Obstetrics

Magnetic resonance imaging is an effective means of diagnosing acute abdominal and pelvic pain in pregnant patients, and it avoids fetal exposure to the radiation of a computerized axial tomography exam, Katherine Birchard, M.D., and her colleagues have reported.

Although there have been no documented cases of MRI causing adverse effects to the fetus, MRI scans should be used in pregnant patients only when the benefits clearly outweigh the risks, the researchers said. “However, we should stress that the single greatest factor in morbidity and mortality of the pregnant patient is delay in diagnosis,” reported Dr. Birchard of the University of North Carolina, and associates (AJR Am. J. Roentgenol. 2005;184:452-8).

The researchers retrospectively analyzed all MRI studies of 29 pregnant patients referred to their facility from 2002 to 2004 for evaluation of acute abdominal or pelvic pain. The patients' mean age was 25 years (18-35 years), and mean gestational age was 23 weeks (10-36 weeks). Most of the patients (22) did not have gadolinium administered.

Every patient underwent fetal sonography before any other imaging. Six also underwent complete abdominal sonographic examination before the MRI, which was the imaging exam used in 23 patients.

MRI identified appendiceal abscess (1 case), appendicitis (2 cases), intraabdominal and rectus muscle abscess (1), pancreatitis (1), and ulcerative colitis (1). MRI also showed Crohn's disease with diffuse peritoneal inflammation (1), intussusception (1), bilateral adrenal hemorrhage (1), pyelonephritis (2), hydronephrosis (1), uterine fibroid degeneration (2), degeneration and torsion of a subserosal uterine fibroid (1), simple ovarian cysts (1), and ovarian torsion (1). The other 12 examinations were normal.

The MRI results were congruent with follow-up medical records in 28 of the 29 patients and accurately described the disease process in all except one patient. This patient was at 18 weeks' gestation and complained of acute right lower quadrant pain. The MRI identified multiple ovarian cysts, but a laparoscopy 1 month later showed a torsed right ovary with multiple cysts. When examined retrospectively, the MRI did not shown this finding.

“We believe this is due to the fact that the ovary was largely cystic, and therefore, edematous tissue was not seen,” the researchers said.

Magnetic resonance imaging is an effective means of diagnosing acute abdominal and pelvic pain in pregnant patients, and it avoids fetal exposure to the radiation of a computerized axial tomography exam, Katherine Birchard, M.D., and her colleagues have reported.

Although there have been no documented cases of MRI causing adverse effects to the fetus, MRI scans should be used in pregnant patients only when the benefits clearly outweigh the risks, the researchers said. “However, we should stress that the single greatest factor in morbidity and mortality of the pregnant patient is delay in diagnosis,” reported Dr. Birchard of the University of North Carolina, and associates (AJR Am. J. Roentgenol. 2005;184:452-8).

The researchers retrospectively analyzed all MRI studies of 29 pregnant patients referred to their facility from 2002 to 2004 for evaluation of acute abdominal or pelvic pain. The patients' mean age was 25 years (18-35 years), and mean gestational age was 23 weeks (10-36 weeks). Most of the patients (22) did not have gadolinium administered.

Every patient underwent fetal sonography before any other imaging. Six also underwent complete abdominal sonographic examination before the MRI, which was the imaging exam used in 23 patients.

MRI identified appendiceal abscess (1 case), appendicitis (2 cases), intraabdominal and rectus muscle abscess (1), pancreatitis (1), and ulcerative colitis (1). MRI also showed Crohn's disease with diffuse peritoneal inflammation (1), intussusception (1), bilateral adrenal hemorrhage (1), pyelonephritis (2), hydronephrosis (1), uterine fibroid degeneration (2), degeneration and torsion of a subserosal uterine fibroid (1), simple ovarian cysts (1), and ovarian torsion (1). The other 12 examinations were normal.

The MRI results were congruent with follow-up medical records in 28 of the 29 patients and accurately described the disease process in all except one patient. This patient was at 18 weeks' gestation and complained of acute right lower quadrant pain. The MRI identified multiple ovarian cysts, but a laparoscopy 1 month later showed a torsed right ovary with multiple cysts. When examined retrospectively, the MRI did not shown this finding.

“We believe this is due to the fact that the ovary was largely cystic, and therefore, edematous tissue was not seen,” the researchers said.

Magnetic resonance imaging is an effective means of diagnosing acute abdominal and pelvic pain in pregnant patients, and it avoids fetal exposure to the radiation of a computerized axial tomography exam, Katherine Birchard, M.D., and her colleagues have reported.

Although there have been no documented cases of MRI causing adverse effects to the fetus, MRI scans should be used in pregnant patients only when the benefits clearly outweigh the risks, the researchers said. “However, we should stress that the single greatest factor in morbidity and mortality of the pregnant patient is delay in diagnosis,” reported Dr. Birchard of the University of North Carolina, and associates (AJR Am. J. Roentgenol. 2005;184:452-8).

The researchers retrospectively analyzed all MRI studies of 29 pregnant patients referred to their facility from 2002 to 2004 for evaluation of acute abdominal or pelvic pain. The patients' mean age was 25 years (18-35 years), and mean gestational age was 23 weeks (10-36 weeks). Most of the patients (22) did not have gadolinium administered.

Every patient underwent fetal sonography before any other imaging. Six also underwent complete abdominal sonographic examination before the MRI, which was the imaging exam used in 23 patients.

