Society of Obstetricians and Gynecologists of Canada (SOGC): Annual Clinical Meeting

VANCOUVER – A clinical trial is needed to assess the risk-benefit profile of salpingectomy for ovarian cancer prevention, said Dr. Barry Rosen.

A recent, serendipitous discovery, resulting from pathology examination of tissues removed during prophylactic salpingo-oophorectomy in patients with BRCA mutations, was that serous "ovarian" cancers actually arise from the fimbriae of the fallopian tubes.

"We didn’t know it when we started doing [the surgery]," Dr. Rosen explained at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. "We sort of all of a sudden started to identify cancers, and most of them were in the tube. ... All of a sudden, there has been a shift in the understanding that serous carcinomas do come from the tube."

In the wake of this new information, the Society of Gynecologic Oncology of Canada (GOC) issued two key recommendations, according to Dr. Rosen, professor of ob.gyn. and head of gynecologic oncology at the University of Toronto.

First, the GOC recommends that physicians discuss the risk-benefit profile of salpingectomy with women who are already having a hysterectomy or seeking irreversible contraception. "We don’t come out and say ‘Do it,’ " he noted. "But we are coming out to say that it makes sense, and you should discuss it, and in that discussion, if it makes sense, that you should go ahead and proceed to do it."

Second, the GOC recommends that, given the lack of evidence, a national study of ovarian cancer prevention through salpingectomy be a priority of the society. "We want to collect the evidence to support this, and we want to be sure that the evidence supports it before we really jump in and say everybody should be doing this," Dr. Rosen said.

"I don’t think there’s any question that salpingectomy makes sense. Serous carcinoma is the worst [ovarian] cancer, it’s the most common cancer, [and] it causes more deaths than any," he commented. "So if you can prevent this cancer, you are probably going to have the biggest impact on ovarian cancer that we have today. Bigger than screening, for sure – we know [screening] doesn’t work. But bigger than any treatment and any of the fancy treatments that are coming out that are really very expensive treatments."

Adding salpingectomy to other, planned surgeries could potentially provide preventive benefit to tens of thousands of women annually in Canada alone. For starters, roughly 47,000 Canadian women undergo hysterectomy nationally each year. Removal of the ovaries and tubes at the same time is fairly standard for those who are postmenopausal. "But it’s the premenopausal women for whom you would have the benefit of taking out the tubes and leaving the ovaries so that they could continue to have their hormone function," he noted.

And the procedure could be offered even more widely. For example, approximately 10,100 new cases of colon cancer are diagnosed annually among Canadian women, many of whom undergo pelvic surgery as a result.

There are many "other situations where urologists or general surgeons are doing surgery, so I don’t think we have to limit this discussion to gynecologists," commented Dr. Rosen. "We need to expand it to all disciplines that may operate in the pelvis, because a surgeon can take out the tubes as well as we can."

When asked by an attendee whether it might perhaps be better to recommend simpler distal salpingectomy instead of total salpingectomy, he expressed reservations.

"While the belief is that most of these cancers arise in the fimbriated end, there are some that do arise further up the tube." Additionally, "we have to be careful if we put in the word ‘distal.’ We also have to define what distal is. So it’s trickier than you think."

Dr. Rosen offered a few notes of caution from his own perspective. "Salpingectomy at open hysterectomy is different than at laparoscopic hysterectomy or tubal ligation," he said. "It’s pretty simple if you have an open case to be able to put your favorite clamp across the tube and remove it; laparascopically, [for some it may be] a little bit more difficult. ... When doing the procedure, you need to treat this as a surgical procedure, and not just think, ‘Oh yeah, we’ll just take out the tubes,’ and find yourself in some trouble with bleeding or an injury of some sort."

Also, the medical profession must decide what level of complications is acceptable. "I don’t know the answer to that, but we need to know what the complication rate is, and we do know that there will be complications," he said.

Finally, the new recommendations are currently based on a hypothesis, not on evidence. "There are other situations in our history in medicine where physicians really believed something very strongly and proceeded with limited information," he noted, citing by way of example the use of diethylstilbestrol in the 1940s and 1950s to prevent miscarriage, and its subsequent linkage to cancer. "We need to be sure that we get the evidence. I believe that we need to evaluate this in some form of clinical trial."

Should salpingectomy prove to be effective and adequately safe for preventing ovarian cancer, it would constitute a major turning point in a disease that still has a poor prognosis, according to Dr. Rosen.

To be sure, treatments have improved steadily over the past 25 years, prolonging life and improving its quality. "We can continue to expect improvements, but I think they are going to be gradual and they are going to be small," he said. "I don’t think anybody would say that there are any home runs out there right now."

Efforts to detect the cancer early through screening have thus far not panned out. Three large screening studies were initiated in 1985-2001, one each in the United Kingdom, Japan, and the United States.

Results from the last – the PLCO (Prostate, Lung, Colorectal, and Ovarian) trial, which tested screening with cancer antigen 125 (CA 125) and transvaginal ultrasound – were recently reported (JAMA 2011;305:2295-303). They showed that 20 surgeries had to be performed to detect one cancer, and the rate of major complications was 20% among patients who underwent surgery. And at the end of the day, there was no reduction in ovarian cancer mortality.

"This is a big study, it is very well done, [and] it has a very long follow-up," Dr. Rosen commented. "And I think this pretty much conclusively says that ultrasound and CA 125 [screening] just don’t work." Results of the U.K. study, which is using a different, serial multimodality approach to screening, are expected in the 2014 timeframe.

Prevention efforts up to this point have been limited to birth control pills and to BRCA testing with prophylactic surgery for carriers, but this group makes up only about a tenth of all patients with ovarian cancer, he noted.

Dr. Rosen said he had no relevant financial disclosures.

VANCOUVER – A clinical trial is needed to assess the risk-benefit profile of salpingectomy for ovarian cancer prevention, said Dr. Barry Rosen.

A recent, serendipitous discovery, resulting from pathology examination of tissues removed during prophylactic salpingo-oophorectomy in patients with BRCA mutations, was that serous "ovarian" cancers actually arise from the fimbriae of the fallopian tubes.

"We didn’t know it when we started doing [the surgery]," Dr. Rosen explained at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. "We sort of all of a sudden started to identify cancers, and most of them were in the tube. ... All of a sudden, there has been a shift in the understanding that serous carcinomas do come from the tube."

In the wake of this new information, the Society of Gynecologic Oncology of Canada (GOC) issued two key recommendations, according to Dr. Rosen, professor of ob.gyn. and head of gynecologic oncology at the University of Toronto.

First, the GOC recommends that physicians discuss the risk-benefit profile of salpingectomy with women who are already having a hysterectomy or seeking irreversible contraception. "We don’t come out and say ‘Do it,’ " he noted. "But we are coming out to say that it makes sense, and you should discuss it, and in that discussion, if it makes sense, that you should go ahead and proceed to do it."

Second, the GOC recommends that, given the lack of evidence, a national study of ovarian cancer prevention through salpingectomy be a priority of the society. "We want to collect the evidence to support this, and we want to be sure that the evidence supports it before we really jump in and say everybody should be doing this," Dr. Rosen said.

"I don’t think there’s any question that salpingectomy makes sense. Serous carcinoma is the worst [ovarian] cancer, it’s the most common cancer, [and] it causes more deaths than any," he commented. "So if you can prevent this cancer, you are probably going to have the biggest impact on ovarian cancer that we have today. Bigger than screening, for sure – we know [screening] doesn’t work. But bigger than any treatment and any of the fancy treatments that are coming out that are really very expensive treatments."

Adding salpingectomy to other, planned surgeries could potentially provide preventive benefit to tens of thousands of women annually in Canada alone. For starters, roughly 47,000 Canadian women undergo hysterectomy nationally each year. Removal of the ovaries and tubes at the same time is fairly standard for those who are postmenopausal. "But it’s the premenopausal women for whom you would have the benefit of taking out the tubes and leaving the ovaries so that they could continue to have their hormone function," he noted.

And the procedure could be offered even more widely. For example, approximately 10,100 new cases of colon cancer are diagnosed annually among Canadian women, many of whom undergo pelvic surgery as a result.

There are many "other situations where urologists or general surgeons are doing surgery, so I don’t think we have to limit this discussion to gynecologists," commented Dr. Rosen. "We need to expand it to all disciplines that may operate in the pelvis, because a surgeon can take out the tubes as well as we can."

When asked by an attendee whether it might perhaps be better to recommend simpler distal salpingectomy instead of total salpingectomy, he expressed reservations.

"While the belief is that most of these cancers arise in the fimbriated end, there are some that do arise further up the tube." Additionally, "we have to be careful if we put in the word ‘distal.’ We also have to define what distal is. So it’s trickier than you think."

