Obstetrics

NEW YORK — Nonpharmacologic treatments are particularly worth considering when mood problems develop during pregnancy and in the postpartum period, Linda S. Mullen, M.D., said at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

Medication should not be dismissed as an option, however, and is generally preferable when symptoms are severe.

Pregnancy itself appears to be neither a time of particular mental well-being nor vulnerability; surveys find that about 20% of women suffer from mood or anxiety disorders at this time, essentially the same proportion as women in general, said Dr. Mullen, director of women's mental health at the university and the hospital.

But such difficulties clearly are more common in the postpartum period and run along a spectrum of severity from “baby blues” to psychosis.

“Postpartum blues” are extremely common, affecting 50%ndash;85% of women. Rather than depression, typical symptoms are mood lability, anxiety, irritability, and difficulty in eating, sleeping, and caring for oneself and the baby. These symptoms may be troubling, but do not interfere markedly with functioning; they usually peak 4ndash;5 days post partum and resolve by day 10.

“Reassurance rather than treatment is generally enough,” Dr. Mullen said. But if difficulties persist for at least 2 weeks, an evaluation for serious mood disorder is in order.

About one-fourth of women with postpartum blues later develop clinically significant depression, she said.

Postpartum depression actually can emerge any time within 2ndash;3 months of childbirth. It is clinically indistinguishable from depression generally and may include comorbid anxiety syndromes such as panic, obsessive-compulsive disorder, or generalized anxiety.

“Many women don't come to see the physician until late; they think what they experience is a normal part of the postpartum, or feel ashamed at their difficulties in caring for their baby,” Dr. Mullen said.

Unlike depression in other groups, age, marital status, education level, and socioeconomic status are not associated with increased prevalence, but marital problems, inadequate social support, and recent stressful life events are major risk factors. Women with a history of depression also are at increased risk, she said.

Treatment depends in part on severity. For mild to moderate symptoms, certain types of psychotherapy seem as effective as medication and are preferred by many women, particularly those who are breastfeeding.

Cognitive-behavioral therapy, in particular, has been shown to be as effective as fluoxetine. Interpersonal therapy, which focuses on relationship issues, has also been found efficacious in mild to moderate depression in the postpartum. “It may be especially useful for women with marital difficulties,” Dr. Mullen said.

Couples therapy and group therapy are also helpful, and there is some evidence that psychoeducational groups for pregnant women at risk may prevent postpartum depression. Psychosocial management should include interventions to increase social support and help with childcare, she said.

Light therapy appears to be effective for depression during pregnancy, and may be helpful in the postpartum as well.

When medication is necessary or preferred, conventional antidepressants at standard doses are as efficacious for postpartum depression as for depression generally. Selective serotonin reuptake inhibitors are the agents of choice, and benzodiazepines may be added for concurrent anxiety, particularly in the first weeks of treatment.

The addition of psychotherapy actually makes medication more effective, Dr. Mullen said.

NEW YORK — Nonpharmacologic treatments are particularly worth considering when mood problems develop during pregnancy and in the postpartum period, Linda S. Mullen, M.D., said at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

Medication should not be dismissed as an option, however, and is generally preferable when symptoms are severe.

Pregnancy itself appears to be neither a time of particular mental well-being nor vulnerability; surveys find that about 20% of women suffer from mood or anxiety disorders at this time, essentially the same proportion as women in general, said Dr. Mullen, director of women's mental health at the university and the hospital.

But such difficulties clearly are more common in the postpartum period and run along a spectrum of severity from “baby blues” to psychosis.

“Postpartum blues” are extremely common, affecting 50%ndash;85% of women. Rather than depression, typical symptoms are mood lability, anxiety, irritability, and difficulty in eating, sleeping, and caring for oneself and the baby. These symptoms may be troubling, but do not interfere markedly with functioning; they usually peak 4ndash;5 days post partum and resolve by day 10.

“Reassurance rather than treatment is generally enough,” Dr. Mullen said. But if difficulties persist for at least 2 weeks, an evaluation for serious mood disorder is in order.

About one-fourth of women with postpartum blues later develop clinically significant depression, she said.

Postpartum depression actually can emerge any time within 2ndash;3 months of childbirth. It is clinically indistinguishable from depression generally and may include comorbid anxiety syndromes such as panic, obsessive-compulsive disorder, or generalized anxiety.

“Many women don't come to see the physician until late; they think what they experience is a normal part of the postpartum, or feel ashamed at their difficulties in caring for their baby,” Dr. Mullen said.

Unlike depression in other groups, age, marital status, education level, and socioeconomic status are not associated with increased prevalence, but marital problems, inadequate social support, and recent stressful life events are major risk factors. Women with a history of depression also are at increased risk, she said.

Treatment depends in part on severity. For mild to moderate symptoms, certain types of psychotherapy seem as effective as medication and are preferred by many women, particularly those who are breastfeeding.

Cognitive-behavioral therapy, in particular, has been shown to be as effective as fluoxetine. Interpersonal therapy, which focuses on relationship issues, has also been found efficacious in mild to moderate depression in the postpartum. “It may be especially useful for women with marital difficulties,” Dr. Mullen said.

Couples therapy and group therapy are also helpful, and there is some evidence that psychoeducational groups for pregnant women at risk may prevent postpartum depression. Psychosocial management should include interventions to increase social support and help with childcare, she said.

Light therapy appears to be effective for depression during pregnancy, and may be helpful in the postpartum as well.

When medication is necessary or preferred, conventional antidepressants at standard doses are as efficacious for postpartum depression as for depression generally. Selective serotonin reuptake inhibitors are the agents of choice, and benzodiazepines may be added for concurrent anxiety, particularly in the first weeks of treatment.

The addition of psychotherapy actually makes medication more effective, Dr. Mullen said.