MRI identified appendiceal abscess (1 case), appendicitis (2 cases), intraabdominal and rectus muscle abscess (1), pancreatitis (1), and ulcerative colitis (1). MRI also showed Crohn's disease with diffuse peritoneal inflammation (1), intussusception (1), bilateral adrenal hemorrhage (1), pyelonephritis (2), hydronephrosis (1), uterine fibroid degeneration (2), degeneration and torsion of a subserosal uterine fibroid (1), simple ovarian cysts (1), and ovarian torsion (1). The other 12 examinations were normal.

The MRI results were congruent with follow-up medical records in 28 of the 29 patients and accurately described the disease process in all except one patient. This patient was at 18 weeks' gestation and complained of acute right lower quadrant pain. The MRI identified multiple ovarian cysts, but a laparoscopy 1 month later showed a torsed right ovary with multiple cysts. When examined retrospectively, the MRI did not shown this finding.

“We believe this is due to the fact that the ovary was largely cystic, and therefore, edematous tissue was not seen,” the researchers said.

Women who do not conceive within 1 year of trying may face an increased risk of their babies dying by the first month post partum, according to Danish researchers.

“Subfecundity may be associated with an increased risk of neonatal death and should be included as a risk indicator in neonatal care,” reported Olga Basso, Ph.D., and Jørn Olsen, M.D., from the Danish Epidemiology Center at the University of Aarhus in Denmark (BMJ [Epub ahead of print], Feb. 4, 2005. Article DOI number: 10.1136/bmj.38336.616806.8F).

“Unlike advanced age, or pregnancy following in vitro fertilization, a period of infertility is not routinely considered a risk factor in pregnancy,” Dr. Basso told this newspaper. “We think it would be advisable to include this when evaluating pregnant women, because it is possible that some complications might be noticed earlier,” she said.

The study analyzed 27,329 singleton births and 66 deaths recorded in the Danish national birth cohort. The analysis was restricted to primiparous women, 73.5% of whom had no previous pregnancies.

The women were grouped by waiting time to pregnancy: up to 2 months (reference group); 3-12 months; more than 12 months with no infertility treatment; more than 12 months with infertility treatment; and those who hadn't planned their pregnancy.

After adjustment for maternal age, body mass index, smoking, and social class (derived from the mother's job title), the analysis found an increased risk of neonatal death associated with increasing time to pregnancy.

Women who reported trying to conceive for more than 12 months had an odds ratio (OR) of 2.80 for neonatal death. Within this group, there was little difference in risk between those who reported infertility treatment (OR 2.21), and those who reported none (OR 3.38).

The authors noted potential weaknesses in their data. About 35% of eligible women participated in the study, and the mother's job title may be a poor proxy for social class (even though adjustment for confounders did not change the estimates). Moreover, subfertile women who do not seek fertility treatment may also not seek or receive adequate prenatal care.

The researchers noted that the findings do not indicate a causal relationship.

“Our finding needs … to be corroborated elsewhere before it can be stated that a long time to pregnancy increases the risk of neonatal death,” they said.

Women who do not conceive within 1 year of trying may face an increased risk of their babies dying by the first month post partum, according to Danish researchers.

“Subfecundity may be associated with an increased risk of neonatal death and should be included as a risk indicator in neonatal care,” reported Olga Basso, Ph.D., and Jørn Olsen, M.D., from the Danish Epidemiology Center at the University of Aarhus in Denmark (BMJ [Epub ahead of print], Feb. 4, 2005. Article DOI number: 10.1136/bmj.38336.616806.8F).

“Unlike advanced age, or pregnancy following in vitro fertilization, a period of infertility is not routinely considered a risk factor in pregnancy,” Dr. Basso told this newspaper. “We think it would be advisable to include this when evaluating pregnant women, because it is possible that some complications might be noticed earlier,” she said.

The study analyzed 27,329 singleton births and 66 deaths recorded in the Danish national birth cohort. The analysis was restricted to primiparous women, 73.5% of whom had no previous pregnancies.

The women were grouped by waiting time to pregnancy: up to 2 months (reference group); 3-12 months; more than 12 months with no infertility treatment; more than 12 months with infertility treatment; and those who hadn't planned their pregnancy.

After adjustment for maternal age, body mass index, smoking, and social class (derived from the mother's job title), the analysis found an increased risk of neonatal death associated with increasing time to pregnancy.

Women who reported trying to conceive for more than 12 months had an odds ratio (OR) of 2.80 for neonatal death. Within this group, there was little difference in risk between those who reported infertility treatment (OR 2.21), and those who reported none (OR 3.38).

The authors noted potential weaknesses in their data. About 35% of eligible women participated in the study, and the mother's job title may be a poor proxy for social class (even though adjustment for confounders did not change the estimates). Moreover, subfertile women who do not seek fertility treatment may also not seek or receive adequate prenatal care.

The researchers noted that the findings do not indicate a causal relationship.

“Our finding needs … to be corroborated elsewhere before it can be stated that a long time to pregnancy increases the risk of neonatal death,” they said.

Women who do not conceive within 1 year of trying may face an increased risk of their babies dying by the first month post partum, according to Danish researchers.

“Subfecundity may be associated with an increased risk of neonatal death and should be included as a risk indicator in neonatal care,” reported Olga Basso, Ph.D., and Jørn Olsen, M.D., from the Danish Epidemiology Center at the University of Aarhus in Denmark (BMJ [Epub ahead of print], Feb. 4, 2005. Article DOI number: 10.1136/bmj.38336.616806.8F).

