Test Leads to Needless C-Sections

My patient needed to be delivered. She had just developed eclampsia, a potentially fatal disease that afflicts women in the second half of pregnancy. She had suffered a seizure and dangerously high blood pressure, and was at risk for far worse, including a stroke. No one knows why this condition arises, but delivery sure clears it up in a hurry.

So we gave medication to start labor, and the nurses placed a fetal heart monitor.

Worn like a belt, but higher on the abdomen, the ultrasound monitor would play a crucial role in the hours to come. It prints a read-out strip of the baby’s heart rate, and the pattern would guide us in determining whether the delivery would be natural or through cesarean section.

As I suspected, the baby’s heart-rate strip showed worrisome changes soon after labor began, and I knew it would get worse as labor progressed. We would fight through the night to have a natural delivery. But ultimately that single heart-rate test, which is surprisingly unreliable, would be a key factor in whether my patient would get a C-section or not.

Nearly all American mothers are monitored during labor, and bad fetal heart strips are an important cause of high cesarean section rates. A recent report detailed the dizzying increases: Almost one in three babies was delivered by cesarean in 2007, the most recent year for which data are available. That rate has grown by more than 50 percent in a decade.

I have performed hundreds of cesarean sections during residency, and many were the result of bad heart-rate strips.

A jagged pattern indicating increases in the heart rate reassures us that the baby’s brain is awake and alert, and that labor could continue. But a flat line or decreases in the heart rate after contractions make us think the baby is not getting enough oxygen and pushes us to do a C-section – delivering the baby through incisions in the abdominal wall and the uterus.

For the worst readings, we believed every second counted and rushed the surgery: If the baby wasn’t delivered one minute from the first incision into the skin, we had moved too slowly.

The complication we feared most was hypoxia, the baby not getting enough oxygen during labor. Going too long without adequate oxygen could result in a serious permanent injury, such as cerebral palsy, or even death.

No test is perfect. But almost every time we whisked a mother back to the operating room, and I cut through skin, fat, fascia, and finally the muscle of the uterus, expecting a blue, floppy baby, the child I delivered emerged pink, healthy, and a little bit angry.

Were we saving lives and averting disaster? Or were we performing unnecessary surgery?

Fetal heart-rate monitoring is a screening test. Good tests get several things right; they are cheap, detect a possible problem when there is still time to act, and minimize unnecessary follow-up tests.

The Pap smear is an excellent screening test: By examining a few cells brushed from the cervix – where the vagina opens into the uterus – doctors catch precancerous changes – or even early cancer – when it is easy to treat.

But fetal heart monitoring is an appallingly poor test. The test misses the majority of babies with cerebral palsy, the condition researchers hoped it would prevent. It causes increased rates of a painful and invasive surgery: cesarean section. Even worse, almost all women undergo continuous heart monitoring during labor, not just those at highest risk.

The odds of my patient’s baby suffering from dangerous lack of oxygen were slim. A study in the New England Journal of Medicine found that only 1 of 500 babies with a bad strip had cerebral palsy. Moreover, it remained unclear if the condition had developed before labor, in which case cesarean couldn’t prevent it.

A 2006 analysis by the British Cochrane Collaboration, evaluating all available research, found that fetal heart monitoring failed to reduce perinatal mortality – the risk of a baby’s dying late in pregnancy, during birth, or shortly after birth – and increased cesarean section rates and forceps deliveries, compared with listening to a baby’s heart rate intermittently.

As a medical student, I loved watching emergency cesarean sections. The baby’s heart rate went down, doors swung open, residents rushed the patient down to the OR, and a frantic minute or two of surgery later, a screaming baby was out. The excitement pushed me to choose a career in obstetrics. I never questioned the need for the surgery.

Now, cesarean sections for bad tracings are one of the least satisfying parts of my job.

Steven Clark and Gary Hankins, two prominent obstetricians, voiced my frustration. “A test leading to an unnecessary major abdominal operation in more than 99.5 percent of cases should be regarded by the medical community as absurd at best,” they wrote in the American Journal of Obstetrics and Gynecology. “Electronic fetal heart rate monitoring has probably done more harm than good.”

