Michele G. Sullivan

WHITE SULPHUR SPRINGS, W.VA. — Women who experience a fourth-degree tear during delivery are significantly more likely to have persistent anal sphincter defects leading to fecal urgency or incontinence than are women with a third-degree tear, Catherine M. Nichols, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Third-degree tears are much more likely to heal without persistent sphincter defects, which are associated with up to an 18‐fold increase in the development of new postpartum bowel symptoms, said Dr. Nichols of Virginia Commonwealth University in Richmond.

Her prospective cohort study included 56 primiparous women, of whom 39 experienced a third-degree tear and 17 a fourth-degree tear at delivery.

There were no significant demographic differences between the groups. The mean age of the women was 25 years.

Infant birth weight (median about 3,400 grams) was similar in the two groups. Women who had a fourth-degree tear had a longer second stage of labor than did those with a third-degree tear (133 minutes vs. 78 minutes). Forceps deliveries occurred in 21% of the third-degree group and 47% of the fourth-degree group. Shoulder dystocia was more common in the fourth-degree group (24% vs. 13%), as was persistent occiput posterior position (24% vs. 13%) and midline episiotomy (76% vs. 49%).

After delivery, all of the women completed the Manchester Modified Bowel Function questionnaire to assess predelivery bowel function. At 6 weeks post partum, all women were examined at a dedicated perineal clinic, where they completed another questionnaire to assess new bowel symptoms and received a pelvic exam and an endoanal ultrasound exam to determine the state of both internal and external anal sphincters.

Of the 56 women, 21 (38%) reported new bowel symptoms, which were incontinency to liquid stool or gas (14 women) and fecal urgency (19 women). Among those reporting new symptoms, 59% had a fourth-degree tear and 28% had a third-degree tear.

Disruption of both sphincters was more common among fourth-degree-tear patients. (See box.)

Conversely, most women with third-degree tears had both sphincters intact. Intact internal sphincters were found in significantly more women with third-degree tears than in those with fourth-degree tears.

Intact external sphincters were found in a total of 67% of women who had third-degree tears and in 41% of those with fourth-degree tears. This difference, however, was not statistically significant.

There was a very strong correlation between sphincter disruption and the development of new symptoms. Women with an isolated defect of the external sphincter were 15.7 times more likely than those with no defects to report symptoms, and women with combined defects were 18.7 times more likely to report new symptoms, Dr. Nichols said at the meeting.

Arrows indicate an area of disruption in the external anal sphincter (circular hyperechoic region). The internal anal sphincter (adjacent circular hypoechoic region) remains intact. Courtesy Dr. Catherine M. Nichols

KEVIN FOLEY, RESEARCH/SARAH GALLANT, DESIGN

WHITE SULPHUR SPRINGS, W.VA. — Women who experience a fourth-degree tear during delivery are significantly more likely to have persistent anal sphincter defects leading to fecal urgency or incontinence than are women with a third-degree tear, Catherine M. Nichols, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Third-degree tears are much more likely to heal without persistent sphincter defects, which are associated with up to an 18‐fold increase in the development of new postpartum bowel symptoms, said Dr. Nichols of Virginia Commonwealth University in Richmond.

Her prospective cohort study included 56 primiparous women, of whom 39 experienced a third-degree tear and 17 a fourth-degree tear at delivery.

There were no significant demographic differences between the groups. The mean age of the women was 25 years.

Infant birth weight (median about 3,400 grams) was similar in the two groups. Women who had a fourth-degree tear had a longer second stage of labor than did those with a third-degree tear (133 minutes vs. 78 minutes). Forceps deliveries occurred in 21% of the third-degree group and 47% of the fourth-degree group. Shoulder dystocia was more common in the fourth-degree group (24% vs. 13%), as was persistent occiput posterior position (24% vs. 13%) and midline episiotomy (76% vs. 49%).

After delivery, all of the women completed the Manchester Modified Bowel Function questionnaire to assess predelivery bowel function. At 6 weeks post partum, all women were examined at a dedicated perineal clinic, where they completed another questionnaire to assess new bowel symptoms and received a pelvic exam and an endoanal ultrasound exam to determine the state of both internal and external anal sphincters.

Of the 56 women, 21 (38%) reported new bowel symptoms, which were incontinency to liquid stool or gas (14 women) and fecal urgency (19 women). Among those reporting new symptoms, 59% had a fourth-degree tear and 28% had a third-degree tear.

Disruption of both sphincters was more common among fourth-degree-tear patients. (See box.)

