition, asthma symptoms worsen in one-third and remain the same in another third. But physicians and pregnant women alike are often conservative with asthma medication during pregnancy to avoid overexposing the fetus, said Dr. Degala, a fellow in allergy and clinical immunology at Henry Ford Hospital in Detroit.

In her study, which was presented as a poster at the annual meeting of the American Academy of Asthma, Allergy, and Immunology, the asthma medication refill habits of 240 women with asthma were observed for a 1-year surveillance period.

After this time, the refill habits of 80 women who became pregnant were compared during the last two trimesters with the refill habits of 160 nonpregnant participants who were assigned matched delivery dates.

Among women who did not take their controller medication during the surveillance period, only 9% started taking the medication when they became pregnant, compared with 22% of the nonpregnant controls during this same period. And 25% of the pregnant women used their rescue medication, compared with 59% of controls.

A similar pattern was seen among women who did take their controller medication during the surveillance period, with only 33% of pregnant women continuing their controller medications, compared with 59% of controls, and 52% of pregnant women continuing their rescue medications, compared with 62% of controls.

Overall, there was a statistically significant difference between pregnant women and controls in the reduction in medication between the surveillance and pregnancy periods. Medication refills were reduced by 43% in pregnant women over this period, while they were reduced by 15% in controls.

Although there is evidence that oral corticosteroids can have adverse effects on the fetus, there is no such evidence for β-agonists, inhaled corticosteroids, or even theophylline, Dr. Degala said.

In contrast, there is evidence of both fetal and maternal risks in undertreating asthma.

“There's a risk of fetal and maternal hypoxia, and studies also show an increased risk of perinatal mortality and low birth weight,” she said.

LOS ANGELES — A pregnant smoker who cuts back just one cigarette a day in her third trimester can hope to increase her newborn's birth weight by24 g, according to a prospective study reported at the annual meeting of the Society for Gynecologic Investigation.

“The message is, Keep at 'em. Don't stop trying to get women to reduce their smoking volume,” said Ira M. Bernstein, M.D., who presented data on 160 women and their offspring.

The mothers were enrolled in a randomized, prospective trial of a voucher system designed to help pregnant women stop smoking or stay cigarette free. Dr. Bernstein of the University of Vermont, Burlington, said investigators determined a woman's smoking volume by a combination of self-reports, and measurement of urinary cotinine and exhaled carbon monoxide.

Before pregnancy, the group averaged 18.2 cigarettes a day. They had already cut down to 6.7 cigarettes per day by the time they enrolled in the study, which was at 12 weeks' gestation on average. By 28 weeks, they were down to 4.8 cigarettes daily.

All had singleton pregnancies with a mean birth weight of 3,266 g. The mean gestational age at delivery was 38.6 weeks, with 17 babies born preterm. Stepwise multivariate regression analysis found smoking in the third trimester accounted for 10% of variance in birth weight. Dr. Bernstein reported a linear relationship in which babies weighed 24 g less at birth for every cigarette their mothers smoked per day in the third trimester.

“The literature is mixed. Some data say the first trimester is critical. These data support that the third trimester is more important,” he said.

The National Institutes of Health and a General Clinical Research Center grant supported the study.

LOS ANGELES — A pregnant smoker who cuts back just one cigarette a day in her third trimester can hope to increase her newborn's birth weight by24 g, according to a prospective study reported at the annual meeting of the Society for Gynecologic Investigation.

“The message is, Keep at 'em. Don't stop trying to get women to reduce their smoking volume,” said Ira M. Bernstein, M.D., who presented data on 160 women and their offspring.

The mothers were enrolled in a randomized, prospective trial of a voucher system designed to help pregnant women stop smoking or stay cigarette free. Dr. Bernstein of the University of Vermont, Burlington, said investigators determined a woman's smoking volume by a combination of self-reports, and measurement of urinary cotinine and exhaled carbon monoxide.

Before pregnancy, the group averaged 18.2 cigarettes a day. They had already cut down to 6.7 cigarettes per day by the time they enrolled in the study, which was at 12 weeks' gestation on average. By 28 weeks, they were down to 4.8 cigarettes daily.

All had singleton pregnancies with a mean birth weight of 3,266 g. The mean gestational age at delivery was 38.6 weeks, with 17 babies born preterm. Stepwise multivariate regression analysis found smoking in the third trimester accounted for 10% of variance in birth weight. Dr. Bernstein reported a linear relationship in which babies weighed 24 g less at birth for every cigarette their mothers smoked per day in the third trimester.

“The literature is mixed. Some data say the first trimester is critical. These data support that the third trimester is more important,” he said.

The National Institutes of Health and a General Clinical Research Center grant supported the study.

LOS ANGELES — A pregnant smoker who cuts back just one cigarette a day in her third trimester can hope to increase her newborn's birth weight by24 g, according to a prospective study reported at the annual meeting of the Society for Gynecologic Investigation.

“The message is, Keep at 'em. Don't stop trying to get women to reduce their smoking volume,” said Ira M. Bernstein, M.D., who presented data on 160 women and their offspring.