“Unlike advanced age, or pregnancy following in vitro fertilization, a period of infertility is not routinely considered a risk factor in pregnancy,” Dr. Basso told this newspaper. “We think it would be advisable to include this when evaluating pregnant women, because it is possible that some complications might be noticed earlier,” she said.

The study analyzed 27,329 singleton births and 66 deaths recorded in the Danish national birth cohort. The analysis was restricted to primiparous women, 73.5% of whom had no previous pregnancies.

The women were grouped by waiting time to pregnancy: up to 2 months (reference group); 3-12 months; more than 12 months with no infertility treatment; more than 12 months with infertility treatment; and those who hadn't planned their pregnancy.

After adjustment for maternal age, body mass index, smoking, and social class (derived from the mother's job title), the analysis found an increased risk of neonatal death associated with increasing time to pregnancy.

Women who reported trying to conceive for more than 12 months had an odds ratio (OR) of 2.80 for neonatal death. Within this group, there was little difference in risk between those who reported infertility treatment (OR 2.21), and those who reported none (OR 3.38).

The authors noted potential weaknesses in their data. About 35% of eligible women participated in the study, and the mother's job title may be a poor proxy for social class (even though adjustment for confounders did not change the estimates). Moreover, subfertile women who do not seek fertility treatment may also not seek or receive adequate prenatal care.

The researchers noted that the findings do not indicate a causal relationship.

“Our finding needs … to be corroborated elsewhere before it can be stated that a long time to pregnancy increases the risk of neonatal death,” they said.

RICHARD FRANKI, RESEARCH/DESIGN

RICHARD FRANKI, RESEARCH/DESIGN

RICHARD FRANKI, RESEARCH/DESIGN

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — Pregnancies achieved using donor-egg in vitro fertilization can present a higher risk of pregnancy-induced hypertension than those achieved through standard IVF, according to the results of a retrospective study.

Investigators compared 50 oocyte-donation pregnancies with 50 standard IVF pregnancies at three private practice medical groups at the California Pacific Medical Center in San Francisco. The rate of pregnancy-induced hypertension (PIH) was more than three times higher in the donor-egg IVF group than in the standard IVF group (27% vs. 8%), said Donna Wiggins, M.D., the study's lead investigator and a San Francisco ob.gyn.

PIH was defined as a systolic blood pressure (BP) of at least 140 mm Hg or a diastolic BP of at least 90 mm Hg occurring after 20 weeks' gestation in a woman with previously normal BP.

In looking separately at nulliparous patients, the researchers found greater PIH rates in the donor-egg IVF group (37% vs. 8%), she said at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

Among women who had twins, 58% of those in the donor-egg IVF group and 17% of the standard IVF group developed PIH.

The women were between the ages of 30 and 50 years, and the average maternal age in the donor-egg IVF group was 42, compared with 38 in the standard IVF group. But Dr. Wiggins explained that when age stratifications were applied, there was not an increasing incidence with advancing age. And when the multiple logistic regression was applied, age fell out as an indicator of significance with regard to PIH.

Aside from the PIH rates, the two groups showed similar results in most other categories. The cesarean-section rate was 43% in the donor-egg group and 45% in the standard IVF group.

First-trimester bleeding occurred in 12% of the donor-egg group and 14% in standard IVF. And the most common postpartum complications of “lactation difficulties” and postpartum depression occurred in both groups at about the same rate of 10%.

Birthweight was an average of 3,044 g in the donor-egg group and 3,017 g in standard IVF group, and premature labor occurred in the donor-egg group at a rate of 16%, compared with 10% in the standard IVF group.

“In looking at donor-egg and [standard] IVF pregnancies, there aren't that many differences, aside from the significant difference in hypertensive disorders,” said Dr. Wiggins. “All things considered, however, the women for the most part had good outcomes.”

The reasons for the higher PIH rates in donor-egg IVF may have to do with the fact that the donor egg is foreign, Dr. Wiggins speculated. “Unlike any other pregnancy, a donor-egg pregnancy is 100% allogeneic, and this may affect the adequacy of trophoblast invasion and hence hypertensive disorders,” she said at the meeting, cosponsored by the American College of Obstetricians and Gynecologists.

When initially introduced in 1984, donor-egg IVF was primarily indicated for premature ovarian failure, defined as menopause occurring before the age of 40. But the primary indication for egg donation at most IVF centers is now diminished ovarian reserve in women with functioning ovaries, Dr. Wiggins said.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

PHOENIX, ARIZ. — About one-quarter of a diverse group of pregnant women would not consider a pregnancy termination for a fetus with Down syndrome, according to a study presented at the annual meeting of the Pacific Coast Obstetrical and Gynecological Society.

The prospective study of 1,038 pregnant women who were participating in research at the University of California, San Francisco, department of obstetrics, gynecology, and reproductive sciences showed that 24% said they would not consider a termination if testing showed the fetus had Down syndrome.

Among the 76% of women who said they would consider an abortion under such circumstances, half said they would do so only in the first trimester, 36% said they would do so only in the first or second trimester, and 14% said they would at any point in the pregnancy, said lead author Lee A. Learman, M.D., of the UCSF department.

The women were interviewed before 20 weeks' gestation and were of diverse socioeconomic backgrounds.

When asked about their attitudes regarding abortion in general, 23% said that they thought abortion should be available only in cases of rape or incest, and 8% said abortion should not be available under any circumstances.

Seventy-two percent of the women answered yes to the question of whether they would ever consider having an abortion, and 52% reported that they had had an abortion in the past.