Dr. Rosen offered a few notes of caution from his own perspective. "Salpingectomy at open hysterectomy is different than at laparoscopic hysterectomy or tubal ligation," he said. "It’s pretty simple if you have an open case to be able to put your favorite clamp across the tube and remove it; laparascopically, [for some it may be] a little bit more difficult. ... When doing the procedure, you need to treat this as a surgical procedure, and not just think, ‘Oh yeah, we’ll just take out the tubes,’ and find yourself in some trouble with bleeding or an injury of some sort."

Also, the medical profession must decide what level of complications is acceptable. "I don’t know the answer to that, but we need to know what the complication rate is, and we do know that there will be complications," he said.

Finally, the new recommendations are currently based on a hypothesis, not on evidence. "There are other situations in our history in medicine where physicians really believed something very strongly and proceeded with limited information," he noted, citing by way of example the use of diethylstilbestrol in the 1940s and 1950s to prevent miscarriage, and its subsequent linkage to cancer. "We need to be sure that we get the evidence. I believe that we need to evaluate this in some form of clinical trial."

Should salpingectomy prove to be effective and adequately safe for preventing ovarian cancer, it would constitute a major turning point in a disease that still has a poor prognosis, according to Dr. Rosen.

To be sure, treatments have improved steadily over the past 25 years, prolonging life and improving its quality. "We can continue to expect improvements, but I think they are going to be gradual and they are going to be small," he said. "I don’t think anybody would say that there are any home runs out there right now."

Efforts to detect the cancer early through screening have thus far not panned out. Three large screening studies were initiated in 1985-2001, one each in the United Kingdom, Japan, and the United States.

Results from the last – the PLCO (Prostate, Lung, Colorectal, and Ovarian) trial, which tested screening with cancer antigen 125 (CA 125) and transvaginal ultrasound – were recently reported (JAMA 2011;305:2295-303). They showed that 20 surgeries had to be performed to detect one cancer, and the rate of major complications was 20% among patients who underwent surgery. And at the end of the day, there was no reduction in ovarian cancer mortality.

"This is a big study, it is very well done, [and] it has a very long follow-up," Dr. Rosen commented. "And I think this pretty much conclusively says that ultrasound and CA 125 [screening] just don’t work." Results of the U.K. study, which is using a different, serial multimodality approach to screening, are expected in the 2014 timeframe.

Prevention efforts up to this point have been limited to birth control pills and to BRCA testing with prophylactic surgery for carriers, but this group makes up only about a tenth of all patients with ovarian cancer, he noted.

Dr. Rosen said he had no relevant financial disclosures.

VANCOUVER – A clinical trial is needed to assess the risk-benefit profile of salpingectomy for ovarian cancer prevention, said Dr. Barry Rosen.

A recent, serendipitous discovery, resulting from pathology examination of tissues removed during prophylactic salpingo-oophorectomy in patients with BRCA mutations, was that serous "ovarian" cancers actually arise from the fimbriae of the fallopian tubes.

"We didn’t know it when we started doing [the surgery]," Dr. Rosen explained at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. "We sort of all of a sudden started to identify cancers, and most of them were in the tube. ... All of a sudden, there has been a shift in the understanding that serous carcinomas do come from the tube."

In the wake of this new information, the Society of Gynecologic Oncology of Canada (GOC) issued two key recommendations, according to Dr. Rosen, professor of ob.gyn. and head of gynecologic oncology at the University of Toronto.

First, the GOC recommends that physicians discuss the risk-benefit profile of salpingectomy with women who are already having a hysterectomy or seeking irreversible contraception. "We don’t come out and say ‘Do it,’ " he noted. "But we are coming out to say that it makes sense, and you should discuss it, and in that discussion, if it makes sense, that you should go ahead and proceed to do it."

Second, the GOC recommends that, given the lack of evidence, a national study of ovarian cancer prevention through salpingectomy be a priority of the society. "We want to collect the evidence to support this, and we want to be sure that the evidence supports it before we really jump in and say everybody should be doing this," Dr. Rosen said.

"I don’t think there’s any question that salpingectomy makes sense. Serous carcinoma is the worst [ovarian] cancer, it’s the most common cancer, [and] it causes more deaths than any," he commented. "So if you can prevent this cancer, you are probably going to have the biggest impact on ovarian cancer that we have today. Bigger than screening, for sure – we know [screening] doesn’t work. But bigger than any treatment and any of the fancy treatments that are coming out that are really very expensive treatments."

Adding salpingectomy to other, planned surgeries could potentially provide preventive benefit to tens of thousands of women annually in Canada alone. For starters, roughly 47,000 Canadian women undergo hysterectomy nationally each year. Removal of the ovaries and tubes at the same time is fairly standard for those who are postmenopausal. "But it’s the premenopausal women for whom you would have the benefit of taking out the tubes and leaving the ovaries so that they could continue to have their hormone function," he noted.

And the procedure could be offered even more widely. For example, approximately 10,100 new cases of colon cancer are diagnosed annually among Canadian women, many of whom undergo pelvic surgery as a result.

There are many "other situations where urologists or general surgeons are doing surgery, so I don’t think we have to limit this discussion to gynecologists," commented Dr. Rosen. "We need to expand it to all disciplines that may operate in the pelvis, because a surgeon can take out the tubes as well as we can."

When asked by an attendee whether it might perhaps be better to recommend simpler distal salpingectomy instead of total salpingectomy, he expressed reservations.

"While the belief is that most of these cancers arise in the fimbriated end, there are some that do arise further up the tube." Additionally, "we have to be careful if we put in the word ‘distal.’ We also have to define what distal is. So it’s trickier than you think."

Dr. Rosen offered a few notes of caution from his own perspective. "Salpingectomy at open hysterectomy is different than at laparoscopic hysterectomy or tubal ligation," he said. "It’s pretty simple if you have an open case to be able to put your favorite clamp across the tube and remove it; laparascopically, [for some it may be] a little bit more difficult. ... When doing the procedure, you need to treat this as a surgical procedure, and not just think, ‘Oh yeah, we’ll just take out the tubes,’ and find yourself in some trouble with bleeding or an injury of some sort."

Also, the medical profession must decide what level of complications is acceptable. "I don’t know the answer to that, but we need to know what the complication rate is, and we do know that there will be complications," he said.

Finally, the new recommendations are currently based on a hypothesis, not on evidence. "There are other situations in our history in medicine where physicians really believed something very strongly and proceeded with limited information," he noted, citing by way of example the use of diethylstilbestrol in the 1940s and 1950s to prevent miscarriage, and its subsequent linkage to cancer. "We need to be sure that we get the evidence. I believe that we need to evaluate this in some form of clinical trial."

Should salpingectomy prove to be effective and adequately safe for preventing ovarian cancer, it would constitute a major turning point in a disease that still has a poor prognosis, according to Dr. Rosen.

To be sure, treatments have improved steadily over the past 25 years, prolonging life and improving its quality. "We can continue to expect improvements, but I think they are going to be gradual and they are going to be small," he said. "I don’t think anybody would say that there are any home runs out there right now."

Efforts to detect the cancer early through screening have thus far not panned out. Three large screening studies were initiated in 1985-2001, one each in the United Kingdom, Japan, and the United States.

Results from the last – the PLCO (Prostate, Lung, Colorectal, and Ovarian) trial, which tested screening with cancer antigen 125 (CA 125) and transvaginal ultrasound – were recently reported (JAMA 2011;305:2295-303). They showed that 20 surgeries had to be performed to detect one cancer, and the rate of major complications was 20% among patients who underwent surgery. And at the end of the day, there was no reduction in ovarian cancer mortality.

"This is a big study, it is very well done, [and] it has a very long follow-up," Dr. Rosen commented. "And I think this pretty much conclusively says that ultrasound and CA 125 [screening] just don’t work." Results of the U.K. study, which is using a different, serial multimodality approach to screening, are expected in the 2014 timeframe.

Prevention efforts up to this point have been limited to birth control pills and to BRCA testing with prophylactic surgery for carriers, but this group makes up only about a tenth of all patients with ovarian cancer, he noted.

Dr. Rosen said he had no relevant financial disclosures.

VANCOUVER, B.C. – The impact of selective serotonin reuptake inhibitors on fetal pulmonary vascular physiology may boil down to genetics, study results suggest.

In a study of 55 pregnant women who were near term, a variety of right pulmonary artery measures (such as flow and impedance) did not differ significantly between fetuses of women who had been taking SSRIs since conception and those of women who had not. There was also no measurable effect of acute exposure to SSRIs.

However, within the SSRI-exposed group only, fetal right pulmonary artery flow was about 40% higher for infants who experienced respiratory distress in the neonatal period than for their counterparts who did not.

"So there is something different about this particular group in terms of the fact that they developed respiratory distress," commented lead investigator Dr. Kenneth Lim. "Maybe they respond to the SSRIs differently; maybe there is a genetic polymorphism that makes them more susceptible."

