Obstetrics

NEW YORK — Three-dimensional ultrasound represents an emerging advance in imaging with important applications in obstetrics, Alfred Z. Abuhamad, M.D., said at an obstetrics symposium that was sponsored by Columbia University and New York Presbyterian Hospital.

The ability to rotate images, change planes, and manipulate displays according to signal strength makes it possible to visualize skeletal and vascular structures and fluid spaces, in addition to providing detailed views of fetal appearance, according to Dr. Abuhamad, who is professor and chair of obstetrics and gynecology and the director of the division of maternal-fetal medicine at Eastern Virginia Medical School, Norfolk.

The term “3-D” is something of a misnomer in that the image is displayed on a 2-D monitor.

“[Instead of '3-D'] the term should be volume sonography that gives the appearance of depth,” Dr. Abuhamad said.

The volume image is created by the summation of 2-D slices from multiple planes, as the probe is steered from side to side.

The size of the acquired image is determined by the angle across which the probe is moved. Since fetal movement makes the speed of volume acquisition highly important, “we use the smallest angle [needed for evaluation of the structure of interest] in the smallest box,” Dr. Abuhamad said.

With a multiplanar display, an image constructed from sagittal, coronal, and transverse planes can be rotated along the x-, y-, and z-axis to visualize the same structure from different angles. To maintain orientation, it is helpful to determine a reference point, and it may be necessary to use 2-D ultrasound to locate key structures.

The surface display shows the external aspects of the fetus, allowing the same views as in 2-D ultrasound, to review in “tremendous detail” such fetal abnormalities as clefting of the lip and palate, he said during the meeting.

With “maximum mode,” which manipulates the signal to enhance light (i.e. echoic) objects and dim dark (anechoic) ones, skeletal structures can be visualized, affording a look at the cranium and its fontanelles and sutures.

It also facilitates assessment of bone quality and detection of fractures and permits close examination of the vertebral column.

“It's like an x-ray of the fetus,” Dr. Abuhamad commented.

“Minimum mode” reveals vasculature; while “inversion mode,” which dims light structures and highlights dim ones, brings out fluid cavities and makes it possible to visualize such structures as the chambers of the heart and determine the number of gestational sacs, he said.

Other image manipulations permit the clinician to see the back of structures and to remove from the image, as with an “electronic scalpel,” structures that may obscure features of interest.

The 3-D procedure does not use more power, increase fetal exposure, or magnify the thermal effect, compared with 2-D ultrasound, he said.

Limitations of the technique include a steep learning curve and the need to dedicate sufficient time for training.

The quality of the volume image is limited by 2-D resolution. Artifacts such as motion of the woman or fetus, surface rendering, and shadowing can interfere with interpretation.

The technique is highly operator dependent, and the lack of standardization magnifies the possibility of human error, Dr. Abuhamad said.

An estimated 10% of ultrasound units currently have this technology, he said.

This 3-D image shows an absent T12 rib on one side in a fetus with balanced translocation.

Swelling involving the dorsal aspect of both feet in a fetus with Turner syndrome is shown here on 3D ultrasound. Photos courtesy Dr. Alfred Z. Abuhamad

NEW YORK — Three-dimensional ultrasound represents an emerging advance in imaging with important applications in obstetrics, Alfred Z. Abuhamad, M.D., said at an obstetrics symposium that was sponsored by Columbia University and New York Presbyterian Hospital.

The ability to rotate images, change planes, and manipulate displays according to signal strength makes it possible to visualize skeletal and vascular structures and fluid spaces, in addition to providing detailed views of fetal appearance, according to Dr. Abuhamad, who is professor and chair of obstetrics and gynecology and the director of the division of maternal-fetal medicine at Eastern Virginia Medical School, Norfolk.

The term “3-D” is something of a misnomer in that the image is displayed on a 2-D monitor.

“[Instead of '3-D'] the term should be volume sonography that gives the appearance of depth,” Dr. Abuhamad said.

The volume image is created by the summation of 2-D slices from multiple planes, as the probe is steered from side to side.

The size of the acquired image is determined by the angle across which the probe is moved. Since fetal movement makes the speed of volume acquisition highly important, “we use the smallest angle [needed for evaluation of the structure of interest] in the smallest box,” Dr. Abuhamad said.

With a multiplanar display, an image constructed from sagittal, coronal, and transverse planes can be rotated along the x-, y-, and z-axis to visualize the same structure from different angles. To maintain orientation, it is helpful to determine a reference point, and it may be necessary to use 2-D ultrasound to locate key structures.

The surface display shows the external aspects of the fetus, allowing the same views as in 2-D ultrasound, to review in “tremendous detail” such fetal abnormalities as clefting of the lip and palate, he said during the meeting.

With “maximum mode,” which manipulates the signal to enhance light (i.e. echoic) objects and dim dark (anechoic) ones, skeletal structures can be visualized, affording a look at the cranium and its fontanelles and sutures.

It also facilitates assessment of bone quality and detection of fractures and permits close examination of the vertebral column.

“It's like an x-ray of the fetus,” Dr. Abuhamad commented.

“Minimum mode” reveals vasculature; while “inversion mode,” which dims light structures and highlights dim ones, brings out fluid cavities and makes it possible to visualize such structures as the chambers of the heart and determine the number of gestational sacs, he said.

Other image manipulations permit the clinician to see the back of structures and to remove from the image, as with an “electronic scalpel,” structures that may obscure features of interest.

The 3-D procedure does not use more power, increase fetal exposure, or magnify the thermal effect, compared with 2-D ultrasound, he said.

Limitations of the technique include a steep learning curve and the need to dedicate sufficient time for training.

The quality of the volume image is limited by 2-D resolution. Artifacts such as motion of the woman or fetus, surface rendering, and shadowing can interfere with interpretation.

The technique is highly operator dependent, and the lack of standardization magnifies the possibility of human error, Dr. Abuhamad said.

An estimated 10% of ultrasound units currently have this technology, he said.

This 3-D image shows an absent T12 rib on one side in a fetus with balanced translocation.

Swelling involving the dorsal aspect of both feet in a fetus with Turner syndrome is shown here on 3D ultrasound. Photos courtesy Dr. Alfred Z. Abuhamad

NEW YORK — Three-dimensional ultrasound represents an emerging advance in imaging with important applications in obstetrics, Alfred Z. Abuhamad, M.D., said at an obstetrics symposium that was sponsored by Columbia University and New York Presbyterian Hospital.

The ability to rotate images, change planes, and manipulate displays according to signal strength makes it possible to visualize skeletal and vascular structures and fluid spaces, in addition to providing detailed views of fetal appearance, according to Dr. Abuhamad, who is professor and chair of obstetrics and gynecology and the director of the division of maternal-fetal medicine at Eastern Virginia Medical School, Norfolk.

The term “3-D” is something of a misnomer in that the image is displayed on a 2-D monitor.

“[Instead of '3-D'] the term should be volume sonography that gives the appearance of depth,” Dr. Abuhamad said.

The volume image is created by the summation of 2-D slices from multiple planes, as the probe is steered from side to side.

The size of the acquired image is determined by the angle across which the probe is moved. Since fetal movement makes the speed of volume acquisition highly important, “we use the smallest angle [needed for evaluation of the structure of interest] in the smallest box,” Dr. Abuhamad said.

With a multiplanar display, an image constructed from sagittal, coronal, and transverse planes can be rotated along the x-, y-, and z-axis to visualize the same structure from different angles. To maintain orientation, it is helpful to determine a reference point, and it may be necessary to use 2-D ultrasound to locate key structures.

The surface display shows the external aspects of the fetus, allowing the same views as in 2-D ultrasound, to review in “tremendous detail” such fetal abnormalities as clefting of the lip and palate, he said during the meeting.

With “maximum mode,” which manipulates the signal to enhance light (i.e. echoic) objects and dim dark (anechoic) ones, skeletal structures can be visualized, affording a look at the cranium and its fontanelles and sutures.

It also facilitates assessment of bone quality and detection of fractures and permits close examination of the vertebral column.

“It's like an x-ray of the fetus,” Dr. Abuhamad commented.

“Minimum mode” reveals vasculature; while “inversion mode,” which dims light structures and highlights dim ones, brings out fluid cavities and makes it possible to visualize such structures as the chambers of the heart and determine the number of gestational sacs, he said.

Other image manipulations permit the clinician to see the back of structures and to remove from the image, as with an “electronic scalpel,” structures that may obscure features of interest.

