Articles Reveal Fetal Surgery Continues To Advance

Fetal surgery is becoming more popular with the advantages it provides: repairing birth defects in the womb; inserting a tiny laser into the mother’s uterus to seal off an abnormal blood flow and save fetal twins; and advancing the science that may allow doctors to deliver cells or DNA to treat sickle cell anemia and other genetic diseases before birth, are a few of the benefits.

“Fetal surgery is a unique field in maternal-fetal medicine,” said pediatric surgeon N. Scott Adzick, M.D., medical director of the Center for Fetal Diagnosis and Treatment (CFDT) at The Children’s Hospital of Philadelphia. “Detecting birth defects prenatally has allowed physicians to provide better perinatal care,” said Adzick, “but many of these babies were already too sick for us to treat them successfully after they were born. This dilemma led to the development of fetal surgery.”

“Some of the fetal anomalies we treat are so rare that a physician may encounter them only once or twice in a career,” continued Adzick, who is surgeon-in-chief at Children’s Hospital. “However, as prenatal diagnosis continues to improve, along with surgical techniques and tools of molecular biology, we have an expanded range of conditions for which we may devise ways to intervene before birth with clear benefits.”

The CFDT, which marks its 15th anniversary this year, is a premier program, one of a handful worldwide to offer a full range of fetal procedures. Since the center opened in 1995, more than 10,000 parents have used its services, from all 50 U.S. states and from 46 other countries.

Internationally prominent as a pioneer in fetal surgery, Adzick edited the an issue of the journal Seminars in Fetal & Neonatal Medicine. That issue is entirely devoted to advances in fetal surgery. Adzick and other practitioners at The Children’s Hospital of Philadelphia describe innovative surgeries, high-tech procedures, and the prospect of prenatal gene therapy and stem cell treatments in a collection of articles reviewing the current state of the science in fetal therapy.

These are the articles:

Open fetal surgery to remove abnormal masses or patch an opening
Open fetal surgery involves cutting into the mother’s abdomen and uterus in order to operate on the fetus. In his article on open fetal surgery, Adzick describes the multidisciplinary team and sophisticated imaging technologies used to assess patients referred to the center, the only such facility that includes a Special Delivery Unit for mothers carrying babies with known birth defects. Adzick describes fetal surgeries for two life-threatening defects: lung masses, which may compress the developing heart, leading to heart failure, and sacrococcygeal teratomas, large tumors attached to the fetus’s tailbone, which can lead to heart failure or a fatal hemorrhage before birth. Fetal surgery, he adds, places special demands on caregivers to ensure safety for two patients — the mother and the fetus.

Adzick’s second article concerns fetal surgery for open spina bifida, referred to as myelomeningocele. A defect in which part of the spinal cord remains unprotected by skin and tissue, it may result in hydrocephalus, mental retardation, bowel and bladder problems, and lifelong paralysis. While usually non-lethal, it is a relatively common cause of major disability, affecting one in 2,000 live births.

To repair a myelomeningocele, fetal surgeons shield the developing spinal cord by closing the defect with the fetus’s own tissue. Definitive results of outcomes after fetal surgery are expected from a randomized clinical trial sponsored by the National Institutes of Health.

The Management of Myelomeningocele Study (MOMS), which began in 2003, is expected to conclude treatments in the trial in 2011 at three fetal surgery centers, The Children’s Hospital of Philadelphia, Vanderbilt University and the University of California-San Francisco.

Laser treatment shuts off dangerous twin-to-twin connection
Another application of fetal surgery is for twin-twin transfusion syndrome, occurring in 10 to 15 percent of identical twins. In this condition, one fetus grows at the expense of its twin because of abnormal blood vessel connections in their shared placenta. Michael Bebbington, M.D., of the CFDT, reviews current therapies for this condition, noting that the scientific evidence favors selective laser photocoagulation. In this procedure, using a viewing instrument called a fetoscope, the fetal surgeon employs a laser to seal off the blood vessels that carry hazardous blood flow between the two fetuses.