NEW YORK — Nonpharmacologic treatments are particularly worth considering when mood problems develop during pregnancy and in the postpartum period, Linda S. Mullen, M.D., said at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

Medication should not be dismissed as an option, however, and is generally preferable when symptoms are severe.

Pregnancy itself appears to be neither a time of particular mental well-being nor vulnerability; surveys find that about 20% of women suffer from mood or anxiety disorders at this time, essentially the same proportion as women in general, said Dr. Mullen, director of women's mental health at the university and the hospital.

But such difficulties clearly are more common in the postpartum period and run along a spectrum of severity from “baby blues” to psychosis.

“Postpartum blues” are extremely common, affecting 50%ndash;85% of women. Rather than depression, typical symptoms are mood lability, anxiety, irritability, and difficulty in eating, sleeping, and caring for oneself and the baby. These symptoms may be troubling, but do not interfere markedly with functioning; they usually peak 4ndash;5 days post partum and resolve by day 10.

“Reassurance rather than treatment is generally enough,” Dr. Mullen said. But if difficulties persist for at least 2 weeks, an evaluation for serious mood disorder is in order.

About one-fourth of women with postpartum blues later develop clinically significant depression, she said.

Postpartum depression actually can emerge any time within 2ndash;3 months of childbirth. It is clinically indistinguishable from depression generally and may include comorbid anxiety syndromes such as panic, obsessive-compulsive disorder, or generalized anxiety.

“Many women don't come to see the physician until late; they think what they experience is a normal part of the postpartum, or feel ashamed at their difficulties in caring for their baby,” Dr. Mullen said.

Unlike depression in other groups, age, marital status, education level, and socioeconomic status are not associated with increased prevalence, but marital problems, inadequate social support, and recent stressful life events are major risk factors. Women with a history of depression also are at increased risk, she said.

Treatment depends in part on severity. For mild to moderate symptoms, certain types of psychotherapy seem as effective as medication and are preferred by many women, particularly those who are breastfeeding.

Cognitive-behavioral therapy, in particular, has been shown to be as effective as fluoxetine. Interpersonal therapy, which focuses on relationship issues, has also been found efficacious in mild to moderate depression in the postpartum. “It may be especially useful for women with marital difficulties,” Dr. Mullen said.

Couples therapy and group therapy are also helpful, and there is some evidence that psychoeducational groups for pregnant women at risk may prevent postpartum depression. Psychosocial management should include interventions to increase social support and help with childcare, she said.

Light therapy appears to be effective for depression during pregnancy, and may be helpful in the postpartum as well.

When medication is necessary or preferred, conventional antidepressants at standard doses are as efficacious for postpartum depression as for depression generally. Selective serotonin reuptake inhibitors are the agents of choice, and benzodiazepines may be added for concurrent anxiety, particularly in the first weeks of treatment.

The addition of psychotherapy actually makes medication more effective, Dr. Mullen said.

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003 while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5).

Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

Despite greater risk of major complications, Dr. Lipkind said she would consider VBAC in women who choose labor over a repeat cesarean. “You have to talk to each patient and find out what they want, and look at indications why they had a previous section, and look at risks and benefits like anything else,” she said.

Dr. Lipkind said the study underscored the importance of counseling women undergoing their first C-section about the risks they would face if they become pregnant again.

“I think you really have to talk about family planning and how many children people want to have when they start,” she concluded.

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003 while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5).

Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

Despite greater risk of major complications, Dr. Lipkind said she would consider VBAC in women who choose labor over a repeat cesarean. “You have to talk to each patient and find out what they want, and look at indications why they had a previous section, and look at risks and benefits like anything else,” she said.

Dr. Lipkind said the study underscored the importance of counseling women undergoing their first C-section about the risks they would face if they become pregnant again.

“I think you really have to talk about family planning and how many children people want to have when they start,” she concluded.

LOS ANGELES — Women who choose vaginal birth after a cesarean section have a 2.5 times greater risk of major complications than if they were to opt for a second elective cesarean section, according to a poster presentation at the annual meeting of the Society for Gynecologic Investigation.

The adjusted odds ratio of 2.5 for major morbidities comes from a retrospective cohort study, comparing 5,299 women who attempted vaginal birth after a cesarean (VBAC) section with 4,065 women who elected a second cesarean delivery. Major complications occurred in 295 women (6%) in the VBAC group and 101 women (3%) who delivered by a second C-section.

“I think we are … seeing a swing where more people are getting sectioned, and now we are going to see complications from the sections,” investigator Heather S. Lipkind, M.D., said in presenting the data.

Cesarean deliveries accounted for 27.3% of all births in 2003 while the VBAC rate plunged to a low of 10.6%, according to Dr. Lipkind, a fellow in maternal-fetal medicine at Columbia University College of Physicians and Surgeons in New York City, and her colleagues.

Dr. Lipkind and her associates reported that numerous studies have looked at VBAC complication rates, but none has been a randomized, controlled trial. Therefore, the researchers used propensity scores, a statistical technique, to approximate a trial by controlling for confounders resulting from the nonrandomized assignment of women to the VBAC or repeat C-section cohorts.

The patients came from a 5-year database of births at 17 university and community hospitals. All had a single gestation and one prior low-transverse cesarean delivery. None had previously given birth vaginally. Dr. Lipkind said the success rate was 68% for the women who attempted VBAC.

Rupture was the most common major complication, occurring in 106 (2%) VBAC patients, compared with 19 (less than 1%) patients who elected C-sections (adjusted odds ratio 4.8).

Although the other major complications occurred in less than 1% of both groups, bladder injury more than tripled in the VBAC cohort; it occurred in 27 VBACs and 7 repeat C-sections (adjusted odds ratio 3.5).