With adjustment for various factors, women were more likely to consider an abortion if they were older, had a previous abortion, or expressed distrust in the health care system. Conversely, they were less likely to consider an abortion if they had at least two prior births, were married, were fatalistic about the outcome of their pregnancy, or were not white.

“The overarching goal of the project is to help understand the tradeoffs involved in screening and testing strategies and to help patients make decisions that are consistent with their personal values and feelings,” Dr. Learman said.

In a commentary on the study, Anita Nelson, M.D., medical director of Women's Health Care Programs at Harbor-UCLA Medical Center in Torrance, Calif., brought up the possibility that patients' actions may not always be consistent with their declared beliefs. Dr. Learman agreed, saying his lab is working on research to track discrepancies between actions and beliefs.

Dr. Nelson added that efforts to better prepare women for the many possible outcomes of a pregnancy should also extend to the preconception period to prevent unrealistic expectations.

“When women expect perfect outcomes, we can find ourselves in a bit of a legal jam, and it's therefore important to lay on the table all the risks of pregnancy while all options are still open—including the option to not become pregnant,” she said during the meeting.

BRECKENRIDGE, COLO. — A strong case can be made for encouraging a few weeks or months of breast-feeding by epileptic women who continued their seizure medication throughout pregnancy, Jose E. Cavazos, M.D., said at a conference on epilepsy syndromes sponsored by the University of Texas at San Antonio.

In addition to all the usual benefits of breast-feeding, this practice greatly reduces the likelihood of neonatal antiepileptic drug (AED) withdrawal syndrome, said Dr. Cavazos, a neurologist at the university's South Texas Comprehensive Epilepsy Center.

Transplacental passage of AEDs occurs readily. Studies have shown maternal serum and umbilical cord blood concentrations of AEDs are generally similar. After being exposed to therapeutic AED concentrations throughout fetal life, a baby who experiences abrupt postpartum discontinuation often develops a withdrawal syndrome marked by increased irritability. This can be avoided by taking advantage of the fact that most AEDs enter breast milk in concentrations similar to those found in maternal serum.

“Many women have an irrational attitude of 'I don't want to give my baby this medicine.' I tell such a patient that for the last 9 months, her baby has been exposed to an AED. I suggest breast-feeding for the first several weeks, then weaning from the breast and, in that way, gradually weaning the baby off the medication. When it's presented in that light, it's more often that breast-feeding will occur,” the neurologist explained.

There is little downside to such an approach, he added. Idiosyncratic drug reactions are extremely unlikely in a neonate exposed in utero. There have been no large prospective studies of the neurodevelopmental impact of breast-feeding by mothers on AEDs, although several studies suggest in utero exposure is associated with mild, partially reversible delays in motor coordination. Breast-feeding while the mother is on an AED can result in neonatal sedation, but it's typically mild and of little concern unless the mother is taking large doses of phenobarbital.

And speaking of phenobarbital, some obstetricians still favor it for seizure control in pregnancy, although the practice is no longer recommended. “In fact, in the past year, I've had two women who were switched from other AEDs to phenobarbital because they became pregnant and happened to visit their ob.gyns. before seeing their neurologists. This is not necessarily the best way to go,” Dr. Cavazos said.

A recent report from the North American AED Registry is instructive. Of 77 pregnancies exposed to phenobarbital monotherapy from conception and followed prospectively, 5 (6.5%) resulted in major malformations identified by 5 days of age. This represented a 4.2-fold elevation over the background risk (Arch. Neurol. 2004;61:673-8).

BRECKENRIDGE, COLO. — A strong case can be made for encouraging a few weeks or months of breast-feeding by epileptic women who continued their seizure medication throughout pregnancy, Jose E. Cavazos, M.D., said at a conference on epilepsy syndromes sponsored by the University of Texas at San Antonio.

In addition to all the usual benefits of breast-feeding, this practice greatly reduces the likelihood of neonatal antiepileptic drug (AED) withdrawal syndrome, said Dr. Cavazos, a neurologist at the university's South Texas Comprehensive Epilepsy Center.

Transplacental passage of AEDs occurs readily. Studies have shown maternal serum and umbilical cord blood concentrations of AEDs are generally similar. After being exposed to therapeutic AED concentrations throughout fetal life, a baby who experiences abrupt postpartum discontinuation often develops a withdrawal syndrome marked by increased irritability. This can be avoided by taking advantage of the fact that most AEDs enter breast milk in concentrations similar to those found in maternal serum.

“Many women have an irrational attitude of 'I don't want to give my baby this medicine.' I tell such a patient that for the last 9 months, her baby has been exposed to an AED. I suggest breast-feeding for the first several weeks, then weaning from the breast and, in that way, gradually weaning the baby off the medication. When it's presented in that light, it's more often that breast-feeding will occur,” the neurologist explained.

There is little downside to such an approach, he added. Idiosyncratic drug reactions are extremely unlikely in a neonate exposed in utero. There have been no large prospective studies of the neurodevelopmental impact of breast-feeding by mothers on AEDs, although several studies suggest in utero exposure is associated with mild, partially reversible delays in motor coordination. Breast-feeding while the mother is on an AED can result in neonatal sedation, but it's typically mild and of little concern unless the mother is taking large doses of phenobarbital.

And speaking of phenobarbital, some obstetricians still favor it for seizure control in pregnancy, although the practice is no longer recommended. “In fact, in the past year, I've had two women who were switched from other AEDs to phenobarbital because they became pregnant and happened to visit their ob.gyns. before seeing their neurologists. This is not necessarily the best way to go,” Dr. Cavazos said.