Why do doctors cling to continuous fetal heart monitoring? An obstetrician will most likely point to the fear of being sued, but the complete answer is more complex. Our medical culture prizes technology and tests, even if they don’t work and can cause harm.

“It’s our bias that anything that can be quantified is an improvement,” said H. Gilbert Welch, a professor at Dartmouth Medical School whose research focuses on harm caused by screening and over-diagnosis.

“I think we get in trouble when we start promising things to . . . well [patients],” Welch said in an interview. “It is not that hard to make them worse.”

For three or four hours that night, I struggled with my patient’s bad fetal heart strip. I wanted her to avoid a cesarean section. She had type 1 diabetes, and I expected her sugars to swing wildly after surgery, and her recovery to be slow.

To improve the strip, the nurses and I tried giving her oxygen, changing her position in the bed, even rubbing the baby’s head through the cervix to wake it up.

Finally, at 3 a.m., I felt compelled to recommend cesarean. The strip continued to look bad, and my patient’s labor progressed slowly.

We went to the operating room, and delivered the baby by cesarean. My patient’s child greeted the world pink and well-oxygenated.

The test was wrong again.

Alex Friedman

Dr. Friedman is a fellow in maternal-fetal medicine at the Hospital of the University of Pennsylvania. His e-mail address is alexander.friedman@gmail.com

Is There an Obesity Tipping Point in Infancy?

April 26, 2010 by Admin  
Filed under News

If there is any reason for hope among the data on national obesity rates in the U.S. (the numbers should be familiar by now: two-thirds of adults and nearly one-third of children are overweight or obese in this country), it is that they finally seem to be leveling off. According to the most recent published reports by epidemiologists at the Centers for Disease Control and Prevention (CDC), long-term federal obesity data suggest that after decades of ballooning in size, American adults and children may have gotten about as fat as they’re ever going to get.

Of course that still means that the majority of Americans are currently overweight and at high risk of chronic health problems, such as heart disease, diabetes and certain cancers. These risks continue to propel several national campaigns aimed at preventing obesity, particularly in children, including those spearheaded by First Lady Michelle Obama and former President Bill Clinton. But some researchers say such programs, which involve school-age children, may begin too late to benefit all children.

Increasingly, evidence suggests that obesity prevention measures need to be taken earlier, in infancy or even before birth. According to the CDC’s National Health and Nutrition Examination Survey, rates of obesity in youngsters ages 2 to 5 have more than doubled since 1980, from 5.0% to 12.4%. And once a child sets down the road to unhealthy weight, it becomes increasingly difficult for him to change course: according to one study, 80% of children who are overweight between ages 10 to 15 grow up to become obese 25-year-olds.

In November 2009, with funding from the Robert Wood Johnson Foundation, the Institute of Medicine (IOM) formed the Committee on Obesity Prevention Policies for Young Children, whose members will for the first time review evidence on obesity risk factors and health effects in children from birth to five years old, and identify potential opportunities for intervention in this age group. The committee’s first report is expected in early 2011.

Early Warning Signs

In a recent study of more than 1,800 children, who were tracked from before birth to age 4, Harvard researchers identified several risk factors for obesity that began in pregnancy or early childhood. They included pre-pregnancy obesity; gestational diabetes; low birth weight and rapid weight gain in infancy; stopping breast-feeding early; introducing solid foods before 4 months; short sleep in infancy; TV in children’s bedrooms; and higher consumption of fast food and sugary beverages in childhood. In many cases, these early risk factors were more common in black or Hispanic families than in white families, regardless of income.

The findings, first published online March 1 by the journal Pediatrics, help explain why minority children are at a higher risk for obesity early on: 16.7% of Mexican-American children ages 2 to 5 are obese, compared with 14.9% of black children and 10.7% of white children, according to CDC data. The authors emphasize that obesity prevention must not only begin early, but also address cultural issues and include education targeted to specific groups. The good news, says study author Dr. Elsie Taveras, an assistant professor of pediatrics and prevention at Harvard Medical School and a member of the IOM obesity committee, is that many risk factors involve behaviors than can be modified, and are not due only to socioeconomic inequalities. “As a pediatrician, it’s frustrating for me to think, How am I going to change this person’s household income? But, what a hopeful message to know that, it’s actually not that in many cases,” she says.

