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Ob.Gyn. News

VO L . 4 3 , N O. 1 6 T he Leading Inde p endent Ne wspaper for the Obstetrician/Gynecologist—Since 1966 AU G U S T 1 5 , 2 0 0 8

This coronal T2 image

(top) of a fetus diagnosed

Induction Effect
HT May Benefit
with an aberrant
pulmonary vein shows
agenesis of the corpus
Declines in mean birth
weight and gestational age
are linked to an increase in
callosum, abnormal and
retarded gyration,
malrotation of both
labor induction.
PAGE 6 Cognition, Memory
hippocampi, and D R . G REGOR K ASPRIAN

associated signal
Preterm Triggers
Three new studies contradict past results.
abnormalities of the
developing white matter Low HDL cholesterol and B Y M I C H E L E G. trolled trials using conjugated
at 28 weeks. high homocysteine levels may S U L L I VA N equine estrogens have shown no
The brain of a fetus be keys to preterm delivery. Mid-Atlantic Bureau treatment effects in women at
(bottom) with Fallot’s risk for Alzheimer’s disease, or in

tetralogy shows bilateral PAGE 10 C H I C A G O — Hormone thera- women who have the illness.”
germinolytic cysts in the py might preserve cognition and These concerns, plus her own

caudothalamic groove at memory in postmenopausal hypothesis that the “minidoses”

25 weeks. Trump the Triad women, and even attenuate of hormones used in many ran-
Education and professional some of the cognitive deficits domized trials might be too low
teamwork can prevent the that occur in Alzheimer’s disease, to offer protective benefit,

Fetal Cardiac, Brain female athlete triad.

new research suggests.
Controversy exists over the
possible cognitive benefits of hor-
prompted Dr. Tierney of the
Sunnybrook Health Sciences
Centre, Toronto, and her col-

Defects Are Linked mone therapy in older women,

Dr. Mary Tierney said at the In-
ternational Conference on
leagues to undertake a new study.
The 2-year trial randomized 142
women aged 61-87 years to either
Alzheimer’s Disease. “While pre- placebo or to 1 mg estradiol dai-
BY AMY ROTHMAN echo-planar sequences in three clinical and observational studies ly plus 0.35 mg progestin 3 days
SCHONFELD orthogonal section planes), brain have shown a positive effect of per week.
Contributing Writer pathology was found in 33 cases estradiol on the brain and cogni- The primary outcome was the
(59%), said Dr. Kasprian, a radiol- tive function, randomized con- See Cognition page 6
N E W O R L E A N S — Fetal MRI ogist at the Medical University of
shows that almost 60% of fetus- Vienna. This rate is generally
es with cardiac defects also have
brain abnormalities, according to
higher than that reported using
prenatal ultrasonography First-Trimester Lamotrigine
the findings of an imaging study The study was carried out un-
conducted in Vienna.
A total of 57 pregnant women
der the auspices of the Fetal MRI
Work Group, led by Dr. Daniela
Health Politics
Sen. John McCain proposes
Use Linked to Oral Clefts
whose fetuses had cardiac mal- Prayer, also of the Medical Uni- to replace the tax exclusion BY ROBERT FINN mations, Dr. Lewis B. Holmes
formations identified by ultra- versity of Vienna. for employee health benefits San Francisco Bureau said at the annual meeting of the
sound were studied. The find- Eighteen fetuses demonstrated with a tax credit. Teratology Society. This trans-
ings were presented by Dr. brain malformations, such as M O N T E R E Y, C A L I F. — lates to a rate of 2.3%, compared
Gregor Kasprian at the Ameri- commissural anomalies (three PAGE 26 Women who take the anticon- with a baseline rate of 1.6% in un-
can Society of Neuroradiology. cases), holoprosencephaly (one), vulsant lamotrigine during their exposed newborn infants (Neu-
The fetuses had a variety of car- See Defects page 7 first trimester of pregnancy have rology 2008;70:2152-8).
diac malformations, including: a 10-fold greater risk of having a Although this difference in com-
Fallot’s tetralogy (nine cases); VITAL SIGNS baby with nonsyndromal cleft bined major malformation rates
transposition of the great vessels lip, cleft palate, or both, accord- was not statistically significant, the
(three); ventricle septum defect ing to a peer-reviewed study. investigators observed a signifi-
with or without associated car- Median Income for Ob.Gyns. Among 684 women enrolled cantly increased risk when they re-
diac malformations (nine); rhab- in the North American Anti- stricted the analysis to oral clefts.
domyoma (three); aortic steno- $300,000 Epileptic Drug (AED) Pregnancy Three of the infants had an iso-
sis at the isthmus (three); $280,629 Registry who reported taking lated cleft palate, one had an iso-
arteriovenous canal (three); car- Actual lamotrigine monotherapy during lated cleft lip, and one had bilater-
diomegaly (unilateral or bilater- their first trimester, there were 16 al cleft lip and palate, for an overall
$250,000 $237,191
al) (three); or other pathologies infants born with major malfor- See Lamotrigine page 7
such as an aneurysm, cardiac
teratoma, missing inferior vena $233,066
$221,980 Adjusted*
cava, and double-outlet right $200,000