A recent report from the North American AED Registry is instructive. Of 77 pregnancies exposed to phenobarbital monotherapy from conception and followed prospectively, 5 (6.5%) resulted in major malformations identified by 5 days of age. This represented a 4.2-fold elevation over the background risk (Arch. Neurol. 2004;61:673-8).

BRECKENRIDGE, COLO. — A strong case can be made for encouraging a few weeks or months of breast-feeding by epileptic women who continued their seizure medication throughout pregnancy, Jose E. Cavazos, M.D., said at a conference on epilepsy syndromes sponsored by the University of Texas at San Antonio.

In addition to all the usual benefits of breast-feeding, this practice greatly reduces the likelihood of neonatal antiepileptic drug (AED) withdrawal syndrome, said Dr. Cavazos, a neurologist at the university's South Texas Comprehensive Epilepsy Center.

Transplacental passage of AEDs occurs readily. Studies have shown maternal serum and umbilical cord blood concentrations of AEDs are generally similar. After being exposed to therapeutic AED concentrations throughout fetal life, a baby who experiences abrupt postpartum discontinuation often develops a withdrawal syndrome marked by increased irritability. This can be avoided by taking advantage of the fact that most AEDs enter breast milk in concentrations similar to those found in maternal serum.

“Many women have an irrational attitude of 'I don't want to give my baby this medicine.' I tell such a patient that for the last 9 months, her baby has been exposed to an AED. I suggest breast-feeding for the first several weeks, then weaning from the breast and, in that way, gradually weaning the baby off the medication. When it's presented in that light, it's more often that breast-feeding will occur,” the neurologist explained.

There is little downside to such an approach, he added. Idiosyncratic drug reactions are extremely unlikely in a neonate exposed in utero. There have been no large prospective studies of the neurodevelopmental impact of breast-feeding by mothers on AEDs, although several studies suggest in utero exposure is associated with mild, partially reversible delays in motor coordination. Breast-feeding while the mother is on an AED can result in neonatal sedation, but it's typically mild and of little concern unless the mother is taking large doses of phenobarbital.

And speaking of phenobarbital, some obstetricians still favor it for seizure control in pregnancy, although the practice is no longer recommended. “In fact, in the past year, I've had two women who were switched from other AEDs to phenobarbital because they became pregnant and happened to visit their ob.gyns. before seeing their neurologists. This is not necessarily the best way to go,” Dr. Cavazos said.

A recent report from the North American AED Registry is instructive. Of 77 pregnancies exposed to phenobarbital monotherapy from conception and followed prospectively, 5 (6.5%) resulted in major malformations identified by 5 days of age. This represented a 4.2-fold elevation over the background risk (Arch. Neurol. 2004;61:673-8).

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said during a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, who is the chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

Dr. Zimmerman described several intracranial infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery. Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury.

Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing. Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia. Clinical findings become extremely important in differentiating the two, according to Dr. Zimmerman.

Infarction of the basal ganglia as a result of streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury.

The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however.

Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging.

Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is considered the best modality for imaging the neonatal central nervous system; CT scans can help look for brain calcifications, Dr. Zimmerman said during the meeting.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said during a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, who is the chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

Dr. Zimmerman described several intracranial infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery. Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury.

Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing. Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia. Clinical findings become extremely important in differentiating the two, according to Dr. Zimmerman.

Infarction of the basal ganglia as a result of streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury.

The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however.

Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging.

Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is considered the best modality for imaging the neonatal central nervous system; CT scans can help look for brain calcifications, Dr. Zimmerman said during the meeting.

CABO SAN LUCAS, MEXICO — What looks like damage from hypoxic ischemic encephalopathy on neonatal brain imaging actually can be caused by intracranial infection, Robert A. Zimmerman, M.D., said during a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always correlate clinical findings and laboratory results with images of brain abnormalities to detect intracranial infections and to avoid attributing the infant's problems to hypoxic ischemic brain injury, said Dr. Zimmerman, who is the chief of pediatric neuroradiology at Children's Hospital of Philadelphia.

Dr. Zimmerman described several intracranial infections that could be confused with hypoxic ischemic encephalopathy:

▸ Acute cytomegalovirus infection, the most common intracranial infection that occurs in utero, causes fetal brain abnormalities in the second and third trimesters. Edema in the brain seen on imaging shortly after birth may simulate a toxic ischemic brain injury.

“The clinical work-up of the patient turns out to be critical” to differentiate the two, he said during the conference, which was sponsored by Boston University and the Center for Human Genetics.

▸ Neonatal meningitis may result from exposure to a pathogen in utero, at the time of delivery, or in the neonatal nursery. Both gram-negative and gram-positive bacterial meningitis can be a problem, since neonates lack a functional immune system to resist CNS infection.

Severe brain swelling secondary to E. coli meningitis infection can look like severe brain swelling from hypoxic ischemic brain injury, Dr. Zimmerman said.

When infection damages areas of the brain rather than causing complete brain injury, this also can be confused with hypoxic ischemic injury.

Cortical infarction from infection with streptococci or gram-negative rods, for example, may be confusing. Areas of cortical hyperintensity on imaging due to these infections can simulate damage from a partial prolonged asphyxia. Clinical findings become extremely important in differentiating the two, according to Dr. Zimmerman.

Infarction of the basal ganglia as a result of streptococcal infection may be confused with a profound asphyxial injury, but a gadolinium-enhanced MRI can highlight changes characteristic of meningitis to help make the diagnosis.