Prenatal stem cell and gene therapy moving toward clinical use
The greatest future impact of fetal treatments probably lies in non-surgical approaches — prenatal stem cell therapy and gene therapy. In contrast to the relatively rare anatomical defects addressed in fetal surgery, cell and gene therapy offer the possibility of treating many genetic diseases before birth, including sickle cell anemia, immune deficiency disorders and some types of muscular dystrophy.

These potential therapies are reviewed by Alan W. Flake, M.D., and his colleagues at the Center for Fetal Research at Children’s Hospital. Now in his third decade of investigating fetal surgery, Flake pioneered fetal bone marrow transplantation in 1996, successfully treating severe combined immunodeficiency disease (SCID) in utero.

In-utero hematopoietic stem cell transplantation (IUHCT) focuses on stem cells that develop into all the types of cells found in the blood. The keystone of this approach is the fetal immune system’s unique tolerance of transplanted cells. Flake’s strategy involves using prenatal stem cell transplants to achieve tolerance of foreign cells, which are incorporated into the fetal circulation. This sets the stage for postnatal transplant of therapeutic blood cells from the same donor that will not be rejected by the infant’s immune system.

The specific characteristics of SCID make this disease uniquely amenable to a prenatal stem cell approach. Now, says Flake, research in animal models is progressing toward using IUHCT to treat other immune deficiency diseases, the hemoglobin disorders sickle cell anemia and thalassemia, and lysosomal storage diseases (genetic disorders in which the lack of an enzyme causes metabolic chemicals to accumulate to toxic levels in cells).

Some diseases that progress to irreversible organ damage may offer targets for prenatal gene therapy — in which physicians deliver therapeutic DNA to correct a genetic defect. Proof-of-principle studies in animals have produced preclinical successes for prenatal gene therapy in cystic fibrosis, Duchenne’s muscular dystrophy, Pompe disease and the lysosomal storage disease Sly syndrome. There have also been promising animal studies in types of hemophilia. As with postnatal gene therapy, important safety issues remain to be solved before prenatal gene therapy can be offered in the clinic. “Fetal gene therapy is still in the early experimental stage,” said Flake, while noting great progress in this field.

EXIT procedure — a partial delivery buys time for fetal surgery
Other articles in the special issue discuss fetal treatments for congenital diaphragmatic hernia, thoracic and bladder shunts, fetal anesthesia, and the ex-utero intrapartum therapy (EXIT) procedure. The EXIT procedure is a “partial delivery” in which the fetus is partially removed from the uterus but remains attached to the circulation carried by the umbilical cord and placenta so that surgeons can correct airway blockages before performing a full delivery. Clinicians at Children’s Hospital have the world’s most extensive experience in performing the EXIT procedure.

For more information, visit: www.chop.edu.

One in Four Women Show Ambivalence Toward Pregnancy

For years, a widely held assumption was that women of childbearing age fell neatly into two camps: those trying to have children, and those not trying to have children.

A new nationwide study suggests, however, that nearly a fourth of women consider themselves “OK either way” about getting pregnant — a wide swath of ambivalence that surprised researchers, and that could reshape how doctors approach many aspects of women’s healthcare.

In a study of nearly 4,000 women ages 25 to 45 who are sexually active, about 71 percent said they were not trying to get pregnant, while 6 percent said they were. But nearly one in four, 23 percent, told researchers they were “OK either way” — they were neither trying to conceive, nor trying to prevent a pregnancy.

Among women who had no children, 60 percent said they were trying to not get pregnant, 14 percent were trying to get pregnant and 26 percent responded that they were “OK either way.”

“This finding dramatically challenges the idea that women are always trying, one way or another, to either get pregnant or not get pregnant,” said Julia McQuillan, professor of sociology at the University of Nebraska-Lincoln and the study’s lead author. “It also shows that women who are OK either way should be assessed separately from women who are intentional about pregnancy.”