ventricle. In some cases, it was

too early to classify the defect.
When these fetuses then un-
derwent fetal MRI between 20 2003 2004 2005 2006 2007
and 38 gestational weeks (with a
1.5-T superconducting system us- *Adjusted for inflation to 2000 dollars.
ing ultrafast T2-weighted, T1- Source: Medical Group Management Association
weighted, diffusion-weighted, and
Au g u s t 1 5 , 2 0 0 8 • w w w. o b g y n n e w s . c o m News 7

AMA Apologizes for Past Racial Discrimination

A national minority physicians’ group wants to use (JAMA 2008;300:306-13). The paper, which cians and medical students, less than in 1910
chronicles the origins of the racial divide when 2.5% were African American.
the apology as a springboard for three initiatives. in AMA history, was prepared by an inde- In a commentary to accompany the his-
pendent panel of experts convened by the tory, Dr. Ronald M. Davis, immediate past
B Y M A RY E L L E N S C H N E I D E R to reduce health disparities, he is unim- AMA in 2005. The panel reviewed archives president of the AMA, acknowledged the
Ne w York Bureau pressed by the apology alone. Instead, he of the AMA, the NMA, and newspapers “stain left by a legacy of discrimination”
would like the AMA to take a stand on is- from the time to provide a history from and outlined what AMA is doing to elim-

frican American physicians are sues that would advance minority health in the founding of the AMA through the civ- inate prejudice within the organization
looking for action to back up the the United States. For example, he wants il rights movement. and improve the health of minority pa-
words of apology recently ten- to see the AMA push for single-payer na- The paper notes a number of instances tients ( JAMA 2008;300:323-5).
dered by the American Medical Associa- tional health insurance, be stronger in chal- where the AMA leadership fostered racial Dr. Davis said that the AMA leadership
tion for more than a century of racial in- lenging the pharmaceutical industry, do a segregation and bias. For example, in 1874 felt it was important to offer the apology
equity and bias. better job of promoting public health, and the AMA began restricting delegations to because it demonstrates the “current
In accepting the AMA’s apology, the Na- support research into minority health and the organization’s national convention to moral orientation of the organization”
tional Medical Asso- mental health is- state and local med- and lays down a
ciation (NMA), sues. ical societies. This marker to compare
which represents Dr. Warren A. move effectively ex- current and future
minority physicians, The AMA needs Jones, who was the cluded most ‘Now is the time actions.
urged the AMA to take a stand on first African Ameri- African American for the AMA to Within the orga-
leadership to work issues that would can president of the physicians because put its resources nization, AMA has
with them on three advance minority American Academy many medical soci- where its in place a number
initiatives: recruiting health in the U.S. of Family Physi- eties, especially mouth is.’ of policies that ex-
more African Amer- cians, agreed that those in the South, plicitly prohibit dis-
ican physicians, re- DR. BELL further action will openly refused DR. JONES crimination in
ducing health dis- be needed but membership to membership and
parities among minorities, and requiring called the AMA’s apology “appropriate” them. Later, in the 1960s, the AMA re- support funding for “pipeline” programs
medical schools and licensing boards to and “timely.” This is not an apology of con- jected the idea of excluding medical soci- to engage minority individuals to enter
make cultural competency mandatory for venience, he said, but a signal of a change eties with discriminatory practices. medical school. In addition, in 2004, the
medical students, residents, and practicing in the mind-set of the AMA leadership. During the civil rights era, the AMA AMA joined the NMA and the National
physicians. The AMA now has an opportunity to was seen as obstructing the civil rights Hispanic Medical Association to form the
“We really want to use this apology as a ensure that cultural competency becomes agenda, the paper noted. In 1961, the Commission to End Health Care Dispar-
springboard,” said Dr. Nedra H. Joyner, a tool in the medical armamentarium in AMA refused to defend eight African ities. That group has been working to ex-
chair of the NMA board of trustees and an the same way as the stethoscope or the American physicians who were arrested pand the “Doctors Back to School” pro-
otolaryngologist in Chicago. These changes scalpel, he said. “Now is the time for the after asking to be served at a medical so- gram, which brings minority physicians
will be critical to reversing racial health dis- AMA to put its resources where its mouth ciety luncheon in Atlanta. into schools to encourage students to con-
parities that have led to poorer health out- is,” said Dr. Jones, executive director of the In its review, the independent panel ap- sider careers in medicine.
comes in African Americans, she said. Mississippi Institute for Improvement of plauded AMA for its willingness to explore The ultimate goal is to have as much di-
“Talk is cheap,” said Dr. Carl Bell, pro- Geographic Minority Health. its history. But the researchers also noted versity among physicians as in the gener-
fessor of public health and psychiatry at The AMA offered the apology in July to that the legacy of inequality continues to al population, where African Americans
the University of Illinois at Chicago. coincide with the release of a historic pa- negatively affect African American physi- make up about 12% of the U.S. popula-
Dr. Bell said that while he is hopeful that per in its flagship journal that examined cians and patients. For example, in 2006 tion, Dr. Davis said. “Obviously, we have
the AMA will take some meaningful action race relations in organized medicine African Americans made up 2.2% of physi- a long way to go,” he said. ■