The 3-D procedure does not use more power, increase fetal exposure, or magnify the thermal effect, compared with 2-D ultrasound, he said.

Limitations of the technique include a steep learning curve and the need to dedicate sufficient time for training.

The quality of the volume image is limited by 2-D resolution. Artifacts such as motion of the woman or fetus, surface rendering, and shadowing can interfere with interpretation.

The technique is highly operator dependent, and the lack of standardization magnifies the possibility of human error, Dr. Abuhamad said.

An estimated 10% of ultrasound units currently have this technology, he said.

This 3-D image shows an absent T12 rib on one side in a fetus with balanced translocation.

Swelling involving the dorsal aspect of both feet in a fetus with Turner syndrome is shown here on 3D ultrasound. Photos courtesy Dr. Alfred Z. Abuhamad

RENO, NEV. — The rate of very low birth weight in twin pregnancies can be reduced safely with a plan of care that includes cervical length evaluation at 23-25 weeks and long-term indomethacin therapy for women with a short, funneled cervix, Theodore Peck, M.D. reported in a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

The rate of very low birth-weight twins fell significantly from 11.5% during 1989-1993 to 6.89% during 1999-2003 at Gundersen Lutheran Medical Center in LaCrosse, Wis., where Dr. Peck practices maternal-fetal medicine.

In contrast, the national rate of very low birth-weight infants from twin pregnancies was 10.1% during 1989-1993 and 10.2% during 1999-2003.

The percentage of very low birth-weight twins born at the Wisconsin medical center because of premature rupture of membranes or preterm labor also fell significantly, from 91.2% to 53.2%.

During the more recent time period, women pregnant with twins underwent cervical evaluation by vaginal ultrasound at 23-25 weeks' gestation. Women with cervical lengths less than 3 cm and cervical funneling were instructed to take 25 mg of indomethacin q.i.d. They were not placed routinely on activity restriction, and no cerclages were done.

Fetuses were monitored with amniotic fluid assessment and periodic growth determinations, and indomethacin dosages were adjusted accordingly.

Women were excluded from indomethacin therapy if they had premature rupture of membranes, oligohydramnios, asymmetric intrauterine growth retardation, indication for delivery, or they had attained 33 weeks' gestation.

RENO, NEV. — The rate of very low birth weight in twin pregnancies can be reduced safely with a plan of care that includes cervical length evaluation at 23-25 weeks and long-term indomethacin therapy for women with a short, funneled cervix, Theodore Peck, M.D. reported in a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

The rate of very low birth-weight twins fell significantly from 11.5% during 1989-1993 to 6.89% during 1999-2003 at Gundersen Lutheran Medical Center in LaCrosse, Wis., where Dr. Peck practices maternal-fetal medicine.

In contrast, the national rate of very low birth-weight infants from twin pregnancies was 10.1% during 1989-1993 and 10.2% during 1999-2003.

The percentage of very low birth-weight twins born at the Wisconsin medical center because of premature rupture of membranes or preterm labor also fell significantly, from 91.2% to 53.2%.

During the more recent time period, women pregnant with twins underwent cervical evaluation by vaginal ultrasound at 23-25 weeks' gestation. Women with cervical lengths less than 3 cm and cervical funneling were instructed to take 25 mg of indomethacin q.i.d. They were not placed routinely on activity restriction, and no cerclages were done.

Fetuses were monitored with amniotic fluid assessment and periodic growth determinations, and indomethacin dosages were adjusted accordingly.

Women were excluded from indomethacin therapy if they had premature rupture of membranes, oligohydramnios, asymmetric intrauterine growth retardation, indication for delivery, or they had attained 33 weeks' gestation.

RENO, NEV. — The rate of very low birth weight in twin pregnancies can be reduced safely with a plan of care that includes cervical length evaluation at 23-25 weeks and long-term indomethacin therapy for women with a short, funneled cervix, Theodore Peck, M.D. reported in a poster session at the annual meeting of the Society for Maternal-Fetal Medicine.

The rate of very low birth-weight twins fell significantly from 11.5% during 1989-1993 to 6.89% during 1999-2003 at Gundersen Lutheran Medical Center in LaCrosse, Wis., where Dr. Peck practices maternal-fetal medicine.

In contrast, the national rate of very low birth-weight infants from twin pregnancies was 10.1% during 1989-1993 and 10.2% during 1999-2003.

The percentage of very low birth-weight twins born at the Wisconsin medical center because of premature rupture of membranes or preterm labor also fell significantly, from 91.2% to 53.2%.

During the more recent time period, women pregnant with twins underwent cervical evaluation by vaginal ultrasound at 23-25 weeks' gestation. Women with cervical lengths less than 3 cm and cervical funneling were instructed to take 25 mg of indomethacin q.i.d. They were not placed routinely on activity restriction, and no cerclages were done.

Fetuses were monitored with amniotic fluid assessment and periodic growth determinations, and indomethacin dosages were adjusted accordingly.

Women were excluded from indomethacin therapy if they had premature rupture of membranes, oligohydramnios, asymmetric intrauterine growth retardation, indication for delivery, or they had attained 33 weeks' gestation.

LOS ANGELES — Vaginal delivery is a viable option for most women who've had a previous cesarean section and experience intrauterine fetal demise in a subsequent pregnancy, Mildred M. Ramirez, M.D., and her colleagues reported at the annual meeting of the Society for Gynecologic Investigation.

In a study of 209 women who faced this difficult situation, vaginal birth after cesarean section (VBAC) had an 86.7% success rate in 158 women who chose this procedure, according to the researchers' poster presentation.

Dr. Ramirez said in an interview that VBAC's success rate in this population was higher than in live births. She attributed the procedure's efficacy to there being no need for normal fetal monitoring and other attention to the well-being of the fetus.

A total of 51 women had a repeat cesarean section without attempting vaginal delivery. The surgical procedure was elective and not medically indicated in 37% of these patients, said Dr. Ramirez of the University of Texas Health Science Center at Houston Medical School.

The study involved data from the National Institute of Child Health and Human Development's Maternal Fetal Medicine Units (MFMU) Network. It represents a new subset analysis from a published observational study of more than 33,000 women in 19 hospitals (N. Engl. J. Med.2004; 351:2581-9; N. Engl. J. Med. 2004; 351:2647-9).

Only women with antepartum singleton pregnancies that resulted in intrauterine fetal demise at or after 20 weeks or when the fetus weighed at least 500 g were included in the new analysis. More than two-thirds of the women had undergone only one prior cesarean delivery; the rest had at least two. A total of 77 women had previously given birth vaginally, 38 of them after a cesarean section.

Labor had to be augmented in 14 patients, however, and induced in 116. Induction of labor appeared to play a role in the uterine rupture rate of 2.4%, which Dr. Ramirez said was higher than the 0.9%-2% rates previously reported for VBAC patients who delivered a live baby.

The rupture rate was even higher, 3.1%, in patients for whom labor had to be induced; four of five uterine ruptures occurred during induction. None of the patients who experienced rupture required a hysterectomy.

“We can probably modify the risk a little, maybe by not inducing patients so aggressively that we have a higher rate of rupture,” Dr. Ramirez said.

The transfusion rate was higher in the women who had repeat cesareans: 11.8% in the repeat cesarean group vs. 6.3% in the VBAC group. The VBAC group transfusion rate was higher than is usual with live births, according to Dr. Ramirez, who said the need for transfusion was often associated with the underlying condition that caused the death of the fetus.

The median hospital stay was three days, regardless of whether a woman chose VBAC or had a repeat cesarean section.

Dr. Ramirez said the study reinforced her preference for VBAC in these cases, but predicted physicians would reach different conclusions when advising patients. But, she said, the success rate of VBAC outweighs the physical and emotional toll of cesarean section.

“We have not even looked at the psychological component of how devastating it can be to undergo surgery for a dead baby,” she said.

LOS ANGELES — Vaginal delivery is a viable option for most women who've had a previous cesarean section and experience intrauterine fetal demise in a subsequent pregnancy, Mildred M. Ramirez, M.D., and her colleagues reported at the annual meeting of the Society for Gynecologic Investigation.

In a study of 209 women who faced this difficult situation, vaginal birth after cesarean section (VBAC) had an 86.7% success rate in 158 women who chose this procedure, according to the researchers' poster presentation.

Dr. Ramirez said in an interview that VBAC's success rate in this population was higher than in live births. She attributed the procedure's efficacy to there being no need for normal fetal monitoring and other attention to the well-being of the fetus.