Conversely, most women with third-degree tears had both sphincters intact. Intact internal sphincters were found in significantly more women with third-degree tears than in those with fourth-degree tears.

Intact external sphincters were found in a total of 67% of women who had third-degree tears and in 41% of those with fourth-degree tears. This difference, however, was not statistically significant.

There was a very strong correlation between sphincter disruption and the development of new symptoms. Women with an isolated defect of the external sphincter were 15.7 times more likely than those with no defects to report symptoms, and women with combined defects were 18.7 times more likely to report new symptoms, Dr. Nichols said at the meeting.

Arrows indicate an area of disruption in the external anal sphincter (circular hyperechoic region). The internal anal sphincter (adjacent circular hypoechoic region) remains intact. Courtesy Dr. Catherine M. Nichols

KEVIN FOLEY, RESEARCH/SARAH GALLANT, DESIGN

WHITE SULPHUR SPRINGS, W.VA. — Women who experience a fourth-degree tear during delivery are significantly more likely to have persistent anal sphincter defects leading to fecal urgency or incontinence than are women with a third-degree tear, Catherine M. Nichols, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Third-degree tears are much more likely to heal without persistent sphincter defects, which are associated with up to an 18‐fold increase in the development of new postpartum bowel symptoms, said Dr. Nichols of Virginia Commonwealth University in Richmond.

Her prospective cohort study included 56 primiparous women, of whom 39 experienced a third-degree tear and 17 a fourth-degree tear at delivery.

There were no significant demographic differences between the groups. The mean age of the women was 25 years.

Infant birth weight (median about 3,400 grams) was similar in the two groups. Women who had a fourth-degree tear had a longer second stage of labor than did those with a third-degree tear (133 minutes vs. 78 minutes). Forceps deliveries occurred in 21% of the third-degree group and 47% of the fourth-degree group. Shoulder dystocia was more common in the fourth-degree group (24% vs. 13%), as was persistent occiput posterior position (24% vs. 13%) and midline episiotomy (76% vs. 49%).

After delivery, all of the women completed the Manchester Modified Bowel Function questionnaire to assess predelivery bowel function. At 6 weeks post partum, all women were examined at a dedicated perineal clinic, where they completed another questionnaire to assess new bowel symptoms and received a pelvic exam and an endoanal ultrasound exam to determine the state of both internal and external anal sphincters.

Of the 56 women, 21 (38%) reported new bowel symptoms, which were incontinency to liquid stool or gas (14 women) and fecal urgency (19 women). Among those reporting new symptoms, 59% had a fourth-degree tear and 28% had a third-degree tear.

Disruption of both sphincters was more common among fourth-degree-tear patients. (See box.)

Conversely, most women with third-degree tears had both sphincters intact. Intact internal sphincters were found in significantly more women with third-degree tears than in those with fourth-degree tears.

Intact external sphincters were found in a total of 67% of women who had third-degree tears and in 41% of those with fourth-degree tears. This difference, however, was not statistically significant.

There was a very strong correlation between sphincter disruption and the development of new symptoms. Women with an isolated defect of the external sphincter were 15.7 times more likely than those with no defects to report symptoms, and women with combined defects were 18.7 times more likely to report new symptoms, Dr. Nichols said at the meeting.

Arrows indicate an area of disruption in the external anal sphincter (circular hyperechoic region). The internal anal sphincter (adjacent circular hypoechoic region) remains intact. Courtesy Dr. Catherine M. Nichols

KEVIN FOLEY, RESEARCH/SARAH GALLANT, DESIGN

WHITE SULPHUR SPRINGS, W.VA. — A high dose of vaginal misoprostol effects more rapid termination of second-trimester pregnancy than does a low dose and is not associated with an increase in side effects or complications, Rodney K. Edwards, M.D., reported during the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Dr. Edwards presented the results of a retrospective study comparing delivery outcomes with two misoprostol induction protocols at his institution, the University of Florida.

The low-dose regimen (200 mcg every 12 hours) was in use before July 1, 2002, and the current high-dose regimen (400 mcg every 6 hours) has been in use since then.

The cohort included 147 women who sought termination of second-trimester pregnancy from 1996 to 2004. All the women were carrying a singleton fetus of 13–27 weeks' gestation (median 20 weeks).

There were 100 women in the low-dose group and 47 in the high-dose group. Their mean age was 27 years. About 36% of the women were nulliparous; 56% had a prior vaginal delivery, and 12% had a prior cesarean delivery.

The most common indication for induction was fetal anomaly. Other indications were fetal death, premature rupture of membranes, and maternal indications, such as severe preeclampsia.