Regardless, this difference can be tapped to elucidate the effects of in utero exposure, he added. "It just sort of gives us an idea that maybe we need to look at that a little bit more closely in the next phase of our studies, to try to determine whether there is something going on in the pulmonary system of these babies."

Some 4% of pregnant women in British Columbia are taking SSRIs, according to Dr. Lim of the department of obstetrics and gynecology at the University of British Columbia in Vancouver. "In a province our size, that’s about 1,500-2,000 patients a year who are exposed to SSRIs," he noted at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Previous studies have determined that maternal use of this class of drugs has a variety of deleterious effects on the infant, including low birth weight, prematurity, and a type of withdrawal syndrome characterized by irritability and jitteriness.

"But interestingly, there is also a link with respiratory distress, which tends to be more like a TTN [transient tachypnea of the newborn]-type respiratory distress, and also, there have been case reports of primary pulmonary hypertension," he noted.

The pathogenesis of these pulmonary abnormalities is unclear. "We do know that serotonin itself is a very powerful vasoconstrictor, but it has differential effects in different tissues," Dr. Lim explained.

Preclinically, serotonin impairs lung fluid resorption, suggesting that SSRI-exposed infants may be unable to reabsorb lung fluid after birth; one SSRI has been found to increase arterial smooth muscle cell proliferation.

Pregnant women were eligible for the study if their fetus did not have any anomalies, if they were not taking any illicit or prescription drugs (other than SSRIs), and if they did not have any serious medical conditions.

The investigators enrolled two groups. The nonexposed control group consisted of healthy women who were at low risk for complications and who had not taken SSRIs during pregnancy. The exposed group consisted of women with a mood disorder who had been taking SSRIs since the time of conception.

At a gestational age of about 36 weeks, the women underwent a morning ultrasound exam to assess fetal pulmonary vasculature. Those taking an SSRI then took their medication for the day. In the afternoon, all women had a second ultrasound.

This approach allowed assessment of the effects of both chronic SSRI exposure (by comparing exposed and nonexposed groups) and acute SSRI exposure (by comparing morning and afternoon measurements in the exposed group), Dr. Lim explained.

Results were based on 23 women taking SSRIs (predominantly fluoxetine) and 32 control women. They were 33 years old, on average. Only a single woman in each group smoked during pregnancy. Those in the SSRI group had higher scores for depression.

At delivery, the gestational age was significantly younger in the SSRI-exposed group (39.0 vs. 40.0 weeks). Additionally, the SSRI-exposed infants had a smaller head circumference (34.1 vs. 35.0 cm) and poorer Apgar scores at 1 minute (7.5 vs. 8.4).

Infants in the SSRI-exposed group also were more likely to have respiratory distress (30% vs. 3%) and jitteriness (39% vs. 3%).

"These are all things that have been previously documented, so basically, these kids are behaving the way that we expect from previous studies," commented Dr. Lim.

When it came to fetal right pulmonary artery parameters, there were no significant differences between SSRI-exposed and SSRI-nonexposed groups, or between morning and afternoon within the exposed group, in terms of pulsatility index, resistance index (a measure of blood flow impedance in the artery), peak systolic velocity, diameter, area, and flow.

However, within the SSRI-exposed group, fetal right pulmonary artery flow was higher for infants who experienced respiratory distress in the neonatal period than for those who did not, with a value of approximately 280 mL/min vs. 175 mL/min (P = .03).

Dr. Lim reported no relevant financial disclosures.

VANCOUVER, B.C. – The impact of selective serotonin reuptake inhibitors on fetal pulmonary vascular physiology may boil down to genetics, study results suggest.

In a study of 55 pregnant women who were near term, a variety of right pulmonary artery measures (such as flow and impedance) did not differ significantly between fetuses of women who had been taking SSRIs since conception and those of women who had not. There was also no measurable effect of acute exposure to SSRIs.

However, within the SSRI-exposed group only, fetal right pulmonary artery flow was about 40% higher for infants who experienced respiratory distress in the neonatal period than for their counterparts who did not.

"So there is something different about this particular group in terms of the fact that they developed respiratory distress," commented lead investigator Dr. Kenneth Lim. "Maybe they respond to the SSRIs differently; maybe there is a genetic polymorphism that makes them more susceptible."

Regardless, this difference can be tapped to elucidate the effects of in utero exposure, he added. "It just sort of gives us an idea that maybe we need to look at that a little bit more closely in the next phase of our studies, to try to determine whether there is something going on in the pulmonary system of these babies."

Some 4% of pregnant women in British Columbia are taking SSRIs, according to Dr. Lim of the department of obstetrics and gynecology at the University of British Columbia in Vancouver. "In a province our size, that’s about 1,500-2,000 patients a year who are exposed to SSRIs," he noted at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Previous studies have determined that maternal use of this class of drugs has a variety of deleterious effects on the infant, including low birth weight, prematurity, and a type of withdrawal syndrome characterized by irritability and jitteriness.

"But interestingly, there is also a link with respiratory distress, which tends to be more like a TTN [transient tachypnea of the newborn]-type respiratory distress, and also, there have been case reports of primary pulmonary hypertension," he noted.

The pathogenesis of these pulmonary abnormalities is unclear. "We do know that serotonin itself is a very powerful vasoconstrictor, but it has differential effects in different tissues," Dr. Lim explained.

Preclinically, serotonin impairs lung fluid resorption, suggesting that SSRI-exposed infants may be unable to reabsorb lung fluid after birth; one SSRI has been found to increase arterial smooth muscle cell proliferation.

Pregnant women were eligible for the study if their fetus did not have any anomalies, if they were not taking any illicit or prescription drugs (other than SSRIs), and if they did not have any serious medical conditions.

The investigators enrolled two groups. The nonexposed control group consisted of healthy women who were at low risk for complications and who had not taken SSRIs during pregnancy. The exposed group consisted of women with a mood disorder who had been taking SSRIs since the time of conception.

At a gestational age of about 36 weeks, the women underwent a morning ultrasound exam to assess fetal pulmonary vasculature. Those taking an SSRI then took their medication for the day. In the afternoon, all women had a second ultrasound.

This approach allowed assessment of the effects of both chronic SSRI exposure (by comparing exposed and nonexposed groups) and acute SSRI exposure (by comparing morning and afternoon measurements in the exposed group), Dr. Lim explained.

Results were based on 23 women taking SSRIs (predominantly fluoxetine) and 32 control women. They were 33 years old, on average. Only a single woman in each group smoked during pregnancy. Those in the SSRI group had higher scores for depression.

At delivery, the gestational age was significantly younger in the SSRI-exposed group (39.0 vs. 40.0 weeks). Additionally, the SSRI-exposed infants had a smaller head circumference (34.1 vs. 35.0 cm) and poorer Apgar scores at 1 minute (7.5 vs. 8.4).

Infants in the SSRI-exposed group also were more likely to have respiratory distress (30% vs. 3%) and jitteriness (39% vs. 3%).

"These are all things that have been previously documented, so basically, these kids are behaving the way that we expect from previous studies," commented Dr. Lim.

When it came to fetal right pulmonary artery parameters, there were no significant differences between SSRI-exposed and SSRI-nonexposed groups, or between morning and afternoon within the exposed group, in terms of pulsatility index, resistance index (a measure of blood flow impedance in the artery), peak systolic velocity, diameter, area, and flow.

However, within the SSRI-exposed group, fetal right pulmonary artery flow was higher for infants who experienced respiratory distress in the neonatal period than for those who did not, with a value of approximately 280 mL/min vs. 175 mL/min (P = .03).

Dr. Lim reported no relevant financial disclosures.

VANCOUVER, B.C. – The impact of selective serotonin reuptake inhibitors on fetal pulmonary vascular physiology may boil down to genetics, study results suggest.

In a study of 55 pregnant women who were near term, a variety of right pulmonary artery measures (such as flow and impedance) did not differ significantly between fetuses of women who had been taking SSRIs since conception and those of women who had not. There was also no measurable effect of acute exposure to SSRIs.

However, within the SSRI-exposed group only, fetal right pulmonary artery flow was about 40% higher for infants who experienced respiratory distress in the neonatal period than for their counterparts who did not.

"So there is something different about this particular group in terms of the fact that they developed respiratory distress," commented lead investigator Dr. Kenneth Lim. "Maybe they respond to the SSRIs differently; maybe there is a genetic polymorphism that makes them more susceptible."

Regardless, this difference can be tapped to elucidate the effects of in utero exposure, he added. "It just sort of gives us an idea that maybe we need to look at that a little bit more closely in the next phase of our studies, to try to determine whether there is something going on in the pulmonary system of these babies."

Some 4% of pregnant women in British Columbia are taking SSRIs, according to Dr. Lim of the department of obstetrics and gynecology at the University of British Columbia in Vancouver. "In a province our size, that’s about 1,500-2,000 patients a year who are exposed to SSRIs," he noted at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Previous studies have determined that maternal use of this class of drugs has a variety of deleterious effects on the infant, including low birth weight, prematurity, and a type of withdrawal syndrome characterized by irritability and jitteriness.