Brain-Cardio Tie Tenfold Increase in Risk EDITORIAL

Defects from page 1 Lamotrigine from page 1 ERIC J. BIEBER, M.D., Geisinger Health
System, Danville, Pa.
posterior fossa pathologies (four), tuberous sclerosis prevalence rate of 7.3/1,000 in- this is the sort of thing that preg-
(three), cortical malformations (three), and a combination fants. In comparison, the rate was nancy registries were intended town University, Washington
of anomalies. 0.7/1,000 for unexposed controls, for, getting larger and larger sam-
EZRA C. DAVIDSON JR., M.D., Charles R.
For example, the coronal T2 image of a fetus aged 28 yielding a statistically significant ples.” (Women in North Ameri-
Drew University of Medicine and
gestational weeks (see top figure, page 1) diagnosed with relative risk of 10.4. ca can enroll in the AED registry
Science, Los Angeles
an aberrant pulmonary vein by fetal echocardiography “That’s a whopping increase,” by calling 888-233-2334 or by vis-
shows agenesis of the corpus callosum, abnormal and re- said Dr. Holmes of Massachu- iting www.AEDPregnancyreg- BRUCE L. FLAMM, M.D., University of
California, Irvine
tarded gyration, malrotation of both hippocampi, and as- setts General Hospital for Chil-
sociated signal abnormalities of the developing white mat- dren, Boston. “You wonder if it’s Other anticonvulsant drugs are CHARLES B. HAMMOND, M.D., Duke Uni-
ter. Widening of the internal or external CSF fluid spaces a sample size [effect], but it’s cer- associated with much greater in- versity Medical Center, Durham,
was seen in 12 fetal brains. This group included problems tainly a point to be pursued in creased risks of oral clefts. For ex- N.C.
such as ventricular enlargement of more than 12 mm and comparison to other databases.” ample, the risk of oral clefts goes LUELLA V. KLEIN, M.D., Emory Univer-
widened subarachnoid spaces. One fetus showed hem- Dr. Holmes examined data up 20-fold in women taking val- sity, Atlanta
orrhagic lesions and two others had germinolytic cysts from five other pregnancy reg- proate, 21-fold in women taking HAL C. LAWRENCE III, M.D.,
(for an example of cysts in a fetus with Fallot’s tetralo- istries—an international registry carbamazepine, and 32-fold in University of North Carolina,
gy, see bottom figure, page 1, white arrows). maintained by GlaxoSmithKline, women taking phenobarbital. Chapel Hill
Genetic analysis was conducted in 15 cases. Three cas- and national registries in the Unit- The investigators noted one oth- CHARLES E. MILLER, M.D., University of
es had Di George syndrome and two cases had trisomy ed Kingdom, Sweden, Denmark, er fact about the five women in Chicago
13. The remaining 11 analyses were unremarkable. and Australia. There was a com- the North American Registry E. ALBERT REECE, M.D., University of
“This high frequency of brain abnormalities associat- bined total of 4 infants born with whose infants had oral clefts: All Maryland, Baltimore
ed with congenital heart disease is higher than previous- oral clefts among 1,623 lamotri- five had been taking folic acid JAN LESLIE SHIFREN, M.D., Harvard
ly reported with ultrasounds,” said Dr. Kasprian. “This gine-exposed women, for an over- supplementation at conception. Medical School, Boston
may be due to the higher sensitivity of fetal MRI to all rate of 2.5/1,000 and a relative Dr. Holmes disclosed that he CYRIL O. SPANN JR., M.D., Emory Uni-
demonstrate brain lesions.” risk of 3.6 vs. unexposed controls. receives financial support from versity, Atlanta
Dr. Kasprian said that he believes these brain abnor- “So a larger sample size is the six sponsors of the North Technical Consultant:
malities have a heterogenous etiology. He ascribed some needed to see whether the rate of American AED Registry: Abbott
LUIS E. SANZ, M.D., Virginia Hospital
to genetic defects, while others may be acquired as cere- clefts is a 10-fold increase or as Laboratories, Eisai Co., Glaxo-
Center, Arlington, Va.
bral sequelae of altered cardiac hemodynamics or arise low as fourfold, or somewhere in SmithKline, Novartis, Ortho-Mc-
as a result of focal ischemia or hemorrhage. ■ between,” Dr. Holmes said. “But Neil, and Pfizer Inc. ■