Obstetrics

WASHINGTON — Nothing is gained by giving prophylactic antibiotics earlier than usual in the course of cesarean deliveries, W. Ashley Hood, D.O., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The traditional approach to antibiotic prophylaxis in cesarean deliveries is to give the mother the drugs just after the cord is clamped. This prevents the antibiotics from being transmitted to the neonate, where they could mask neonatal infection and raise the risk that resistance will develop.

Some physicians argue that to best prevent maternal infection, however, antibiotics should be started just before skin incision so they will be on board as surgery commences. Proponents of this approach note that C-sections still account for 10% of all maternal mortality and that postcesarean infections—endometritis, wound infection, urinary tract infection, and pneumonia—are still a leading cause of maternal morbidity and death, said Dr. Hood of the University of Mississippi Medical Center, Jackson.

He and his associates assessed the effect of the timing of antibiotic prophylaxis in a study of 302 women undergoing nonelective cesarean delivery. Antibiotic prophylaxis was started at skin incision in 153 women and at cord clamping in 149. There were no significant differences between the two groups of patients in demographic characteristics, indications for cesarean delivery, or operative time.

There were fewer cases of postoperative endometritis in the group that received antibiotics at skin incision (12 patients, or 8%) than in the other group (22 patients, or 15%), but this difference was not statistically significant. The rates of wound infection also were similar, with 6 cases (4%) among women who received antibiotics at skin incision and 8 cases (5%) among those who received antibiotics at cord clamping.

Neonatal outcomes also were comparable between the two groups. Both groups had similar rates of neonatal sepsis, Apgar scores, and rates of admission to the neonatal intensive care unit, Dr. Hood said.

These findings confirm that it is still prudent to delay antibiotic prophylaxis until the cord is clamped, since giving the drugs earlier doesn't prevent more maternal infections or improve neonatal outcomes, he said.

WASHINGTON — Nothing is gained by giving prophylactic antibiotics earlier than usual in the course of cesarean deliveries, W. Ashley Hood, D.O., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The traditional approach to antibiotic prophylaxis in cesarean deliveries is to give the mother the drugs just after the cord is clamped. This prevents the antibiotics from being transmitted to the neonate, where they could mask neonatal infection and raise the risk that resistance will develop.

Some physicians argue that to best prevent maternal infection, however, antibiotics should be started just before skin incision so they will be on board as surgery commences. Proponents of this approach note that C-sections still account for 10% of all maternal mortality and that postcesarean infections—endometritis, wound infection, urinary tract infection, and pneumonia—are still a leading cause of maternal morbidity and death, said Dr. Hood of the University of Mississippi Medical Center, Jackson.

He and his associates assessed the effect of the timing of antibiotic prophylaxis in a study of 302 women undergoing nonelective cesarean delivery. Antibiotic prophylaxis was started at skin incision in 153 women and at cord clamping in 149. There were no significant differences between the two groups of patients in demographic characteristics, indications for cesarean delivery, or operative time.

There were fewer cases of postoperative endometritis in the group that received antibiotics at skin incision (12 patients, or 8%) than in the other group (22 patients, or 15%), but this difference was not statistically significant. The rates of wound infection also were similar, with 6 cases (4%) among women who received antibiotics at skin incision and 8 cases (5%) among those who received antibiotics at cord clamping.

Neonatal outcomes also were comparable between the two groups. Both groups had similar rates of neonatal sepsis, Apgar scores, and rates of admission to the neonatal intensive care unit, Dr. Hood said.

These findings confirm that it is still prudent to delay antibiotic prophylaxis until the cord is clamped, since giving the drugs earlier doesn't prevent more maternal infections or improve neonatal outcomes, he said.

WASHINGTON — Nothing is gained by giving prophylactic antibiotics earlier than usual in the course of cesarean deliveries, W. Ashley Hood, D.O., said at the annual meeting of the Central Association of Obstetricians and Gynecologists.

The traditional approach to antibiotic prophylaxis in cesarean deliveries is to give the mother the drugs just after the cord is clamped. This prevents the antibiotics from being transmitted to the neonate, where they could mask neonatal infection and raise the risk that resistance will develop.

Some physicians argue that to best prevent maternal infection, however, antibiotics should be started just before skin incision so they will be on board as surgery commences. Proponents of this approach note that C-sections still account for 10% of all maternal mortality and that postcesarean infections—endometritis, wound infection, urinary tract infection, and pneumonia—are still a leading cause of maternal morbidity and death, said Dr. Hood of the University of Mississippi Medical Center, Jackson.

He and his associates assessed the effect of the timing of antibiotic prophylaxis in a study of 302 women undergoing nonelective cesarean delivery. Antibiotic prophylaxis was started at skin incision in 153 women and at cord clamping in 149. There were no significant differences between the two groups of patients in demographic characteristics, indications for cesarean delivery, or operative time.

There were fewer cases of postoperative endometritis in the group that received antibiotics at skin incision (12 patients, or 8%) than in the other group (22 patients, or 15%), but this difference was not statistically significant. The rates of wound infection also were similar, with 6 cases (4%) among women who received antibiotics at skin incision and 8 cases (5%) among those who received antibiotics at cord clamping.

Neonatal outcomes also were comparable between the two groups. Both groups had similar rates of neonatal sepsis, Apgar scores, and rates of admission to the neonatal intensive care unit, Dr. Hood said.

These findings confirm that it is still prudent to delay antibiotic prophylaxis until the cord is clamped, since giving the drugs earlier doesn't prevent more maternal infections or improve neonatal outcomes, he said.

The number of women having primary cesarean sections without any apparent medical risk grew significantly during the 1990s and topped 80,000 in 2001, according to a new analysis of U.S. birth certificate data.

First-time C-sections in women with “no indicated risk” rose 67% between 1991 and 2001, from approximately 3.3% to 5.5%. The increase was gradual until 1996 and rapid toward the end of the study period. Increases were seen across all ages and parities.

Eugene Declercq, Ph.D., and his associates studied birth certificate data on approximately 4 million births per year between 1991 and 2001.

They looked specifically at women who had singleton, full-term, vertex-presentation births, without any medical risk factors or complications of labor or delivery listed on the birth certificate. They then focused on women who had a first-time cesarean.

The investigators declined to call these deliveries “elective” and instead used the term “no indicated risk” cesareans.

“Birth certificate data provide no record of the mother's intent,” said Dr. Declercq, professor in the maternal and child health department at Boston University, and his associates (BMJ [Epub ahead of print] Nov. 19, 2004. Article DOI number: 10.1136/bmj.38279.705336. Available from www.bmj.com

Age was a major factor in the rate of no-indicated-risk cesareans, they said. First-time mothers over 40 were five times more likely to have the procedure than were primiparous mothers aged 20-24.

Of multiparous women over 34 years of age who had previous vaginal births, more than 5% had a no-indicated-risk cesarean in 2001.