"But interestingly, there is also a link with respiratory distress, which tends to be more like a TTN [transient tachypnea of the newborn]-type respiratory distress, and also, there have been case reports of primary pulmonary hypertension," he noted.

The pathogenesis of these pulmonary abnormalities is unclear. "We do know that serotonin itself is a very powerful vasoconstrictor, but it has differential effects in different tissues," Dr. Lim explained.

Preclinically, serotonin impairs lung fluid resorption, suggesting that SSRI-exposed infants may be unable to reabsorb lung fluid after birth; one SSRI has been found to increase arterial smooth muscle cell proliferation.

Pregnant women were eligible for the study if their fetus did not have any anomalies, if they were not taking any illicit or prescription drugs (other than SSRIs), and if they did not have any serious medical conditions.

The investigators enrolled two groups. The nonexposed control group consisted of healthy women who were at low risk for complications and who had not taken SSRIs during pregnancy. The exposed group consisted of women with a mood disorder who had been taking SSRIs since the time of conception.

At a gestational age of about 36 weeks, the women underwent a morning ultrasound exam to assess fetal pulmonary vasculature. Those taking an SSRI then took their medication for the day. In the afternoon, all women had a second ultrasound.

This approach allowed assessment of the effects of both chronic SSRI exposure (by comparing exposed and nonexposed groups) and acute SSRI exposure (by comparing morning and afternoon measurements in the exposed group), Dr. Lim explained.

Results were based on 23 women taking SSRIs (predominantly fluoxetine) and 32 control women. They were 33 years old, on average. Only a single woman in each group smoked during pregnancy. Those in the SSRI group had higher scores for depression.

At delivery, the gestational age was significantly younger in the SSRI-exposed group (39.0 vs. 40.0 weeks). Additionally, the SSRI-exposed infants had a smaller head circumference (34.1 vs. 35.0 cm) and poorer Apgar scores at 1 minute (7.5 vs. 8.4).

Infants in the SSRI-exposed group also were more likely to have respiratory distress (30% vs. 3%) and jitteriness (39% vs. 3%).

"These are all things that have been previously documented, so basically, these kids are behaving the way that we expect from previous studies," commented Dr. Lim.

When it came to fetal right pulmonary artery parameters, there were no significant differences between SSRI-exposed and SSRI-nonexposed groups, or between morning and afternoon within the exposed group, in terms of pulsatility index, resistance index (a measure of blood flow impedance in the artery), peak systolic velocity, diameter, area, and flow.

However, within the SSRI-exposed group, fetal right pulmonary artery flow was higher for infants who experienced respiratory distress in the neonatal period than for those who did not, with a value of approximately 280 mL/min vs. 175 mL/min (P = .03).

Dr. Lim reported no relevant financial disclosures.

VANCOUVER, B.C. – An ultrasound diagnosis of fetal macrosomia at term is inaccurate in the majority of cases, and this inaccuracy may be contributing to unnecessary cesarean deliveries, new data suggest.

In an observational cohort study of 235 pregnancies at term in which ultrasound measurements led to a diagnosis of fetal macrosomia, only about a third of the infants were actually macrosomic at birth. Additionally, these pregnancies with ultrasound-diagnosed fetal macrosomia were more than twice as likely as all pregnancies in the population to end in cesarean delivery, according to results reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Ultrasound-estimated fetal weight "is not very accurate, and we have to counsel patients on that, when they come to ultrasounds and they are worried that they are going to have this [enormous] monstrosity of a baby," lead investigator Dr. Alese Wagner said in an interview. "You can tell them [that] most of the time, we are off."

She further recommended that physicians keep this new information in mind when it comes to recommending delivery interventions for a pregnancy in which the ultrasound suggests macrosomia.

Surprisingly, the accuracy of ultrasound in assessing fetal weight is similar to that found with simple clinical palpation, according to Dr. Wagner, a third-year resident in the department of obstetrics and gynecology at the University of Calgary in Alberta.

The study used the Hadlock formula for calculating weight from ultrasound fetal measurements, "which is supposed to be one of the better formulas for macrosomic infants," she noted.

"Interestingly enough, people have shown that through the years, as the technology has gotten better – these ultrasound machines that we have now are amazing, what they can do – this [accuracy] hasn’t gotten better," she added, speculating that the disconnect may in part be the result of reliance on simple measurements that don’t take into account tissue densities.

Additionally, ultrasound assessment late in pregnancy is inherently more difficult because the fetus is so low in the pelvis and there is less amniotic fluid. Maternal body habitus also may play a role.

Using the clinical database of a tertiary referral center for the years 2005-2009, Dr. Wagner and her coinvestigators identified 235 women who had an ultrasound exam within 2 weeks of delivery that indicated the presence of fetal macrosomia (defined as an estimated fetal weight of at least 4,500 g, as calculated via the Hadlock formula).

However, they found that at the time of delivery, just 88 of these infants had an actual birth weight of at least 4,500 g, for a positive predictive value of merely 37.4%, according to results reported in a poster session.

"It looked like most of the providers were overestimating weight," she observed; the median estimated fetal weight was 4,693 g, whereas the median birth weight was 4,368 g.

The mean percentage error of the estimated fetal weight was 8.6% overall. Viewed another way, 44% of the weights were off by more than 10%, and 7% were off by more than 20%.

There were only weak correlations between estimated fetal weight and birth weight, as well as between the individual fetal measurements used in the Hadlock formula and birth weight.

The mode of delivery was cesarean section in 66% of the pregnancies, compared with just 29% of all pregnancies in Calgary during the same period. "So it’s [more than] double, the percentage who are getting C-sections, on what is [an inaccurate weight]," said Dr. Wagner.

Before the study, "there was a general feeling that we were pretty [far off] in the estimates of the fetal weights that we were getting closer to term, especially for the bigger babies," she commented. "People ... usually thought that they were overestimating them, so it was nice to actually look at ... what the actual numbers were."

"This opens up a lot of other areas that we can explore more within just this study," such as whether maternal body mass index is affecting ultrasound accuracy, Dr. Wagner concluded. "So this is kind of a starting project."

Dr. Wagner reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – An ultrasound diagnosis of fetal macrosomia at term is inaccurate in the majority of cases, and this inaccuracy may be contributing to unnecessary cesarean deliveries, new data suggest.

In an observational cohort study of 235 pregnancies at term in which ultrasound measurements led to a diagnosis of fetal macrosomia, only about a third of the infants were actually macrosomic at birth. Additionally, these pregnancies with ultrasound-diagnosed fetal macrosomia were more than twice as likely as all pregnancies in the population to end in cesarean delivery, according to results reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Ultrasound-estimated fetal weight "is not very accurate, and we have to counsel patients on that, when they come to ultrasounds and they are worried that they are going to have this [enormous] monstrosity of a baby," lead investigator Dr. Alese Wagner said in an interview. "You can tell them [that] most of the time, we are off."

She further recommended that physicians keep this new information in mind when it comes to recommending delivery interventions for a pregnancy in which the ultrasound suggests macrosomia.

Surprisingly, the accuracy of ultrasound in assessing fetal weight is similar to that found with simple clinical palpation, according to Dr. Wagner, a third-year resident in the department of obstetrics and gynecology at the University of Calgary in Alberta.

The study used the Hadlock formula for calculating weight from ultrasound fetal measurements, "which is supposed to be one of the better formulas for macrosomic infants," she noted.

"Interestingly enough, people have shown that through the years, as the technology has gotten better – these ultrasound machines that we have now are amazing, what they can do – this [accuracy] hasn’t gotten better," she added, speculating that the disconnect may in part be the result of reliance on simple measurements that don’t take into account tissue densities.

Additionally, ultrasound assessment late in pregnancy is inherently more difficult because the fetus is so low in the pelvis and there is less amniotic fluid. Maternal body habitus also may play a role.

Using the clinical database of a tertiary referral center for the years 2005-2009, Dr. Wagner and her coinvestigators identified 235 women who had an ultrasound exam within 2 weeks of delivery that indicated the presence of fetal macrosomia (defined as an estimated fetal weight of at least 4,500 g, as calculated via the Hadlock formula).

However, they found that at the time of delivery, just 88 of these infants had an actual birth weight of at least 4,500 g, for a positive predictive value of merely 37.4%, according to results reported in a poster session.

"It looked like most of the providers were overestimating weight," she observed; the median estimated fetal weight was 4,693 g, whereas the median birth weight was 4,368 g.

The mean percentage error of the estimated fetal weight was 8.6% overall. Viewed another way, 44% of the weights were off by more than 10%, and 7% were off by more than 20%.

There were only weak correlations between estimated fetal weight and birth weight, as well as between the individual fetal measurements used in the Hadlock formula and birth weight.

