ISSUES AND ANSWERS IN OBSTETRICS
Selections from Antepartum & Intrapartum Management, sponsored by the University of California, San Francisco,
School of Medicine
| SAVING UMBILICAL CORD BLOOD: IS IT ADVISABLE ?—Russell K. Laros, Jr, MD, Professor, Obstetrics,
Gynecology and Reproductive Sciences; University of California, San Francisco, School of Medicine
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| History: 1983 Boyce rodent study demonstrated placental blood contains hematopoietic progenitor cells, useful in
transplantation; 1988 Gluckman performed first related-donor transplant in child with Fanconi’s anemia; 1994
Kurtzberg achieved first successful, unrelated cord-blood donor transplant
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| Private cord-blood bank controversy: speaker believes misdirection of resources; minimal screening studies of
collection before storage; little preparation of cells before storage and little known about transplantation outcomes;
statistics not available, only anecdotal reports; likelihood of anyone using own cord blood estimated 1:200,000
(speaker believes conservative); currently no government regulation overseeing cord-blood banking industry
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| Issues to be resolved: donation may be motivated by guilt on part of parents; 1997 American College of Obstetricians
and Gynecologists (ACOG) published guidelines concerning donation; ethical issues—stem-cell transplantation
still investigational procedure (requires coordinated effort in analyzing data); should identity of donor be
linked to donated blood? minority populations underrepresented in private donations; 3 types of cord-blood banks:
public, private, and directed-donation; Institutes of Medicine issued recommendations in 2005 for national program;
New York Blood Center National Cord Blood Program in existence longest (≈23,000 units stored); public
banks throughout country; donating cord blood not practical if patient outside area of bank; no collection fee for
public donation; ≈$25,000 for unit of cord blood
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| Advantages and disadvantages of cord blood: method and volume of collection important; >100 potential indications
for cord-blood transplantation; advantages—limitless supply, available on short notice for transplant, no
donor attrition compared with bone marrow registry, ethnic diversity easier to achieve, painless collection of stem
cells, higher proliferative capacity, lower rate of acute graft-vs-host disease, and adjusted 3-yr survival and treatment
failure similar; disadvantages—unable to obtain additional “donor” cells for leukocyte infusion or second
transplant, fewer hematopoietic progenitor cells compared with bone marrow donor, slower engraftment of neutrophils
and platelets, and large inventory product with high up-front costs (units may become outdated due to changing
banking standards); legal (eg, consent process) and collection process guidelines needed to maximize volume
of usable stem cells
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| Collection: factors that increase cell count—first-born infants, prolonged labor, mother nonsmoker, short interval
to cord clamping, infant placed on maternal abdomen before clamping, collection while placenta in situ, large baby,
increase in gestational age, white ethnicity; factors decreasing cell count—preeclampsia (regardless of weight of
placenta) and gestational age <34 weeks (related to size of placenta); donor screening—extensive and expensive;
exclusion criteria do not include: positive carrier state for group B streptococcus, presence of meconium, or prolonged
rupture of membranes (in absence of suspected maternal infection); exclusion criteria—suspected chorioamnionitis,
malodorous placenta, active genital herpes (or suspicion of), perineal condylomata, any chromosomal
or major phenotypic structural abnormality of neonate; follow-up of infant (donor) should be undertaken
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| DIAGNOSIS AND MANAGEMENT OF ANTENATAL AND POSTPARTUM DEPRESSION —Patricia A. Robertson,
MD, Professor of Clinical Obstetrics and Gynecology and Director of Medical Student Education, Department
of Obstetrics, Gynecology, and Reproductive Sciences; University of California, San Francisco, School of
Medicine
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| Introduction: ask patient about mood at least once during pregnancy and at 6-wk postpartum visit; data show
<20% of patients eventually diagnosed with postpartum depression reported symptoms to health care provider;
prevalence of depression in pregnancy similar to nonpregnant patients; lifelong impact on neonate/infant; behavioral
disorders, inappropriate aggression, and cognitive and attention deficits seen in offspring
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| Risk factors for postpartum depression: personal history of depression or bipolar disorder (ask whether medication
prescribed or hospitalization occurred); family history of depression, bipolar disorder, or suicide; history of
childhood sexual abuse; lack of safe environment; substance use including smoking; recent stressful life events;
concurrent medical illness; multiparity; increased number of children; history of miscarriage; complications during
pregnancy; relationship conflict; lack of perceived social support from family and friends; living alone during pregnancy;
unplanned pregnancy; having contemplated termination of pregnancy; previous spontaneous abortion; poor
relationship with one’s own mother; not currently breastfeeding; unemployment (patient and/or partner); childcare-