The study also gave more accurate measures of women’s pregnancy intentions, which are important for estimating unmet need for contraception, building more effective family planning programs, promoting infant health and helping maternal and infant well-being.

“If healthcare providers only ask women if they are currently trying to get pregnant and women say no, then the assumption is that they are trying not to get pregnant,” McQuillan said. “Clearly, many women are less intentional about pregnancy. Yet this group should be treated as if they will likely conceive and should therefore get recommendations such as ensuring adequate folic acid intake and limiting alcohol intake.”
In addition, the study examined the attitudes and social pressures regarding pregnancy of the respondents, as well as their socioeconomic status.

Among the findings:
*Women who said they were OK either way reported the highest number when asked what the ideal number of children would be — 3.17 on average. They also tended to be slightly more religious than women who were either trying to get pregnant or not trying to get pregnant.
*Seventy-three percent of women who said they were OK either way said they would like a baby, compared with 34 percent of women who were not trying to get pregnant, and 95 percent of women who said they were trying to get pregnant.
*Those who were trying to get pregnant were more likely to report that having a child — or another child — was very important to their partner compared with women in the other two groups. Among women who had not yet had children and who said they were trying, 40 percent said it was important to their partner.
*Half of all women in the survey said their career was very important to them, while 45 percent said the same about having an adequate amount of leisure time. All three groups — women who were trying, women who weren’t trying, and women who were OK either way — reported similar attitudes about work and leisure.

The study, which is forthcoming in Maternal and Child Health Journal, was authored by UNL’s McQuillan along with Arthur L. Greil of Alfred University and Karina Shreffler of Oklahoma State University.

For more information, visit: www.unl.edu/.

Osteopathic Manipulative Treatment Improves Back Function in Late Pregnancy

As pregnancy progresses, tasks that involve the low back often get more difficult for women. It is harder to bend over, lift, sit or walk for long periods of time and back pain increases.

Treating back pain, and improving daily function relative to tasks that involve the low back is a challenge because pregnant women are limited to treatments that will not create problems for their developing baby, said the Osteopathic Research Center.

“Osteopathic manipulative treatment (OMT) is a viable option for improving function related to the low back and reducing back pain in the third trimester of pregnancy because its does not appear to have any negative side effects,” said John C. Licciardone, D.O., M.S., M.B.A., the lead author of a study on OMT in the third trimester of pregnancy that was recently published in the American Journal of Obstetrics and Gynecology.

Results from this study showed that osteopathic manipulative treatment slows or halts the deterioration of back-specific function in the third trimester of pregnancy.

Osteopathic manipulative treatment is a system of hands-on diagnosis and treatment that is used to reduce pain, restore range of motion and to restore normal function and balance in the body.

The Phase II randomized clinical trial of 144 subjects showed that women in the usual obstetric care+osteopathic manipulative treatment group reported less deterioration of back-specific function on the Roland-Morris Disability Scale than women in the usual obstetric care+sham ultrasound and the usual obstetric care only groups when these groups were compared using an intention-to-treat analysis. This study is the first randomized, placebo-controlled trial to explore the potential effects of osteopathic manipulative treatment during the third trimester of pregnancy.

In the study, conducted by The Osteopathic Research Center in conjunction with the Department of Obstetrics and Gynecology at the University of North Texas Health Science Center in Fort Worth, Texas, women were enrolled between the 28th and 30th week of pregnancy.

After being randomized to one of the three treatment groups, the women in the usual obstetric care+osteopathic manipulative treatment and usual obstetric care+sham ultrasound groups received treatments immediately following each of their third trimester prenatal visits. Women were excluded or dropped from the study if they were determined to be at high risk by their obstetrician. The median age for women included in the study was 24 years.