The mode of delivery was cesarean section in 66% of the pregnancies, compared with just 29% of all pregnancies in Calgary during the same period. "So it’s [more than] double, the percentage who are getting C-sections, on what is [an inaccurate weight]," said Dr. Wagner.

Before the study, "there was a general feeling that we were pretty [far off] in the estimates of the fetal weights that we were getting closer to term, especially for the bigger babies," she commented. "People ... usually thought that they were overestimating them, so it was nice to actually look at ... what the actual numbers were."

"This opens up a lot of other areas that we can explore more within just this study," such as whether maternal body mass index is affecting ultrasound accuracy, Dr. Wagner concluded. "So this is kind of a starting project."

Dr. Wagner reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – An ultrasound diagnosis of fetal macrosomia at term is inaccurate in the majority of cases, and this inaccuracy may be contributing to unnecessary cesarean deliveries, new data suggest.

In an observational cohort study of 235 pregnancies at term in which ultrasound measurements led to a diagnosis of fetal macrosomia, only about a third of the infants were actually macrosomic at birth. Additionally, these pregnancies with ultrasound-diagnosed fetal macrosomia were more than twice as likely as all pregnancies in the population to end in cesarean delivery, according to results reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada.

Ultrasound-estimated fetal weight "is not very accurate, and we have to counsel patients on that, when they come to ultrasounds and they are worried that they are going to have this [enormous] monstrosity of a baby," lead investigator Dr. Alese Wagner said in an interview. "You can tell them [that] most of the time, we are off."

She further recommended that physicians keep this new information in mind when it comes to recommending delivery interventions for a pregnancy in which the ultrasound suggests macrosomia.

Surprisingly, the accuracy of ultrasound in assessing fetal weight is similar to that found with simple clinical palpation, according to Dr. Wagner, a third-year resident in the department of obstetrics and gynecology at the University of Calgary in Alberta.

The study used the Hadlock formula for calculating weight from ultrasound fetal measurements, "which is supposed to be one of the better formulas for macrosomic infants," she noted.

"Interestingly enough, people have shown that through the years, as the technology has gotten better – these ultrasound machines that we have now are amazing, what they can do – this [accuracy] hasn’t gotten better," she added, speculating that the disconnect may in part be the result of reliance on simple measurements that don’t take into account tissue densities.

Additionally, ultrasound assessment late in pregnancy is inherently more difficult because the fetus is so low in the pelvis and there is less amniotic fluid. Maternal body habitus also may play a role.

Using the clinical database of a tertiary referral center for the years 2005-2009, Dr. Wagner and her coinvestigators identified 235 women who had an ultrasound exam within 2 weeks of delivery that indicated the presence of fetal macrosomia (defined as an estimated fetal weight of at least 4,500 g, as calculated via the Hadlock formula).

However, they found that at the time of delivery, just 88 of these infants had an actual birth weight of at least 4,500 g, for a positive predictive value of merely 37.4%, according to results reported in a poster session.

"It looked like most of the providers were overestimating weight," she observed; the median estimated fetal weight was 4,693 g, whereas the median birth weight was 4,368 g.

The mean percentage error of the estimated fetal weight was 8.6% overall. Viewed another way, 44% of the weights were off by more than 10%, and 7% were off by more than 20%.

There were only weak correlations between estimated fetal weight and birth weight, as well as between the individual fetal measurements used in the Hadlock formula and birth weight.

The mode of delivery was cesarean section in 66% of the pregnancies, compared with just 29% of all pregnancies in Calgary during the same period. "So it’s [more than] double, the percentage who are getting C-sections, on what is [an inaccurate weight]," said Dr. Wagner.

Before the study, "there was a general feeling that we were pretty [far off] in the estimates of the fetal weights that we were getting closer to term, especially for the bigger babies," she commented. "People ... usually thought that they were overestimating them, so it was nice to actually look at ... what the actual numbers were."

"This opens up a lot of other areas that we can explore more within just this study," such as whether maternal body mass index is affecting ultrasound accuracy, Dr. Wagner concluded. "So this is kind of a starting project."

Dr. Wagner reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – Use of tampons or menstrual cups does not increase the risk of early expulsion of an intrauterine device, according to findings of a retrospective cohort study of nearly 1,000 women.

In the study, the overall rate of IUD expulsion within 2 months of insertion was low (3.5%), and was statistically no higher for women who used tampons or cups than it was for their counterparts who used pads.

"Women can be reassured that they can use whatever their usual menstrual product is and not increase their risk of expelling the IUD," said coinvestigator Dr. Ellen Wiebe of the department of family practice at the University of British Columbia, Vancouver.

She noted that it is a common concern that vaginal menstrual products will tug on the IUD strings protruding from the cervix, thereby pulling the device out. And most IUD expulsions in the first year occur within a month of insertion (Hum. Reprod. Update 2008;14:197-208).

"Every day, I would get asked the question, ‘Is it okay to use tampons with the IUD?’ And every week or so, I would get asked the question, ‘Is it okay to use a cup with the IUD?’ " she said in an interview at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. "And I looked in the literature, and there were no answers."

Moreover, IUD package inserts are inconsistent on the issue. For example, of the four IUDs on the market in Canada, the Mirena package insert says that tampons can be used, the Liberté insert notes that tampons can be used (but is silent on the use of menstrual cups), and the Flexi-T and Nova-T inserts do not mention menstrual products at all, she said.

She further noted that little is known about the prevalence of menstrual cup use today, as most studies on this product were done in the 1960s and focused on acceptability.

Dr. Wiebe and her colleague retrospectively reviewed the charts of 999 women who underwent IUD insertion at two reproductive health clinics in 2009.

Study results, reported in a poster session at the meeting, showed that about half the women had the hormonal Mirena IUD inserted and about half had one of the copper IUDs inserted. Among the 930 women having data on the type of menstrual product used, 74% used tampons, 43% used pads, and 10% used menstrual cups, with many using more than one product.

Cup users were more likely than pad users and tampon users to be younger than 30 years of age (77% vs. 51% and 61%, respectively) and nulliparous (88% vs. 54% and 69%, respectively). Additionally, cup users were more likely than pad users to be white (85% vs. 69%).

Among the 620 women who had adequate follow-up, the rate of early IUD expulsion (defined as within 2 months of insertion) was 3.5% overall, and was statistically indistinguishable among women who used pads (4%), tampons (2%), and menstrual cups (6%).

Based on anecdotal evidence, "I knew it was fine, and most of our colleagues thought it was fine" to use tampons and menstrual cups with an IUD, said Dr. Wiebe.

"But that’s not the evidence you want to give your patient," she added. "You’d rather say, ‘Well, we looked at 1,000 women and it didn’t make any difference what they used.’ "

Dr. Wiebe reported that she had no relevant conflicts of interest.

VANCOUVER, B.C. – Use of tampons or menstrual cups does not increase the risk of early expulsion of an intrauterine device, according to findings of a retrospective cohort study of nearly 1,000 women.

In the study, the overall rate of IUD expulsion within 2 months of insertion was low (3.5%), and was statistically no higher for women who used tampons or cups than it was for their counterparts who used pads.

"Women can be reassured that they can use whatever their usual menstrual product is and not increase their risk of expelling the IUD," said coinvestigator Dr. Ellen Wiebe of the department of family practice at the University of British Columbia, Vancouver.

She noted that it is a common concern that vaginal menstrual products will tug on the IUD strings protruding from the cervix, thereby pulling the device out. And most IUD expulsions in the first year occur within a month of insertion (Hum. Reprod. Update 2008;14:197-208).

"Every day, I would get asked the question, ‘Is it okay to use tampons with the IUD?’ And every week or so, I would get asked the question, ‘Is it okay to use a cup with the IUD?’ " she said in an interview at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. "And I looked in the literature, and there were no answers."

Moreover, IUD package inserts are inconsistent on the issue. For example, of the four IUDs on the market in Canada, the Mirena package insert says that tampons can be used, the Liberté insert notes that tampons can be used (but is silent on the use of menstrual cups), and the Flexi-T and Nova-T inserts do not mention menstrual products at all, she said.

She further noted that little is known about the prevalence of menstrual cup use today, as most studies on this product were done in the 1960s and focused on acceptability.

Dr. Wiebe and her colleague retrospectively reviewed the charts of 999 women who underwent IUD insertion at two reproductive health clinics in 2009.

Study results, reported in a poster session at the meeting, showed that about half the women had the hormonal Mirena IUD inserted and about half had one of the copper IUDs inserted. Among the 930 women having data on the type of menstrual product used, 74% used tampons, 43% used pads, and 10% used menstrual cups, with many using more than one product.

Cup users were more likely than pad users and tampon users to be younger than 30 years of age (77% vs. 51% and 61%, respectively) and nulliparous (88% vs. 54% and 69%, respectively). Additionally, cup users were more likely than pad users to be white (85% vs. 69%).