A total of 51 women had a repeat cesarean section without attempting vaginal delivery. The surgical procedure was elective and not medically indicated in 37% of these patients, said Dr. Ramirez of the University of Texas Health Science Center at Houston Medical School.

The study involved data from the National Institute of Child Health and Human Development's Maternal Fetal Medicine Units (MFMU) Network. It represents a new subset analysis from a published observational study of more than 33,000 women in 19 hospitals (N. Engl. J. Med.2004; 351:2581-9; N. Engl. J. Med. 2004; 351:2647-9).

Only women with antepartum singleton pregnancies that resulted in intrauterine fetal demise at or after 20 weeks or when the fetus weighed at least 500 g were included in the new analysis. More than two-thirds of the women had undergone only one prior cesarean delivery; the rest had at least two. A total of 77 women had previously given birth vaginally, 38 of them after a cesarean section.

Labor had to be augmented in 14 patients, however, and induced in 116. Induction of labor appeared to play a role in the uterine rupture rate of 2.4%, which Dr. Ramirez said was higher than the 0.9%-2% rates previously reported for VBAC patients who delivered a live baby.

The rupture rate was even higher, 3.1%, in patients for whom labor had to be induced; four of five uterine ruptures occurred during induction. None of the patients who experienced rupture required a hysterectomy.

“We can probably modify the risk a little, maybe by not inducing patients so aggressively that we have a higher rate of rupture,” Dr. Ramirez said.

The transfusion rate was higher in the women who had repeat cesareans: 11.8% in the repeat cesarean group vs. 6.3% in the VBAC group. The VBAC group transfusion rate was higher than is usual with live births, according to Dr. Ramirez, who said the need for transfusion was often associated with the underlying condition that caused the death of the fetus.

The median hospital stay was three days, regardless of whether a woman chose VBAC or had a repeat cesarean section.

Dr. Ramirez said the study reinforced her preference for VBAC in these cases, but predicted physicians would reach different conclusions when advising patients. But, she said, the success rate of VBAC outweighs the physical and emotional toll of cesarean section.

“We have not even looked at the psychological component of how devastating it can be to undergo surgery for a dead baby,” she said.

LOS ANGELES — Vaginal delivery is a viable option for most women who've had a previous cesarean section and experience intrauterine fetal demise in a subsequent pregnancy, Mildred M. Ramirez, M.D., and her colleagues reported at the annual meeting of the Society for Gynecologic Investigation.

In a study of 209 women who faced this difficult situation, vaginal birth after cesarean section (VBAC) had an 86.7% success rate in 158 women who chose this procedure, according to the researchers' poster presentation.

Dr. Ramirez said in an interview that VBAC's success rate in this population was higher than in live births. She attributed the procedure's efficacy to there being no need for normal fetal monitoring and other attention to the well-being of the fetus.

A total of 51 women had a repeat cesarean section without attempting vaginal delivery. The surgical procedure was elective and not medically indicated in 37% of these patients, said Dr. Ramirez of the University of Texas Health Science Center at Houston Medical School.

The study involved data from the National Institute of Child Health and Human Development's Maternal Fetal Medicine Units (MFMU) Network. It represents a new subset analysis from a published observational study of more than 33,000 women in 19 hospitals (N. Engl. J. Med.2004; 351:2581-9; N. Engl. J. Med. 2004; 351:2647-9).

Only women with antepartum singleton pregnancies that resulted in intrauterine fetal demise at or after 20 weeks or when the fetus weighed at least 500 g were included in the new analysis. More than two-thirds of the women had undergone only one prior cesarean delivery; the rest had at least two. A total of 77 women had previously given birth vaginally, 38 of them after a cesarean section.

Labor had to be augmented in 14 patients, however, and induced in 116. Induction of labor appeared to play a role in the uterine rupture rate of 2.4%, which Dr. Ramirez said was higher than the 0.9%-2% rates previously reported for VBAC patients who delivered a live baby.

The rupture rate was even higher, 3.1%, in patients for whom labor had to be induced; four of five uterine ruptures occurred during induction. None of the patients who experienced rupture required a hysterectomy.

“We can probably modify the risk a little, maybe by not inducing patients so aggressively that we have a higher rate of rupture,” Dr. Ramirez said.

The transfusion rate was higher in the women who had repeat cesareans: 11.8% in the repeat cesarean group vs. 6.3% in the VBAC group. The VBAC group transfusion rate was higher than is usual with live births, according to Dr. Ramirez, who said the need for transfusion was often associated with the underlying condition that caused the death of the fetus.

The median hospital stay was three days, regardless of whether a woman chose VBAC or had a repeat cesarean section.

Dr. Ramirez said the study reinforced her preference for VBAC in these cases, but predicted physicians would reach different conclusions when advising patients. But, she said, the success rate of VBAC outweighs the physical and emotional toll of cesarean section.

“We have not even looked at the psychological component of how devastating it can be to undergo surgery for a dead baby,” she said.

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

LOS ANGELES — Older women are less likely to attempt vaginal birth after cesarean delivery and more likely to fail when they do, Sindhu K. Srinivas, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

Dr. Srinivas of the University of Pennsylvania, Philadelphia, presented a retrospective study of 25,005 women who were offered the option of vaginal birth after cesarean (VBAC) delivery at 17 community and university hospitals from 1996 to 2000. While 13,706 women (55%) attempted VBAC, 11,299 (45%) had an elective repeat cesarean section.

“We found as women got older, they attempted [VBAC] much less frequently than other women, but they also failed more,” Dr. Srinivas said. “Biologically why that is the case, we are not quite sure.”

Maternal age did not appear to be associated with risk of complications such as uterine rupture, bowel and bladder injury, blood transfusion, sepsis, and neonatal death. VBAC-related complication rates remained relatively constant in all age groups studied by Dr. Srinivas and her colleagues.

The youngest patients, 922 women ages 15 to 20 years, served as a reference group. A majority of these women—699—chose VBAC.

The largest cohort included 17,415 women, ages 21 to 34 years, 9,801 of whom elected VBAC. Compared with the youngest women, those in this group were about half as likely to attempt VBAC (adjusted odds ratio 0.46) and somewhat more likely to have a failed VBAC (adjusted odds ratio 1.74).

Among 5,574 women ages 35 to 39 years, 2,710 chose VBAC. The likelihood of a woman in this age group electing VBAC was about a third that of the youngest mothers (adjusted odds ratio 0.37). For mothers in their upper 30s, VBAC was more than twice as likely to fail (adjusted odds ratio 2.12).

The oldest group comprised 1,165 women at least 40 years of age. Only 496 in this group opted for VBAC (adjusted odds ratio 0.27), and VBAC was again more than twice as likely to fail (adjusted odds ratio 2.21). All these ratios were highly statistically significant.

The adjusted odds ratios for complications were 1.1 for ages 21-34, 1.03 for ages 35-39, and 0.91 for women 40, none of which approached statistical significance.

Dr. Srinivas' group adjusted the odds ratios to control for factors such as race, insurance type, university hospital, chronic hypertension, preeclampsia, diabetes, prior vaginal deliveries, induced or augmented labor, low birth weight, gestational age, and number of previous cesarean sections.

Some characteristics varied considerably among age cohorts. Black women accounted for two-thirds of all the teenaged mothers. Medicaid covered two-thirds of the teenaged mothers but only 10% of women over the age of 35. The youngest women also were more likely to give birth at a university hospital.

The occurrence of preeclampsia ranged from 3% to 4% across the age groups. Diabetes and chronic hypertension each increased with age: diabetes ranged from 2% to 10% and hypertension ranged from 1% to 6%.

The proportion of women who had previous vaginal deliveries increased from 19% in the youngest group to 31% of women age 40 years and older. Conversely, Pitocin use declined from 32% of all the youngest women to 15% in the oldest cohort.

LOS ANGELES — Older women are less likely to attempt vaginal birth after cesarean delivery and more likely to fail when they do, Sindhu K. Srinivas, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

Dr. Srinivas of the University of Pennsylvania, Philadelphia, presented a retrospective study of 25,005 women who were offered the option of vaginal birth after cesarean (VBAC) delivery at 17 community and university hospitals from 1996 to 2000. While 13,706 women (55%) attempted VBAC, 11,299 (45%) had an elective repeat cesarean section.

“We found as women got older, they attempted [VBAC] much less frequently than other women, but they also failed more,” Dr. Srinivas said. “Biologically why that is the case, we are not quite sure.”

Maternal age did not appear to be associated with risk of complications such as uterine rupture, bowel and bladder injury, blood transfusion, sepsis, and neonatal death. VBAC-related complication rates remained relatively constant in all age groups studied by Dr. Srinivas and her colleagues.