Licicardone noted that outcomes were statistically significant relative to improved low back function in the OMT group. “The results also showed a trend toward pain reduction in the group that received OMT, but pain remained the same or increased in the other groups.”

Usual obstetric care was defined in this study as the conventional prenatal care received during pregnancy. Osteopathic manipulative treatment is generally considered a complementary treatment that is not included as part of routine prenatal care.

“This study is exciting because pregnant women frequently experience a negative impact on their ability to function and perform tasks related to daily living as their pregnancy progresses,” said Licciardone, the principal investigator for the project, and the executive director of The Osteopathic Research Center. “Since pregnant women are limited in the medications they can take for pain, osteopathic manipulative treatment offers a way to improve back function and decrease pain in the third trimester of pregnancy, when a majority of women experience these symptoms.”

“What is also interesting about this study is that osteopathic physicians (D.O.s) who provide obstetrical care can potentially include osteopathic manipulative treatment as part of their prenatal care for patients,” Licciardone said. “For more than 100 years, osteopathic physicians who have treated pregnant women using osteopathic manipulation have claimed that their patients have less pain, better function and improved delivery outcomes. This study may be the first step in confirming the clinical success of osteopathic physicians in this area of medicine.”

Licciardone added, “If osteopathic obstetricians view this study as the first step in developing a strong evidence base to support the use of OMT to improve back function and pain in the third trimester of pregnancy, this study could have a significant clinical impact on prenatal care, and it could have important economic implications for treating common back-related symptoms and functional disabilities in late pregnancy.”

Full text of the article is available online at http://www.ajog.org/.

$25,000 Available For Reproductive Health In Free Student-Clinics

The Reproductive Health Access Project (RHAP) is requesting proposals for student-run free clinics to serve the uninsured and underserved women of the community.

RHAP’s Women’s Health Free Clinic Project: Expanding Access and Education will award up to five grants, at a maximum of $5,000; deadline for applications is May 30, 2010.

“Free clinics play an important role in providing medical care to Americans. Many free clinics are associated with a medical school and are staffed by its medical students … Fewer than 5 percent of US medical schools include contraception and family planning in their curriculum. This partnership provides students with a rich educational experience,” said RHAP.

“Integrating comprehensive reproductive healthcare into student-run free clinics would fill an educational gap in our country’s medical education system. Furthermore, this arrangement would also provide important services to a needy population,” RHAP continued.

RHAP offers grants to established student-run health centers to fund the start-up expenses associated with introducing a reproductive health curriculum.

Priority will be given to proposals including: Cervical cancer screening; Contraceptive education, counseling and dispensing, including emergency contraception IUD/Implanon insertion and Depo-Provera injections; Pregnancy testing, early pregnancy ultrasound and options counseling for unintended pregnancy; Medication abortion.

Besides being a student-run facility, services should be provided at a nominal or no cost to the patient, and have a partnership with a physician whom can educate and supervise reproductive health services administered.

“An additional key criterion in the selection process will be the free clinic’s commitment to sustaining the added training for medical students and services for patients after the incentive grant ends,” said RHAP.

Applications can be submitted by mail or e-mail. The full RFP, along with a guide on integrating reproductive health, can be accessed here: www.reproductiveaccess.org/freeclinic.html.

Antidepressants Linked to Delayed Lactation

Women taking commonly used forms of antidepressant drugs may experience delayed lactation after giving birth and may need additional support to achieve their breastfeeding goals, according to recent research.

Breastfeeding benefits both infants and mothers in many ways as breast milk is easy to digest and contains antibodies that can protect infants from bacterial and viral infections. The World Health Organization recommends that infants should be exclusively breastfed for the first six months of life.

This new study shows that certain common antidepressant drugs may be linked to a common difficulty experienced by new mothers known as delayed secretory activation, defined as a delay in the initiation of full milk secretion.