No-risk, primary cesareans were performed in a similar proportion—almost 5%- of women under 30 (all parities) in 2001; this represented growth of almost 60% since 1991.

All told, there were 80,028 no-indicated-risk primary C-sections performed in 2001—an increase of more than 25,000 since 1996. This represented approximately 26% of the total increase in primary cesareans between 1996 and 2001.

The number of women having primary cesarean sections without any apparent medical risk grew significantly during the 1990s and topped 80,000 in 2001, according to a new analysis of U.S. birth certificate data.

First-time C-sections in women with “no indicated risk” rose 67% between 1991 and 2001, from approximately 3.3% to 5.5%. The increase was gradual until 1996 and rapid toward the end of the study period. Increases were seen across all ages and parities.

Eugene Declercq, Ph.D., and his associates studied birth certificate data on approximately 4 million births per year between 1991 and 2001.

They looked specifically at women who had singleton, full-term, vertex-presentation births, without any medical risk factors or complications of labor or delivery listed on the birth certificate. They then focused on women who had a first-time cesarean.

The investigators declined to call these deliveries “elective” and instead used the term “no indicated risk” cesareans.

“Birth certificate data provide no record of the mother's intent,” said Dr. Declercq, professor in the maternal and child health department at Boston University, and his associates (BMJ [Epub ahead of print] Nov. 19, 2004. Article DOI number: 10.1136/bmj.38279.705336. Available from www.bmj.com

Age was a major factor in the rate of no-indicated-risk cesareans, they said. First-time mothers over 40 were five times more likely to have the procedure than were primiparous mothers aged 20-24.

Of multiparous women over 34 years of age who had previous vaginal births, more than 5% had a no-indicated-risk cesarean in 2001.

No-risk, primary cesareans were performed in a similar proportion—almost 5%- of women under 30 (all parities) in 2001; this represented growth of almost 60% since 1991.

All told, there were 80,028 no-indicated-risk primary C-sections performed in 2001—an increase of more than 25,000 since 1996. This represented approximately 26% of the total increase in primary cesareans between 1996 and 2001.

The number of women having primary cesarean sections without any apparent medical risk grew significantly during the 1990s and topped 80,000 in 2001, according to a new analysis of U.S. birth certificate data.

First-time C-sections in women with “no indicated risk” rose 67% between 1991 and 2001, from approximately 3.3% to 5.5%. The increase was gradual until 1996 and rapid toward the end of the study period. Increases were seen across all ages and parities.

Eugene Declercq, Ph.D., and his associates studied birth certificate data on approximately 4 million births per year between 1991 and 2001.

They looked specifically at women who had singleton, full-term, vertex-presentation births, without any medical risk factors or complications of labor or delivery listed on the birth certificate. They then focused on women who had a first-time cesarean.

The investigators declined to call these deliveries “elective” and instead used the term “no indicated risk” cesareans.

“Birth certificate data provide no record of the mother's intent,” said Dr. Declercq, professor in the maternal and child health department at Boston University, and his associates (BMJ [Epub ahead of print] Nov. 19, 2004. Article DOI number: 10.1136/bmj.38279.705336. Available from www.bmj.com

Age was a major factor in the rate of no-indicated-risk cesareans, they said. First-time mothers over 40 were five times more likely to have the procedure than were primiparous mothers aged 20-24.

Of multiparous women over 34 years of age who had previous vaginal births, more than 5% had a no-indicated-risk cesarean in 2001.

No-risk, primary cesareans were performed in a similar proportion—almost 5%- of women under 30 (all parities) in 2001; this represented growth of almost 60% since 1991.

All told, there were 80,028 no-indicated-risk primary C-sections performed in 2001—an increase of more than 25,000 since 1996. This represented approximately 26% of the total increase in primary cesareans between 1996 and 2001.

KEVIN FOLEY, RESEARCH, DESIGN

KEVIN FOLEY, RESEARCH, DESIGN

KEVIN FOLEY, RESEARCH, DESIGN

VIENNA — The largest-ever systematic data review of the use of low-molecular- weight heparin during pregnancy suggests that it is safe and effective for both prophylaxis and treatment of venous thromboembolism, Catherine Nelson-Piercy, M.B., reported at the annual meeting of the International Society of Obstetric Medicine.

In recent years, low-molecular-weight heparin (LMWH) has become the standard therapy for both thromboprophylaxis and management of acute venous thromboembolism (VTE). “Thromboembolism is still the leading cause of maternal death in the U.K. For that reason, we are keen to promote the use of low-molecular-weight heparin for prophylaxis,” said Dr. Nelson-Piercy, an obstetrician at Guy's and St. Thomas' Hospitals Trust, London.

There are still no large randomized trials to help guide practice in this area, however. To overcome this lack of data, Dr. Nelson-Piercy and her associate Ian Greer, M.D., of Glasgow (Scotland) University, conducted a systematic electronic database review of all studies through December 2003 that investigated the use of LMWH during pregnancy. Exclusion of studies of women with artificial heart valves, those that did not provide data on LMWH administration, and a few others for methodologic reasons left a total of 2,659 pregnancies from 59 separate reports.

Prophylaxis of VTE was by far the most common indication for LMWH use, comprising 28 studies and 1,319 pregnancies. Prevention of recurrent pregnancy loss, a rapidly growing use for LMWH, was the indication in 370 pregnancies in 14 studies, while treatment of VTE was the indication for 174 pregnancies in 15 studies.

Enoxaparin was the most common low-molecular-weight heparin used (1,158 pregnancies, including 105 for treatment and 1,048 for prophylaxis), followed by dalteparin (783) and nadroparin (530).

The reason for LMWH prophylaxis use during pregnancy wasn't specified in all the studies, but those cases were still included in the safety analysis, Dr. Nelson-Piercy explained.

In the treatment studies, the rate of deep vein thrombosis among the 174 LMWH recipients was 1.15%, which was extremely low, compared with 5% for unfractionated heparin use among men and nonpregnant women. Bleeding complications occurred in a total of 1.72%, including prenatal bleeding in 0.57% and postpartum hemorrhage of more than 500 mL in 1.15%. Non-heparin-induced thrombocytopenia occurred in 0.57%.

Among the 2,485 pregnancies in which LMWH was used for thromboprophylaxis, 1.4% of the women had thrombosis, including 0.84% with VTE and 0.56% with arterial thrombosis. All the women who experienced arterial thrombosis were known to have antiphospholipid antibody syndrome.

Bleeding complications, including prenatal bleeding, postpartum hemorrhage, and wound hematoma occurred in 2.1%.

Thrombocytopenia was rare, occurring in just 0.08%. “I hope this provides the evidence that we can stop doing platelet counts 1 week after starting” LMWH, she said.

Allergic skin reactions to LMWH occurred in 1.15% during treatment and 1.9% with prophylaxis. This complication usually occurred at the site of injection and was most common with nadroparin and least with enoxaparin, with dalteparin falling between the two.