The youngest patients, 922 women ages 15 to 20 years, served as a reference group. A majority of these women—699—chose VBAC.

The largest cohort included 17,415 women, ages 21 to 34 years, 9,801 of whom elected VBAC. Compared with the youngest women, those in this group were about half as likely to attempt VBAC (adjusted odds ratio 0.46) and somewhat more likely to have a failed VBAC (adjusted odds ratio 1.74).

Among 5,574 women ages 35 to 39 years, 2,710 chose VBAC. The likelihood of a woman in this age group electing VBAC was about a third that of the youngest mothers (adjusted odds ratio 0.37). For mothers in their upper 30s, VBAC was more than twice as likely to fail (adjusted odds ratio 2.12).

The oldest group comprised 1,165 women at least 40 years of age. Only 496 in this group opted for VBAC (adjusted odds ratio 0.27), and VBAC was again more than twice as likely to fail (adjusted odds ratio 2.21). All these ratios were highly statistically significant.

The adjusted odds ratios for complications were 1.1 for ages 21-34, 1.03 for ages 35-39, and 0.91 for women 40, none of which approached statistical significance.

Dr. Srinivas' group adjusted the odds ratios to control for factors such as race, insurance type, university hospital, chronic hypertension, preeclampsia, diabetes, prior vaginal deliveries, induced or augmented labor, low birth weight, gestational age, and number of previous cesarean sections.

Some characteristics varied considerably among age cohorts. Black women accounted for two-thirds of all the teenaged mothers. Medicaid covered two-thirds of the teenaged mothers but only 10% of women over the age of 35. The youngest women also were more likely to give birth at a university hospital.

The occurrence of preeclampsia ranged from 3% to 4% across the age groups. Diabetes and chronic hypertension each increased with age: diabetes ranged from 2% to 10% and hypertension ranged from 1% to 6%.

The proportion of women who had previous vaginal deliveries increased from 19% in the youngest group to 31% of women age 40 years and older. Conversely, Pitocin use declined from 32% of all the youngest women to 15% in the oldest cohort.

LOS ANGELES — Older women are less likely to attempt vaginal birth after cesarean delivery and more likely to fail when they do, Sindhu K. Srinivas, M.D., said at the annual meeting of the Society for Gynecologic Investigation.

Dr. Srinivas of the University of Pennsylvania, Philadelphia, presented a retrospective study of 25,005 women who were offered the option of vaginal birth after cesarean (VBAC) delivery at 17 community and university hospitals from 1996 to 2000. While 13,706 women (55%) attempted VBAC, 11,299 (45%) had an elective repeat cesarean section.

“We found as women got older, they attempted [VBAC] much less frequently than other women, but they also failed more,” Dr. Srinivas said. “Biologically why that is the case, we are not quite sure.”

Maternal age did not appear to be associated with risk of complications such as uterine rupture, bowel and bladder injury, blood transfusion, sepsis, and neonatal death. VBAC-related complication rates remained relatively constant in all age groups studied by Dr. Srinivas and her colleagues.

The youngest patients, 922 women ages 15 to 20 years, served as a reference group. A majority of these women—699—chose VBAC.

The largest cohort included 17,415 women, ages 21 to 34 years, 9,801 of whom elected VBAC. Compared with the youngest women, those in this group were about half as likely to attempt VBAC (adjusted odds ratio 0.46) and somewhat more likely to have a failed VBAC (adjusted odds ratio 1.74).

Among 5,574 women ages 35 to 39 years, 2,710 chose VBAC. The likelihood of a woman in this age group electing VBAC was about a third that of the youngest mothers (adjusted odds ratio 0.37). For mothers in their upper 30s, VBAC was more than twice as likely to fail (adjusted odds ratio 2.12).

The oldest group comprised 1,165 women at least 40 years of age. Only 496 in this group opted for VBAC (adjusted odds ratio 0.27), and VBAC was again more than twice as likely to fail (adjusted odds ratio 2.21). All these ratios were highly statistically significant.

The adjusted odds ratios for complications were 1.1 for ages 21-34, 1.03 for ages 35-39, and 0.91 for women 40, none of which approached statistical significance.

Dr. Srinivas' group adjusted the odds ratios to control for factors such as race, insurance type, university hospital, chronic hypertension, preeclampsia, diabetes, prior vaginal deliveries, induced or augmented labor, low birth weight, gestational age, and number of previous cesarean sections.

Some characteristics varied considerably among age cohorts. Black women accounted for two-thirds of all the teenaged mothers. Medicaid covered two-thirds of the teenaged mothers but only 10% of women over the age of 35. The youngest women also were more likely to give birth at a university hospital.

The occurrence of preeclampsia ranged from 3% to 4% across the age groups. Diabetes and chronic hypertension each increased with age: diabetes ranged from 2% to 10% and hypertension ranged from 1% to 6%.

The proportion of women who had previous vaginal deliveries increased from 19% in the youngest group to 31% of women age 40 years and older. Conversely, Pitocin use declined from 32% of all the youngest women to 15% in the oldest cohort.

NEW YORK — Women who develop preeclampsia should be counseled about the risk in subsequent gestations and strategies to contain these risks, according to Baha M. Sibai, M.D.

In addition, more general implications about health in later life should be discussed with the patient, said Dr. Sibai, who is professor and chairman of obstetrics and gynecology at the University of Cincinnati.

He made his report at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

About 20%-30% of women who have had an episode of preeclampsia will develop the disorder in a subsequent pregnancy, which makes this history at least as significant a risk factor for future preeclampsia as chronic hypertension, renal disease, and pregestational diabetes.

The earlier in the first gestation preeclampsia developed, the higher the risk of recurrence in the next: the condition returned in more than half of women who had their first episode before week 27, compared with a 40% recurrence when the index episode was between week 27 and 30, and 20% at week 37 or after.

A severe episode of preeclampsia or eclampsia also is associated with a worse outcome in subsequent pregnancies, with an increased risk of intrauterine growth retardation, perinatal loss, and abruptio placentae. Here, too, the earlier the episode occurred in the first gestation, the greater the risk to the second, Dr. Sibai said.

Preventive measures can contain the risk of preeclampsia and poor outcome in subsequent pregnancies. These include attention to weight, blood pressure, and blood sugar.

“Aggressive control of hypertension before and early in pregnancy can reduce the risk of preeclampsia from 50% to [a range of] 10%-15%,” Dr. Sibai commented.

In women with diabetes, good control of blood sugar from early in the pregnancy will markedly reduce the rate of preeclampsia, he said.

In vitro fertilization should involve the transfer of no more than two embryos, as a risk-containment measure.

A number of other strategies have been suggested to reduce the incidence of preeclampsia. Prophylactic aspirin has had particular attention, but a large multicenter trial found no difference in outcome among women at highest risk. A metaanalysis of studies using calcium supplementation likewise found no benefit.

Women who have had preeclampsia should also be counseled about its implications for health problems later in life, such as chronic hypertension, diabetes, and ischemic heart disease.

“Preeclampsia is a manifestation of underlying silent disease that will develop into a clinical condition that develops later; it doesn't cause [later health problems],” he said.

The incidence of chronic hypertension in women who have had a severe episode of preeclampsia, at an average follow-up of 7 years, ranges from 7% when the preeclampsia developed after 37 weeks, to 25% when it had developed before 27 weeks.

The risk of later renal and cardiovascular disease is particularly heightened after an episode of preeclampsia that developed before 30 weeks' gestation, that was severe, or that recurred, according to Dr. Sibai. In fact, he said, preeclampsia during one singleton gestation doubles the risk of ischemic heart disease and raises it nearly threefold when preeclampsia is severe.

Gestational hypertension without proteinuria is associated with a 1.6 relative risk of ischemic heart disease.

“The risk factors for preeclampsia and coronary artery disease overlap considerably,” Dr. Sibai observed during the meeting.

NEW YORK — Women who develop preeclampsia should be counseled about the risk in subsequent gestations and strategies to contain these risks, according to Baha M. Sibai, M.D.

In addition, more general implications about health in later life should be discussed with the patient, said Dr. Sibai, who is professor and chairman of obstetrics and gynecology at the University of Cincinnati.

He made his report at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

About 20%-30% of women who have had an episode of preeclampsia will develop the disorder in a subsequent pregnancy, which makes this history at least as significant a risk factor for future preeclampsia as chronic hypertension, renal disease, and pregestational diabetes.