“The breasts are serotonin-regulated glands, meaning the breasts’ ability to secrete milk at the right time is closely related to the body’s production and regulation of the hormone serotonin,” said Nelson Horseman, PhD, of the University of Cincinnati and co-author of the study. “Common antidepressant drugs like fluoxetine, sertraline and paroxetine are known as selective serotonin reuptake inhibitor (SSRI) drugs and while they can affect mood, emotion and sleep they may also impact serotonin regulation in the breast, placing new mothers at greater risk of a delay in the establishment of a full milk supply.”

In this study, researchers examined the effects of SSRI drugs on lactation using laboratory studies of human and animal cell lines and genetically modified mice. Furthermore, an observational study evaluated the impact of SSRI drugs on the onset of milk production in postpartum women. In this study of 431 postpartum women, median onset of lactation was 85.8 hours postpartum for the SSRI-treated mothers and 69.1 hours for mothers not treated with SSRI drugs. Researchers commonly define delayed secretory activation as occurring later than 72 hours postpartum.

“SSRI drugs are very helpful medications for many moms, so understanding and ameliorating difficulties moms experience can help them achieve their goals for breastfeeding their babies,” said Horseman. “More human research is needed before we can make specific recommendations regarding SSRI use during breastfeeding.”

Other researchers working on the study include: Aaron Marshall, Laura Hernandez and Karen Gregerson of the University of Cincinnati in Ohio; Laurie Nommsen-Rivers of Cincinnati Children’s Hospital Medical Center in Ohio; Kathryn Dewey of the University of California at Davis; and Caroline Chantry of the University of California Davis Medical Center in Sacramento.

The article will appear in the February 2010 issue of The Endocrine Society’s Journal of Clinical Endocrinology & Metabolism. For more information, visit: http://www.endo-society.org/

Chinese-American, Korean-American Women At Highest Risk For Diabetes In Pregnancy

More than 10 percent of women of Chinese and Korean heritage may be at risk for developing diabetes during pregnancy, according to a Kaiser Permanente study of 16,000 women in Hawaii. The study also found that Korean-American and Chinese-American women’s gestational diabetes risk is one-third higher than average — and more than double that of Caucasian and African-American women.

Funded by the American Diabetes Association, the study found that Pacific Islanders, Filipinos, Puerto Ricans, and Samoans are also at higher-than-average risk — while Caucasian, Native-American, and African-American women have a lower-than-average risk.

Untreated gestational diabetes mellitus (GDM) can lead to serious pregnancy and birthing complications, including early delivery and C-sections. It can also increase the child’s risk of developing obesity later in life, researchers said.

While previous studies have shown that GDM is more prevalent among Asian women and Pacific Islanders, this study separates those ethnic groups into sub-categories to find out who is at higher risk. Researchers chose Hawaii for the study because it has one of the most ethnically diverse populations in the world.

Researchers divided Asians into five ethnic sub-groups and found some striking differences: Korean and Chinese women have the greatest risk of developing GDM. Filipinos are next, but Japanese and Vietnamese women have the same risk as the rest of the population. Among three groups of Pacific Islanders, Samoans and other Pacific Islanders (including women from Fiji and Tahiti) have a higher-than-average risk, while women classified as Native Hawaiians are at average risk. Caucasian, Native-American, and African-American women have the lowest risk for developing GDM.

“This study has important implications for diagnosis and treatment of gestational diabetes,” said study lead author Kathryn Pedula, MS, a researcher at the Kaiser Permanente Center for Health Research. “All pregnant women and their caregivers need to be educated about gestational diabetes, but it is especially important for women in these ethnic groups at higher risk.”

“Many previous studies have lumped all Asians and Pacific Islanders together—we now know that the risk for developing GDM varies greatly depending on your specific ethnic background,” said study co-author Teresa Hillier, MD, MS, an endocrinologist and senior investigator at the Kaiser Permanente Center for Health Research. “Future studies should also look at whether women in these higher risk groups also have more complications.”