Other major complications were hemorrhage (29 VBACs vs. 17 repeat cesareans; adjusted odds ratio 1.5) and abruption (65 VBACs vs. 39 repeat cesareans: adjusted odds ratio 1.4).

Minor complications were similar between groups: 757 (14%) in the VBAC cohort and 489 (12%) in the elective C-section patients (adjusted odds ratio 1.0). Fever was the most common, occurring in 626 (12%) women who chose VBAC and 424 (10%) women who had repeat C-sections (adjusted odds ratio 0.9).

Despite greater risk of major complications, Dr. Lipkind said she would consider VBAC in women who choose labor over a repeat cesarean. “You have to talk to each patient and find out what they want, and look at indications why they had a previous section, and look at risks and benefits like anything else,” she said.

Dr. Lipkind said the study underscored the importance of counseling women undergoing their first C-section about the risks they would face if they become pregnant again.

“I think you really have to talk about family planning and how many children people want to have when they start,” she concluded.

RENO, NEV. — Increased maternal morbidity is significantly associated with magnesium sulfate tocolysis that lasts longer than 48 hours, a retrospective study has demonstrated.

Investigators compared 78 women who received MgSO4 tocolysis for longer than 48 hours with 77 women who received MgSO4 tocolysis for 48 hours or less. Women who received prolonged tocolysis were significantly more likely to have at least one adverse event (56.4% vs. 28.5%).

The most common adverse events were chest tightness, pulmonary edema, and visual disturbances, investigators wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Babies born to the two groups of mothers had similar Apgar scores, hypotonia, and neonatal mortality rates. But babies born to women who underwent prolonged tocolysis had significantly higher magnesium levels, averaging 3.6 mg/dL, compared with 2.8 mg/dL for babies born to control women, reported Anwar Nassar, M.D., and colleagues at the American University of Beirut (Lebanon).

In addition, three infants born to mothers who had received large amounts of MgSO4 showed radiolucent bones and metaphyseal widening, evidence of abnormal bone mineralization.

“Given the scarcity of evidence of its effectiveness as a tocolytic and the potential of significant adverse effects on the mother and neonate, aggressive attempts at prolonging pregnancy with intravenous magnesium sulfate are unjustifiable,” the investigators wrote.

RENO, NEV. — Increased maternal morbidity is significantly associated with magnesium sulfate tocolysis that lasts longer than 48 hours, a retrospective study has demonstrated.

Investigators compared 78 women who received MgSO4 tocolysis for longer than 48 hours with 77 women who received MgSO4 tocolysis for 48 hours or less. Women who received prolonged tocolysis were significantly more likely to have at least one adverse event (56.4% vs. 28.5%).

The most common adverse events were chest tightness, pulmonary edema, and visual disturbances, investigators wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Babies born to the two groups of mothers had similar Apgar scores, hypotonia, and neonatal mortality rates. But babies born to women who underwent prolonged tocolysis had significantly higher magnesium levels, averaging 3.6 mg/dL, compared with 2.8 mg/dL for babies born to control women, reported Anwar Nassar, M.D., and colleagues at the American University of Beirut (Lebanon).

In addition, three infants born to mothers who had received large amounts of MgSO4 showed radiolucent bones and metaphyseal widening, evidence of abnormal bone mineralization.

“Given the scarcity of evidence of its effectiveness as a tocolytic and the potential of significant adverse effects on the mother and neonate, aggressive attempts at prolonging pregnancy with intravenous magnesium sulfate are unjustifiable,” the investigators wrote.

RENO, NEV. — Increased maternal morbidity is significantly associated with magnesium sulfate tocolysis that lasts longer than 48 hours, a retrospective study has demonstrated.

Investigators compared 78 women who received MgSO4 tocolysis for longer than 48 hours with 77 women who received MgSO4 tocolysis for 48 hours or less. Women who received prolonged tocolysis were significantly more likely to have at least one adverse event (56.4% vs. 28.5%).

The most common adverse events were chest tightness, pulmonary edema, and visual disturbances, investigators wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Babies born to the two groups of mothers had similar Apgar scores, hypotonia, and neonatal mortality rates. But babies born to women who underwent prolonged tocolysis had significantly higher magnesium levels, averaging 3.6 mg/dL, compared with 2.8 mg/dL for babies born to control women, reported Anwar Nassar, M.D., and colleagues at the American University of Beirut (Lebanon).

In addition, three infants born to mothers who had received large amounts of MgSO4 showed radiolucent bones and metaphyseal widening, evidence of abnormal bone mineralization.

“Given the scarcity of evidence of its effectiveness as a tocolytic and the potential of significant adverse effects on the mother and neonate, aggressive attempts at prolonging pregnancy with intravenous magnesium sulfate are unjustifiable,” the investigators wrote.

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

HOUSTON — Pregnant women should be treated for human immunodeficiency virus infections even if they are asymptomatic with normal CD4 counts and have a low viral load, said Hunter A. Hammill, M.D.

Pregnancy itself does not affect the course of the disease. The woman's condition will not become worse, but the baby is at risk, he said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

“Optimum therapy should be offered to minimize vertical transmission to the infant,” said Dr. Hammill of the college.

Infants of HIV-positive mothers will test positive for 6-8 weeks after birth. Without treatment, about one-third will be infected and remain positive. Breast-feeding can increase the vertical infection rate by 20%.

Studies summarized by Dr. Hammill have reported transmission rates of less than 1%-13% when various therapies were tested in pregnant women. “My series is now down to less than a tenth of a percent vertical transmission with vaginal delivery when treating with HAART [Highly Active Antiretroviral Therapy],” he said.

Dr. Hammill urged practitioners to get up to date on new antiretroviral treatments. About 30 different treatment options are available, he said, and these are typically given in three-drug combinations.