The mothers were enrolled in a randomized, prospective trial of a voucher system designed to help pregnant women stop smoking or stay cigarette free. Dr. Bernstein of the University of Vermont, Burlington, said investigators determined a woman's smoking volume by a combination of self-reports, and measurement of urinary cotinine and exhaled carbon monoxide.

Before pregnancy, the group averaged 18.2 cigarettes a day. They had already cut down to 6.7 cigarettes per day by the time they enrolled in the study, which was at 12 weeks' gestation on average. By 28 weeks, they were down to 4.8 cigarettes daily.

All had singleton pregnancies with a mean birth weight of 3,266 g. The mean gestational age at delivery was 38.6 weeks, with 17 babies born preterm. Stepwise multivariate regression analysis found smoking in the third trimester accounted for 10% of variance in birth weight. Dr. Bernstein reported a linear relationship in which babies weighed 24 g less at birth for every cigarette their mothers smoked per day in the third trimester.

“The literature is mixed. Some data say the first trimester is critical. These data support that the third trimester is more important,” he said.

The National Institutes of Health and a General Clinical Research Center grant supported the study.

NEWPORT BEACH, CALIF. — When a new mother reports having infanticidal thoughts, how should one decide whether she poses an imminent danger to the child? The key is to assess several risk factors, Gagan Dhaliwal, M.D., said at the annual meeting of the American College of Forensic Psychiatry.

Dr. Dhaliwal, of the University of South Alabama, Mobile, discussed the hypothetical case of a 19-year-old woman with a 2-week-old son who is seen in an outpatient psychiatric clinic. She reports feeling depressed and lacking energy, and has a loss of appetite and frequent crying spells. She says she's not being a good mother and has thoughts of killing her son.

“First of all, we have to figure out whether these thoughts are in the context of psychosis,” Dr. Dhaliwal said. Upon further questioning, the woman reported that she felt suspicious of others and cannot trust other people. She says that she hears a voice in her head saying, “do it,” a command hallucination related to hurting her son.

The woman says she lives alone, is not sure of the identity of the child's father, and doesn't want to involve her family. She's concerned that her child will be taken away if she's admitted for inpatient treatment, but she agrees to take medication as an outpatient.

At this point there's sufficient cause to break confidentiality and contact the woman's family, Dr. Dhaliwal said. The family reports the woman had been taking medication for bipolar disorder but discontinued it during pregnancy.

Now the physician must answer several questions. Does the woman have a mental illness? Clearly she does, because of her previous history of bipolar disorder.

But is she imminently dangerous to her child? Should inpatient or outpatient treatment be recommended? Should she be committed involuntarily? How does one weigh the issue of mother-child privacy, compared with the governmental intrusion that would be involved in involuntary treatment? What effect would involuntary commitment have on the mother-child relationship? Is that presumably deleterious effect enough to outweigh the mother's potential dangerousness to the child?

Clearly, there's no reason to commit all mothers with aggressive or infanticidal thoughts. Studies have shown that many women post partum have obsessive thoughts about harming their children. The physician must differentiate those common obsessive thoughts from true psychosis, which involves a loss of touch with reality.

The mother with obsessions will attempt to suppress these obsessions and generally recognizes they're products of her own mind. The psychotic mother, believes the thoughts are imposed by an outside force.

In the hypothetical case, the woman's history, her command hallucinations, and her lack of insight argue for psychosis. She also has other risk factors linked with infanticide.

Among the risk factors identified in one study are maternal age less than 17 (relative risk 10.9), second or subsequent-born infants (relative risk 9.3), lack of prenatal care (relative risk 10.3), and low education levels (relative risk about 8 for women who did not complete high school) (N. Engl. J. Med. 1998;339:1211ndash;6).

Other factors that increase the risk are substance abuse; a history of major mental illness, especially major depression or bipolar disorder; a family history of psychiatric illness; childhood abuse; self-doubt as a mother; poverty, a poor support system; and an unavailable partner.

The hypothetical woman doesn't exhibit all of those risk factors. But Dr. Dhaliwal says she exhibits enough to warrant involuntary commitment.

NEWPORT BEACH, CALIF. — When a new mother reports having infanticidal thoughts, how should one decide whether she poses an imminent danger to the child? The key is to assess several risk factors, Gagan Dhaliwal, M.D., said at the annual meeting of the American College of Forensic Psychiatry.

Dr. Dhaliwal, of the University of South Alabama, Mobile, discussed the hypothetical case of a 19-year-old woman with a 2-week-old son who is seen in an outpatient psychiatric clinic. She reports feeling depressed and lacking energy, and has a loss of appetite and frequent crying spells. She says she's not being a good mother and has thoughts of killing her son.

“First of all, we have to figure out whether these thoughts are in the context of psychosis,” Dr. Dhaliwal said. Upon further questioning, the woman reported that she felt suspicious of others and cannot trust other people. She says that she hears a voice in her head saying, “do it,” a command hallucination related to hurting her son.