This study involved 16,757 women aged 13-39, who gave birth in the Kaiser Permanente Health Plan in Hawaii between 1995 and 2003. Some women had more than one child during that time, bringing the total number of pregnancies to 22,110. Researchers obtained ethnic classification from the mothers’ birth certificates on file with the Hawaii Department of Health.

All women in the Kaiser Permanente system are screened for gestational diabetes between 24-28 weeks of pregnancy. If they have GDM, they are treated as part of routine care. More than 20 percent of women in the study had elevated glucose levels, and 6.7 percent of women met the Carpenter and Coustan threshold for gestational diabetes.

“This study underscores Kaiser Permanente’s commitment to identify differences in risk and clinical outcomes for different ethnic and racial groups,” said Winston F. Wong, MD, MS, medical director of Kaiser Permanente’s Community Benefit Disparities Improvement and Quality Initiatives. “While we cannot eliminate the increased risk of prenatal diabetes among our Korean and Chinese patients, we use this kind of research to alert and empower our health care professionals and physicians to reduce disparities and achieve the best possible outcomes for our patients and their children.”

Study authors include Kathryn L. Pedula, MS, and Teresa A. Hillier, MD, MS, from the Kaiser Permanente Center for Health Research in Portland, Ore.; Mark M. Schmidt, BA, Kaiser Permanente Center for Health Research, Honolulu; Judith A. Mullen, APRN, BC,CDE, Kaiser Permanente, Honolulu, Hawaii; Marie-Aline Charles, MD, MPH, INSERM, Paris, France; and David J. Pettitt, MD, Sansum Diabetes Research Institute, Santa Barbara, CA.

The study was published in the Dec. issue of the Ethnicity and Disease journal. For more information, visit: www.dor.kaiser.org.

Good News On Multiple Sclerosis And Pregnancy

According to a new study, pregnant women with multiple sclerosis (MS) are only slightly more likely to have cesarean deliveries and babies with a poor prenatal growth rate than women who do not have MS.

Women with MS were no more likely to have other pregnancy problems, such as preeclampsia and other high blood pressure problems and premature rupture of membranes, than women in the general population, the study found.

The large study used a national database from all non-federal short-stay hospitals in 38 states. The data included an estimated 18.8 million deliveries, with about 10,000 of those occurring in women with MS.

The women with MS were more likely than women without chronic medical conditions (2.7 percent for women with MS compared to 1.9 percent for women without chronic medical conditions) to have a fetus with intrauterine growth restriction, defined as a weight less than the tenth percentile for the gestational age, as measured by ultrasound. Women with MS were more likely to have a cesarean delivery than those in the general population (42 percent versus 33 percent).

“These results are reassuring for women with MS,” said study author Eliza Chakravarty, MD, MS, of Stanford University School of Medicine in Stanford, CA. “Women and their doctors have been uncertain about the effect of MS on pregnancy, and some women have chosen to delay or even avoid pregnancy due to the uncertainty. We found that women with MS did not have an increased risk of most pregnancy complications.”

Chakravarty said that previous studies on MS and pregnancy have focused on the impact of pregnancy on disease activity.

The study also looked at women who had diabetes prior to becoming pregnant (not gestational diabetes), and found that they had higher rates of complications than women with MS and high rates of complications in areas where the women with MS did not have increased rates.

The study was published in the November online issue of Neurology, the medical journal of the American Academy of Neurology. For more information, visit: www.aan.com.

Mental Health Linked To Stillbirth And Newborn Deaths

Women with a history of serious mental illness are much more likely to have babies that are stillborn or die within the first month of life, new research revealed.

Researchers at the Centre for Women’s Mental Health at The University of Manchester studied almost 1.5 million births in Denmark between 1973 and 1998, including 7,021 stillbirths.

The risk of stillbirth and newborn deaths from any cause was at least twice as high for mothers admitted with a serious psychiatric illness than for women with no such history.