Patients have to be monitored as some agents will have side effects. Among these, he listed unusual dreams, yellow skin, liver and renal toxicities, and nausea lasting several weeks until the patient's body adapts.

Some HAART drugs do pose special risks. He cited rash and hepatic toxicity with nevirapine (Viramune), hyperglycemia with protease inhibitors, and mitochondrial toxicity with nucleoside analogs.

His greatest concern is efavirenz (Sustiva), which is sometimes prescribed because it is considered safe in pregnancy. Because one animal study has linked it to monkey anencephaly, Dr. Hammill said he switches his patients to another drug.

“If you see an HIV patient on Sustiva, please think of birth control,” he said.

Dr. Hammill also urged physicians to provide intensive counseling about the importance of complying with treatment. “The big thing in AIDS is adherence,” he said. “If you don't take the drug, it doesn't work.”

GRAPEVINE, TEX. — Patients referred for genetic testing are more likely to agree to carrier status testing if they already have accepted an invasive procedure.

A study of 3,131 patients referred for genetic testing found that individuals were more likely to accept cystic fibrosis carrier testing and were more likely to accept both CF and fragile X syndrome (FXS) carrier testing if they underwent an invasive procedure such as amniocentesis.

“Patients who underwent such a procedure were more than twice as likely to accept both screening tests, compared with patients who had declined invasive testing, said Amy Cronister, the study's lead author and regional manager of genetic services, Genzyme Genetics, Phoenix, Ariz.

This finding suggests that there may be specific populations of patients who generally tend to avoid genetic testing, and other populations for whom the concept of genetic testing is much more acceptable, she said at a meeting sponsored by the American College of Medical Genetics.

Overall, 33% of referrals agreed to carrier status testing for CF and 28% for FXS; 25% accepted CF and FXS testing; and 64% declined both. Significantly fewer (11%) accepted one test but declined the other.

There was no difference in carrier testing acceptance in patients referred because of maternal age and those with a positive maternal serum screening, Ms. Cronister said.

The study included patients referred for prenatal genetic counseling during a 22-month period because of maternal age, positive maternal serum screening, chemical exposure, or parental anxiety. The patients were offered both CF and FXS carrier testing on the basis of population screening only.

Because they would be more likely than the general population to accept CF and FSX screening, patients with a known or suggestive family history of either disease were excluded from the study.

Additionally, because CF risk is linked to ethnicity, only patients of white and Ashkenazi Jewish backgrounds, for whom the risk of being a CF carrier is 1 in 25 people, were included in the study.

GRAPEVINE, TEX. — Patients referred for genetic testing are more likely to agree to carrier status testing if they already have accepted an invasive procedure.

A study of 3,131 patients referred for genetic testing found that individuals were more likely to accept cystic fibrosis carrier testing and were more likely to accept both CF and fragile X syndrome (FXS) carrier testing if they underwent an invasive procedure such as amniocentesis.

“Patients who underwent such a procedure were more than twice as likely to accept both screening tests, compared with patients who had declined invasive testing, said Amy Cronister, the study's lead author and regional manager of genetic services, Genzyme Genetics, Phoenix, Ariz.

This finding suggests that there may be specific populations of patients who generally tend to avoid genetic testing, and other populations for whom the concept of genetic testing is much more acceptable, she said at a meeting sponsored by the American College of Medical Genetics.

Overall, 33% of referrals agreed to carrier status testing for CF and 28% for FXS; 25% accepted CF and FXS testing; and 64% declined both. Significantly fewer (11%) accepted one test but declined the other.

There was no difference in carrier testing acceptance in patients referred because of maternal age and those with a positive maternal serum screening, Ms. Cronister said.

The study included patients referred for prenatal genetic counseling during a 22-month period because of maternal age, positive maternal serum screening, chemical exposure, or parental anxiety. The patients were offered both CF and FXS carrier testing on the basis of population screening only.

Because they would be more likely than the general population to accept CF and FSX screening, patients with a known or suggestive family history of either disease were excluded from the study.

Additionally, because CF risk is linked to ethnicity, only patients of white and Ashkenazi Jewish backgrounds, for whom the risk of being a CF carrier is 1 in 25 people, were included in the study.

GRAPEVINE, TEX. — Patients referred for genetic testing are more likely to agree to carrier status testing if they already have accepted an invasive procedure.

A study of 3,131 patients referred for genetic testing found that individuals were more likely to accept cystic fibrosis carrier testing and were more likely to accept both CF and fragile X syndrome (FXS) carrier testing if they underwent an invasive procedure such as amniocentesis.

“Patients who underwent such a procedure were more than twice as likely to accept both screening tests, compared with patients who had declined invasive testing, said Amy Cronister, the study's lead author and regional manager of genetic services, Genzyme Genetics, Phoenix, Ariz.

This finding suggests that there may be specific populations of patients who generally tend to avoid genetic testing, and other populations for whom the concept of genetic testing is much more acceptable, she said at a meeting sponsored by the American College of Medical Genetics.

Overall, 33% of referrals agreed to carrier status testing for CF and 28% for FXS; 25% accepted CF and FXS testing; and 64% declined both. Significantly fewer (11%) accepted one test but declined the other.

There was no difference in carrier testing acceptance in patients referred because of maternal age and those with a positive maternal serum screening, Ms. Cronister said.

The study included patients referred for prenatal genetic counseling during a 22-month period because of maternal age, positive maternal serum screening, chemical exposure, or parental anxiety. The patients were offered both CF and FXS carrier testing on the basis of population screening only.

Because they would be more likely than the general population to accept CF and FSX screening, patients with a known or suggestive family history of either disease were excluded from the study.

Additionally, because CF risk is linked to ethnicity, only patients of white and Ashkenazi Jewish backgrounds, for whom the risk of being a CF carrier is 1 in 25 people, were included in the study.