related stressors; sick leave during pregnancy; high number of visits to prenatal clinic; neonate with congenital
anomaly
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| Screening tools: not shown to improve mental health outcomes, important to identify patients at risk for postpartum
depression because of negative impact on offspring; Edinburgh Postnatal Depression Scale—takes <5 min to
complete; 10-item self-report screening scale; questions apply to past 7 days; 100% sensitivity for identifying
women with major depression, specificity 87%;sensitivity for minor depression 64%, specificity 90%; Beck Depression
Inventory—21 symptoms and attitudes rated by intensity; 3 different versions based on time frame selected;
relies on somatic symptoms (possibility of higher scores and more false-positives during pregnancy);
sensitivity slightly lower than Edinburgh scale, but specificity higher; validation not as extensive as Edinburgh;
narrow racial and ethnic mixes; sensitivity and specificity good, suggesting good positive predictive value; Postpartum
Depression Screening Scale—35-item Likert-type self-report instrument created for new mothers, can be administered
in 5 to 10 min; written at third grade level; utilizes 5-point scale (from “strongly disagree” to “strongly
agree”); evaluates sleeping and eating disturbances, anxiety (both connected with depression and not), insecurity,
emotional lability, mental confusion, loss of self, guilt and shame, and suicidal thoughts; Center for Epidemiological
Studies Depression Scale—20-item self-report inventory; designed for general population
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| Identifying depression: depression mnemonic (Sig: E Cap[s])—sadness: depressed, interest: decrease, guilt: feelings
of worthlessness, energy: decrease, fatigue; concentration: decrease, can’t think; appetite: decrease/increase,
weight change; psychomotor activity: decrease/increase, sleep: decrease or increase, suicide; quick screening
questions—“was this what you expected motherhood to be like?”; “is this what you expected having a second baby
to be like?”; response such as “it’s so much better than I ever imagined” passes screen; response such as “it wasn’t
exactly what I expected” warrants further exploration; response of “I had no idea, I’m overwhelmed, it isn’t exactly
what I had in mind” fails screen; major depressive episode—diagnosed with 5 symptoms lasting >2 wk; diagnosis
of depression can impact future insurability; use caution in entering diagnosis in medical record; diagnosis of stress
adjustment disorder recommended until patient seen by mental health provider; signs and symptoms of postpartum
depression—feelings of guilt, sense of being overwhelmed or unable to care for baby, feelings of inadequacy, failure
as mother and not bonding with baby; instruct nurses to interact with patient about feelings of motherhood, patient
may not express true feelings to clinician; depression in partners—≈50% of prevalence of postpartum
depression in women; anxiety—can be expressed as generalized anxiety disorder, panic attacks, phobias, obsessive-
compulsive disorder (OCD), and posttraumatic stress disorder
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| Differential diagnosis: “baby blues” (usually lasts for 3 days, 70% of women effected); postpartum psychosis (incidence
of 1 in 1000, psychiatric emergency, have patient escorted to emergency department); OCD; anxiety; panic
attacks
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| Treatment: therapy plus medication most effective; cognitive behavioral therapy (group therapy sessions) teaches patient
how to manage depressive symptoms; teratogenic considerations—associated with some selective serotonin reuptake
inhibitors (SSRIs); eg, Paxil (paroxetine) reclassified as category D medication because of increased risk of
birth defects, and Celexa (citalopram) category C but also associated with increased risk; weigh risks of medication
against benefits; ultrasonography and fetal echocardiography recommended for patient on medication in first trimester;
potential neonatal withdrawal syndrome—Zeskind study shows infants whose mothers took SSRIs had slightly
shorter gestational age and some physiologic signs; postpartum period most dangerous for women with depression to
be without medication; discontinuing medication in third trimester to avoid neonatal withdrawal syndrome not recommended;
minimizing medication exposure—encourage preconception consult; assess need for continuing medication
in pregnancy; breastfeeding—avoid at peak of medication; do not discourage even if patient using SSRI; Zoloft (sertraline),
Paxil, and Celexa undetectable in breast milk; measurable serum levels with Effexor (venlafaxine); prophylactic
treatment—conflicting evidence; consider with severe depression
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| AFTER GESTATIONAL DIABETES MELLITUS: WHAT YOU SHOULD KNOW ABOUT POSTPARTUM
MANAGEMENT IN THE 21ST CENTURY —Maribeth Inturrisi, RN, MS, CNS; Assistant Clinical Professor and
Certified Diabetes Educator, University of California, San Francisco, School of Medicine
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| Introduction: age- and ethnicity-adjusted yearly cumulative incidence of gestational diabetes mellitus (GDM) increased
steadily from 5.1% prevalence in 1991 to 7.4% in 1997; O’Sullivan (1991) showed conversion rate of
GDM to type 2 diabetes 19% to 87% 10 to 20 yr after index pregnancy; Kim (2002) showed incidence of diabetes
ranged from 3% to 70% in 3 to 6 yr after index pregnancy; Ratner showed risk lifelong, no longer 5 to 20 yr, as in