The high-dose group delivered significantly quicker than the low-dose group (mean time 13.25 hours vs. 22.5 hours). In the high-dose group, 81% of patients had delivered by 24 hours, compared with 54% of the low-dose group.

More patients in the low-dose group required a second abortifacient to effect delivery (27% vs. 6%).

Four low-dose patients failed to deliver vaginally during the same hospital admission. One had a hysterotomy due to a failed induction and rupture of membranes. Three were discharged home undelivered and returned for another attempt.

One high-dose patient, who had a prior cesarean and a collagen abnormality, experienced a ruptured uterus posteriorly and underwent hysterotomy.

Side effects (nausea, vomiting, and diarrhea) were uncommon in both groups, occurring at rates of less than 5%.

Postpartum hemorrhage also occurred in fewer than 5% of patients in both groups.

Dr. Edwards reported an unexplained finding of a higher incidence of clinical chorioamnionitis in the high-dose group (17% vs. 5% in the low-dose group). Among the 100 patients for whom placental pathology was available, histologic chorioamnionitis was also more common in the high-dose group (29% vs. 11%).

“Because of this finding, we think the high-dose regimen did not cause fever and a false diagnosis of chorioamnionitis, but the group for some reason actually did have a higher incidence,” Dr. Edwards said.

He could offer no clear explanation of this finding, which he called “counterintuitive,” given that the shorter labors seen in the high-dose group might have been associated with fewer vaginal exams.

In both groups, dead fetuses were more quickly delivered than live fetuses. In the low-dose group, the median time to delivery was 23.5 hours for a live fetus and 11 hours for a dead fetus. In the high-dose group, the median time to deliver a live fetus was 15.5 hours, compared with 11 hours for a dead fetus.

When the two groups were analyzed considering only live fetuses, however, the high-dose protocol still effected earlier delivery, with a median time to delivery of 15.5 hours, compared with 23.5 hours for the low-dose group, according to Dr. Edwards.

WHITE SULPHUR SPRINGS, W.VA. — A high dose of vaginal misoprostol effects more rapid termination of second-trimester pregnancy than does a low dose and is not associated with an increase in side effects or complications, Rodney K. Edwards, M.D., reported during the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Dr. Edwards presented the results of a retrospective study comparing delivery outcomes with two misoprostol induction protocols at his institution, the University of Florida.

The low-dose regimen (200 mcg every 12 hours) was in use before July 1, 2002, and the current high-dose regimen (400 mcg every 6 hours) has been in use since then.

The cohort included 147 women who sought termination of second-trimester pregnancy from 1996 to 2004. All the women were carrying a singleton fetus of 13–27 weeks' gestation (median 20 weeks).

There were 100 women in the low-dose group and 47 in the high-dose group. Their mean age was 27 years. About 36% of the women were nulliparous; 56% had a prior vaginal delivery, and 12% had a prior cesarean delivery.

The most common indication for induction was fetal anomaly. Other indications were fetal death, premature rupture of membranes, and maternal indications, such as severe preeclampsia.

The high-dose group delivered significantly quicker than the low-dose group (mean time 13.25 hours vs. 22.5 hours). In the high-dose group, 81% of patients had delivered by 24 hours, compared with 54% of the low-dose group.

More patients in the low-dose group required a second abortifacient to effect delivery (27% vs. 6%).

Four low-dose patients failed to deliver vaginally during the same hospital admission. One had a hysterotomy due to a failed induction and rupture of membranes. Three were discharged home undelivered and returned for another attempt.

One high-dose patient, who had a prior cesarean and a collagen abnormality, experienced a ruptured uterus posteriorly and underwent hysterotomy.

Side effects (nausea, vomiting, and diarrhea) were uncommon in both groups, occurring at rates of less than 5%.

Postpartum hemorrhage also occurred in fewer than 5% of patients in both groups.

Dr. Edwards reported an unexplained finding of a higher incidence of clinical chorioamnionitis in the high-dose group (17% vs. 5% in the low-dose group). Among the 100 patients for whom placental pathology was available, histologic chorioamnionitis was also more common in the high-dose group (29% vs. 11%).

“Because of this finding, we think the high-dose regimen did not cause fever and a false diagnosis of chorioamnionitis, but the group for some reason actually did have a higher incidence,” Dr. Edwards said.

He could offer no clear explanation of this finding, which he called “counterintuitive,” given that the shorter labors seen in the high-dose group might have been associated with fewer vaginal exams.