Heparin-induced osteoporosis was reported in just one patient, in whom dalteparin was used for thromboprophylaxis. However, a recent abstract from researchers in the United Kingdom reported three cases of osteoporosis associated with the use of tinzaparin during pregnancy. “Although our data are reassuring, we can't [ignore] osteoporosis,” she said.

There were no maternal deaths in the treatment or the prophylaxis group.

VIENNA — The largest-ever systematic data review of the use of low-molecular- weight heparin during pregnancy suggests that it is safe and effective for both prophylaxis and treatment of venous thromboembolism, Catherine Nelson-Piercy, M.B., reported at the annual meeting of the International Society of Obstetric Medicine.

In recent years, low-molecular-weight heparin (LMWH) has become the standard therapy for both thromboprophylaxis and management of acute venous thromboembolism (VTE). “Thromboembolism is still the leading cause of maternal death in the U.K. For that reason, we are keen to promote the use of low-molecular-weight heparin for prophylaxis,” said Dr. Nelson-Piercy, an obstetrician at Guy's and St. Thomas' Hospitals Trust, London.

There are still no large randomized trials to help guide practice in this area, however. To overcome this lack of data, Dr. Nelson-Piercy and her associate Ian Greer, M.D., of Glasgow (Scotland) University, conducted a systematic electronic database review of all studies through December 2003 that investigated the use of LMWH during pregnancy. Exclusion of studies of women with artificial heart valves, those that did not provide data on LMWH administration, and a few others for methodologic reasons left a total of 2,659 pregnancies from 59 separate reports.

Prophylaxis of VTE was by far the most common indication for LMWH use, comprising 28 studies and 1,319 pregnancies. Prevention of recurrent pregnancy loss, a rapidly growing use for LMWH, was the indication in 370 pregnancies in 14 studies, while treatment of VTE was the indication for 174 pregnancies in 15 studies.

Enoxaparin was the most common low-molecular-weight heparin used (1,158 pregnancies, including 105 for treatment and 1,048 for prophylaxis), followed by dalteparin (783) and nadroparin (530).

The reason for LMWH prophylaxis use during pregnancy wasn't specified in all the studies, but those cases were still included in the safety analysis, Dr. Nelson-Piercy explained.

In the treatment studies, the rate of deep vein thrombosis among the 174 LMWH recipients was 1.15%, which was extremely low, compared with 5% for unfractionated heparin use among men and nonpregnant women. Bleeding complications occurred in a total of 1.72%, including prenatal bleeding in 0.57% and postpartum hemorrhage of more than 500 mL in 1.15%. Non-heparin-induced thrombocytopenia occurred in 0.57%.

Among the 2,485 pregnancies in which LMWH was used for thromboprophylaxis, 1.4% of the women had thrombosis, including 0.84% with VTE and 0.56% with arterial thrombosis. All the women who experienced arterial thrombosis were known to have antiphospholipid antibody syndrome.

Bleeding complications, including prenatal bleeding, postpartum hemorrhage, and wound hematoma occurred in 2.1%.

Thrombocytopenia was rare, occurring in just 0.08%. “I hope this provides the evidence that we can stop doing platelet counts 1 week after starting” LMWH, she said.

Allergic skin reactions to LMWH occurred in 1.15% during treatment and 1.9% with prophylaxis. This complication usually occurred at the site of injection and was most common with nadroparin and least with enoxaparin, with dalteparin falling between the two.

Heparin-induced osteoporosis was reported in just one patient, in whom dalteparin was used for thromboprophylaxis. However, a recent abstract from researchers in the United Kingdom reported three cases of osteoporosis associated with the use of tinzaparin during pregnancy. “Although our data are reassuring, we can't [ignore] osteoporosis,” she said.

There were no maternal deaths in the treatment or the prophylaxis group.

VIENNA — The largest-ever systematic data review of the use of low-molecular- weight heparin during pregnancy suggests that it is safe and effective for both prophylaxis and treatment of venous thromboembolism, Catherine Nelson-Piercy, M.B., reported at the annual meeting of the International Society of Obstetric Medicine.

In recent years, low-molecular-weight heparin (LMWH) has become the standard therapy for both thromboprophylaxis and management of acute venous thromboembolism (VTE). “Thromboembolism is still the leading cause of maternal death in the U.K. For that reason, we are keen to promote the use of low-molecular-weight heparin for prophylaxis,” said Dr. Nelson-Piercy, an obstetrician at Guy's and St. Thomas' Hospitals Trust, London.

There are still no large randomized trials to help guide practice in this area, however. To overcome this lack of data, Dr. Nelson-Piercy and her associate Ian Greer, M.D., of Glasgow (Scotland) University, conducted a systematic electronic database review of all studies through December 2003 that investigated the use of LMWH during pregnancy. Exclusion of studies of women with artificial heart valves, those that did not provide data on LMWH administration, and a few others for methodologic reasons left a total of 2,659 pregnancies from 59 separate reports.

Prophylaxis of VTE was by far the most common indication for LMWH use, comprising 28 studies and 1,319 pregnancies. Prevention of recurrent pregnancy loss, a rapidly growing use for LMWH, was the indication in 370 pregnancies in 14 studies, while treatment of VTE was the indication for 174 pregnancies in 15 studies.

Enoxaparin was the most common low-molecular-weight heparin used (1,158 pregnancies, including 105 for treatment and 1,048 for prophylaxis), followed by dalteparin (783) and nadroparin (530).

The reason for LMWH prophylaxis use during pregnancy wasn't specified in all the studies, but those cases were still included in the safety analysis, Dr. Nelson-Piercy explained.

In the treatment studies, the rate of deep vein thrombosis among the 174 LMWH recipients was 1.15%, which was extremely low, compared with 5% for unfractionated heparin use among men and nonpregnant women. Bleeding complications occurred in a total of 1.72%, including prenatal bleeding in 0.57% and postpartum hemorrhage of more than 500 mL in 1.15%. Non-heparin-induced thrombocytopenia occurred in 0.57%.

Among the 2,485 pregnancies in which LMWH was used for thromboprophylaxis, 1.4% of the women had thrombosis, including 0.84% with VTE and 0.56% with arterial thrombosis. All the women who experienced arterial thrombosis were known to have antiphospholipid antibody syndrome.

Bleeding complications, including prenatal bleeding, postpartum hemorrhage, and wound hematoma occurred in 2.1%.

Thrombocytopenia was rare, occurring in just 0.08%. “I hope this provides the evidence that we can stop doing platelet counts 1 week after starting” LMWH, she said.

Allergic skin reactions to LMWH occurred in 1.15% during treatment and 1.9% with prophylaxis. This complication usually occurred at the site of injection and was most common with nadroparin and least with enoxaparin, with dalteparin falling between the two.

Heparin-induced osteoporosis was reported in just one patient, in whom dalteparin was used for thromboprophylaxis. However, a recent abstract from researchers in the United Kingdom reported three cases of osteoporosis associated with the use of tinzaparin during pregnancy. “Although our data are reassuring, we can't [ignore] osteoporosis,” she said.