Lead researcher Dr. Kathryn Abel, working with Danish colleagues at Arhus University said, “We found that the chances of stillborn or newborn death from all causes were greater for babies whose mothers had a serious mental-health illness.”

“The risk of stillbirth for women with schizophrenia was twice as high than healthy mothers, while women with affective disorders were also more than twice as likely to give birth to stillborn babies,” she said.

Women with other psychotic illnesses, including mood-affective disorders, manic depression and drug and alcohol addiction, were also shown to have a much greater risk of stillborn and newborn deaths.

The risk of stillbirth due to complications during delivery among women with drug and alcohol problems was more than double that of healthy women. Women with affective disorders were more than twice as likely to give birth to babies with congenital abnormalities, leading to stillbirth, researchers said.

“For most causes of death, offspring of women with schizophrenia had no greater risk of stillbirth or neonatal death than other psychiatrically-ill mothers,” said Abel, who is based in the University’s School of Medicine.

“The fact that the link between the cause of death and the illness of the mother varies, suggests that factors other than the mental disorder itself are involved,” she said.

“Lifestyle, such as smoking and poor diet, and less antenatal care and poverty can also increase the chances of complication during childbirth. These findings suggest that further resources are needed to support these vulnerable women and their children,” she concluded.

For more information, please visit: www.manchester.ac.uk.

Economy Affects Fertility Treatment Treatments, RMACT Offers Payment Plans

The current turbulent economy has influenced all aspects of consumers’ spending habits, even family planning.

According to the National Center for Health Statistics, there was a nearly 2 percent drop in the nationwide birth rate in 2008. This trend seems to extend to infertility treatment, which many are opting to delay, especially when they are without insurance or worry about a potential job loss.

To help patients who face tough decisions between their dreams for a family and financial realities, Reproductive Medicine Associates of Connecticut (RMACT) fertility clinic has created RMACT Opportunity Plans. The service and payment plans allow infertility patients to choose a flat rate for fertility care. In the first 8 weeks, 20 patients have signed up.

RMACT Opportunity Plan patients receive the same quality of care as the practice’s other patients because infertility treatment plans are based on their individual needs. The goal is to help patients grow their families and fulfill their family plans by taking fertility treatment financial worries out of the equation. Along with the fertility treatment plan, RMACT doctors encourage patients to be mindful of their overall wellness, including healthy eating, exercise and stress reduction.

“Over the past year, we’ve seen a decline in the number of patients going through with fertility treatment because of finances,” said Dr. Mark Leondires, medical director at RMACT.

“Our patients talk to us about how they want children, but have financial concerns that cause them to delay starting a family. We want our patients to have all the necessary tools for fulfilling their dreams for a family – including financial solutions. This is why we created RMACT Opportunity Plans, which give patients without fertility benefits access to customized medical fertility treatment plans at an affordable cost,” he said.

RMACT Opportunity Plans cover two of the most common treatment options – intrauterine insemination (IUI) and in vitro fertilization (IVF).

IUI places a concentrated semen sample into the uterine cavity. This treatment involves cycle monitoring, sperm washes, intrauterine insemination and injections for ovulation. RMACT IUI Opportunity Plan covers IUI cost for up to three cycles of ovulation induction and intrauterine insemination with oral medications.

The second option is RMACT IVF Opportunity Plan, which covers costs of IVF for one cycle. IVF starts by treating a woman with medications to stimulate the development of multiple ovarian follicles to produce eggs. These eggs are retrieved from the woman and are combined with sperm in a laboratory. One or more embryos are then transferred into the woman’s uterus. The IVF Opportunity Plan includes all cycle monitoring (blood work and ultrasounds), egg retrieval, anesthesia, embryo transfer, assisted hatching and cycle medications.

For more information, visit: www.RMACT.com.