Among the 620 women who had adequate follow-up, the rate of early IUD expulsion (defined as within 2 months of insertion) was 3.5% overall, and was statistically indistinguishable among women who used pads (4%), tampons (2%), and menstrual cups (6%).

Based on anecdotal evidence, "I knew it was fine, and most of our colleagues thought it was fine" to use tampons and menstrual cups with an IUD, said Dr. Wiebe.

"But that’s not the evidence you want to give your patient," she added. "You’d rather say, ‘Well, we looked at 1,000 women and it didn’t make any difference what they used.’ "

Dr. Wiebe reported that she had no relevant conflicts of interest.

VANCOUVER, B.C. – Use of tampons or menstrual cups does not increase the risk of early expulsion of an intrauterine device, according to findings of a retrospective cohort study of nearly 1,000 women.

In the study, the overall rate of IUD expulsion within 2 months of insertion was low (3.5%), and was statistically no higher for women who used tampons or cups than it was for their counterparts who used pads.

"Women can be reassured that they can use whatever their usual menstrual product is and not increase their risk of expelling the IUD," said coinvestigator Dr. Ellen Wiebe of the department of family practice at the University of British Columbia, Vancouver.

She noted that it is a common concern that vaginal menstrual products will tug on the IUD strings protruding from the cervix, thereby pulling the device out. And most IUD expulsions in the first year occur within a month of insertion (Hum. Reprod. Update 2008;14:197-208).

"Every day, I would get asked the question, ‘Is it okay to use tampons with the IUD?’ And every week or so, I would get asked the question, ‘Is it okay to use a cup with the IUD?’ " she said in an interview at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. "And I looked in the literature, and there were no answers."

Moreover, IUD package inserts are inconsistent on the issue. For example, of the four IUDs on the market in Canada, the Mirena package insert says that tampons can be used, the Liberté insert notes that tampons can be used (but is silent on the use of menstrual cups), and the Flexi-T and Nova-T inserts do not mention menstrual products at all, she said.

She further noted that little is known about the prevalence of menstrual cup use today, as most studies on this product were done in the 1960s and focused on acceptability.

Dr. Wiebe and her colleague retrospectively reviewed the charts of 999 women who underwent IUD insertion at two reproductive health clinics in 2009.

Study results, reported in a poster session at the meeting, showed that about half the women had the hormonal Mirena IUD inserted and about half had one of the copper IUDs inserted. Among the 930 women having data on the type of menstrual product used, 74% used tampons, 43% used pads, and 10% used menstrual cups, with many using more than one product.

Cup users were more likely than pad users and tampon users to be younger than 30 years of age (77% vs. 51% and 61%, respectively) and nulliparous (88% vs. 54% and 69%, respectively). Additionally, cup users were more likely than pad users to be white (85% vs. 69%).

Among the 620 women who had adequate follow-up, the rate of early IUD expulsion (defined as within 2 months of insertion) was 3.5% overall, and was statistically indistinguishable among women who used pads (4%), tampons (2%), and menstrual cups (6%).

Based on anecdotal evidence, "I knew it was fine, and most of our colleagues thought it was fine" to use tampons and menstrual cups with an IUD, said Dr. Wiebe.

"But that’s not the evidence you want to give your patient," she added. "You’d rather say, ‘Well, we looked at 1,000 women and it didn’t make any difference what they used.’ "

Dr. Wiebe reported that she had no relevant conflicts of interest.

VANCOUVER, B.C. – When it comes to counseling women about weight gain during pregnancy, there is plenty of room for improvement, new data suggest.

In a survey of more than 300 pregnant women, less than a third reported being counseled on the topic, researchers reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. And even fewer, merely an eighth, were counseled correctly about how much weight to gain.

In likely related findings, three-fourths of women who were overweight or obese before conceiving planned to gain more weight than was recommended for them in guidelines.

"A lack of reported counseling has been associated in the literature with inappropriate weight gain, both excessive and inadequate," said lead investigator Dr. Sarah McDonald, an obstetrician-gynecologist at McMaster University in Hamilton, Ont. "So these findings were very concerning for us."

She noted that most women who were approached agreed to participate in the survey and were comfortable when it came to discussing weight. Therefore, "it appeared unlikely that the lack of reported counseling was due to patient-driven factors, apart from possibly forgetting."

Interestingly, a staggered companion survey of the providers had dramatically different findings, showing high reported rates of counseling. "It was like I was surveying people on a different planet," she commented. "We think we are doing very well," yet there is an obvious discrepancy that is as yet unexplained.

Citing the obesity epidemic, Dr. McDonald endorsed repeated counseling of women about weight, both before and during pregnancy.

"Obviously, an optimal BMI [body mass index] prepregnancy is ideal, but that’s not the situation where most of us come into contact with our patients – it’s when they are already pregnant. Then, I think talking about optimal gestational weight gain to not compound the problems of overweight and obesity is important," she said. "But given the size of the [obesity] epidemic, [the approach has] got to be multipronged."

In 2009, the U.S. Institute of Medicine released new recommendations regarding gestational weight gain, tailored to prepregnancy BMI, that have been adopted by Canada and other countries.

"However, previous studies done in the era of the 1990 guidelines have shown that only about 30% to 40% of pregnant women gained the appropriate amount of weight during pregnancy," Dr. McDonald noted. "And we were curious what was going on in the era of the new guidelines."

The investigators surveyed 310 women (94% of those approached) who made at least one visit to representative Hamilton prenatal clinics, other than for pregnancy diagnosis, and currently had a live, singleton gestation. The women’s mean age was 30 years, and the median gestational age was 33.0 weeks. Fully 74% were white, and for 43%, the birth would be their first. They had a mean prepregnancy BMI of 25.1 kg/m².

"Interestingly enough, 84% of the women reported that they were either comfortable or very comfortable talking about weight-related issues with their care provider, despite the fact that the mean BMI [in this study] is already in the overweight category prepregnancy," Dr. McDonald observed.

Only 29% of the women reported that their provider counseled them to gain a specific amount or range of weight, and for just 12% overall, that amount or range was correct according to the new guidelines. Additionally, only about a quarter of women reported being told that there were risks associated with gaining too much weight or too little weight during pregnancy.

The median number of prenatal visits before the survey was 10 for the study population, she pointed out, and "so there were multiple opportunities for discussion about weight gain."

"We wondered, are clinicians just too busy to be talking about weight and weight-related matters, and nutrition, and preventive-type medicine?" said Dr. McDonald. Yet, nearly all of the women (97%) reported being counseled to take a vitamin.

When asked how much weight they planned to gain during pregnancy, only 12%-54% of women, depending on prepregnancy BMI category, cited an amount within the guideline-recommended range for them. In particular, in a finding that she described as "alarming," 75% of overweight and obese women were planning to gain more weight than was recommended for them.

The proportion of women counseled about weight gain differed by the type of provider that had provided the majority of a woman’s pregnancy care; it was 40% for midwives, 24% for obstetricians, 23% for general practitioners, and 28% for other providers. The proportion that was correctly counseled showed a similar pattern, but the differences were not significant.

The investigators are still analyzing data on whether women had been counseled about weight in a previous pregnancy, which might have led providers to assume they already had the information, according to Dr. McDonald. But "that is a dangerous assumption, it would appear, based on our results."

Dr. McDonald reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – When it comes to counseling women about weight gain during pregnancy, there is plenty of room for improvement, new data suggest.

In a survey of more than 300 pregnant women, less than a third reported being counseled on the topic, researchers reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. And even fewer, merely an eighth, were counseled correctly about how much weight to gain.

In likely related findings, three-fourths of women who were overweight or obese before conceiving planned to gain more weight than was recommended for them in guidelines.

"A lack of reported counseling has been associated in the literature with inappropriate weight gain, both excessive and inadequate," said lead investigator Dr. Sarah McDonald, an obstetrician-gynecologist at McMaster University in Hamilton, Ont. "So these findings were very concerning for us."

She noted that most women who were approached agreed to participate in the survey and were comfortable when it came to discussing weight. Therefore, "it appeared unlikely that the lack of reported counseling was due to patient-driven factors, apart from possibly forgetting."

Interestingly, a staggered companion survey of the providers had dramatically different findings, showing high reported rates of counseling. "It was like I was surveying people on a different planet," she commented. "We think we are doing very well," yet there is an obvious discrepancy that is as yet unexplained.

Citing the obesity epidemic, Dr. McDonald endorsed repeated counseling of women about weight, both before and during pregnancy.

"Obviously, an optimal BMI [body mass index] prepregnancy is ideal, but that’s not the situation where most of us come into contact with our patients – it’s when they are already pregnant. Then, I think talking about optimal gestational weight gain to not compound the problems of overweight and obesity is important," she said. "But given the size of the [obesity] epidemic, [the approach has] got to be multipronged."

In 2009, the U.S. Institute of Medicine released new recommendations regarding gestational weight gain, tailored to prepregnancy BMI, that have been adopted by Canada and other countries.