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

GRAPEVINE, TEX. — Chromosome microarray analysis may play a vital role in the diagnosis of genetic disorders prenatally, Christine Eng, M.D., commented during a meeting that was sponsored by the American College of Medical Genetics.

Although chromosome microarray analysis (CMA) already has an established role in the genetic evaluation of both children and adults, its use still is being evaluated in the prenatal setting.

“This study represents the initial use of CMA in pregnancies being monitored due to increased risk of chromosomal abnormalities,” said Dr. Eng of Baylor College of Medicine, Houston.

“It demonstrates a high level of acceptance and accuracy.”

Dr. Eng and her associates discovered that there was a 71% acceptance rate of CMA among couples in which the woman was undergoing amniocentesis or chorionic villi sampling (CVS).

Reasons for acceptance of the CMA test included having a previous child with anomalies, an abnormal ultrasound finding, maternal age, and a desire to learn as much as possible about the current pregnancy.

Reasons for declining testing included the perception that the disorders being tested were rare and concern that the test results would raise anxiety.

The study also demonstrated that the CMA test is highly accurate: Only 13% of the initial tests showed inconclusive results.

The study was undertaken to determine the reliability of CMA to detect cytogenetic abnormalities in fetal samples, design a program of parental counseling, and assess acceptance of CMA among couples who were undergoing prenatal diagnosis.

A total of 38 couples, who were recruited among patients undergoing amniocentesis or CVS, agreed to participate in the study.

Of the 38 samples assessed in the study, 60% were amniotic fluid and 37% were CVS. One was a fetal blood sample.

Indications for prenatal testing included advanced maternal age (58%), anomalies detected on fetal ultrasound (26%), and having a previously affected child (13%), Dr. Eng reported.

All genetic abnormalities that were detected by karyotype also were detected by CMA and consisted of three cases of trisomy 21, according to Dr. Eng.

In addition, in five of the cases (13%) initial CMA analysis yielded inconclusive results that required study of parental samples for further clarification.

The microarray that was used in the study contains 362 fluorescent in situ hybridization-verified clones that span genomic regions implicated in 55 known human genetic disorders as well as subtelomeric clones of all 41 relevant human chromosome telomeric regions.

“This greatly expands the capability to detect abnormalities in these regions, when compared with conventional prenatal karyotyping,” she said during the meeting.

Dr. Eng commented that additional experience will optimize patient education and counseling and yield further insight into the degree of normal variation in these regions.

GRAPEVINE, TEX. — Chromosome microarray analysis may play a vital role in the diagnosis of genetic disorders prenatally, Christine Eng, M.D., commented during a meeting that was sponsored by the American College of Medical Genetics.

Although chromosome microarray analysis (CMA) already has an established role in the genetic evaluation of both children and adults, its use still is being evaluated in the prenatal setting.

“This study represents the initial use of CMA in pregnancies being monitored due to increased risk of chromosomal abnormalities,” said Dr. Eng of Baylor College of Medicine, Houston.

“It demonstrates a high level of acceptance and accuracy.”

Dr. Eng and her associates discovered that there was a 71% acceptance rate of CMA among couples in which the woman was undergoing amniocentesis or chorionic villi sampling (CVS).

Reasons for acceptance of the CMA test included having a previous child with anomalies, an abnormal ultrasound finding, maternal age, and a desire to learn as much as possible about the current pregnancy.

Reasons for declining testing included the perception that the disorders being tested were rare and concern that the test results would raise anxiety.

The study also demonstrated that the CMA test is highly accurate: Only 13% of the initial tests showed inconclusive results.

The study was undertaken to determine the reliability of CMA to detect cytogenetic abnormalities in fetal samples, design a program of parental counseling, and assess acceptance of CMA among couples who were undergoing prenatal diagnosis.

A total of 38 couples, who were recruited among patients undergoing amniocentesis or CVS, agreed to participate in the study.

Of the 38 samples assessed in the study, 60% were amniotic fluid and 37% were CVS. One was a fetal blood sample.

Indications for prenatal testing included advanced maternal age (58%), anomalies detected on fetal ultrasound (26%), and having a previously affected child (13%), Dr. Eng reported.

All genetic abnormalities that were detected by karyotype also were detected by CMA and consisted of three cases of trisomy 21, according to Dr. Eng.

In addition, in five of the cases (13%) initial CMA analysis yielded inconclusive results that required study of parental samples for further clarification.

The microarray that was used in the study contains 362 fluorescent in situ hybridization-verified clones that span genomic regions implicated in 55 known human genetic disorders as well as subtelomeric clones of all 41 relevant human chromosome telomeric regions.

“This greatly expands the capability to detect abnormalities in these regions, when compared with conventional prenatal karyotyping,” she said during the meeting.

Dr. Eng commented that additional experience will optimize patient education and counseling and yield further insight into the degree of normal variation in these regions.

GRAPEVINE, TEX. — Chromosome microarray analysis may play a vital role in the diagnosis of genetic disorders prenatally, Christine Eng, M.D., commented during a meeting that was sponsored by the American College of Medical Genetics.

Although chromosome microarray analysis (CMA) already has an established role in the genetic evaluation of both children and adults, its use still is being evaluated in the prenatal setting.

“This study represents the initial use of CMA in pregnancies being monitored due to increased risk of chromosomal abnormalities,” said Dr. Eng of Baylor College of Medicine, Houston.

“It demonstrates a high level of acceptance and accuracy.”

Dr. Eng and her associates discovered that there was a 71% acceptance rate of CMA among couples in which the woman was undergoing amniocentesis or chorionic villi sampling (CVS).

Reasons for acceptance of the CMA test included having a previous child with anomalies, an abnormal ultrasound finding, maternal age, and a desire to learn as much as possible about the current pregnancy.