There were no maternal deaths in the treatment or the prophylaxis group.

VIENNA — An elevated serum bile acid level is a highly reliable indicator of intrahepatic cholestasis of pregnancy in a woman who presents with itching and excoriated skin lesions late in gestation, Christina M. Rudolph, M.D., reported at the annual meeting of the European Society for Dermatological Research.

The differential diagnosis of pruritic skin conditions during pregnancy has often been vexing because of extensive overlap in clinical presentation. But in her series of 75 patients who presented with pruritic skin changes to a specialized dermatology clinic for pregnant women, the lowest serum bile acid level among the 11 patients with intrahepatic cholestasis of pregnancy (ICP)—7.3 μmol/L—was markedly greater than the highest value among women with other pruritic conditions, said Dr. Rudolph of the University of Graz, Austria.

The distinction is clinically important because ICP, if untreated, is associated with increased risks of stillbirth and preterm delivery, she noted.

Other dermatologic diagnoses made in this cohort were atopy-related skin changes, specific dermatoses of pregnancy, psoriasis, pityriasis rosea, and drug reaction. The mean serum bile acid level in these women was 2.3 μmol/L, with a range of 0.4-4.5 μmol/L.

In contrast, the range of serum bile acid levels in women with ICP was 7.3-138 μmol/L, with a mean value of 37.4 μmol/L.

VIENNA — An elevated serum bile acid level is a highly reliable indicator of intrahepatic cholestasis of pregnancy in a woman who presents with itching and excoriated skin lesions late in gestation, Christina M. Rudolph, M.D., reported at the annual meeting of the European Society for Dermatological Research.

The differential diagnosis of pruritic skin conditions during pregnancy has often been vexing because of extensive overlap in clinical presentation. But in her series of 75 patients who presented with pruritic skin changes to a specialized dermatology clinic for pregnant women, the lowest serum bile acid level among the 11 patients with intrahepatic cholestasis of pregnancy (ICP)—7.3 μmol/L—was markedly greater than the highest value among women with other pruritic conditions, said Dr. Rudolph of the University of Graz, Austria.

The distinction is clinically important because ICP, if untreated, is associated with increased risks of stillbirth and preterm delivery, she noted.

Other dermatologic diagnoses made in this cohort were atopy-related skin changes, specific dermatoses of pregnancy, psoriasis, pityriasis rosea, and drug reaction. The mean serum bile acid level in these women was 2.3 μmol/L, with a range of 0.4-4.5 μmol/L.

In contrast, the range of serum bile acid levels in women with ICP was 7.3-138 μmol/L, with a mean value of 37.4 μmol/L.

VIENNA — An elevated serum bile acid level is a highly reliable indicator of intrahepatic cholestasis of pregnancy in a woman who presents with itching and excoriated skin lesions late in gestation, Christina M. Rudolph, M.D., reported at the annual meeting of the European Society for Dermatological Research.

The differential diagnosis of pruritic skin conditions during pregnancy has often been vexing because of extensive overlap in clinical presentation. But in her series of 75 patients who presented with pruritic skin changes to a specialized dermatology clinic for pregnant women, the lowest serum bile acid level among the 11 patients with intrahepatic cholestasis of pregnancy (ICP)—7.3 μmol/L—was markedly greater than the highest value among women with other pruritic conditions, said Dr. Rudolph of the University of Graz, Austria.

The distinction is clinically important because ICP, if untreated, is associated with increased risks of stillbirth and preterm delivery, she noted.

Other dermatologic diagnoses made in this cohort were atopy-related skin changes, specific dermatoses of pregnancy, psoriasis, pityriasis rosea, and drug reaction. The mean serum bile acid level in these women was 2.3 μmol/L, with a range of 0.4-4.5 μmol/L.

In contrast, the range of serum bile acid levels in women with ICP was 7.3-138 μmol/L, with a mean value of 37.4 μmol/L.

An 8-year follow-up study from a randomized, controlled trial of repeated prenatal ultrasound examinations found no evidence of any lasting harm to any aspect of child development.

The initial study demonstrated that infants exposed prenatally to five ultrasound imaging studies between 18 and 38 weeks' gestation had a significantly greater risk of low birth weight than children exposed to only a single ultrasound at 18 weeks of gestation.

Included in the follow-up analysis were 1,352 children who previously had been randomized to the regular ultrasound group and 1,362 children randomized to the intensive ultrasound group (Lancet 2004;364:2038-44).

After 8 years of repeated follow-up examinations, children in the two groups showed no statistically significant differences in a wide variety of developmental measures. These included measures of physical growth, toddler temperament, language development, and behavior, reported John P. Newham, M.D., of the University of Western Australia (Subiaco), and his colleagues.

The groups showed a statistically significant difference on only a single measure of child development. At 1 year of age children in the intensive ultrasound group showed a smaller number of abnormal scores on a test of early language milestones than children in the regular ultrasound groups.

The authors suggested that this may have been a statistical fluke—a seemingly significant result that showed up by chance because of the many end points examined in the study. An alternative explanation may be that women who had repeated ultrasound examinations may have had greater awareness of the study, which in turn enhanced parental attention, resulting in earlier language acquisition.

While this study showed no deleterious effects of repeated ultrasound examinations to the developing fetus, the authors cautioned that contemporary ultrasound instruments have higher power outputs than the instruments used in the study.

An 8-year follow-up study from a randomized, controlled trial of repeated prenatal ultrasound examinations found no evidence of any lasting harm to any aspect of child development.

The initial study demonstrated that infants exposed prenatally to five ultrasound imaging studies between 18 and 38 weeks' gestation had a significantly greater risk of low birth weight than children exposed to only a single ultrasound at 18 weeks of gestation.

Included in the follow-up analysis were 1,352 children who previously had been randomized to the regular ultrasound group and 1,362 children randomized to the intensive ultrasound group (Lancet 2004;364:2038-44).

After 8 years of repeated follow-up examinations, children in the two groups showed no statistically significant differences in a wide variety of developmental measures. These included measures of physical growth, toddler temperament, language development, and behavior, reported John P. Newham, M.D., of the University of Western Australia (Subiaco), and his colleagues.

The groups showed a statistically significant difference on only a single measure of child development. At 1 year of age children in the intensive ultrasound group showed a smaller number of abnormal scores on a test of early language milestones than children in the regular ultrasound groups.

The authors suggested that this may have been a statistical fluke—a seemingly significant result that showed up by chance because of the many end points examined in the study. An alternative explanation may be that women who had repeated ultrasound examinations may have had greater awareness of the study, which in turn enhanced parental attention, resulting in earlier language acquisition.

While this study showed no deleterious effects of repeated ultrasound examinations to the developing fetus, the authors cautioned that contemporary ultrasound instruments have higher power outputs than the instruments used in the study.

An 8-year follow-up study from a randomized, controlled trial of repeated prenatal ultrasound examinations found no evidence of any lasting harm to any aspect of child development.