In both groups, dead fetuses were more quickly delivered than live fetuses. In the low-dose group, the median time to delivery was 23.5 hours for a live fetus and 11 hours for a dead fetus. In the high-dose group, the median time to deliver a live fetus was 15.5 hours, compared with 11 hours for a dead fetus.

When the two groups were analyzed considering only live fetuses, however, the high-dose protocol still effected earlier delivery, with a median time to delivery of 15.5 hours, compared with 23.5 hours for the low-dose group, according to Dr. Edwards.

WHITE SULPHUR SPRINGS, W.VA. — A high dose of vaginal misoprostol effects more rapid termination of second-trimester pregnancy than does a low dose and is not associated with an increase in side effects or complications, Rodney K. Edwards, M.D., reported during the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

Dr. Edwards presented the results of a retrospective study comparing delivery outcomes with two misoprostol induction protocols at his institution, the University of Florida.

The low-dose regimen (200 mcg every 12 hours) was in use before July 1, 2002, and the current high-dose regimen (400 mcg every 6 hours) has been in use since then.

The cohort included 147 women who sought termination of second-trimester pregnancy from 1996 to 2004. All the women were carrying a singleton fetus of 13–27 weeks' gestation (median 20 weeks).

There were 100 women in the low-dose group and 47 in the high-dose group. Their mean age was 27 years. About 36% of the women were nulliparous; 56% had a prior vaginal delivery, and 12% had a prior cesarean delivery.

The most common indication for induction was fetal anomaly. Other indications were fetal death, premature rupture of membranes, and maternal indications, such as severe preeclampsia.

The high-dose group delivered significantly quicker than the low-dose group (mean time 13.25 hours vs. 22.5 hours). In the high-dose group, 81% of patients had delivered by 24 hours, compared with 54% of the low-dose group.

More patients in the low-dose group required a second abortifacient to effect delivery (27% vs. 6%).

Four low-dose patients failed to deliver vaginally during the same hospital admission. One had a hysterotomy due to a failed induction and rupture of membranes. Three were discharged home undelivered and returned for another attempt.

One high-dose patient, who had a prior cesarean and a collagen abnormality, experienced a ruptured uterus posteriorly and underwent hysterotomy.

Side effects (nausea, vomiting, and diarrhea) were uncommon in both groups, occurring at rates of less than 5%.

Postpartum hemorrhage also occurred in fewer than 5% of patients in both groups.

Dr. Edwards reported an unexplained finding of a higher incidence of clinical chorioamnionitis in the high-dose group (17% vs. 5% in the low-dose group). Among the 100 patients for whom placental pathology was available, histologic chorioamnionitis was also more common in the high-dose group (29% vs. 11%).

“Because of this finding, we think the high-dose regimen did not cause fever and a false diagnosis of chorioamnionitis, but the group for some reason actually did have a higher incidence,” Dr. Edwards said.

He could offer no clear explanation of this finding, which he called “counterintuitive,” given that the shorter labors seen in the high-dose group might have been associated with fewer vaginal exams.

In both groups, dead fetuses were more quickly delivered than live fetuses. In the low-dose group, the median time to delivery was 23.5 hours for a live fetus and 11 hours for a dead fetus. In the high-dose group, the median time to deliver a live fetus was 15.5 hours, compared with 11 hours for a dead fetus.

When the two groups were analyzed considering only live fetuses, however, the high-dose protocol still effected earlier delivery, with a median time to delivery of 15.5 hours, compared with 23.5 hours for the low-dose group, according to Dr. Edwards.

WHITE SULPHUR SPRINGS, W.VA. — Occiput posterior fetal head position during a vacuum delivery incrementally increases the risk of anal sphincter injury above the risk imposed by the vacuum alone, Jennifer Wu, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

In her retrospective study, vacuum delivery from the OP position was four times more likely to result in a sphincter-injuring third- or fourth-degree tear than vacuum delivery from the occiput anterior (OA) position.

“This is an important issue to consider when weighing the risks and benefits of performing a vacuum delivery from the OP position, especially when one of the goals is to reduce the risk of maternal perineal trauma,” said Dr. Wu of the University of North Carolina, Chapel Hill.

She retrospectively analyzed a total of 393 vacuum deliveries performed at the university from 1996 to 2003. Anal sphincter injury was defined as a third‐ or fourth-degree laceration.

There were 48 deliveries from the OP position and 345 deliveries from the OA position. Women in the OP group were significantly younger than those in the OA group (24 years vs. 28 years), more likely to be nulliparous (87% vs. 74%), and more likely to have received an episiotomy (35% vs. 14%).