The earlier in the first gestation preeclampsia developed, the higher the risk of recurrence in the next: the condition returned in more than half of women who had their first episode before week 27, compared with a 40% recurrence when the index episode was between week 27 and 30, and 20% at week 37 or after.

A severe episode of preeclampsia or eclampsia also is associated with a worse outcome in subsequent pregnancies, with an increased risk of intrauterine growth retardation, perinatal loss, and abruptio placentae. Here, too, the earlier the episode occurred in the first gestation, the greater the risk to the second, Dr. Sibai said.

Preventive measures can contain the risk of preeclampsia and poor outcome in subsequent pregnancies. These include attention to weight, blood pressure, and blood sugar.

“Aggressive control of hypertension before and early in pregnancy can reduce the risk of preeclampsia from 50% to [a range of] 10%-15%,” Dr. Sibai commented.

In women with diabetes, good control of blood sugar from early in the pregnancy will markedly reduce the rate of preeclampsia, he said.

In vitro fertilization should involve the transfer of no more than two embryos, as a risk-containment measure.

A number of other strategies have been suggested to reduce the incidence of preeclampsia. Prophylactic aspirin has had particular attention, but a large multicenter trial found no difference in outcome among women at highest risk. A metaanalysis of studies using calcium supplementation likewise found no benefit.

Women who have had preeclampsia should also be counseled about its implications for health problems later in life, such as chronic hypertension, diabetes, and ischemic heart disease.

“Preeclampsia is a manifestation of underlying silent disease that will develop into a clinical condition that develops later; it doesn't cause [later health problems],” he said.

The incidence of chronic hypertension in women who have had a severe episode of preeclampsia, at an average follow-up of 7 years, ranges from 7% when the preeclampsia developed after 37 weeks, to 25% when it had developed before 27 weeks.

The risk of later renal and cardiovascular disease is particularly heightened after an episode of preeclampsia that developed before 30 weeks' gestation, that was severe, or that recurred, according to Dr. Sibai. In fact, he said, preeclampsia during one singleton gestation doubles the risk of ischemic heart disease and raises it nearly threefold when preeclampsia is severe.

Gestational hypertension without proteinuria is associated with a 1.6 relative risk of ischemic heart disease.

“The risk factors for preeclampsia and coronary artery disease overlap considerably,” Dr. Sibai observed during the meeting.

NEW YORK — Women who develop preeclampsia should be counseled about the risk in subsequent gestations and strategies to contain these risks, according to Baha M. Sibai, M.D.

In addition, more general implications about health in later life should be discussed with the patient, said Dr. Sibai, who is professor and chairman of obstetrics and gynecology at the University of Cincinnati.

He made his report at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

About 20%-30% of women who have had an episode of preeclampsia will develop the disorder in a subsequent pregnancy, which makes this history at least as significant a risk factor for future preeclampsia as chronic hypertension, renal disease, and pregestational diabetes.

The earlier in the first gestation preeclampsia developed, the higher the risk of recurrence in the next: the condition returned in more than half of women who had their first episode before week 27, compared with a 40% recurrence when the index episode was between week 27 and 30, and 20% at week 37 or after.

A severe episode of preeclampsia or eclampsia also is associated with a worse outcome in subsequent pregnancies, with an increased risk of intrauterine growth retardation, perinatal loss, and abruptio placentae. Here, too, the earlier the episode occurred in the first gestation, the greater the risk to the second, Dr. Sibai said.

Preventive measures can contain the risk of preeclampsia and poor outcome in subsequent pregnancies. These include attention to weight, blood pressure, and blood sugar.

“Aggressive control of hypertension before and early in pregnancy can reduce the risk of preeclampsia from 50% to [a range of] 10%-15%,” Dr. Sibai commented.

In women with diabetes, good control of blood sugar from early in the pregnancy will markedly reduce the rate of preeclampsia, he said.

In vitro fertilization should involve the transfer of no more than two embryos, as a risk-containment measure.

A number of other strategies have been suggested to reduce the incidence of preeclampsia. Prophylactic aspirin has had particular attention, but a large multicenter trial found no difference in outcome among women at highest risk. A metaanalysis of studies using calcium supplementation likewise found no benefit.

Women who have had preeclampsia should also be counseled about its implications for health problems later in life, such as chronic hypertension, diabetes, and ischemic heart disease.

“Preeclampsia is a manifestation of underlying silent disease that will develop into a clinical condition that develops later; it doesn't cause [later health problems],” he said.

The incidence of chronic hypertension in women who have had a severe episode of preeclampsia, at an average follow-up of 7 years, ranges from 7% when the preeclampsia developed after 37 weeks, to 25% when it had developed before 27 weeks.

The risk of later renal and cardiovascular disease is particularly heightened after an episode of preeclampsia that developed before 30 weeks' gestation, that was severe, or that recurred, according to Dr. Sibai. In fact, he said, preeclampsia during one singleton gestation doubles the risk of ischemic heart disease and raises it nearly threefold when preeclampsia is severe.

Gestational hypertension without proteinuria is associated with a 1.6 relative risk of ischemic heart disease.

“The risk factors for preeclampsia and coronary artery disease overlap considerably,” Dr. Sibai observed during the meeting.

NEW YORK — Eclampsia has become increasingly rare in Western countries, but it still occurs in 1 in 2,000-3,500 pregnancies—and obstetric clinics must be prepared to treat it, Baha M. Sibai, M.D., said at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

Although most episodes occur late in pregnancy, an increasing number occur more than 2 days after delivery, and patients should be counseled accordingly, said Dr. Sibai, professor and chairman of the obstetrics and gynecology department at the University of Cincinnati.

Eclampsia does not always come with a warning. It has been reported that in 15%-20% of cases neither hypertension nor proteinuria has occurred.

“Most women with eclampsia have had good prenatal care,” Dr. Sibai said. In a 1992 U.K. study of 383 women, 85% had been seen by a medical care provider within a week before the episode.

Eclampsia is largely a late event: in a sample of 399 U.S. women, the episode occurred after the 32nd week of gestation in 72%, and before week 28 in roughly 10%.

In a substantial number of cases—28%, in the U.S. study—the condition developed after delivery; in two-thirds of these cases, it happened more than 48 hours later.

“More and more, the onset of convulsions is in the postpartum period. We've done an excellent job educating women to report signs and symptoms during pregnancy, but a poor one in educating them that they can have eclampsia after leaving the hospital,” Dr. Sibai said.

The lapse can have medicolegal implications, he said.

Emergency management of eclampsia should focus on protecting the mother from injury (e.g., cushioning extremities and preventing a fall off the bed), ensuring adequate oxygenation, and preventing aspiration. Once these are addressed, steps should be taken to avoid recurrent convulsions.

“Never give anything to stop the convulsion: no one dies from a seizure, and you could do damage if you give the wrong dose,” Dr. Sibai said. Most seizures are self-limiting, and medications to contain them may depress respiration.

Hypertension should be the next concern, and then delivery. “[It] should be the last thing on your mind,” he said.

If hypoxemia develops, 8-10 L/min of supplementary oxygen should be supplied by face mask, and pulse oximetry monitored. Sodium bicarbonate may be required for acidemia.

To prevent further convulsions, IV magnesium sulfate should be begun with a loading dose of 6 g over a 20-minute period, followed by maintenance at 2 g/hour. The anticonvulsants diazepam and phenytoin, which can depress respiration and compromise alveolar reflexes, carry a higher mortality rate and should be avoided.

“Don't listen to what the neurologist or internist tells you to do,” Dr. Sibai said.

The risk of magnesium toxicity should be kept in mind: look for such signs of rising serum levels as double vision, a feeling of warmth or flushing, and lethargy; monitor patellar reflexes hourly.

“Always talk to the patient. Slurred speech shows paralysis of the muscles of the jaw,” he said.

Magnesium sulfate should be discontinued immediately while a blood level is taken, and restarted with appropriate adjustments. If serum magnesium is above 15 mg/dL—a level that threatens respiratory and cardiac arrest—1 g of calcium gluconate should be given intravenously and intubation and assisted ventilation provided if necessary.

For control of severe hypertension, labetalol and nifedipine are drugs of choice; hydralazine should be avoided, he said.

When possible, delivery should be done within 24 hours. Cesarean delivery is not always necessary, and vaginal delivery can be done with epidural or spinal anesthesia.