The most severe forms of infection with Citrobacter or Serratia cause diffuse brain swelling with supratentorial necrosis due to lack of perfusion, which can look like a severe hypoxic ischemic brain injury.

The clinical findings and cerebral spinal fluid analysis look quite different between the two problems, however.

Close to half of patients with meningitis due to Citrobacter or Serratia also will show brain abscesses on imaging.

▸ Herpes encephalitis can result from infection in utero or from infection acquired at birth. Symptoms from infection at birth typically present as seizures and fever days or weeks after birth. Herpes encephalitis can be a focal or diffuse disease. The diffuse form of herpes encephalitis causes cytotoxic edema that can mimic a hypoxic-ischemic type of injury on imaging.

Herpes usually is easily recognizable on good-quality MRI scans with diffusion studies and using gadolinium enhancement.

In general, MRI is considered the best modality for imaging the neonatal central nervous system; CT scans can help look for brain calcifications, Dr. Zimmerman said during the meeting.

RENO, NEVADA — Attempting vaginal birth after cesarean section in twin deliveries may be no more risky than attempting VBAC in singleton pregnancies, according to a review of almost 25,000 deliveries.

The review found that women with twins who had a prior C-section were less likely to attempt a vaginal birth but that they had the same rate of VBAC failures and no higher rate of maternal complications, Alison Cahill, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Women with twins should not be discouraged from making a VBAC attempt if that is their desire, according to data reported by Dr. Cahill of the University of Pennsylvania, Philadelphia, and her colleagues.

The study's subjects were patients from 17 different tertiary and community hospitals who were delivered between 1996 and 2000, and who were identified by coding in their pregnancy records as having had a previous cesarean section.

Of the 24,842 deliveries identified, 535 were twin pregnancies.

A total of 33% of the mothers with twins chose to attempt VBAC, compared with 55% of the women with singleton pregnancies.

The VBAC failed in 24% of the attempts of both groups.

Uterine rupture occurred in 2 of the twin pregnancies (1% of those who attempted VBAC), and 125 of the singleton pregnancies (also 1%).

In addition, 3% of the women with twins who attempted VBAC had either a uterine rupture, uterine artery laceration, bladder injury, and/or bowel injury.

That compared with 2% of the women with singletons, the researchers reported in the poster.

RENO, NEVADA — Attempting vaginal birth after cesarean section in twin deliveries may be no more risky than attempting VBAC in singleton pregnancies, according to a review of almost 25,000 deliveries.

The review found that women with twins who had a prior C-section were less likely to attempt a vaginal birth but that they had the same rate of VBAC failures and no higher rate of maternal complications, Alison Cahill, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Women with twins should not be discouraged from making a VBAC attempt if that is their desire, according to data reported by Dr. Cahill of the University of Pennsylvania, Philadelphia, and her colleagues.

The study's subjects were patients from 17 different tertiary and community hospitals who were delivered between 1996 and 2000, and who were identified by coding in their pregnancy records as having had a previous cesarean section.

Of the 24,842 deliveries identified, 535 were twin pregnancies.

A total of 33% of the mothers with twins chose to attempt VBAC, compared with 55% of the women with singleton pregnancies.

The VBAC failed in 24% of the attempts of both groups.

Uterine rupture occurred in 2 of the twin pregnancies (1% of those who attempted VBAC), and 125 of the singleton pregnancies (also 1%).

In addition, 3% of the women with twins who attempted VBAC had either a uterine rupture, uterine artery laceration, bladder injury, and/or bowel injury.

That compared with 2% of the women with singletons, the researchers reported in the poster.

RENO, NEVADA — Attempting vaginal birth after cesarean section in twin deliveries may be no more risky than attempting VBAC in singleton pregnancies, according to a review of almost 25,000 deliveries.

The review found that women with twins who had a prior C-section were less likely to attempt a vaginal birth but that they had the same rate of VBAC failures and no higher rate of maternal complications, Alison Cahill, M.D., and her associates wrote in a poster presentation at the annual meeting of the Society for Maternal-Fetal Medicine.

Women with twins should not be discouraged from making a VBAC attempt if that is their desire, according to data reported by Dr. Cahill of the University of Pennsylvania, Philadelphia, and her colleagues.

The study's subjects were patients from 17 different tertiary and community hospitals who were delivered between 1996 and 2000, and who were identified by coding in their pregnancy records as having had a previous cesarean section.

Of the 24,842 deliveries identified, 535 were twin pregnancies.

A total of 33% of the mothers with twins chose to attempt VBAC, compared with 55% of the women with singleton pregnancies.

The VBAC failed in 24% of the attempts of both groups.

Uterine rupture occurred in 2 of the twin pregnancies (1% of those who attempted VBAC), and 125 of the singleton pregnancies (also 1%).

In addition, 3% of the women with twins who attempted VBAC had either a uterine rupture, uterine artery laceration, bladder injury, and/or bowel injury.

That compared with 2% of the women with singletons, the researchers reported in the poster.

RENO, NEVADA — Forceps delivery is associated with more perineal tears than is vacuum delivery, but the vacuum is associated with more complications for the infant, including shoulder dystocia, Aaron B. Caughey, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Caughey presented results of a review of 4,120 consecutive, operative, vaginal deliveries of singleton, term neonates at a University of California, San Francisco, hospital, and those results surprised him, he said during an interview.