Reasons for declining testing included the perception that the disorders being tested were rare and concern that the test results would raise anxiety.

The study also demonstrated that the CMA test is highly accurate: Only 13% of the initial tests showed inconclusive results.

The study was undertaken to determine the reliability of CMA to detect cytogenetic abnormalities in fetal samples, design a program of parental counseling, and assess acceptance of CMA among couples who were undergoing prenatal diagnosis.

A total of 38 couples, who were recruited among patients undergoing amniocentesis or CVS, agreed to participate in the study.

Of the 38 samples assessed in the study, 60% were amniotic fluid and 37% were CVS. One was a fetal blood sample.

Indications for prenatal testing included advanced maternal age (58%), anomalies detected on fetal ultrasound (26%), and having a previously affected child (13%), Dr. Eng reported.

All genetic abnormalities that were detected by karyotype also were detected by CMA and consisted of three cases of trisomy 21, according to Dr. Eng.

In addition, in five of the cases (13%) initial CMA analysis yielded inconclusive results that required study of parental samples for further clarification.

The microarray that was used in the study contains 362 fluorescent in situ hybridization-verified clones that span genomic regions implicated in 55 known human genetic disorders as well as subtelomeric clones of all 41 relevant human chromosome telomeric regions.

“This greatly expands the capability to detect abnormalities in these regions, when compared with conventional prenatal karyotyping,” she said during the meeting.

Dr. Eng commented that additional experience will optimize patient education and counseling and yield further insight into the degree of normal variation in these regions.

GRAPEVINE, TEX. — Researchers are attempting to develop a first-trimester cervical swab test to detect fetal genetic disorders.

While the test still is under development, if proven effective, it could provide noninvasive, earlier prenatal screening and possibly eliminate the need for amniocentesis and chorionic villi sampling (CVS).

“Early prenatal diagnosis to detect fetal genetic disorders is desired by both expectant mothers and physicians to make informed decisions,” Farideh Z. Bischoff, Ph.D., of Baylor College of Medicine, Houston, said at a meeting sponsored by the American College of Medical Genetics.

“Current methods of prenatal testing carry a small but finite risk of miscarriage, and the results rarely are available before 12 to 16 weeks of pregnancy, due to the time required for cell culture,” Dr. Bischoff said.

Recovery and analysis of fetal trophoblast cells would provide a safe alternative approach for rapid noninvasive prenatal diagnosis, she said.

The researchers are using micro electro mechanism system (MEMS) channels to isolate, purify, and characterize fetal trophoblasts from maternal transcervical mucous specimens. The trophoblast cells migrate from the placenta to the endocervical canal.

In a pilot study, the researchers were able to take cervical swab specimens from 17 women during the first trimester, and trophoblasts were detected in all.

The swab specimens were taken during the first trimester of pregnancy, between 8 and 12 weeks. Samples were washed and processed using a novel MEMS device coated with a proprietary reagent and trophoblast specific antibody.

Although only 0.02% to 1.94% of the initial total cell populations were trophoblasts, the recovered cell population was determined to be predominately of trophoblast origin. Trophoblast isolation was optimal in samples not contaminated by blood.

Now investigations are underway to detect fetal chromosomal aneuploidy and diagnostic potential using fluorescent in situ hybridization and polymerase chain reaction-based methods, Dr. Bischoff said.

GRAPEVINE, TEX. — Researchers are attempting to develop a first-trimester cervical swab test to detect fetal genetic disorders.

While the test still is under development, if proven effective, it could provide noninvasive, earlier prenatal screening and possibly eliminate the need for amniocentesis and chorionic villi sampling (CVS).

“Early prenatal diagnosis to detect fetal genetic disorders is desired by both expectant mothers and physicians to make informed decisions,” Farideh Z. Bischoff, Ph.D., of Baylor College of Medicine, Houston, said at a meeting sponsored by the American College of Medical Genetics.

“Current methods of prenatal testing carry a small but finite risk of miscarriage, and the results rarely are available before 12 to 16 weeks of pregnancy, due to the time required for cell culture,” Dr. Bischoff said.

Recovery and analysis of fetal trophoblast cells would provide a safe alternative approach for rapid noninvasive prenatal diagnosis, she said.

The researchers are using micro electro mechanism system (MEMS) channels to isolate, purify, and characterize fetal trophoblasts from maternal transcervical mucous specimens. The trophoblast cells migrate from the placenta to the endocervical canal.

In a pilot study, the researchers were able to take cervical swab specimens from 17 women during the first trimester, and trophoblasts were detected in all.

The swab specimens were taken during the first trimester of pregnancy, between 8 and 12 weeks. Samples were washed and processed using a novel MEMS device coated with a proprietary reagent and trophoblast specific antibody.

Although only 0.02% to 1.94% of the initial total cell populations were trophoblasts, the recovered cell population was determined to be predominately of trophoblast origin. Trophoblast isolation was optimal in samples not contaminated by blood.

Now investigations are underway to detect fetal chromosomal aneuploidy and diagnostic potential using fluorescent in situ hybridization and polymerase chain reaction-based methods, Dr. Bischoff said.

GRAPEVINE, TEX. — Researchers are attempting to develop a first-trimester cervical swab test to detect fetal genetic disorders.

While the test still is under development, if proven effective, it could provide noninvasive, earlier prenatal screening and possibly eliminate the need for amniocentesis and chorionic villi sampling (CVS).

“Early prenatal diagnosis to detect fetal genetic disorders is desired by both expectant mothers and physicians to make informed decisions,” Farideh Z. Bischoff, Ph.D., of Baylor College of Medicine, Houston, said at a meeting sponsored by the American College of Medical Genetics.

“Current methods of prenatal testing carry a small but finite risk of miscarriage, and the results rarely are available before 12 to 16 weeks of pregnancy, due to the time required for cell culture,” Dr. Bischoff said.