NEW YORK — Eclampsia has become increasingly rare in Western countries, but it still occurs in 1 in 2,000-3,500 pregnancies—and obstetric clinics must be prepared to treat it, Baha M. Sibai, M.D., said at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

Although most episodes occur late in pregnancy, an increasing number occur more than 2 days after delivery, and patients should be counseled accordingly, said Dr. Sibai, professor and chairman of the obstetrics and gynecology department at the University of Cincinnati.

Eclampsia does not always come with a warning. It has been reported that in 15%-20% of cases neither hypertension nor proteinuria has occurred.

“Most women with eclampsia have had good prenatal care,” Dr. Sibai said. In a 1992 U.K. study of 383 women, 85% had been seen by a medical care provider within a week before the episode.

Eclampsia is largely a late event: in a sample of 399 U.S. women, the episode occurred after the 32nd week of gestation in 72%, and before week 28 in roughly 10%.

In a substantial number of cases—28%, in the U.S. study—the condition developed after delivery; in two-thirds of these cases, it happened more than 48 hours later.

“More and more, the onset of convulsions is in the postpartum period. We've done an excellent job educating women to report signs and symptoms during pregnancy, but a poor one in educating them that they can have eclampsia after leaving the hospital,” Dr. Sibai said.

The lapse can have medicolegal implications, he said.

Emergency management of eclampsia should focus on protecting the mother from injury (e.g., cushioning extremities and preventing a fall off the bed), ensuring adequate oxygenation, and preventing aspiration. Once these are addressed, steps should be taken to avoid recurrent convulsions.

“Never give anything to stop the convulsion: no one dies from a seizure, and you could do damage if you give the wrong dose,” Dr. Sibai said. Most seizures are self-limiting, and medications to contain them may depress respiration.

Hypertension should be the next concern, and then delivery. “[It] should be the last thing on your mind,” he said.

If hypoxemia develops, 8-10 L/min of supplementary oxygen should be supplied by face mask, and pulse oximetry monitored. Sodium bicarbonate may be required for acidemia.

To prevent further convulsions, IV magnesium sulfate should be begun with a loading dose of 6 g over a 20-minute period, followed by maintenance at 2 g/hour. The anticonvulsants diazepam and phenytoin, which can depress respiration and compromise alveolar reflexes, carry a higher mortality rate and should be avoided.

“Don't listen to what the neurologist or internist tells you to do,” Dr. Sibai said.

The risk of magnesium toxicity should be kept in mind: look for such signs of rising serum levels as double vision, a feeling of warmth or flushing, and lethargy; monitor patellar reflexes hourly.

“Always talk to the patient. Slurred speech shows paralysis of the muscles of the jaw,” he said.

Magnesium sulfate should be discontinued immediately while a blood level is taken, and restarted with appropriate adjustments. If serum magnesium is above 15 mg/dL—a level that threatens respiratory and cardiac arrest—1 g of calcium gluconate should be given intravenously and intubation and assisted ventilation provided if necessary.

For control of severe hypertension, labetalol and nifedipine are drugs of choice; hydralazine should be avoided, he said.

When possible, delivery should be done within 24 hours. Cesarean delivery is not always necessary, and vaginal delivery can be done with epidural or spinal anesthesia.

NEW YORK — Eclampsia has become increasingly rare in Western countries, but it still occurs in 1 in 2,000-3,500 pregnancies—and obstetric clinics must be prepared to treat it, Baha M. Sibai, M.D., said at an obstetrics symposium sponsored by Columbia University and New York Presbyterian Hospital.

Although most episodes occur late in pregnancy, an increasing number occur more than 2 days after delivery, and patients should be counseled accordingly, said Dr. Sibai, professor and chairman of the obstetrics and gynecology department at the University of Cincinnati.

Eclampsia does not always come with a warning. It has been reported that in 15%-20% of cases neither hypertension nor proteinuria has occurred.

“Most women with eclampsia have had good prenatal care,” Dr. Sibai said. In a 1992 U.K. study of 383 women, 85% had been seen by a medical care provider within a week before the episode.

Eclampsia is largely a late event: in a sample of 399 U.S. women, the episode occurred after the 32nd week of gestation in 72%, and before week 28 in roughly 10%.

In a substantial number of cases—28%, in the U.S. study—the condition developed after delivery; in two-thirds of these cases, it happened more than 48 hours later.

“More and more, the onset of convulsions is in the postpartum period. We've done an excellent job educating women to report signs and symptoms during pregnancy, but a poor one in educating them that they can have eclampsia after leaving the hospital,” Dr. Sibai said.

The lapse can have medicolegal implications, he said.

Emergency management of eclampsia should focus on protecting the mother from injury (e.g., cushioning extremities and preventing a fall off the bed), ensuring adequate oxygenation, and preventing aspiration. Once these are addressed, steps should be taken to avoid recurrent convulsions.

“Never give anything to stop the convulsion: no one dies from a seizure, and you could do damage if you give the wrong dose,” Dr. Sibai said. Most seizures are self-limiting, and medications to contain them may depress respiration.

Hypertension should be the next concern, and then delivery. “[It] should be the last thing on your mind,” he said.

If hypoxemia develops, 8-10 L/min of supplementary oxygen should be supplied by face mask, and pulse oximetry monitored. Sodium bicarbonate may be required for acidemia.

To prevent further convulsions, IV magnesium sulfate should be begun with a loading dose of 6 g over a 20-minute period, followed by maintenance at 2 g/hour. The anticonvulsants diazepam and phenytoin, which can depress respiration and compromise alveolar reflexes, carry a higher mortality rate and should be avoided.

“Don't listen to what the neurologist or internist tells you to do,” Dr. Sibai said.

The risk of magnesium toxicity should be kept in mind: look for such signs of rising serum levels as double vision, a feeling of warmth or flushing, and lethargy; monitor patellar reflexes hourly.

“Always talk to the patient. Slurred speech shows paralysis of the muscles of the jaw,” he said.

Magnesium sulfate should be discontinued immediately while a blood level is taken, and restarted with appropriate adjustments. If serum magnesium is above 15 mg/dL—a level that threatens respiratory and cardiac arrest—1 g of calcium gluconate should be given intravenously and intubation and assisted ventilation provided if necessary.

For control of severe hypertension, labetalol and nifedipine are drugs of choice; hydralazine should be avoided, he said.

When possible, delivery should be done within 24 hours. Cesarean delivery is not always necessary, and vaginal delivery can be done with epidural or spinal anesthesia.

Gestational diabetes is on the rise. The finding is not surprising given the dramatic increases in obesity and type 2 diabetes in recent years, but until now few studies have examined trends in gestational diabetes mellitus (GDM) in populations other than the Pima Indians, reported Dana Dabelea, M.D., of the University of Colorado, Denver, and her associates (Diabetes Care 2005;28:579-84).

The findings from Kaiser Permanente of Colorado's perinatal database include all 36,403 pregnancies among 30,216 initially nondiabetic women who delivered singleton infants from 1994 to 2002 and had been screened at 24-28 weeks by the same protocol: a 1-hour 50-g oral glucose tolerance test (OGTT), followed by a diagnostic 3-hour 100-g OGTT among those with glucose values at or above 140 mg/dL on the 50-g test.

A total of 1,183 pregnancies were complicated by GDM from 1994 to 2002. The prevalence of GDM during that time almost doubled—from 2.1% in 1994 to 4.1% in 2002. The rate increased by an average of 12% per year during that period.

The rise in GDM occurred in all ethnic groups, from 1.9% to 3.4% in non-Hispanic whites, 2.8% to 5.1% among Hispanics, 2.5% to 4.6% in African Americans, and 6.3% to 8.6% among Asians. Throughout the study period, pregnant women of all the minority ethnic groups combined consistently had a twofold higher prevalence of GDM than did white women.

When broken down by the mother's birth period, the prevalence of GDM was approximately 40% higher for each successive birth decade from 1946 to 1990. This finding probably reflects women's exposure to increasing rates of obesity in later versus earlier time periods. Obesity is one of the strongest risk factors for GDM, Dr. Dabelea and her associates said.

Gestational diabetes is on the rise. The finding is not surprising given the dramatic increases in obesity and type 2 diabetes in recent years, but until now few studies have examined trends in gestational diabetes mellitus (GDM) in populations other than the Pima Indians, reported Dana Dabelea, M.D., of the University of Colorado, Denver, and her associates (Diabetes Care 2005;28:579-84).

The findings from Kaiser Permanente of Colorado's perinatal database include all 36,403 pregnancies among 30,216 initially nondiabetic women who delivered singleton infants from 1994 to 2002 and had been screened at 24-28 weeks by the same protocol: a 1-hour 50-g oral glucose tolerance test (OGTT), followed by a diagnostic 3-hour 100-g OGTT among those with glucose values at or above 140 mg/dL on the 50-g test.