His hypothesis at the start of the study was that he would see more shoulder dystocia in the neonates delivered with forceps, because doctors would choose the forceps for bigger babies. What he found, however, is consistent with another recent study, which looked at deliveries at many different institutions (Obstet. Gynecol. Surv. 2005;60:86-7).

In the study by Dr. Caughey and his colleagues at the university, shoulder dystocia occurred in 2% of the forceps deliveries, compared with 4% of the vacuum deliveries.

Cephalohematoma occurred in 4% of the forceps deliveries and 15% of the vacuum deliveries, Dr. Caughey wrote in a poster presentation.

On the maternal side, there was a difference in third- and fourth-degree perineal and cervical tears (37% for the forceps deliveries, versus 27% for the vacuum deliveries).

The study found no significant difference in more serious birth trauma, which included skull and clavicle fracture, intracranial hemorrhage, facial nerve palsy, and Erb's palsy (1.7% for forceps and 2.1% for vacuum).

But the children delivered with the vacuum were more likely to have a 5-minute Apgar score that was less than 7 (4% vs. 3%) and to have neonatal jaundice (13% vs. 10%).

In the interview, Dr. Caughey said his study adds to what the previous study reported because that study used a database of births nationwide—data in which coding and practices could differ.

His data, culled from a single institution, likely reflect more consistent practice, he said.

Of the study's 4,120 deliveries, 2,045 were forceps deliveries and 2,075 were vacuum-assisted deliveries.

The differences in outcome overall remained consistent even when the investigators took into account factors such as birth weight, station at delivery, length of the first and second stages of labor, and episiotomy.

The study results indicate that the trade-off in choosing which device to use is that one puts the mother at risk for tears, while the other entails risk for the neonate, Dr. Caughey noted.

In most of those situations, therefore, he is going to choose putting the mother at risk, he said.

Certainly, with multiparous women, the forceps make more sense because they have less likelihood of tearing, he added.

RENO, NEVADA — Forceps delivery is associated with more perineal tears than is vacuum delivery, but the vacuum is associated with more complications for the infant, including shoulder dystocia, Aaron B. Caughey, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Caughey presented results of a review of 4,120 consecutive, operative, vaginal deliveries of singleton, term neonates at a University of California, San Francisco, hospital, and those results surprised him, he said during an interview.

His hypothesis at the start of the study was that he would see more shoulder dystocia in the neonates delivered with forceps, because doctors would choose the forceps for bigger babies. What he found, however, is consistent with another recent study, which looked at deliveries at many different institutions (Obstet. Gynecol. Surv. 2005;60:86-7).

In the study by Dr. Caughey and his colleagues at the university, shoulder dystocia occurred in 2% of the forceps deliveries, compared with 4% of the vacuum deliveries.

Cephalohematoma occurred in 4% of the forceps deliveries and 15% of the vacuum deliveries, Dr. Caughey wrote in a poster presentation.

On the maternal side, there was a difference in third- and fourth-degree perineal and cervical tears (37% for the forceps deliveries, versus 27% for the vacuum deliveries).

The study found no significant difference in more serious birth trauma, which included skull and clavicle fracture, intracranial hemorrhage, facial nerve palsy, and Erb's palsy (1.7% for forceps and 2.1% for vacuum).

But the children delivered with the vacuum were more likely to have a 5-minute Apgar score that was less than 7 (4% vs. 3%) and to have neonatal jaundice (13% vs. 10%).

In the interview, Dr. Caughey said his study adds to what the previous study reported because that study used a database of births nationwide—data in which coding and practices could differ.

His data, culled from a single institution, likely reflect more consistent practice, he said.

Of the study's 4,120 deliveries, 2,045 were forceps deliveries and 2,075 were vacuum-assisted deliveries.

The differences in outcome overall remained consistent even when the investigators took into account factors such as birth weight, station at delivery, length of the first and second stages of labor, and episiotomy.

The study results indicate that the trade-off in choosing which device to use is that one puts the mother at risk for tears, while the other entails risk for the neonate, Dr. Caughey noted.

In most of those situations, therefore, he is going to choose putting the mother at risk, he said.

Certainly, with multiparous women, the forceps make more sense because they have less likelihood of tearing, he added.

RENO, NEVADA — Forceps delivery is associated with more perineal tears than is vacuum delivery, but the vacuum is associated with more complications for the infant, including shoulder dystocia, Aaron B. Caughey, M.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Dr. Caughey presented results of a review of 4,120 consecutive, operative, vaginal deliveries of singleton, term neonates at a University of California, San Francisco, hospital, and those results surprised him, he said during an interview.

His hypothesis at the start of the study was that he would see more shoulder dystocia in the neonates delivered with forceps, because doctors would choose the forceps for bigger babies. What he found, however, is consistent with another recent study, which looked at deliveries at many different institutions (Obstet. Gynecol. Surv. 2005;60:86-7).

In the study by Dr. Caughey and his colleagues at the university, shoulder dystocia occurred in 2% of the forceps deliveries, compared with 4% of the vacuum deliveries.

Cephalohematoma occurred in 4% of the forceps deliveries and 15% of the vacuum deliveries, Dr. Caughey wrote in a poster presentation.

On the maternal side, there was a difference in third- and fourth-degree perineal and cervical tears (37% for the forceps deliveries, versus 27% for the vacuum deliveries).

The study found no significant difference in more serious birth trauma, which included skull and clavicle fracture, intracranial hemorrhage, facial nerve palsy, and Erb's palsy (1.7% for forceps and 2.1% for vacuum).