The initial study demonstrated that infants exposed prenatally to five ultrasound imaging studies between 18 and 38 weeks' gestation had a significantly greater risk of low birth weight than children exposed to only a single ultrasound at 18 weeks of gestation.

Included in the follow-up analysis were 1,352 children who previously had been randomized to the regular ultrasound group and 1,362 children randomized to the intensive ultrasound group (Lancet 2004;364:2038-44).

After 8 years of repeated follow-up examinations, children in the two groups showed no statistically significant differences in a wide variety of developmental measures. These included measures of physical growth, toddler temperament, language development, and behavior, reported John P. Newham, M.D., of the University of Western Australia (Subiaco), and his colleagues.

The groups showed a statistically significant difference on only a single measure of child development. At 1 year of age children in the intensive ultrasound group showed a smaller number of abnormal scores on a test of early language milestones than children in the regular ultrasound groups.

The authors suggested that this may have been a statistical fluke—a seemingly significant result that showed up by chance because of the many end points examined in the study. An alternative explanation may be that women who had repeated ultrasound examinations may have had greater awareness of the study, which in turn enhanced parental attention, resulting in earlier language acquisition.

While this study showed no deleterious effects of repeated ultrasound examinations to the developing fetus, the authors cautioned that contemporary ultrasound instruments have higher power outputs than the instruments used in the study.

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

KEVIN FOLEY, RESEARCH/ANGIE RIES, DESIGN

VIENNA — Guidelines are sorely needed for postpartum blood pressure management in women who experience hypertension during pregnancy, speakers said at the 14th World Congress of the International Society for the Study of Hypertension in Pregnancy.

“It's a problem we have very little guidance on and very little information about,” said Jason Waugh, a senior lecturer in the reproductive science section at the University of Leicester, England. He presented one of three studies highlighting the knowledge gaps regarding postpartum diagnosis and treatment of women with pregnancies complicated by hypertension.

Determining whether a woman has underlying chronic hypertension can be difficult. Professional societies such as the ISSHP and the American College of Obstetricians and Gynecologists define chronic hypertension in pregnancy as that occurring prior to pregnancy or diagnosed before 20 weeks' gestation.

But a study of 501 women with hypertension at delivery suggests that the 20-week cutoff is not a reliable one. Instead, thorough postnatal follow-up is essential for accurate diagnosis, Mr. Waugh said.

The women were given preliminary diagnoses at the time of delivery. They subsequently performed home blood pressure monitoring—during which they followed a strict protocol for medication dosage reduction—for 1-8 weeks and were given final diagnoses. Those with persistent hypertension were referred to cardiovascular physicians for follow-up of more than 1 year, during which none of the final diagnoses changed.

The final diagnoses were preeclampsia in 36% (178 women), gestational hypertension in 42% (210), new diagnosis of chronic hypertension in 10% (51), and preexisting hypertension in 12% (49 with essential hypertension and 13 with renal disease).

Standard risk factors were poor predictors of underlying hypertension during pregnancy: Among the 51 women with chronic hypertension not diagnosed prior to pregnancy, only parity and gestation diagnosis were predictive of the final diagnosis, with smoking also showing a strong but nonsignificant trend.

Age, weight, and body mass index were not related to the final diagnosis, nor was antenatal suspicion of hypertension. Of the 28 women with blood pressures greater than 140/90 mm Hg at less than 20 weeks' gestation, 16 (57%) were later proved to have only gestational hypertension, while 12 (43%) were ultimately found to have chronic hypertension. On the flip side, this means that of the 51 women newly diagnosed with chronic hypertension postnatally, just 12, or 24%, had been hypertensive prior to 20 weeks.

“We must proceed with great caution in both clinical and research practice if a postnatal confirmation of blood pressure is not available following antenatal hypertension,” Mr. Waugh remarked at the meeting.

Findings from another study suggest that gestational hypertension commonly persists post partum, particularly in older women.

Tiina Podymow, M.D., of the division of nephrology and hypertension at Weill Medical College, Cornell University, New York City, reviewed clinic charts of 29 women who developed gestational hypertension or preeclampsia; all had been normotensive prior to pregnancy.

The women had a mean age of 35 years. Hypertension had developed at gestational age 15-40 weeks, with 13 developing hypertension within 3 days of delivery and the remainder at 1-18 weeks prior to delivery. The average blood pressure was 161/94 mn Hg; the mean arterial pressure was 116. Eleven women were diagnosed with preeclampsia, and 25 were treated with antihypertensive drugs in the puerperium.

Blood pressure normalized between 0 and 4 weeks post partum in 12 women, between 5 and 12 weeks in 7, and between 13 and 20 weeks in 3. However, blood pressure remained elevated beyond 6 months in seven women, of whom one was found to have primary hyperaldosteronism. This finding suggests that secondary causes of hypertension should be considered in patients with hypertension persisting beyond 6 months, according to Dr. Podymow.

Age was a significant risk factor. The women who remained persistently hypertensive had a mean age of 41 years, compared with 33.5 years among those whose hypertension resolved, she reported.

And few data are available to guide physicians in treating these patients, Susan Sadeghi, M.D., of the University of British Columbia, Vancouver, reported in a poster presentation.

“Peak postpartum blood pressure occurs on days 3-6 after delivery, when most women have already been discharged home. [Yet] there is little information on how best to treat postpartum hypertension in order to minimize maternal hospital stay and optimize maternal safety,” she pointed out.

Indeed, in an extensive review of the literature dating back to 1980, only six randomized clinical trials involving 459 women addressed postpartum antihypertensive treatment with regard to maternal and neonatal efficacy and safety outcomes. The largest study involved 266 subjects and the smallest, just 18.

Three of the six trials looked at prevention of postpartum hypertension in a total of 315 women. All compared drug vs. placebo or no treatment; two involved oral furosemide 20-40 mg/day, and the other involved nifedipine capsules 10 mg every 4 hours. There were no cases of hypotension, serious maternal morbidity, or maternal death. Only one study—which included just 18 patients—examined maternal length of stay, finding an insignificant difference of 7.3 vs. 7.6 days.

The other three trials were treatment studies that included just 144 women. None compared antihypertensive medication with placebo or no treatment for mild to moderate hypertension. Two of the studies—involving 106 women—compared oral timolol or hydralazine with methyldopa for mild to moderate hypertension, and the third compared hydralazine plus nifedipine with nifedipine alone for severe postpartum hypertension.

There were no maternal deaths in the three treatment studies, and the need for additional antihypertensive therapy did not differ between groups.

Based on these minimal data, Dr. Sadeghi and her associates concluded: “If a clinician feels that antihypertensive therapy is needed, the agent used should be based on his/her familiarity with the drug.”

VIENNA — Guidelines are sorely needed for postpartum blood pressure management in women who experience hypertension during pregnancy, speakers said at the 14th World Congress of the International Society for the Study of Hypertension in Pregnancy.