A total of 1,183 pregnancies were complicated by GDM from 1994 to 2002. The prevalence of GDM during that time almost doubled—from 2.1% in 1994 to 4.1% in 2002. The rate increased by an average of 12% per year during that period.

The rise in GDM occurred in all ethnic groups, from 1.9% to 3.4% in non-Hispanic whites, 2.8% to 5.1% among Hispanics, 2.5% to 4.6% in African Americans, and 6.3% to 8.6% among Asians. Throughout the study period, pregnant women of all the minority ethnic groups combined consistently had a twofold higher prevalence of GDM than did white women.

When broken down by the mother's birth period, the prevalence of GDM was approximately 40% higher for each successive birth decade from 1946 to 1990. This finding probably reflects women's exposure to increasing rates of obesity in later versus earlier time periods. Obesity is one of the strongest risk factors for GDM, Dr. Dabelea and her associates said.

Gestational diabetes is on the rise. The finding is not surprising given the dramatic increases in obesity and type 2 diabetes in recent years, but until now few studies have examined trends in gestational diabetes mellitus (GDM) in populations other than the Pima Indians, reported Dana Dabelea, M.D., of the University of Colorado, Denver, and her associates (Diabetes Care 2005;28:579-84).

The findings from Kaiser Permanente of Colorado's perinatal database include all 36,403 pregnancies among 30,216 initially nondiabetic women who delivered singleton infants from 1994 to 2002 and had been screened at 24-28 weeks by the same protocol: a 1-hour 50-g oral glucose tolerance test (OGTT), followed by a diagnostic 3-hour 100-g OGTT among those with glucose values at or above 140 mg/dL on the 50-g test.

A total of 1,183 pregnancies were complicated by GDM from 1994 to 2002. The prevalence of GDM during that time almost doubled—from 2.1% in 1994 to 4.1% in 2002. The rate increased by an average of 12% per year during that period.

The rise in GDM occurred in all ethnic groups, from 1.9% to 3.4% in non-Hispanic whites, 2.8% to 5.1% among Hispanics, 2.5% to 4.6% in African Americans, and 6.3% to 8.6% among Asians. Throughout the study period, pregnant women of all the minority ethnic groups combined consistently had a twofold higher prevalence of GDM than did white women.

When broken down by the mother's birth period, the prevalence of GDM was approximately 40% higher for each successive birth decade from 1946 to 1990. This finding probably reflects women's exposure to increasing rates of obesity in later versus earlier time periods. Obesity is one of the strongest risk factors for GDM, Dr. Dabelea and her associates said.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low-birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single-drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” he said. “If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries.

Dr. Brown estimated that 15%-20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate. Recurrence can be up to 30% in 3 months and 80% in 9-12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709-16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant. Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk. All pregnant women should be screened early in pregnancy, he said. For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC. In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003;102:527-34). Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, Dr. Brown said.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown. In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and using the new regimen for a longer period of time. Though randomized studies haven't shown improvement with treatment of the male partner, he advocated treating the partner as well. Among other management strategies for treating recurrent BV, he listed condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, and boric acid suppositories.

The underlying physiologic and pathologic conditions are not well understood, he said. He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low-birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single-drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” he said. “If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries.

Dr. Brown estimated that 15%-20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate. Recurrence can be up to 30% in 3 months and 80% in 9-12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709-16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant. Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk. All pregnant women should be screened early in pregnancy, he said. For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC. In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003;102:527-34). Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, Dr. Brown said.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown. In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and using the new regimen for a longer period of time. Though randomized studies haven't shown improvement with treatment of the male partner, he advocated treating the partner as well. Among other management strategies for treating recurrent BV, he listed condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, and boric acid suppositories.

The underlying physiologic and pathologic conditions are not well understood, he said. He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV.

HOUSTON — Bacterial vaginosis in pregnant women requires a two-drug regimen to reduce the incidence of low-birth-weight and preterm babies, Dale Brown Jr., M.D., said at a conference on vulvovaginal diseases sponsored by Baylor College of Medicine.

Dr. Brown, chair of clinical affairs in the obstetrics and gynecology department at Baylor, said clinical studies involving single-drug therapy have failed to show a reduction in the incidence of low-birth-weight and preterm babies, because such therapy is not aggressive enough to prevent recurrence of bacterial vaginosis (BV).

“I just don't think that the single-drug treatment … is eradicating the organisms appropriately, because we know this vaginosis itself is a coterie of several types of organisms,” he said. “If we allow any options for gram-negative organisms to take hold, that's why we continue to see” low-birth-weight babies and preterm deliveries.

Dr. Brown estimated that 15%-20% of pregnant women are diagnosed with BV. They face a fivefold increased risk of late miscarriage in the second trimester, he said. While more than 30% of infections will spontaneously resolve, there is a high recurrence rate. Recurrence can be up to 30% in 3 months and 80% in 9-12 months in nonpregnant patients.

The American College of Obstetricians and Gynecologists has taken the position (in a practice bulletin) that “there are insufficient data to suggest screening and treating women at either low or high risk will reduce the overall rate of preterm birth” (Obstet. Gynecol. 2001;98:709-16).

For its part, the Centers for Disease Control and Prevention recommends BV screening in symptomatic pregnant women and asymptomatic pregnant women who are at high risk because they have previously delivered a premature infant. Treatment can be given to pregnant women who test positive for BV, the CDC says.

In contrast with the ACOG and CDC positions, Dr. Brown called for aggressive screening for BV in pregnant women regardless of their risk. All pregnant women should be screened early in pregnancy, he said. For those who test positive, he endorsed treatment before 20 weeks with an oral regimen recommended by the CDC. In addition, he advocated reevaluating high-risk women at every visit up to 32 weeks.

Dr. Brown said the ACOG and CDC guidelines were driven by evidence-based studies that tested one-drug treatments, whereas his opinion derived from clinical practice. He also cited the hypothesis that BV is an inflammatory condition as evidenced by increased levels of proinflammatory cytokines in women with BV (Obstet. Gynecol. 2003;102:527-34). Symptomatic women may be hyperresponders to BV, and asymptomatic women may be hyporesponders and also would benefit from aggressive treatment, Dr. Brown said.

The CDC recommends pregnant women be treated with 250 mg of metronidazole orally three times a day or 300 mg of clindamycin orally twice a day, both for 7 days, according to Dr. Brown. In addition, he advocated using a second agent, probably erythromycin or azithromycin. “Gardnerella vaginalis is not really attacked by metronidazole,” he said.

If BV recurs, he recommended switching medications and using the new regimen for a longer period of time. Though randomized studies haven't shown improvement with treatment of the male partner, he advocated treating the partner as well. Among other management strategies for treating recurrent BV, he listed condoms, intravaginal use of Lactobacillus crispatus, oral or vaginal use of yogurt containing L. acidophilus, povidone iodine suppositories, hydrogen peroxide douches, lactate gel/acid preparation, and boric acid suppositories.

The underlying physiologic and pathologic conditions are not well understood, he said. He speculated that “some unknown factor involving interaction between vaginal bacteria” might be behind the perseverance of BV.

NEW YORK — Macrophage migration inhibitory factor, a newly characterized cytokine that inhibits cortisol and increases production of inflammatory cytokines, may be the key to understanding depression during pregnancy, Brad D. Pearce, Ph.D., said at a symposium sponsored by the National Alliance for Research on Schizophrenia and Depression.

Pregnant women seeking treatment for major depression have markedly higher levels of macrophage migration inhibitory factor (MIF) than do nondepressed pregnant women of similar age. In general, MIF levels are slightly elevated in pregnant vs. nonpregnant women, but the difference is insignificant compared with the difference between depressed and nondepressed pregnant women, said Dr. Pearce of the department of psychology at Emory University, Atlanta.

“We all hear that pregnancy is a time of joy, a natural high, and that pregnancy-related hormones are protective. The data, however, collide with these truisms,” said Dr. Pearce, noting that roughly 7% of all American women experience episodes of major depression during their first pregnancies. The proportion increases to 12%-14% for second and third pregnancies.

The prevalence of major depression among nonpregnant women is roughly 8%. So, on a statistical basis, pregnancy is hardly protective and may actually increase the incidence of depression, particularly in multiparous women, he said.

“There are some very big changes in body chemistry during pregnancy. The shift in the balance of hormones, cytokines, cortisol, and many other things can be huge and very complex. Some women feel bliss; many others become depressed,” he noted.