"However, previous studies done in the era of the 1990 guidelines have shown that only about 30% to 40% of pregnant women gained the appropriate amount of weight during pregnancy," Dr. McDonald noted. "And we were curious what was going on in the era of the new guidelines."

The investigators surveyed 310 women (94% of those approached) who made at least one visit to representative Hamilton prenatal clinics, other than for pregnancy diagnosis, and currently had a live, singleton gestation. The women’s mean age was 30 years, and the median gestational age was 33.0 weeks. Fully 74% were white, and for 43%, the birth would be their first. They had a mean prepregnancy BMI of 25.1 kg/m².

"Interestingly enough, 84% of the women reported that they were either comfortable or very comfortable talking about weight-related issues with their care provider, despite the fact that the mean BMI [in this study] is already in the overweight category prepregnancy," Dr. McDonald observed.

Only 29% of the women reported that their provider counseled them to gain a specific amount or range of weight, and for just 12% overall, that amount or range was correct according to the new guidelines. Additionally, only about a quarter of women reported being told that there were risks associated with gaining too much weight or too little weight during pregnancy.

The median number of prenatal visits before the survey was 10 for the study population, she pointed out, and "so there were multiple opportunities for discussion about weight gain."

"We wondered, are clinicians just too busy to be talking about weight and weight-related matters, and nutrition, and preventive-type medicine?" said Dr. McDonald. Yet, nearly all of the women (97%) reported being counseled to take a vitamin.

When asked how much weight they planned to gain during pregnancy, only 12%-54% of women, depending on prepregnancy BMI category, cited an amount within the guideline-recommended range for them. In particular, in a finding that she described as "alarming," 75% of overweight and obese women were planning to gain more weight than was recommended for them.

The proportion of women counseled about weight gain differed by the type of provider that had provided the majority of a woman’s pregnancy care; it was 40% for midwives, 24% for obstetricians, 23% for general practitioners, and 28% for other providers. The proportion that was correctly counseled showed a similar pattern, but the differences were not significant.

The investigators are still analyzing data on whether women had been counseled about weight in a previous pregnancy, which might have led providers to assume they already had the information, according to Dr. McDonald. But "that is a dangerous assumption, it would appear, based on our results."

Dr. McDonald reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – When it comes to counseling women about weight gain during pregnancy, there is plenty of room for improvement, new data suggest.

In a survey of more than 300 pregnant women, less than a third reported being counseled on the topic, researchers reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada. And even fewer, merely an eighth, were counseled correctly about how much weight to gain.

In likely related findings, three-fourths of women who were overweight or obese before conceiving planned to gain more weight than was recommended for them in guidelines.

"A lack of reported counseling has been associated in the literature with inappropriate weight gain, both excessive and inadequate," said lead investigator Dr. Sarah McDonald, an obstetrician-gynecologist at McMaster University in Hamilton, Ont. "So these findings were very concerning for us."

She noted that most women who were approached agreed to participate in the survey and were comfortable when it came to discussing weight. Therefore, "it appeared unlikely that the lack of reported counseling was due to patient-driven factors, apart from possibly forgetting."

Interestingly, a staggered companion survey of the providers had dramatically different findings, showing high reported rates of counseling. "It was like I was surveying people on a different planet," she commented. "We think we are doing very well," yet there is an obvious discrepancy that is as yet unexplained.

Citing the obesity epidemic, Dr. McDonald endorsed repeated counseling of women about weight, both before and during pregnancy.

"Obviously, an optimal BMI [body mass index] prepregnancy is ideal, but that’s not the situation where most of us come into contact with our patients – it’s when they are already pregnant. Then, I think talking about optimal gestational weight gain to not compound the problems of overweight and obesity is important," she said. "But given the size of the [obesity] epidemic, [the approach has] got to be multipronged."

In 2009, the U.S. Institute of Medicine released new recommendations regarding gestational weight gain, tailored to prepregnancy BMI, that have been adopted by Canada and other countries.

"However, previous studies done in the era of the 1990 guidelines have shown that only about 30% to 40% of pregnant women gained the appropriate amount of weight during pregnancy," Dr. McDonald noted. "And we were curious what was going on in the era of the new guidelines."

The investigators surveyed 310 women (94% of those approached) who made at least one visit to representative Hamilton prenatal clinics, other than for pregnancy diagnosis, and currently had a live, singleton gestation. The women’s mean age was 30 years, and the median gestational age was 33.0 weeks. Fully 74% were white, and for 43%, the birth would be their first. They had a mean prepregnancy BMI of 25.1 kg/m².

"Interestingly enough, 84% of the women reported that they were either comfortable or very comfortable talking about weight-related issues with their care provider, despite the fact that the mean BMI [in this study] is already in the overweight category prepregnancy," Dr. McDonald observed.

Only 29% of the women reported that their provider counseled them to gain a specific amount or range of weight, and for just 12% overall, that amount or range was correct according to the new guidelines. Additionally, only about a quarter of women reported being told that there were risks associated with gaining too much weight or too little weight during pregnancy.

The median number of prenatal visits before the survey was 10 for the study population, she pointed out, and "so there were multiple opportunities for discussion about weight gain."

"We wondered, are clinicians just too busy to be talking about weight and weight-related matters, and nutrition, and preventive-type medicine?" said Dr. McDonald. Yet, nearly all of the women (97%) reported being counseled to take a vitamin.

When asked how much weight they planned to gain during pregnancy, only 12%-54% of women, depending on prepregnancy BMI category, cited an amount within the guideline-recommended range for them. In particular, in a finding that she described as "alarming," 75% of overweight and obese women were planning to gain more weight than was recommended for them.

The proportion of women counseled about weight gain differed by the type of provider that had provided the majority of a woman’s pregnancy care; it was 40% for midwives, 24% for obstetricians, 23% for general practitioners, and 28% for other providers. The proportion that was correctly counseled showed a similar pattern, but the differences were not significant.

The investigators are still analyzing data on whether women had been counseled about weight in a previous pregnancy, which might have led providers to assume they already had the information, according to Dr. McDonald. But "that is a dangerous assumption, it would appear, based on our results."

Dr. McDonald reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – The risk of congenital anomalies for a given pregnancy varies according to the time elapsed since the last pregnancy, a retrospective population-based cohort study of more than 46,000 women has shown.

Study results, reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, showed that the rate of congenital anomalies was lowest when the interpregnancy interval was 12-17 months and increased with both shorter and longer intervals. The pattern was similar for folate-dependent and folate-independent anomalies individually.

"A J-shaped relationship exists between interpregnancy interval and congenital anomalies," said principal investigator Dr. Innie Chen, a resident in the department of obstetrics and gynecology at the University of Alberta, Edmonton. "The observation that long intervals were associated with congenital anomalies as well as the preservation of the association for folate-independent anomalies suggests that the mechanism of the observed effect is unlikely to be mediated by folate deficiency alone.

"To date and to our knowledge, this is the most comprehensive data available on this topic. The implications of this study are broad and touch on prenatal risk assessment, prenatal counseling, and future recommendations regarding birth spacing and nutritional supplementation," she said.

But she also cautioned that it could be problematic to apply the findings to individual women who ask when is the best time to conceive again to minimize risk.

"This is an epidemiological study. Decisions for individuals depend on a lot of things, such as where they are in their life and their career situation," she explained. "But I think this data adds to the growing literature about the effect of interpregnancy interval and adverse perinatal outcomes, which we see again and again. Compared to 50 or 100 years ago, we have much better contraception, so I think it is within our control."

A variety of adverse perinatal outcomes – preterm birth, small for gestational age, low birth weight, and perinatal death – have shown a J-shaped association with interpregnancy interval.

"The most-often-cited postulated mechanism for the observed effect is a folate deficiency hypothesis, which is based on the observation that maternal serum levels are very low in the postpartum period," Dr. Chen said.

A previous retrospective cohort study found an association between both short and long interpregnancy intervals and major congenital malformations (Contraception 2009;80:512-8). But that study did not evaluate specific types of anomalies.

Dr. Chen and her colleagues began with data from the Alberta Perinatal Health Program Database, which collects information on all hospital and midwife births, and all terminations after 20 weeks’ gestation in the Northern part of the province.

They identified women who had a singleton delivery between 1999 and 2007 (the post–folate food fortification era, so that results would be applicable today) and who did not have a miscarriage between their first and second births (so that the interpregnancy interval was more reliable).

They then linked that data with data from other provincial databases to obtain more comprehensive maternal information and ascertain anomalies.

The working data set consisted of 46,559 pregnant women. The interpregnancy interval was 6-59 weeks’ gestation for 90% of them.

Most of the women were 20- to 34-years-old (83%) and para 2 (88%) at the time of the second delivery, and most of their infants had a gestational age of at least 37 weeks (93%) and a birth weight of at least 2,500 g (96%).