A Tipping Point for Obesity?

How early in life that prevention efforts need to target children is quickly becoming a central question to childhood obesity research. One intriguing notion is that there exists an obesity threshold — or tipping point — in infancy, before which a chubby child may be safely steered away from a lifetime of obesity. A small study, led by Dr. John Harrington, an associate professor of pediatrics at Eastern Virginia Medical School and Children’s Hospital of The King’s Daughters, analyzed childhood medical records of 111 obese children and adolescents — those with a body mass index (BMI) equal to or higher than 85% of their same-age peers — in order to determine the age at which children first became overweight.

On average, researchers found, overweight individuals first crossed the threshold into overweight territory before 22 months of age. In some kids it was even earlier, with about 25% of children already having gained more weight than recommended for their age and height at 3 months. The trajectory typically began early and remained consistent: the BMI of overweight children continuously diverged from that of normal-weighted children, the difference increasing by .072 units per month starting at birth and crossing the 85th-percentile mark at about 21 months. Within the small sample, half of overweight children became overweight before age 2, and 90% became overweight by age 5. “You’ve got to look at it in terms of intervention and prevention,” Harrington says. “If you’re trying to intervene at age 5, you’ve already missed the boat.”

Part of the problem is that parents and pediatricians tend to overlook early signs of obesity. Many people view children with excess “baby fat” as healthy, and believe they’ll shed the weight as they grow. Harrington advises physicians to start screening babies earlier for immoderate weight gain and to broach the topic sooner with parents. There’s a lot parents can do at home to encourage healthy weight in their children, Harrington says, and making even one or two small changes can lead to lowered risk. For instance, Harrington advises parents to adhere to infants’ own cues for fullness and hunger, rather than encouraging them to eat more. Keep in mind that toddlers are “grazers” and that it’s perfectly healthy for them not conform to an adult schedule of three squares per day, he says.

Harrington’s study, first published online in February by the journal Clinical Pediatrics, suggests the optimal age for instilling healthy eating and activity behaviors is before age 2. As children get older it becomes more difficult to unlearn behaviors, and reverse the trend, Harrington says. “The first thing to do is to recognize that there’s a problem, and to see that maybe it didn’t start at age 4 or 5, or 6 or 7, but maybe before then,” he says. “The longer you’re overweight, the more likely it is that you’re going to be overweight as an adult.”

Getting a Head Start

Not all chubby kids grow up to be overweight adults; indeed, many heavy babies do shed their baby fat and remain slim thereafter. Determining which children are at higher risk, however, is easier said than done. The study that could answer that question has not yet been conducted. “The only way to do that is to do a prospective study of 10,000 kids, following them from birth to see what their trajectories are,” Harrington says. One such study is currently in the works — the National Children’s Study, which aims to follow 100,000 babies from the womb to age 21, was authorized by Congress in 2000 — but results from that research are still years away.

For now, researchers say national childhood obesity prevention and education efforts should include families with newborns and toddlers, and promote healthy habits starting in pregnancy or earlier. Even seemingly minor actions, such as reminding pregnant women that they should not in fact be “eating for two” — in spite of their grandmother’s best advice — could reduce children’s chances of becoming obese, says Taveras. “Some of these things become so embedded in our thinking that they actually become our standard of care for our children,” laments Taveras. “If we really try to start focusing on prevention earlier,” she says, “we might have a greater impact.”

By Tiffany O’Callaghan

Study: Exercise in Pregnancy Benefits Babies

April 26, 2010 by Admin  
Filed under Women's & Maternal Health

For most pregnant women, exercise is the last thing on their minds. After all, keeping slim while you’re expecting isn’t exactly the top priority — rather, it’s making sure your baby gets enough nutrients to grow. But in a small new study, researchers at the University of Auckland in New Zealand report that a mother’s regular aerobic exercise may be good for a growing fetus’ health — and may even help a baby get a healthier start in life.