But the children delivered with the vacuum were more likely to have a 5-minute Apgar score that was less than 7 (4% vs. 3%) and to have neonatal jaundice (13% vs. 10%).

In the interview, Dr. Caughey said his study adds to what the previous study reported because that study used a database of births nationwide—data in which coding and practices could differ.

His data, culled from a single institution, likely reflect more consistent practice, he said.

Of the study's 4,120 deliveries, 2,045 were forceps deliveries and 2,075 were vacuum-assisted deliveries.

The differences in outcome overall remained consistent even when the investigators took into account factors such as birth weight, station at delivery, length of the first and second stages of labor, and episiotomy.

The study results indicate that the trade-off in choosing which device to use is that one puts the mother at risk for tears, while the other entails risk for the neonate, Dr. Caughey noted.

In most of those situations, therefore, he is going to choose putting the mother at risk, he said.

Certainly, with multiparous women, the forceps make more sense because they have less likelihood of tearing, he added.

RENO, NEV. — Obstetricians are delivering more sets of twins early—a trend that is improving neonatal mortality, Cande V. Ananth, Ph.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Black twins, however, are not benefiting equally by this more aggressive practice. According to federal statistics, 44% of white and 53% of black twin births occurred before 37 weeks' gestation in 1989. In 2000, those percentages rose to 57% for whites and 61% for blacks.

These increases largely reflected obstetricians' decisions to deliver twin infants early—but more so among whites, said Dr. Ananth of the department of obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey, New Brunswick.

Medically indicated preterm delivery among white twins rose 51% for the 11-year period, and 33% among black twins.

Among the whites, this medically indicated early delivery significantly affected perinatal mortality, defined as stillbirth after 22 weeks' gestation or neonatal mortality within 28 days of birth.

Perinatal mortality decreased by 41% during the period overall. It fell by 31% among the medically indicated deliveries, and, because of the large increase in medically indicated preterm births among whites, that 37% reduction accounted for 10% of the overall decline.

Among the black twins, perinatal mortality declined 37% overall and 34% among medically indicated preterm births. However, largely because the increase in medically indicated preterm deliveries was less in blacks, that decline accounted for only 5% of the overall drop.

A reduction in mortality tied to births following premature rupture of membranes was more important among blacks.

The study also found that preterm birth following spontaneous onset of labor rose 3% among white twins and fell 1% among black twins. Preterm birth following premature rupture of membranes fell 3% among whites and 7% among blacks.

RENO, NEV. — Obstetricians are delivering more sets of twins early—a trend that is improving neonatal mortality, Cande V. Ananth, Ph.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Black twins, however, are not benefiting equally by this more aggressive practice. According to federal statistics, 44% of white and 53% of black twin births occurred before 37 weeks' gestation in 1989. In 2000, those percentages rose to 57% for whites and 61% for blacks.

These increases largely reflected obstetricians' decisions to deliver twin infants early—but more so among whites, said Dr. Ananth of the department of obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey, New Brunswick.

Medically indicated preterm delivery among white twins rose 51% for the 11-year period, and 33% among black twins.

Among the whites, this medically indicated early delivery significantly affected perinatal mortality, defined as stillbirth after 22 weeks' gestation or neonatal mortality within 28 days of birth.

Perinatal mortality decreased by 41% during the period overall. It fell by 31% among the medically indicated deliveries, and, because of the large increase in medically indicated preterm births among whites, that 37% reduction accounted for 10% of the overall decline.

Among the black twins, perinatal mortality declined 37% overall and 34% among medically indicated preterm births. However, largely because the increase in medically indicated preterm deliveries was less in blacks, that decline accounted for only 5% of the overall drop.

A reduction in mortality tied to births following premature rupture of membranes was more important among blacks.

The study also found that preterm birth following spontaneous onset of labor rose 3% among white twins and fell 1% among black twins. Preterm birth following premature rupture of membranes fell 3% among whites and 7% among blacks.

RENO, NEV. — Obstetricians are delivering more sets of twins early—a trend that is improving neonatal mortality, Cande V. Ananth, Ph.D., said at the annual meeting of the Society for Maternal-Fetal Medicine.

Black twins, however, are not benefiting equally by this more aggressive practice. According to federal statistics, 44% of white and 53% of black twin births occurred before 37 weeks' gestation in 1989. In 2000, those percentages rose to 57% for whites and 61% for blacks.

These increases largely reflected obstetricians' decisions to deliver twin infants early—but more so among whites, said Dr. Ananth of the department of obstetrics and gynecology at the University of Medicine and Dentistry of New Jersey, New Brunswick.

Medically indicated preterm delivery among white twins rose 51% for the 11-year period, and 33% among black twins.

Among the whites, this medically indicated early delivery significantly affected perinatal mortality, defined as stillbirth after 22 weeks' gestation or neonatal mortality within 28 days of birth.

Perinatal mortality decreased by 41% during the period overall. It fell by 31% among the medically indicated deliveries, and, because of the large increase in medically indicated preterm births among whites, that 37% reduction accounted for 10% of the overall decline.

Among the black twins, perinatal mortality declined 37% overall and 34% among medically indicated preterm births. However, largely because the increase in medically indicated preterm deliveries was less in blacks, that decline accounted for only 5% of the overall drop.

A reduction in mortality tied to births following premature rupture of membranes was more important among blacks.

The study also found that preterm birth following spontaneous onset of labor rose 3% among white twins and fell 1% among black twins. Preterm birth following premature rupture of membranes fell 3% among whites and 7% among blacks.