Depression during pregnancy can have significant complications: It is predictive of preterm labor and delivery, as well as other obstetrical complications, and is linked to an increased risk of behavioral and social problems in the children. “The physiological changes caused by depression during pregnancy result in changes in maternal-fetal interaction, which can have adverse effects on the fetal brain,” Dr. Pearce said.

Antidepressant drug therapy, however, is not a neutral, risk-free proposition during pregnancy. Although none of the major antidepressant drug classes is considered strongly teratogenic, many commonly used medications have been linked to adverse obstetrical outcomes, including preterm delivery.

Dr. Pearce and his colleagues at Emory have been looking at potential biologic mediators involved in depression during pregnancy with the hope of eventually identifying targets for novel treatment strategies.

They've focused largely on inflammatory cytokines, many of which are consistently elevated among individuals with major depression. Patients with chronic inflammatory disorders, characterized by elevated cytokine levels, often have comorbid depression. Some cytokines used as drugs in the treatment of serious illnesses like cancer can actually induce symptoms of depression if given intravenously.

MIF is a fairly recent discovery, and it has attracted considerable attention among immunologists and infectious-disease researchers. “It is a very unique protein. It is not like any of the other cytokines. It is really in its own family,” Dr. Pearce said.

MIF is produced endogenously by a number of different immune cells and appears to block the action of cortisol. This results in an overall up-regulation of inflammation because cortisol normally inhibits inflammatory signaling molecules. MIF is also a modulator of catecholamine metabolism. Interestingly, MIF is also produced in large quantities by the hippocampus. “Nobody knows yet what it is doing there in the brain,” he said.

If the connection between elevated MIF levels and depression in pregnancy is borne out in future studies, Dr. Pearce believes that MIF may be useful as a prognostic marker for both depression and pregnancy complications like preterm labor. Prepregnancy depression predicts depression during and after pregnancy, he said.

“It seems that MIF levels predict postpartum outcomes,” Dr. Pearce commented.

NEW YORK — Macrophage migration inhibitory factor, a newly characterized cytokine that inhibits cortisol and increases production of inflammatory cytokines, may be the key to understanding depression during pregnancy, Brad D. Pearce, Ph.D., said at a symposium sponsored by the National Alliance for Research on Schizophrenia and Depression.

Pregnant women seeking treatment for major depression have markedly higher levels of macrophage migration inhibitory factor (MIF) than do nondepressed pregnant women of similar age. In general, MIF levels are slightly elevated in pregnant vs. nonpregnant women, but the difference is insignificant compared with the difference between depressed and nondepressed pregnant women, said Dr. Pearce of the department of psychology at Emory University, Atlanta.

“We all hear that pregnancy is a time of joy, a natural high, and that pregnancy-related hormones are protective. The data, however, collide with these truisms,” said Dr. Pearce, noting that roughly 7% of all American women experience episodes of major depression during their first pregnancies. The proportion increases to 12%-14% for second and third pregnancies.

The prevalence of major depression among nonpregnant women is roughly 8%. So, on a statistical basis, pregnancy is hardly protective and may actually increase the incidence of depression, particularly in multiparous women, he said.

“There are some very big changes in body chemistry during pregnancy. The shift in the balance of hormones, cytokines, cortisol, and many other things can be huge and very complex. Some women feel bliss; many others become depressed,” he noted.

Depression during pregnancy can have significant complications: It is predictive of preterm labor and delivery, as well as other obstetrical complications, and is linked to an increased risk of behavioral and social problems in the children. “The physiological changes caused by depression during pregnancy result in changes in maternal-fetal interaction, which can have adverse effects on the fetal brain,” Dr. Pearce said.

Antidepressant drug therapy, however, is not a neutral, risk-free proposition during pregnancy. Although none of the major antidepressant drug classes is considered strongly teratogenic, many commonly used medications have been linked to adverse obstetrical outcomes, including preterm delivery.

Dr. Pearce and his colleagues at Emory have been looking at potential biologic mediators involved in depression during pregnancy with the hope of eventually identifying targets for novel treatment strategies.

They've focused largely on inflammatory cytokines, many of which are consistently elevated among individuals with major depression. Patients with chronic inflammatory disorders, characterized by elevated cytokine levels, often have comorbid depression. Some cytokines used as drugs in the treatment of serious illnesses like cancer can actually induce symptoms of depression if given intravenously.

MIF is a fairly recent discovery, and it has attracted considerable attention among immunologists and infectious-disease researchers. “It is a very unique protein. It is not like any of the other cytokines. It is really in its own family,” Dr. Pearce said.

MIF is produced endogenously by a number of different immune cells and appears to block the action of cortisol. This results in an overall up-regulation of inflammation because cortisol normally inhibits inflammatory signaling molecules. MIF is also a modulator of catecholamine metabolism. Interestingly, MIF is also produced in large quantities by the hippocampus. “Nobody knows yet what it is doing there in the brain,” he said.

If the connection between elevated MIF levels and depression in pregnancy is borne out in future studies, Dr. Pearce believes that MIF may be useful as a prognostic marker for both depression and pregnancy complications like preterm labor. Prepregnancy depression predicts depression during and after pregnancy, he said.

“It seems that MIF levels predict postpartum outcomes,” Dr. Pearce commented.

NEW YORK — Macrophage migration inhibitory factor, a newly characterized cytokine that inhibits cortisol and increases production of inflammatory cytokines, may be the key to understanding depression during pregnancy, Brad D. Pearce, Ph.D., said at a symposium sponsored by the National Alliance for Research on Schizophrenia and Depression.

Pregnant women seeking treatment for major depression have markedly higher levels of macrophage migration inhibitory factor (MIF) than do nondepressed pregnant women of similar age. In general, MIF levels are slightly elevated in pregnant vs. nonpregnant women, but the difference is insignificant compared with the difference between depressed and nondepressed pregnant women, said Dr. Pearce of the department of psychology at Emory University, Atlanta.

“We all hear that pregnancy is a time of joy, a natural high, and that pregnancy-related hormones are protective. The data, however, collide with these truisms,” said Dr. Pearce, noting that roughly 7% of all American women experience episodes of major depression during their first pregnancies. The proportion increases to 12%-14% for second and third pregnancies.

The prevalence of major depression among nonpregnant women is roughly 8%. So, on a statistical basis, pregnancy is hardly protective and may actually increase the incidence of depression, particularly in multiparous women, he said.

“There are some very big changes in body chemistry during pregnancy. The shift in the balance of hormones, cytokines, cortisol, and many other things can be huge and very complex. Some women feel bliss; many others become depressed,” he noted.

Depression during pregnancy can have significant complications: It is predictive of preterm labor and delivery, as well as other obstetrical complications, and is linked to an increased risk of behavioral and social problems in the children. “The physiological changes caused by depression during pregnancy result in changes in maternal-fetal interaction, which can have adverse effects on the fetal brain,” Dr. Pearce said.

Antidepressant drug therapy, however, is not a neutral, risk-free proposition during pregnancy. Although none of the major antidepressant drug classes is considered strongly teratogenic, many commonly used medications have been linked to adverse obstetrical outcomes, including preterm delivery.

Dr. Pearce and his colleagues at Emory have been looking at potential biologic mediators involved in depression during pregnancy with the hope of eventually identifying targets for novel treatment strategies.

They've focused largely on inflammatory cytokines, many of which are consistently elevated among individuals with major depression. Patients with chronic inflammatory disorders, characterized by elevated cytokine levels, often have comorbid depression. Some cytokines used as drugs in the treatment of serious illnesses like cancer can actually induce symptoms of depression if given intravenously.

MIF is a fairly recent discovery, and it has attracted considerable attention among immunologists and infectious-disease researchers. “It is a very unique protein. It is not like any of the other cytokines. It is really in its own family,” Dr. Pearce said.

MIF is produced endogenously by a number of different immune cells and appears to block the action of cortisol. This results in an overall up-regulation of inflammation because cortisol normally inhibits inflammatory signaling molecules. MIF is also a modulator of catecholamine metabolism. Interestingly, MIF is also produced in large quantities by the hippocampus. “Nobody knows yet what it is doing there in the brain,” he said.

If the connection between elevated MIF levels and depression in pregnancy is borne out in future studies, Dr. Pearce believes that MIF may be useful as a prognostic marker for both depression and pregnancy complications like preterm labor. Prepregnancy depression predicts depression during and after pregnancy, he said.

“It seems that MIF levels predict postpartum outcomes,” Dr. Pearce commented.