The finding is a bit surprising, because exercise is known to lower the risk of insulin resistance — the precursor condition to diabetes. Although insulin resistance is a detriment in healthy adults, it turns out to be helpful for proper fetal development. Insulin-resistant individuals gradually lose their ability to respond to changing glucose levels in the blood; in pregnant women, the condition, which occurs when hormones produced by the placenta interfere with the proper function of insulin in the body, means nutrients get shunted to the growing baby. (If the condition gets severe, however, it can result in a temporary condition called gestational diabetes in the mother, which is associated with heavier babies and a higher risk of obesity in childhood.)

The question is, Could a mother’s exercise put her developing baby’s food supply at risk? Past studies looking at the effect of exercise on birth weight have been inconclusive, and none have really investigated the influence of exercise on the mother’s sensitivity to insulin. So the University of Auckland’s Dr. Paul Hofman and his team decided to study 84 first-time mothers, who were of normal weight on average, and track any effects aerobic exercise might have on their insulin sensitivity and, ultimately, on their babies’ birth weight.

Researchers asked some women to exercise on a stationary bicycle for at least 40 minutes per session, up to five times each week, starting in the 20th week of pregnancy; the other women were not specifically asked to exercise. When the two groups and their babies were compared, the team found that women who bicycled regularly gave birth to babies who were on average 150 g (about 5 oz.) lighter than those born to the nonexercising mothers. In both groups, however, the babies were of healthy weight, and there was no difference in the mothers’ weights.

Generally speaking, babies on the lower end of the normal weight range are considered healthier and less prone to developing diabetes and obesity than heavier ones, so this was an encouraging result.

Even more reassuring was that regular exercise did not seem to affect the flow of nutrients to the growing babies in the womb. Over the course of the 15-week regimen, there was no additional exercise-related impact on mothers’ insulin-sensitivity measures. Both exercising and nonexercising moms showed the same, expected increase in insulin resistance that accompanies pregnancy. “This suggests that the hormonal regulation of insulin resistance is incredibly strong and occurs irrespective of other environmental factors such as exercise,” says Hofman. “I speculate that it’s an important survival mechanism to make sure that moms maintain insulin resistance so the baby receives enough food.”

Hofman’s theory is supported by previous studies that have documented normal-weight babies born to mothers experiencing famine, says Dr. Raul Artal, chairman of obstetrics and gynecology at St. Louis University. “The fetus is actually quite protected, and there may be a preferential diversion of nutrients to the fetus regardless of how much the mother gains during pregnancy,” he says.

He was encouraged by the new study’s findings, which support the importance of exercise for expectant moms, in particular those who are overweight or obese. Indeed, pregnant women should not be afraid of exercising and should be careful not to gain too much weight, especially if they are already overweight or obese, says Artal. “We’ve published a study on the benefits of lifestyle interventions such as exercise for obese women and found that they deliver normal-size babies, with fewer complications, and often don’t require a C-section,” he says.

Artal and several of his colleagues are concerned about current guidelines that they believe allow too much weight gain during pregnancy. The latest recommendations from the Institute of Medicine (IOM), released last September, allow normal-weight women to gain up to 25 lb. (7.3 kg) while they are expecting, which Artal feels is too much. The women in the New Zealand study gained an average of 16 lb. and gave birth to babies within a healthy weight range. “I am excited by these findings, because here you have normal-size women who engaged in daily exercise and did not gain weight as per the IOM recommendations, and their babies were of normal weight,” he says. “That strengthens the argument that the current recommendations for weight gain during pregnancy are too lax.”

It’s an even more important message for overweight and obese mothers-to-be, who tend to deliver heavier babies (anything over about 8 lb. 12 oz., or 4 kg, is considered a high birth weight), who are then at higher risk of diabetes and obesity later in life. Those heavier children are then more likely to become overweight adults and in turn give birth to bigger babies. The goal, says Hofman, is to break the cycle of ever bigger generations of babies. According to his latest findings, exercise during pregnancy may be a safe and reliable first step; the American Congress of Obstetricians and Gynecologists recommends 30 minutes a day for pregnant women, for as long as they are physically able.

Alice Park

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