The infants' gestational age, head circumference, and birth weight were not significantly different between the groups.

The overall anal sphincter injury rate was 24%. Significantly more women in the OP group sustained an anal sphincter injury (42% vs. 22%).

In a multivariate analysis that took into account fetal head position, body mass index, race, nulliparity, length of second stage, episiotomy, birth weight and head circumference, the OP position was four times more likely to be associated with an anal sphincter injury than the OA position.

In a previous retrospective study of 588 forceps deliveries, Dr. Wu also found an increased anal sphincter injury rate among OP deliveries, compared with OA deliveries (51% vs. 33%).

WHITE SULPHUR SPRINGS, W.VA. — Occiput posterior fetal head position during a vacuum delivery incrementally increases the risk of anal sphincter injury above the risk imposed by the vacuum alone, Jennifer Wu, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

In her retrospective study, vacuum delivery from the OP position was four times more likely to result in a sphincter-injuring third- or fourth-degree tear than vacuum delivery from the occiput anterior (OA) position.

“This is an important issue to consider when weighing the risks and benefits of performing a vacuum delivery from the OP position, especially when one of the goals is to reduce the risk of maternal perineal trauma,” said Dr. Wu of the University of North Carolina, Chapel Hill.

She retrospectively analyzed a total of 393 vacuum deliveries performed at the university from 1996 to 2003. Anal sphincter injury was defined as a third‐ or fourth-degree laceration.

There were 48 deliveries from the OP position and 345 deliveries from the OA position. Women in the OP group were significantly younger than those in the OA group (24 years vs. 28 years), more likely to be nulliparous (87% vs. 74%), and more likely to have received an episiotomy (35% vs. 14%).

The infants' gestational age, head circumference, and birth weight were not significantly different between the groups.

The overall anal sphincter injury rate was 24%. Significantly more women in the OP group sustained an anal sphincter injury (42% vs. 22%).

In a multivariate analysis that took into account fetal head position, body mass index, race, nulliparity, length of second stage, episiotomy, birth weight and head circumference, the OP position was four times more likely to be associated with an anal sphincter injury than the OA position.

In a previous retrospective study of 588 forceps deliveries, Dr. Wu also found an increased anal sphincter injury rate among OP deliveries, compared with OA deliveries (51% vs. 33%).

WHITE SULPHUR SPRINGS, W.VA. — Occiput posterior fetal head position during a vacuum delivery incrementally increases the risk of anal sphincter injury above the risk imposed by the vacuum alone, Jennifer Wu, M.D., said at the annual meeting of the South Atlantic Association of Obstetricians and Gynecologists.

In her retrospective study, vacuum delivery from the OP position was four times more likely to result in a sphincter-injuring third- or fourth-degree tear than vacuum delivery from the occiput anterior (OA) position.

“This is an important issue to consider when weighing the risks and benefits of performing a vacuum delivery from the OP position, especially when one of the goals is to reduce the risk of maternal perineal trauma,” said Dr. Wu of the University of North Carolina, Chapel Hill.

She retrospectively analyzed a total of 393 vacuum deliveries performed at the university from 1996 to 2003. Anal sphincter injury was defined as a third‐ or fourth-degree laceration.

There were 48 deliveries from the OP position and 345 deliveries from the OA position. Women in the OP group were significantly younger than those in the OA group (24 years vs. 28 years), more likely to be nulliparous (87% vs. 74%), and more likely to have received an episiotomy (35% vs. 14%).

The infants' gestational age, head circumference, and birth weight were not significantly different between the groups.

The overall anal sphincter injury rate was 24%. Significantly more women in the OP group sustained an anal sphincter injury (42% vs. 22%).

In a multivariate analysis that took into account fetal head position, body mass index, race, nulliparity, length of second stage, episiotomy, birth weight and head circumference, the OP position was four times more likely to be associated with an anal sphincter injury than the OA position.

In a previous retrospective study of 588 forceps deliveries, Dr. Wu also found an increased anal sphincter injury rate among OP deliveries, compared with OA deliveries (51% vs. 33%).

NEW ORLEANS — The best contraceptive choices for women on antiepileptic medications are probably a progesterone-eluting intrauterine device or intramuscular medroxyprogesterone, with the higher doses of oral contraceptives running in second place, Anne Davis, M.D., said at the annual meeting of the American Epilepsy Society.

Some antiepileptic drugs—carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital and primidone), and topiramate—enhance the P450 cytochrome enzyme system. “This decline potentially decreases the effectiveness of hormonal methods of contraception,” said Dr. Davis of Columbia University, New York.