literature; shortly after pregnancy, ≈5% of women develop diabetes (1% will be type 1); impaired glucose tolerance
(IGT) detected on first antenatal screen 15% to 20% of time
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| Antepartum predictors of GDM conversion to type 2 diabetes: high basal glucose production—elevated
fastings; low insulin sensitivity—obesity associated with insulin resistance; pregnancy state of increasing insulin
resistance; women with insulin resistance demonstrate more destruction of beta cells as pregnancy progresses and
more likely to develop type 2 diabetes antepartum; abnormal first-hour value on 3-hr oral glucose tolerance test
(OGTT)—usually evidence that first phase of insulin being compromised; insulin or glyburide requirement during
pregnancy; early gestational age at time of GDM diagnosis—screen high-risk populations at first prenatal visit
(pick-up rate 18%)
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| Postpartum predictors of GDM to type 2 diabetes: weight—risk of developing type 2 diabetes 50% to 75%
if obese; risk <25% for women with normal body mass index; progesterone—on average, 26.5% of women per
year taking progestin-only mini-pill and breastfeeding developed type 2 diabetes, compared to 8.7% of women using
non-hormonal contraceptives, and 11.7% of those choosing low-dose combination oral contraceptives (OCs);
Depo-Provera (medroxyprogesterone acetate) shown to increase rapidity with which type 2 becomes overt; postpartum
2-hr OGTT—84% of women with IGT progressed to type 2 diabetes, compared to 12% with normal 2-hr
values
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| Prevention of type 2 diabetes after GDM: pre-diabetes confers 2- to 4-fold risk for death from cardiovascular
disease (same as overt); caveats from the GDM cohort of the Diabetes Prevention Program (DPP)study —GDM
can be delayed or prevented by either metformin or lifestyle change; all ethnic groups had similar responses to treatment
when IGT present at baseline; weight loss most effective lifestyle change; postpartum recommendations—
early identification and communication to patient’s primary care provider and pediatrician; instruct patient to return
4 to 12 wk after delivery for retesting; use 2-hr 75-g OGTT and fasting screen (not just fasting screen alone); pre-
diabetes—if fasting levels 100 mg/dL on >1 occasion, or OGTT results show 140 mg/dL on >1 occasion; nutrition
consult recommended; consider insulin sensitizers (metformin and thiazolidinediones (TZDs), demonstrated to delay
type 2 diabetes in patients with IGT; continue to follow up with patient; if pre-diabetic, obtain OGTT and lipid
analysis annually; if normal, every 3 yr from baby’s first birthday; give OGTT before conceiving again; lifestyle
options—encourage breastfeeding (associated with lower rate of type 2 diabetes) and a return to/maintenance of
healthy weight; contraception issues—avoid progesterone-only OCs when breastfeeding; suggest intrauterine device
(IUD) with progesterone (local effect) or low-dose combination OCs 6 to 8 wk after breastfeeding established
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Educational Objectives
| The goal of this program is to educate the listener about umbilical cord-blood banking, postpartum depression and
identifying women at risk, and postpartum management of women with gestational diabetes mellitus (GDM). After
hearing and assimilating this program, the clinician will be better able to:
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 | 1. Discuss the advantages and disadvantages of umbilical cord-blood banking as well as conditions that prevent
donation.
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| 2. Identify patients at risk for postpartum depression.
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| 3. Treat pregnant patients at risk for postpartum depression.
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| 4. Identify predictors for type 2 diabetes after GDM.
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| 5. Manage women postpartum who had pregnancies complicated by GDM.
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Notes
Small Steps.Big Rewards. Prevent type 2 Diabetes: www.ndep.nih.gov/campaigns
Discussed on This Program
Citalopram HBr [Celexa]
Glipizide/metformin HCl [Metaglip]
Medroxyprogesterone acetate [Depo-Provera, several others]
Paroxetine HCl [Paxil, Paxil CR, Pexeva]
Sertraline HCl [Zoloft]
Suggested Reading
Buchanan TA: Gestational diabetes mellitus. J Clin Invest 115:485, 2005; Kjos SL: Postpartum care of the
woman with diabetes. Clin Obstet Gynecol 43:75, 2000; Moise KJ: Umbilical cord stem cells. Obstet Gynecol
106:1393, 2005; Laughlin MJ et al: Outcomes after transplantation or cord blood or bone marrow from unrelated donors
in adults with leukemia. N Engl J Med 351:2265, 2004; Peindle KS et al: Identifying depression in the first
postpartum year: guidelines for office-based screening and referral. J Affect Disord 80:37, 2004; Ratner RE: The
Diabetes Prevention Program Research. Endocr Pract 12 Suppl 1:20, 2006; Wisner KL et al: Prevention of recurrent
postpartum major depression. Hosp Community Psychiatry 45:1191, 1994
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
the faculty reported nothing to disclose.
Drs. Laros and Robertson and Ms. Inturrisi were recorded at Antepartum & Intrapartum Management, sponsored by
the University of California, San Francisco, School of Medicine, and held on June 8-10, 2006 in San Francisco. The
Audio-Digest Foundation thanks the speakers and the sponsor for their cooperation in the production of this program.
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