The rate of congenital anomalies did not vary significantly according to maternal age, maternal weight, smoking in pregnancy, or socioeconomic status, Dr. Chen reported.

For interpregnancy intervals of 59 months or less, there was a J-shaped association between the interval and the rate of congenital anomalies. The rate was lowest, at 1.9%, when the interval was 12-17 months.

It rose to a high of 2.5% when the interval was 0-5 months and 2.4% when the interval was 24-59 months. The corresponding odds ratios were 1.35 and 1.28, respectively.

The pattern was similar for folate-dependent anomalies (neural tube defects, cleft lip and palate, cardiovascular defects, urinary tract anomalies, and limb defects) and for folate-independent anomalies individually.

In addition, an interval of 0-5 months was associated with increased odds of specific anomalies, such as neural tube defects and heart defects, but not significantly so.

"We believe these results to be valid as they are consistent with and corroborate existing studies in the literature," said Dr. Chen.

"Future directions for research include changing the databases to capture more information on all terminations and folate supplementation, combining the databases for more statistical power, and checking other postulated mechanisms for the observed effect," she said.

Dr. Chen reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – The risk of congenital anomalies for a given pregnancy varies according to the time elapsed since the last pregnancy, a retrospective population-based cohort study of more than 46,000 women has shown.

Study results, reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, showed that the rate of congenital anomalies was lowest when the interpregnancy interval was 12-17 months and increased with both shorter and longer intervals. The pattern was similar for folate-dependent and folate-independent anomalies individually.

"A J-shaped relationship exists between interpregnancy interval and congenital anomalies," said principal investigator Dr. Innie Chen, a resident in the department of obstetrics and gynecology at the University of Alberta, Edmonton. "The observation that long intervals were associated with congenital anomalies as well as the preservation of the association for folate-independent anomalies suggests that the mechanism of the observed effect is unlikely to be mediated by folate deficiency alone.

"To date and to our knowledge, this is the most comprehensive data available on this topic. The implications of this study are broad and touch on prenatal risk assessment, prenatal counseling, and future recommendations regarding birth spacing and nutritional supplementation," she said.

But she also cautioned that it could be problematic to apply the findings to individual women who ask when is the best time to conceive again to minimize risk.

"This is an epidemiological study. Decisions for individuals depend on a lot of things, such as where they are in their life and their career situation," she explained. "But I think this data adds to the growing literature about the effect of interpregnancy interval and adverse perinatal outcomes, which we see again and again. Compared to 50 or 100 years ago, we have much better contraception, so I think it is within our control."

A variety of adverse perinatal outcomes – preterm birth, small for gestational age, low birth weight, and perinatal death – have shown a J-shaped association with interpregnancy interval.

"The most-often-cited postulated mechanism for the observed effect is a folate deficiency hypothesis, which is based on the observation that maternal serum levels are very low in the postpartum period," Dr. Chen said.

A previous retrospective cohort study found an association between both short and long interpregnancy intervals and major congenital malformations (Contraception 2009;80:512-8). But that study did not evaluate specific types of anomalies.

Dr. Chen and her colleagues began with data from the Alberta Perinatal Health Program Database, which collects information on all hospital and midwife births, and all terminations after 20 weeks’ gestation in the Northern part of the province.

They identified women who had a singleton delivery between 1999 and 2007 (the post–folate food fortification era, so that results would be applicable today) and who did not have a miscarriage between their first and second births (so that the interpregnancy interval was more reliable).

They then linked that data with data from other provincial databases to obtain more comprehensive maternal information and ascertain anomalies.

The working data set consisted of 46,559 pregnant women. The interpregnancy interval was 6-59 weeks’ gestation for 90% of them.

Most of the women were 20- to 34-years-old (83%) and para 2 (88%) at the time of the second delivery, and most of their infants had a gestational age of at least 37 weeks (93%) and a birth weight of at least 2,500 g (96%).

The rate of congenital anomalies did not vary significantly according to maternal age, maternal weight, smoking in pregnancy, or socioeconomic status, Dr. Chen reported.

For interpregnancy intervals of 59 months or less, there was a J-shaped association between the interval and the rate of congenital anomalies. The rate was lowest, at 1.9%, when the interval was 12-17 months.

It rose to a high of 2.5% when the interval was 0-5 months and 2.4% when the interval was 24-59 months. The corresponding odds ratios were 1.35 and 1.28, respectively.

The pattern was similar for folate-dependent anomalies (neural tube defects, cleft lip and palate, cardiovascular defects, urinary tract anomalies, and limb defects) and for folate-independent anomalies individually.

In addition, an interval of 0-5 months was associated with increased odds of specific anomalies, such as neural tube defects and heart defects, but not significantly so.

"We believe these results to be valid as they are consistent with and corroborate existing studies in the literature," said Dr. Chen.

"Future directions for research include changing the databases to capture more information on all terminations and folate supplementation, combining the databases for more statistical power, and checking other postulated mechanisms for the observed effect," she said.

Dr. Chen reported that she had no relevant financial disclosures.

VANCOUVER, B.C. – The risk of congenital anomalies for a given pregnancy varies according to the time elapsed since the last pregnancy, a retrospective population-based cohort study of more than 46,000 women has shown.

Study results, reported at the annual meeting of the Society of Obstetricians and Gynaecologists of Canada, showed that the rate of congenital anomalies was lowest when the interpregnancy interval was 12-17 months and increased with both shorter and longer intervals. The pattern was similar for folate-dependent and folate-independent anomalies individually.

"A J-shaped relationship exists between interpregnancy interval and congenital anomalies," said principal investigator Dr. Innie Chen, a resident in the department of obstetrics and gynecology at the University of Alberta, Edmonton. "The observation that long intervals were associated with congenital anomalies as well as the preservation of the association for folate-independent anomalies suggests that the mechanism of the observed effect is unlikely to be mediated by folate deficiency alone.

"To date and to our knowledge, this is the most comprehensive data available on this topic. The implications of this study are broad and touch on prenatal risk assessment, prenatal counseling, and future recommendations regarding birth spacing and nutritional supplementation," she said.

But she also cautioned that it could be problematic to apply the findings to individual women who ask when is the best time to conceive again to minimize risk.

"This is an epidemiological study. Decisions for individuals depend on a lot of things, such as where they are in their life and their career situation," she explained. "But I think this data adds to the growing literature about the effect of interpregnancy interval and adverse perinatal outcomes, which we see again and again. Compared to 50 or 100 years ago, we have much better contraception, so I think it is within our control."

A variety of adverse perinatal outcomes – preterm birth, small for gestational age, low birth weight, and perinatal death – have shown a J-shaped association with interpregnancy interval.

"The most-often-cited postulated mechanism for the observed effect is a folate deficiency hypothesis, which is based on the observation that maternal serum levels are very low in the postpartum period," Dr. Chen said.

A previous retrospective cohort study found an association between both short and long interpregnancy intervals and major congenital malformations (Contraception 2009;80:512-8). But that study did not evaluate specific types of anomalies.

Dr. Chen and her colleagues began with data from the Alberta Perinatal Health Program Database, which collects information on all hospital and midwife births, and all terminations after 20 weeks’ gestation in the Northern part of the province.

They identified women who had a singleton delivery between 1999 and 2007 (the post–folate food fortification era, so that results would be applicable today) and who did not have a miscarriage between their first and second births (so that the interpregnancy interval was more reliable).

They then linked that data with data from other provincial databases to obtain more comprehensive maternal information and ascertain anomalies.

The working data set consisted of 46,559 pregnant women. The interpregnancy interval was 6-59 weeks’ gestation for 90% of them.

Most of the women were 20- to 34-years-old (83%) and para 2 (88%) at the time of the second delivery, and most of their infants had a gestational age of at least 37 weeks (93%) and a birth weight of at least 2,500 g (96%).

The rate of congenital anomalies did not vary significantly according to maternal age, maternal weight, smoking in pregnancy, or socioeconomic status, Dr. Chen reported.

For interpregnancy intervals of 59 months or less, there was a J-shaped association between the interval and the rate of congenital anomalies. The rate was lowest, at 1.9%, when the interval was 12-17 months.

It rose to a high of 2.5% when the interval was 0-5 months and 2.4% when the interval was 24-59 months. The corresponding odds ratios were 1.35 and 1.28, respectively.

The pattern was similar for folate-dependent anomalies (neural tube defects, cleft lip and palate, cardiovascular defects, urinary tract anomalies, and limb defects) and for folate-independent anomalies individually.

In addition, an interval of 0-5 months was associated with increased odds of specific anomalies, such as neural tube defects and heart defects, but not significantly so.

"We believe these results to be valid as they are consistent with and corroborate existing studies in the literature," said Dr. Chen.

"Future directions for research include changing the databases to capture more information on all terminations and folate supplementation, combining the databases for more statistical power, and checking other postulated mechanisms for the observed effect," she said.

Dr. Chen reported that she had no relevant financial disclosures.