The intrauterine device (IUD) and the depot medroxy-progesterone acetate (DMPA) (Depo-Provera) injection are not as prone to these drug interactions. The progesterone-eluting IUD thickens cervical mucus, impairs sperm movement, suppresses endometrial development, and has a slight anovulatory effect. DMPA suppresses ovulation and its progesterone content protects its effect from alterations in the enzyme system, Dr. Davis said.

In addition, the high progesterone content might have antiseizure properties. “This is a little bit of a teaser, something that's out there in the literature. Progesterone decreased seizure frequency in animal models, and DMPA decreased seizure frequency in women with intractable epilepsy. It's a tantalizing thing, but there's too little information out there to make any conclusions.”

The second choice for women on the CYP450-enhancing drugs would be higher dose oral contraceptives. “It's a little misleading to actually call some oral contraceptives 'high dose,' because everything these days is really low dose,” she said. “What we're really talking about is differentiating between medium dose, low dose, and very low dose.”

Experts have said that oral contraceptives containing 50 mcg estrogen are probably the most effective for these women, “But there are no real data to back that up,” Dr. Davis said. The contraceptive patch and vaginal ring are comparable in estrogen dose with the 50-mcg pill.

The lower-dose pills are much more prone to failure in these women, as are progesterone-only pills. Neither the six-rod implant currently available nor the soon-to-be-approved single rod implant (Implanon) are good choices for this population, as they are both progesterone-only methods.

Some women may want to consider a barrier method, since this alleviates the concern of failure due to drug interaction. However, the failure rates of barrier methods are so much higher than those of hormonal methods that the chance of pregnancy is vastly increased, even taking into consideration drug interaction failures.

Even women taking medications that don't increase contraceptive failure may have special contraceptive considerations, Dr. Davis said. Numerous studies point to valproate's teratogenicity. Women on this drug who want to conceive may consider switching to another effective drug. If pregnancy is not in the cards for them, sterilization may be a viable alternative.

Women with catamenial epilepsy should use a form of birth control that reliably suppresses ovulation. DMPA is a good choice for this population. “Unlike the amenorrhea produced by the progesterone IUD, where they are still ovulating, the DPMA shot reliably suppresses ovulation,” Dr. Davis said. “This is an important consideration for seizure frequency that's responsive to fluctuations in the menstrual cycle.”

NEW ORLEANS — The best contraceptive choices for women on antiepileptic medications are probably a progesterone-eluting intrauterine device or intramuscular medroxyprogesterone, with the higher doses of oral contraceptives running in second place, Anne Davis, M.D., said at the annual meeting of the American Epilepsy Society.

Some antiepileptic drugs—carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital and primidone), and topiramate—enhance the P450 cytochrome enzyme system. “This decline potentially decreases the effectiveness of hormonal methods of contraception,” said Dr. Davis of Columbia University, New York.

The intrauterine device (IUD) and the depot medroxy-progesterone acetate (DMPA) (Depo-Provera) injection are not as prone to these drug interactions. The progesterone-eluting IUD thickens cervical mucus, impairs sperm movement, suppresses endometrial development, and has a slight anovulatory effect. DMPA suppresses ovulation and its progesterone content protects its effect from alterations in the enzyme system, Dr. Davis said.

In addition, the high progesterone content might have antiseizure properties. “This is a little bit of a teaser, something that's out there in the literature. Progesterone decreased seizure frequency in animal models, and DMPA decreased seizure frequency in women with intractable epilepsy. It's a tantalizing thing, but there's too little information out there to make any conclusions.”

The second choice for women on the CYP450-enhancing drugs would be higher dose oral contraceptives. “It's a little misleading to actually call some oral contraceptives 'high dose,' because everything these days is really low dose,” she said. “What we're really talking about is differentiating between medium dose, low dose, and very low dose.”

Experts have said that oral contraceptives containing 50 mcg estrogen are probably the most effective for these women, “But there are no real data to back that up,” Dr. Davis said. The contraceptive patch and vaginal ring are comparable in estrogen dose with the 50-mcg pill.

The lower-dose pills are much more prone to failure in these women, as are progesterone-only pills. Neither the six-rod implant currently available nor the soon-to-be-approved single rod implant (Implanon) are good choices for this population, as they are both progesterone-only methods.

Some women may want to consider a barrier method, since this alleviates the concern of failure due to drug interaction. However, the failure rates of barrier methods are so much higher than those of hormonal methods that the chance of pregnancy is vastly increased, even taking into consideration drug interaction failures.