“It's a problem we have very little guidance on and very little information about,” said Jason Waugh, a senior lecturer in the reproductive science section at the University of Leicester, England. He presented one of three studies highlighting the knowledge gaps regarding postpartum diagnosis and treatment of women with pregnancies complicated by hypertension.

Determining whether a woman has underlying chronic hypertension can be difficult. Professional societies such as the ISSHP and the American College of Obstetricians and Gynecologists define chronic hypertension in pregnancy as that occurring prior to pregnancy or diagnosed before 20 weeks' gestation.

But a study of 501 women with hypertension at delivery suggests that the 20-week cutoff is not a reliable one. Instead, thorough postnatal follow-up is essential for accurate diagnosis, Mr. Waugh said.

The women were given preliminary diagnoses at the time of delivery. They subsequently performed home blood pressure monitoring—during which they followed a strict protocol for medication dosage reduction—for 1-8 weeks and were given final diagnoses. Those with persistent hypertension were referred to cardiovascular physicians for follow-up of more than 1 year, during which none of the final diagnoses changed.

The final diagnoses were preeclampsia in 36% (178 women), gestational hypertension in 42% (210), new diagnosis of chronic hypertension in 10% (51), and preexisting hypertension in 12% (49 with essential hypertension and 13 with renal disease).

Standard risk factors were poor predictors of underlying hypertension during pregnancy: Among the 51 women with chronic hypertension not diagnosed prior to pregnancy, only parity and gestation diagnosis were predictive of the final diagnosis, with smoking also showing a strong but nonsignificant trend.

Age, weight, and body mass index were not related to the final diagnosis, nor was antenatal suspicion of hypertension. Of the 28 women with blood pressures greater than 140/90 mm Hg at less than 20 weeks' gestation, 16 (57%) were later proved to have only gestational hypertension, while 12 (43%) were ultimately found to have chronic hypertension. On the flip side, this means that of the 51 women newly diagnosed with chronic hypertension postnatally, just 12, or 24%, had been hypertensive prior to 20 weeks.

“We must proceed with great caution in both clinical and research practice if a postnatal confirmation of blood pressure is not available following antenatal hypertension,” Mr. Waugh remarked at the meeting.

Findings from another study suggest that gestational hypertension commonly persists post partum, particularly in older women.

Tiina Podymow, M.D., of the division of nephrology and hypertension at Weill Medical College, Cornell University, New York City, reviewed clinic charts of 29 women who developed gestational hypertension or preeclampsia; all had been normotensive prior to pregnancy.

The women had a mean age of 35 years. Hypertension had developed at gestational age 15-40 weeks, with 13 developing hypertension within 3 days of delivery and the remainder at 1-18 weeks prior to delivery. The average blood pressure was 161/94 mn Hg; the mean arterial pressure was 116. Eleven women were diagnosed with preeclampsia, and 25 were treated with antihypertensive drugs in the puerperium.

Blood pressure normalized between 0 and 4 weeks post partum in 12 women, between 5 and 12 weeks in 7, and between 13 and 20 weeks in 3. However, blood pressure remained elevated beyond 6 months in seven women, of whom one was found to have primary hyperaldosteronism. This finding suggests that secondary causes of hypertension should be considered in patients with hypertension persisting beyond 6 months, according to Dr. Podymow.

Age was a significant risk factor. The women who remained persistently hypertensive had a mean age of 41 years, compared with 33.5 years among those whose hypertension resolved, she reported.

And few data are available to guide physicians in treating these patients, Susan Sadeghi, M.D., of the University of British Columbia, Vancouver, reported in a poster presentation.

“Peak postpartum blood pressure occurs on days 3-6 after delivery, when most women have already been discharged home. [Yet] there is little information on how best to treat postpartum hypertension in order to minimize maternal hospital stay and optimize maternal safety,” she pointed out.

Indeed, in an extensive review of the literature dating back to 1980, only six randomized clinical trials involving 459 women addressed postpartum antihypertensive treatment with regard to maternal and neonatal efficacy and safety outcomes. The largest study involved 266 subjects and the smallest, just 18.

Three of the six trials looked at prevention of postpartum hypertension in a total of 315 women. All compared drug vs. placebo or no treatment; two involved oral furosemide 20-40 mg/day, and the other involved nifedipine capsules 10 mg every 4 hours. There were no cases of hypotension, serious maternal morbidity, or maternal death. Only one study—which included just 18 patients—examined maternal length of stay, finding an insignificant difference of 7.3 vs. 7.6 days.

The other three trials were treatment studies that included just 144 women. None compared antihypertensive medication with placebo or no treatment for mild to moderate hypertension. Two of the studies—involving 106 women—compared oral timolol or hydralazine with methyldopa for mild to moderate hypertension, and the third compared hydralazine plus nifedipine with nifedipine alone for severe postpartum hypertension.

There were no maternal deaths in the three treatment studies, and the need for additional antihypertensive therapy did not differ between groups.

Based on these minimal data, Dr. Sadeghi and her associates concluded: “If a clinician feels that antihypertensive therapy is needed, the agent used should be based on his/her familiarity with the drug.”

VIENNA — Guidelines are sorely needed for postpartum blood pressure management in women who experience hypertension during pregnancy, speakers said at the 14th World Congress of the International Society for the Study of Hypertension in Pregnancy.

“It's a problem we have very little guidance on and very little information about,” said Jason Waugh, a senior lecturer in the reproductive science section at the University of Leicester, England. He presented one of three studies highlighting the knowledge gaps regarding postpartum diagnosis and treatment of women with pregnancies complicated by hypertension.

Determining whether a woman has underlying chronic hypertension can be difficult. Professional societies such as the ISSHP and the American College of Obstetricians and Gynecologists define chronic hypertension in pregnancy as that occurring prior to pregnancy or diagnosed before 20 weeks' gestation.

But a study of 501 women with hypertension at delivery suggests that the 20-week cutoff is not a reliable one. Instead, thorough postnatal follow-up is essential for accurate diagnosis, Mr. Waugh said.

The women were given preliminary diagnoses at the time of delivery. They subsequently performed home blood pressure monitoring—during which they followed a strict protocol for medication dosage reduction—for 1-8 weeks and were given final diagnoses. Those with persistent hypertension were referred to cardiovascular physicians for follow-up of more than 1 year, during which none of the final diagnoses changed.

The final diagnoses were preeclampsia in 36% (178 women), gestational hypertension in 42% (210), new diagnosis of chronic hypertension in 10% (51), and preexisting hypertension in 12% (49 with essential hypertension and 13 with renal disease).

Standard risk factors were poor predictors of underlying hypertension during pregnancy: Among the 51 women with chronic hypertension not diagnosed prior to pregnancy, only parity and gestation diagnosis were predictive of the final diagnosis, with smoking also showing a strong but nonsignificant trend.