Asian-white Couples Face Distinct Pregnancy Risks, Study Found

Pregnant women who are part of an Asian-white couple face an increased risk of gestational diabetes as compared with couples in which both partners are white, according to a new study from Lucile Packard Children’s Hospital and the Stanford University School of Medicine.

The researchers also found that Asian women whose partners are white are more likely than white women with Asian or white partners to have a caesarean delivery, as part of a broad analysis of perinatal outcomes among Asian, white and Asian-white couples.

The study will be published in the October issue of American Journal of Obstetrics and Gynecology. The findings, the authors said, could benefit clinicians working with an increasingly diverse patient population.

“There’s great heterogeneity in our country; there are people of many different races and backgrounds,” said co-author Dr. Yasser El-Sayed, a Packard Children’s Hospital obstetrician and associate professor of obstetrics and gynecology at the medical school. “Gaining better insight into the risks facing specific populations provides for better counseling and better prenatal care.”

It’s difficult to estimate the prevalence of Asian-white couples, but 14.3 percent of Americans reporting Asian race in the U.S. Census Bureau’s 2000 survey also reported being of mixed Asian-white ancestry. Although past studies have looked at ethnic differences in perinatal outcomes, the majority of research has focused on white- African-American couples. Few studies have focused specifically on Asian-white couples, said El-Sayed, who is also associate chief of maternal-fetal medicine.

To learn more about outcomes and risks in this population, the researchers looked at data from white, Asian and Asian-white couples who delivered at the Johnson Center for Pregnancy and Newborn Services at Packard Children’s from 2000 through 2005. (During that time period, 5,575 white, 3,226 Asian and 868 Asian-white couples delivered babies at the hospital.) The team recorded the type of delivery – caesarean vs. vaginal – and examined perinatal outcomes including gestational diabetes, hypertensive disorders of pregnancy, preterm delivery and birth weight.

El-Sayed and his colleagues found, as noted in their paper, that Asian- white couples “represent a population with distinct perinatal risks that differ depending upon which parent is of Asian race.”

More specifically, the researchers found that white mother/Asian father couples had the lowest rate (23 percent) of caesarean delivery, while Asian mother/white father couples had the highest rate (33.2 percent). Because birth weights between these two groups were similar, the researchers say the findings suggest that the average Asian woman’s pelvis may be smaller than the average white woman’s and less able to accommodate babies of a certain size. (Asian couples had babies with the lowest median birth weight, so caesarean delivery was less common among those women.)

It’s important for clinicians to know which women may have an increased risk of caesarean delivery, so they can conduct proper counseling prior to childbirth, El-Sayed said.

El-Sayed and his colleagues also found that the incidence of gestational diabetes was lowest among white couples at 1.61 percent and highest among Asian couples at 5.73 percent – and just under 4 percent for Asian-white couples. These findings weren’t altogether surprising: past studies have shown an increased risk of diabetes among Asian couples, which researchers attribute to an underlying genetic predisposition. But the interesting finding, El-Sayed said, was that the risk for interracial couples was about the same regardless of which parent was Asian.

Based on their findings, El-Sayed said clinicians should consider both maternal and paternal race when determining a patient’s risk for perinatal complications. “One has to factor in as many relevant variables as possible when you counsel a patient about pregnancy,” he said. “We’ve shown in this paper that if you have an interracial couple, depending on which parent is of which race, there may be different relative risks of certain outcomes that could inform and enhance clinical management.”

Noting the growing number of interracial couples in the San Francisco Bay Area and beyond, El-Sayed said he expects to see more outcomes research like this in the future. “These kinds of studies will become increasingly common,” he said.

Michael Nystrom, MD, who was a resident at Stanford when the research was done and is now a resident at UC-San Francisco, was first author of the paper. El-Sayed’s other co-authors were Stanford faculty Deirdre Lyell, MD, and Maurice Druzin, MD; and Aaron Caughey, MD, from UCSF.

For more information, please visit: www.med.stanford.edu.