The woman says she lives alone, is not sure of the identity of the child's father, and doesn't want to involve her family. She's concerned that her child will be taken away if she's admitted for inpatient treatment, but she agrees to take medication as an outpatient.

At this point there's sufficient cause to break confidentiality and contact the woman's family, Dr. Dhaliwal said. The family reports the woman had been taking medication for bipolar disorder but discontinued it during pregnancy.

Now the physician must answer several questions. Does the woman have a mental illness? Clearly she does, because of her previous history of bipolar disorder.

But is she imminently dangerous to her child? Should inpatient or outpatient treatment be recommended? Should she be committed involuntarily? How does one weigh the issue of mother-child privacy, compared with the governmental intrusion that would be involved in involuntary treatment? What effect would involuntary commitment have on the mother-child relationship? Is that presumably deleterious effect enough to outweigh the mother's potential dangerousness to the child?

Clearly, there's no reason to commit all mothers with aggressive or infanticidal thoughts. Studies have shown that many women post partum have obsessive thoughts about harming their children. The physician must differentiate those common obsessive thoughts from true psychosis, which involves a loss of touch with reality.

The mother with obsessions will attempt to suppress these obsessions and generally recognizes they're products of her own mind. The psychotic mother, believes the thoughts are imposed by an outside force.

In the hypothetical case, the woman's history, her command hallucinations, and her lack of insight argue for psychosis. She also has other risk factors linked with infanticide.

Among the risk factors identified in one study are maternal age less than 17 (relative risk 10.9), second or subsequent-born infants (relative risk 9.3), lack of prenatal care (relative risk 10.3), and low education levels (relative risk about 8 for women who did not complete high school) (N. Engl. J. Med. 1998;339:1211ndash;6).

Other factors that increase the risk are substance abuse; a history of major mental illness, especially major depression or bipolar disorder; a family history of psychiatric illness; childhood abuse; self-doubt as a mother; poverty, a poor support system; and an unavailable partner.

The hypothetical woman doesn't exhibit all of those risk factors. But Dr. Dhaliwal says she exhibits enough to warrant involuntary commitment.

NEWPORT BEACH, CALIF. — When a new mother reports having infanticidal thoughts, how should one decide whether she poses an imminent danger to the child? The key is to assess several risk factors, Gagan Dhaliwal, M.D., said at the annual meeting of the American College of Forensic Psychiatry.

Dr. Dhaliwal, of the University of South Alabama, Mobile, discussed the hypothetical case of a 19-year-old woman with a 2-week-old son who is seen in an outpatient psychiatric clinic. She reports feeling depressed and lacking energy, and has a loss of appetite and frequent crying spells. She says she's not being a good mother and has thoughts of killing her son.

“First of all, we have to figure out whether these thoughts are in the context of psychosis,” Dr. Dhaliwal said. Upon further questioning, the woman reported that she felt suspicious of others and cannot trust other people. She says that she hears a voice in her head saying, “do it,” a command hallucination related to hurting her son.

The woman says she lives alone, is not sure of the identity of the child's father, and doesn't want to involve her family. She's concerned that her child will be taken away if she's admitted for inpatient treatment, but she agrees to take medication as an outpatient.

At this point there's sufficient cause to break confidentiality and contact the woman's family, Dr. Dhaliwal said. The family reports the woman had been taking medication for bipolar disorder but discontinued it during pregnancy.

Now the physician must answer several questions. Does the woman have a mental illness? Clearly she does, because of her previous history of bipolar disorder.

But is she imminently dangerous to her child? Should inpatient or outpatient treatment be recommended? Should she be committed involuntarily? How does one weigh the issue of mother-child privacy, compared with the governmental intrusion that would be involved in involuntary treatment? What effect would involuntary commitment have on the mother-child relationship? Is that presumably deleterious effect enough to outweigh the mother's potential dangerousness to the child?

Clearly, there's no reason to commit all mothers with aggressive or infanticidal thoughts. Studies have shown that many women post partum have obsessive thoughts about harming their children. The physician must differentiate those common obsessive thoughts from true psychosis, which involves a loss of touch with reality.

The mother with obsessions will attempt to suppress these obsessions and generally recognizes they're products of her own mind. The psychotic mother, believes the thoughts are imposed by an outside force.

In the hypothetical case, the woman's history, her command hallucinations, and her lack of insight argue for psychosis. She also has other risk factors linked with infanticide.

Among the risk factors identified in one study are maternal age less than 17 (relative risk 10.9), second or subsequent-born infants (relative risk 9.3), lack of prenatal care (relative risk 10.3), and low education levels (relative risk about 8 for women who did not complete high school) (N. Engl. J. Med. 1998;339:1211ndash;6).

Other factors that increase the risk are substance abuse; a history of major mental illness, especially major depression or bipolar disorder; a family history of psychiatric illness; childhood abuse; self-doubt as a mother; poverty, a poor support system; and an unavailable partner.

The hypothetical woman doesn't exhibit all of those risk factors. But Dr. Dhaliwal says she exhibits enough to warrant involuntary commitment.