Age, weight, and body mass index were not related to the final diagnosis, nor was antenatal suspicion of hypertension. Of the 28 women with blood pressures greater than 140/90 mm Hg at less than 20 weeks' gestation, 16 (57%) were later proved to have only gestational hypertension, while 12 (43%) were ultimately found to have chronic hypertension. On the flip side, this means that of the 51 women newly diagnosed with chronic hypertension postnatally, just 12, or 24%, had been hypertensive prior to 20 weeks.

“We must proceed with great caution in both clinical and research practice if a postnatal confirmation of blood pressure is not available following antenatal hypertension,” Mr. Waugh remarked at the meeting.

Findings from another study suggest that gestational hypertension commonly persists post partum, particularly in older women.

Tiina Podymow, M.D., of the division of nephrology and hypertension at Weill Medical College, Cornell University, New York City, reviewed clinic charts of 29 women who developed gestational hypertension or preeclampsia; all had been normotensive prior to pregnancy.

The women had a mean age of 35 years. Hypertension had developed at gestational age 15-40 weeks, with 13 developing hypertension within 3 days of delivery and the remainder at 1-18 weeks prior to delivery. The average blood pressure was 161/94 mn Hg; the mean arterial pressure was 116. Eleven women were diagnosed with preeclampsia, and 25 were treated with antihypertensive drugs in the puerperium.

Blood pressure normalized between 0 and 4 weeks post partum in 12 women, between 5 and 12 weeks in 7, and between 13 and 20 weeks in 3. However, blood pressure remained elevated beyond 6 months in seven women, of whom one was found to have primary hyperaldosteronism. This finding suggests that secondary causes of hypertension should be considered in patients with hypertension persisting beyond 6 months, according to Dr. Podymow.

Age was a significant risk factor. The women who remained persistently hypertensive had a mean age of 41 years, compared with 33.5 years among those whose hypertension resolved, she reported.

And few data are available to guide physicians in treating these patients, Susan Sadeghi, M.D., of the University of British Columbia, Vancouver, reported in a poster presentation.

“Peak postpartum blood pressure occurs on days 3-6 after delivery, when most women have already been discharged home. [Yet] there is little information on how best to treat postpartum hypertension in order to minimize maternal hospital stay and optimize maternal safety,” she pointed out.

Indeed, in an extensive review of the literature dating back to 1980, only six randomized clinical trials involving 459 women addressed postpartum antihypertensive treatment with regard to maternal and neonatal efficacy and safety outcomes. The largest study involved 266 subjects and the smallest, just 18.

Three of the six trials looked at prevention of postpartum hypertension in a total of 315 women. All compared drug vs. placebo or no treatment; two involved oral furosemide 20-40 mg/day, and the other involved nifedipine capsules 10 mg every 4 hours. There were no cases of hypotension, serious maternal morbidity, or maternal death. Only one study—which included just 18 patients—examined maternal length of stay, finding an insignificant difference of 7.3 vs. 7.6 days.

The other three trials were treatment studies that included just 144 women. None compared antihypertensive medication with placebo or no treatment for mild to moderate hypertension. Two of the studies—involving 106 women—compared oral timolol or hydralazine with methyldopa for mild to moderate hypertension, and the third compared hydralazine plus nifedipine with nifedipine alone for severe postpartum hypertension.

There were no maternal deaths in the three treatment studies, and the need for additional antihypertensive therapy did not differ between groups.

Based on these minimal data, Dr. Sadeghi and her associates concluded: “If a clinician feels that antihypertensive therapy is needed, the agent used should be based on his/her familiarity with the drug.”

VIENNA — The use of low-molecular-weight heparin together with low-dose aspirin can improve pregnancy outcomes in women who previously had preeclampsia and low-birth-weight infants, Sergio Ferrazzani, M.D., reported.

Women with preeclampsia and low-birth-weight infants in their first pregnancy have double the recurrence rate of preeclampsia in their second pregnancy, compared with women who did not have preeclampsia previously. Infants of those subsequent pregnancies are at increased risk for fetal growth restriction and low birth weight. Data suggest that preeclampsia and fetal growth restriction might share one or more pathophysiologic mechanisms, said Dr. Ferrazzani of the Catholic University of the Sacred Heart, Rome.

An electronic database search of records from his hospital's high-risk pregnancy ward yielded data on 54 women with previous preeclampsia associated with low birth weight and/or intrauterine growth retardation who were negative for antiphospholipid antibody. The women had not been treated with aspirin during a previous pregnancy, he said at the 14th World Congress of the International Society for the Study of Hypertension in Pregnancy.

Of those 54 women, 23 gave birth during 1990-1996, when hospital policy called for thromboprophylaxis with low-dose (100 mg/day) aspirin alone (ASA); the 31 women who delivered during 1997-2003 were treated with the same daily dose of aspirin plus low-molecular-weight heparin (4,000 units subcutaneous enoxaparin).

Aspirin was prescribed from the 22nd day of the menstrual cycle and discontinued after 36 weeks' gestation. The low-molecular-weight heparin (LMWH) was prescribed after confirmation of a positive pregnancy test and continued until delivery.

The women were similar with regard to demographic and anthropomorphic characteristics. About 20% of the women in each group had chronic hypertension, and almost as many (17% in the ASA alone group and 19% in the ASA-LMWH group) had more than one previous pregnancy complicated by preeclampsia.

Gestational age at delivery of the treated pregnancy was higher in both groups, compared with the women's first pregnancies, but the improvement was greater for those in the ASA-LMWH group. The increase was 32.1 vs. 34.8 weeks for women treated with ASA alone, compared with 30.9 vs. 36.4 weeks for women treated with ASA-LMWH.

Similarly, the proportion of women with small-for-gestational-age fetuses, which was 100% among all the first pregnancies, dropped to just 35% with ASA treatment alone and 16% with ASA-LMWH treatment. Both groups showed a birth weight improvement, but the ASA-LWMH group's increase was nearly double that of the group treated with ASA alone (1,372 g vs. 2,017 g in the ASA group and 1,197 g vs. 2,600 g in the ASA-LMWH group).

In both groups, there were six intrauterine deaths among the first pregnancies and none in the treated pregnancies. Neonatal deaths fell from 6 to 3 with ASA and from 11 to 1 with ASA-LMWH. Only the ASA-LMWH drop was statistically significant.

Preeclampsia (in 100% of all the first pregnancies) occurred in 30% of the subsequent ASA-treated pregnancies, compared with just 3% of pregnancies treated with both ASA and LMWH.

Among the 11 patients with chronic hypertension, the mean gestational age at delivery and the mean birth weight were also significantly greater among the infants of the 6 patients from the ASA-LMWH group, compared with those of the 5 ASA patients, Dr. Ferrazzani added.

None of the women treated with ASA-LMWH developed heparin-induced thrombocytopenia or thrombotic episodes, and there was no clinical evidence of heparin-induced osteoporosis. Mild bruising at the injection site—which was considered to be confirmatory of self-administration of the anticoagulant—was the only complication noted with heparin therapy.