Even women taking medications that don't increase contraceptive failure may have special contraceptive considerations, Dr. Davis said. Numerous studies point to valproate's teratogenicity. Women on this drug who want to conceive may consider switching to another effective drug. If pregnancy is not in the cards for them, sterilization may be a viable alternative.

Women with catamenial epilepsy should use a form of birth control that reliably suppresses ovulation. DMPA is a good choice for this population. “Unlike the amenorrhea produced by the progesterone IUD, where they are still ovulating, the DPMA shot reliably suppresses ovulation,” Dr. Davis said. “This is an important consideration for seizure frequency that's responsive to fluctuations in the menstrual cycle.”

NEW ORLEANS — The best contraceptive choices for women on antiepileptic medications are probably a progesterone-eluting intrauterine device or intramuscular medroxyprogesterone, with the higher doses of oral contraceptives running in second place, Anne Davis, M.D., said at the annual meeting of the American Epilepsy Society.

Some antiepileptic drugs—carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital and primidone), and topiramate—enhance the P450 cytochrome enzyme system. “This decline potentially decreases the effectiveness of hormonal methods of contraception,” said Dr. Davis of Columbia University, New York.

The intrauterine device (IUD) and the depot medroxy-progesterone acetate (DMPA) (Depo-Provera) injection are not as prone to these drug interactions. The progesterone-eluting IUD thickens cervical mucus, impairs sperm movement, suppresses endometrial development, and has a slight anovulatory effect. DMPA suppresses ovulation and its progesterone content protects its effect from alterations in the enzyme system, Dr. Davis said.

In addition, the high progesterone content might have antiseizure properties. “This is a little bit of a teaser, something that's out there in the literature. Progesterone decreased seizure frequency in animal models, and DMPA decreased seizure frequency in women with intractable epilepsy. It's a tantalizing thing, but there's too little information out there to make any conclusions.”

The second choice for women on the CYP450-enhancing drugs would be higher dose oral contraceptives. “It's a little misleading to actually call some oral contraceptives 'high dose,' because everything these days is really low dose,” she said. “What we're really talking about is differentiating between medium dose, low dose, and very low dose.”

Experts have said that oral contraceptives containing 50 mcg estrogen are probably the most effective for these women, “But there are no real data to back that up,” Dr. Davis said. The contraceptive patch and vaginal ring are comparable in estrogen dose with the 50-mcg pill.

The lower-dose pills are much more prone to failure in these women, as are progesterone-only pills. Neither the six-rod implant currently available nor the soon-to-be-approved single rod implant (Implanon) are good choices for this population, as they are both progesterone-only methods.

Some women may want to consider a barrier method, since this alleviates the concern of failure due to drug interaction. However, the failure rates of barrier methods are so much higher than those of hormonal methods that the chance of pregnancy is vastly increased, even taking into consideration drug interaction failures.

Even women taking medications that don't increase contraceptive failure may have special contraceptive considerations, Dr. Davis said. Numerous studies point to valproate's teratogenicity. Women on this drug who want to conceive may consider switching to another effective drug. If pregnancy is not in the cards for them, sterilization may be a viable alternative.

Women with catamenial epilepsy should use a form of birth control that reliably suppresses ovulation. DMPA is a good choice for this population. “Unlike the amenorrhea produced by the progesterone IUD, where they are still ovulating, the DPMA shot reliably suppresses ovulation,” Dr. Davis said. “This is an important consideration for seizure frequency that's responsive to fluctuations in the menstrual cycle.”

NEW ORLEANS — The best contraceptive choices for women on antiepileptic medications are probably a progesterone-eluting intrauterine device or intramuscular medroxyprogesterone, with the higher doses of oral contraceptives running in second place, Anne Davis, M.D., said at the annual meeting of the American Epilepsy Society.

Some antiepileptic drugs—carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital and primidone), and topiramate—enhance the P450 cytochrome enzyme system. “This potentially decreases the effectiveness of hormonal methods of contraception,” said Dr. Davis of Columbia University, New York.

The intrauterine device (IUD) and the depot medroxyprogesterone acetate (Depo-Provera) injection are not as prone to these drug interactions. The progesterone-eluting IUD thickens cervical mucus, impairs sperm movement, suppresses endometrial development, and has a slight anovulatory effect. The depot medroxyprogesterone acetate (DMPA) suppresses ovulation, and its progesterone content protects its effect from alterations in the enzyme system, Dr. Davis said.