Recovery and analysis of fetal trophoblast cells would provide a safe alternative approach for rapid noninvasive prenatal diagnosis, she said.

The researchers are using micro electro mechanism system (MEMS) channels to isolate, purify, and characterize fetal trophoblasts from maternal transcervical mucous specimens. The trophoblast cells migrate from the placenta to the endocervical canal.

In a pilot study, the researchers were able to take cervical swab specimens from 17 women during the first trimester, and trophoblasts were detected in all.

The swab specimens were taken during the first trimester of pregnancy, between 8 and 12 weeks. Samples were washed and processed using a novel MEMS device coated with a proprietary reagent and trophoblast specific antibody.

Although only 0.02% to 1.94% of the initial total cell populations were trophoblasts, the recovered cell population was determined to be predominately of trophoblast origin. Trophoblast isolation was optimal in samples not contaminated by blood.

Now investigations are underway to detect fetal chromosomal aneuploidy and diagnostic potential using fluorescent in situ hybridization and polymerase chain reaction-based methods, Dr. Bischoff said.

SAN DIEGO — Children born to preeclamptic mothers are more likely to have pulmonary hypertension, compared with children born from uncomplicated pregnancies, results from a small study have demonstrated.

The finding provides “the very first evidence that preeclampsia leaves a persistent and potentially fatal imprint in the pulmonary circulation of the offspring, which predisposes them to exaggerated hypoxic pulmonary hypertension in later life,” Pierre-Yves Jayet, M.D., reported at a meeting sponsored by the American Physiological Society.

As part of an ongoing collaboration between the University Hospital in Lausanne, Switzerland, the Swiss Cardiovascular Research Institute in Bern, and the Bolivian High Altitude Research Institute in La Paz.

Dr. Jayet and his associates hypothesized that children born to mothers who had preeclampsia are predisposed to pulmonary hypertension at high altitude. To test this hypothesis, the investigators used echocardiography to measure systolic pulmonary artery pressure in 11 children aged 6-8 years who were born to preeclamptic mothers from La Paz, where the elevation ranges from 12,000 to 13,000 feet above sea level.

For a control group, they evaluated 13 age- and gender-matched children in La Paz born from normal pregnancies, said Dr. Jayet of the department of internal medicine at University Hospital in Lausanne.

The mean systolic pulmonary artery pressure was about 33% higher in children born to preeclamptic mothers, compared with those born from uncomplicated pregnancies (36 mm Hg vs. 27 mm Hg, respectively). Dr. Jayet noted that the hypoxic pulmonary vasoconstriction was not related to more severe hypoxemia or exaggerated polyglobulia.

He said the next step is to study animal models to determine the underlying mechanism of action that causes pulmonary vascular damage in children of preeclamptic mothers.

The Swiss National Science Foundation supported the study.

SAN DIEGO — Children born to preeclamptic mothers are more likely to have pulmonary hypertension, compared with children born from uncomplicated pregnancies, results from a small study have demonstrated.

The finding provides “the very first evidence that preeclampsia leaves a persistent and potentially fatal imprint in the pulmonary circulation of the offspring, which predisposes them to exaggerated hypoxic pulmonary hypertension in later life,” Pierre-Yves Jayet, M.D., reported at a meeting sponsored by the American Physiological Society.

As part of an ongoing collaboration between the University Hospital in Lausanne, Switzerland, the Swiss Cardiovascular Research Institute in Bern, and the Bolivian High Altitude Research Institute in La Paz.

Dr. Jayet and his associates hypothesized that children born to mothers who had preeclampsia are predisposed to pulmonary hypertension at high altitude. To test this hypothesis, the investigators used echocardiography to measure systolic pulmonary artery pressure in 11 children aged 6-8 years who were born to preeclamptic mothers from La Paz, where the elevation ranges from 12,000 to 13,000 feet above sea level.

For a control group, they evaluated 13 age- and gender-matched children in La Paz born from normal pregnancies, said Dr. Jayet of the department of internal medicine at University Hospital in Lausanne.

The mean systolic pulmonary artery pressure was about 33% higher in children born to preeclamptic mothers, compared with those born from uncomplicated pregnancies (36 mm Hg vs. 27 mm Hg, respectively). Dr. Jayet noted that the hypoxic pulmonary vasoconstriction was not related to more severe hypoxemia or exaggerated polyglobulia.

He said the next step is to study animal models to determine the underlying mechanism of action that causes pulmonary vascular damage in children of preeclamptic mothers.

The Swiss National Science Foundation supported the study.

SAN DIEGO — Children born to preeclamptic mothers are more likely to have pulmonary hypertension, compared with children born from uncomplicated pregnancies, results from a small study have demonstrated.

The finding provides “the very first evidence that preeclampsia leaves a persistent and potentially fatal imprint in the pulmonary circulation of the offspring, which predisposes them to exaggerated hypoxic pulmonary hypertension in later life,” Pierre-Yves Jayet, M.D., reported at a meeting sponsored by the American Physiological Society.

As part of an ongoing collaboration between the University Hospital in Lausanne, Switzerland, the Swiss Cardiovascular Research Institute in Bern, and the Bolivian High Altitude Research Institute in La Paz.

Dr. Jayet and his associates hypothesized that children born to mothers who had preeclampsia are predisposed to pulmonary hypertension at high altitude. To test this hypothesis, the investigators used echocardiography to measure systolic pulmonary artery pressure in 11 children aged 6-8 years who were born to preeclamptic mothers from La Paz, where the elevation ranges from 12,000 to 13,000 feet above sea level.

For a control group, they evaluated 13 age- and gender-matched children in La Paz born from normal pregnancies, said Dr. Jayet of the department of internal medicine at University Hospital in Lausanne.