VIENNA — The use of low-molecular-weight heparin together with low-dose aspirin can improve pregnancy outcomes in women who previously had preeclampsia and low-birth-weight infants, Sergio Ferrazzani, M.D., reported.

Women with preeclampsia and low-birth-weight infants in their first pregnancy have double the recurrence rate of preeclampsia in their second pregnancy, compared with women who did not have preeclampsia previously. Infants of those subsequent pregnancies are at increased risk for fetal growth restriction and low birth weight. Data suggest that preeclampsia and fetal growth restriction might share one or more pathophysiologic mechanisms, said Dr. Ferrazzani of the Catholic University of the Sacred Heart, Rome.

An electronic database search of records from his hospital's high-risk pregnancy ward yielded data on 54 women with previous preeclampsia associated with low birth weight and/or intrauterine growth retardation who were negative for antiphospholipid antibody. The women had not been treated with aspirin during a previous pregnancy, he said at the 14th World Congress of the International Society for the Study of Hypertension in Pregnancy.

Of those 54 women, 23 gave birth during 1990-1996, when hospital policy called for thromboprophylaxis with low-dose (100 mg/day) aspirin alone (ASA); the 31 women who delivered during 1997-2003 were treated with the same daily dose of aspirin plus low-molecular-weight heparin (4,000 units subcutaneous enoxaparin).

Aspirin was prescribed from the 22nd day of the menstrual cycle and discontinued after 36 weeks' gestation. The low-molecular-weight heparin (LMWH) was prescribed after confirmation of a positive pregnancy test and continued until delivery.

The women were similar with regard to demographic and anthropomorphic characteristics. About 20% of the women in each group had chronic hypertension, and almost as many (17% in the ASA alone group and 19% in the ASA-LMWH group) had more than one previous pregnancy complicated by preeclampsia.

Gestational age at delivery of the treated pregnancy was higher in both groups, compared with the women's first pregnancies, but the improvement was greater for those in the ASA-LMWH group. The increase was 32.1 vs. 34.8 weeks for women treated with ASA alone, compared with 30.9 vs. 36.4 weeks for women treated with ASA-LMWH.

Similarly, the proportion of women with small-for-gestational-age fetuses, which was 100% among all the first pregnancies, dropped to just 35% with ASA treatment alone and 16% with ASA-LMWH treatment. Both groups showed a birth weight improvement, but the ASA-LWMH group's increase was nearly double that of the group treated with ASA alone (1,372 g vs. 2,017 g in the ASA group and 1,197 g vs. 2,600 g in the ASA-LMWH group).

In both groups, there were six intrauterine deaths among the first pregnancies and none in the treated pregnancies. Neonatal deaths fell from 6 to 3 with ASA and from 11 to 1 with ASA-LMWH. Only the ASA-LMWH drop was statistically significant.

Preeclampsia (in 100% of all the first pregnancies) occurred in 30% of the subsequent ASA-treated pregnancies, compared with just 3% of pregnancies treated with both ASA and LMWH.

Among the 11 patients with chronic hypertension, the mean gestational age at delivery and the mean birth weight were also significantly greater among the infants of the 6 patients from the ASA-LMWH group, compared with those of the 5 ASA patients, Dr. Ferrazzani added.

None of the women treated with ASA-LMWH developed heparin-induced thrombocytopenia or thrombotic episodes, and there was no clinical evidence of heparin-induced osteoporosis. Mild bruising at the injection site—which was considered to be confirmatory of self-administration of the anticoagulant—was the only complication noted with heparin therapy.

VIENNA — The use of low-molecular-weight heparin together with low-dose aspirin can improve pregnancy outcomes in women who previously had preeclampsia and low-birth-weight infants, Sergio Ferrazzani, M.D., reported.

Women with preeclampsia and low-birth-weight infants in their first pregnancy have double the recurrence rate of preeclampsia in their second pregnancy, compared with women who did not have preeclampsia previously. Infants of those subsequent pregnancies are at increased risk for fetal growth restriction and low birth weight. Data suggest that preeclampsia and fetal growth restriction might share one or more pathophysiologic mechanisms, said Dr. Ferrazzani of the Catholic University of the Sacred Heart, Rome.

An electronic database search of records from his hospital's high-risk pregnancy ward yielded data on 54 women with previous preeclampsia associated with low birth weight and/or intrauterine growth retardation who were negative for antiphospholipid antibody. The women had not been treated with aspirin during a previous pregnancy, he said at the 14th World Congress of the International Society for the Study of Hypertension in Pregnancy.

Of those 54 women, 23 gave birth during 1990-1996, when hospital policy called for thromboprophylaxis with low-dose (100 mg/day) aspirin alone (ASA); the 31 women who delivered during 1997-2003 were treated with the same daily dose of aspirin plus low-molecular-weight heparin (4,000 units subcutaneous enoxaparin).

Aspirin was prescribed from the 22nd day of the menstrual cycle and discontinued after 36 weeks' gestation. The low-molecular-weight heparin (LMWH) was prescribed after confirmation of a positive pregnancy test and continued until delivery.

The women were similar with regard to demographic and anthropomorphic characteristics. About 20% of the women in each group had chronic hypertension, and almost as many (17% in the ASA alone group and 19% in the ASA-LMWH group) had more than one previous pregnancy complicated by preeclampsia.

Gestational age at delivery of the treated pregnancy was higher in both groups, compared with the women's first pregnancies, but the improvement was greater for those in the ASA-LMWH group. The increase was 32.1 vs. 34.8 weeks for women treated with ASA alone, compared with 30.9 vs. 36.4 weeks for women treated with ASA-LMWH.

Similarly, the proportion of women with small-for-gestational-age fetuses, which was 100% among all the first pregnancies, dropped to just 35% with ASA treatment alone and 16% with ASA-LMWH treatment. Both groups showed a birth weight improvement, but the ASA-LWMH group's increase was nearly double that of the group treated with ASA alone (1,372 g vs. 2,017 g in the ASA group and 1,197 g vs. 2,600 g in the ASA-LMWH group).

In both groups, there were six intrauterine deaths among the first pregnancies and none in the treated pregnancies. Neonatal deaths fell from 6 to 3 with ASA and from 11 to 1 with ASA-LMWH. Only the ASA-LMWH drop was statistically significant.

Preeclampsia (in 100% of all the first pregnancies) occurred in 30% of the subsequent ASA-treated pregnancies, compared with just 3% of pregnancies treated with both ASA and LMWH.

Among the 11 patients with chronic hypertension, the mean gestational age at delivery and the mean birth weight were also significantly greater among the infants of the 6 patients from the ASA-LMWH group, compared with those of the 5 ASA patients, Dr. Ferrazzani added.

None of the women treated with ASA-LMWH developed heparin-induced thrombocytopenia or thrombotic episodes, and there was no clinical evidence of heparin-induced osteoporosis. Mild bruising at the injection site—which was considered to be confirmatory of self-administration of the anticoagulant—was the only complication noted with heparin therapy.