The mean systolic pulmonary artery pressure was about 33% higher in children born to preeclamptic mothers, compared with those born from uncomplicated pregnancies (36 mm Hg vs. 27 mm Hg, respectively). Dr. Jayet noted that the hypoxic pulmonary vasoconstriction was not related to more severe hypoxemia or exaggerated polyglobulia.

He said the next step is to study animal models to determine the underlying mechanism of action that causes pulmonary vascular damage in children of preeclamptic mothers.

The Swiss National Science Foundation supported the study.

RENO, NEV. — From a societal perspective, the most cost-effective course of action for impending preterm delivery at 24 weeks' gestation is an unwillingness on the part of the physician to perform cesarean section, Gianni Cazan-London, M.D., and colleagues reported in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers, from the University of Michigan Health System in Ann Arbor, conducted a cost-benefit analysis comparing aggressive management (willingness to perform cesarean section) with nonaggressive management (unwillingness to perform cesarean section).

If the overall goal is simply to produce a surviving infant, the choice of management has only a minimal effect on overall costs, with aggressive management costing $38,434 more than nonaggressive management.

On the other hand, if the goal is to produce a surviving infant who is healthy, aggressive management costs $690,969 more per healthy survivor than does nonaggressive management.

While aggressive management does slightly improve the chances of producing a healthy survivor, it also doubles the probability of producing an infant with major and costly morbidity, according to the analysis.

The investigators based their analysis on a comprehensive literature search, which yielded estimates of the probabilities and costs for various options on a decision-tree model.

Costs included neonatal hospitalization, burial for death, and lifetime interventions and/or special education for infants with major disabilities. The investigators expressed the results in 2004 U.S. dollars.

According to the analysis, unwillingness to perform cesarean section would cost $675,425 per survivor (overall) and $1,688,562 per healthy survivor.

In contrast, willingness to perform cesarean section would cost $713,859 per survivor (overall) and $2,379,531 per healthy survivor.

The investigators noted that emotional and financial costs to parents, health care providers, and society at large are substantial, regardless of the physician's management strategy. They concluded that physicians should strive to provide objective information to the parents whose child is likely to be born with extremely low birth weight. The parents, then, should be allowed to make the ultimate decisions on the aggressiveness of obstetric management.

RENO, NEV. — From a societal perspective, the most cost-effective course of action for impending preterm delivery at 24 weeks' gestation is an unwillingness on the part of the physician to perform cesarean section, Gianni Cazan-London, M.D., and colleagues reported in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers, from the University of Michigan Health System in Ann Arbor, conducted a cost-benefit analysis comparing aggressive management (willingness to perform cesarean section) with nonaggressive management (unwillingness to perform cesarean section).

If the overall goal is simply to produce a surviving infant, the choice of management has only a minimal effect on overall costs, with aggressive management costing $38,434 more than nonaggressive management.

On the other hand, if the goal is to produce a surviving infant who is healthy, aggressive management costs $690,969 more per healthy survivor than does nonaggressive management.

While aggressive management does slightly improve the chances of producing a healthy survivor, it also doubles the probability of producing an infant with major and costly morbidity, according to the analysis.

The investigators based their analysis on a comprehensive literature search, which yielded estimates of the probabilities and costs for various options on a decision-tree model.

Costs included neonatal hospitalization, burial for death, and lifetime interventions and/or special education for infants with major disabilities. The investigators expressed the results in 2004 U.S. dollars.

According to the analysis, unwillingness to perform cesarean section would cost $675,425 per survivor (overall) and $1,688,562 per healthy survivor.

In contrast, willingness to perform cesarean section would cost $713,859 per survivor (overall) and $2,379,531 per healthy survivor.

The investigators noted that emotional and financial costs to parents, health care providers, and society at large are substantial, regardless of the physician's management strategy. They concluded that physicians should strive to provide objective information to the parents whose child is likely to be born with extremely low birth weight. The parents, then, should be allowed to make the ultimate decisions on the aggressiveness of obstetric management.

RENO, NEV. — From a societal perspective, the most cost-effective course of action for impending preterm delivery at 24 weeks' gestation is an unwillingness on the part of the physician to perform cesarean section, Gianni Cazan-London, M.D., and colleagues reported in a poster presented at the annual meeting of the Society for Maternal-Fetal Medicine.

The researchers, from the University of Michigan Health System in Ann Arbor, conducted a cost-benefit analysis comparing aggressive management (willingness to perform cesarean section) with nonaggressive management (unwillingness to perform cesarean section).

If the overall goal is simply to produce a surviving infant, the choice of management has only a minimal effect on overall costs, with aggressive management costing $38,434 more than nonaggressive management.

On the other hand, if the goal is to produce a surviving infant who is healthy, aggressive management costs $690,969 more per healthy survivor than does nonaggressive management.

While aggressive management does slightly improve the chances of producing a healthy survivor, it also doubles the probability of producing an infant with major and costly morbidity, according to the analysis.

The investigators based their analysis on a comprehensive literature search, which yielded estimates of the probabilities and costs for various options on a decision-tree model.

Costs included neonatal hospitalization, burial for death, and lifetime interventions and/or special education for infants with major disabilities. The investigators expressed the results in 2004 U.S. dollars.

According to the analysis, unwillingness to perform cesarean section would cost $675,425 per survivor (overall) and $1,688,562 per healthy survivor.

In contrast, willingness to perform cesarean section would cost $713,859 per survivor (overall) and $2,379,531 per healthy survivor.

The investigators noted that emotional and financial costs to parents, health care providers, and society at large are substantial, regardless of the physician's management strategy. They concluded that physicians should strive to provide objective information to the parents whose child is likely to be born with extremely low birth weight. The parents, then, should be allowed to make the ultimate decisions on the aggressiveness of obstetric management.