In addition, the high progesterone content might have antiseizure properties. “This is a little bit of a teaser, something that's out there in the literature. Progesterone decreased seizure frequency in animal models, and DMPA decreased seizure frequency in women with intractable epilepsy.”

The second choice for women on the CYP450-enhancing drugs would be higher-dose oral contraceptives. No OC on the market is “high dose.” “What we're really talking about is differentiating between medium dose, low dose, and very low dose.”

Experts have said that oral contraceptives containing 50 mcg estrogen are probably the most effective for these women, “But there are no real data to back that up,” Dr. Davis said. The contraceptive patch and vaginal ring are comparable in estrogen dose with the 50-mcg pill.

The lower-dose pills are much more prone to failure in these women, as are progesterone-only pills. Neither the six-rod implant currently available nor the soon-to-be-approved single rod implant (Implanon) are good choices for this population, as they are both progesterone-only methods.

Some women may want to consider a barrier method, since this alleviates the concern of failure due to drug interaction. However, the failure rates of barrier methods are so much higher than those of hormonal methods that the chance of pregnancy is vastly increased, even taking into consideration drug interaction failures.

Even women taking medications that don't increase contraceptive failure may have special contraceptive considerations, Dr. Davis said.

Numerous studies point to valproate's teratogenicity. Women on this drug who want to conceive may consider switching to another effective drug. If pregnancy is not in the cards for them, sterilization may be a viable alternative.

Women with catamenial epilepsy should use a form of birth control that reliably suppresses ovulation. DMPA is a good choice for this population. “Unlike the amenorrhea produced by the progesterone IUD, where they are still ovulating, the DPMA shot reliably suppresses ovulation,” Dr. Davis said. “This is an important consideration for seizure frequency that's responsive to fluctuations in the menstrual cycle.”

All women of childbearing age—including those with epilepsy—should be offered a prescription for emergency contraception, Dr. Davis said. No studies have assessed any possible interactions with AEDs, but “there's no downside to giving it,” she said.

“Give it anyway. It doesn't interrupt an established pregnancy. There's no harm in giving it and you might prevent something that would be good to prevent.”

NEW ORLEANS — The best contraceptive choices for women on antiepileptic medications are probably a progesterone-eluting intrauterine device or intramuscular medroxyprogesterone, with the higher doses of oral contraceptives running in second place, Anne Davis, M.D., said at the annual meeting of the American Epilepsy Society.

Some antiepileptic drugs—carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital and primidone), and topiramate—enhance the P450 cytochrome enzyme system. “This potentially decreases the effectiveness of hormonal methods of contraception,” said Dr. Davis of Columbia University, New York.

The intrauterine device (IUD) and the depot medroxyprogesterone acetate (Depo-Provera) injection are not as prone to these drug interactions. The progesterone-eluting IUD thickens cervical mucus, impairs sperm movement, suppresses endometrial development, and has a slight anovulatory effect. The depot medroxyprogesterone acetate (DMPA) suppresses ovulation, and its progesterone content protects its effect from alterations in the enzyme system, Dr. Davis said.

In addition, the high progesterone content might have antiseizure properties. “This is a little bit of a teaser, something that's out there in the literature. Progesterone decreased seizure frequency in animal models, and DMPA decreased seizure frequency in women with intractable epilepsy.”

The second choice for women on the CYP450-enhancing drugs would be higher-dose oral contraceptives. No OC on the market is “high dose.” “What we're really talking about is differentiating between medium dose, low dose, and very low dose.”

Experts have said that oral contraceptives containing 50 mcg estrogen are probably the most effective for these women, “But there are no real data to back that up,” Dr. Davis said. The contraceptive patch and vaginal ring are comparable in estrogen dose with the 50-mcg pill.

The lower-dose pills are much more prone to failure in these women, as are progesterone-only pills. Neither the six-rod implant currently available nor the soon-to-be-approved single rod implant (Implanon) are good choices for this population, as they are both progesterone-only methods.

Some women may want to consider a barrier method, since this alleviates the concern of failure due to drug interaction. However, the failure rates of barrier methods are so much higher than those of hormonal methods that the chance of pregnancy is vastly increased, even taking into consideration drug interaction failures.

Even women taking medications that don't increase contraceptive failure may have special contraceptive considerations, Dr. Davis said.

Numerous studies point to valproate's teratogenicity. Women on this drug who want to conceive may consider switching to another effective drug. If pregnancy is not in the cards for them, sterilization may be a viable alternative.

Women with catamenial epilepsy should use a form of birth control that reliably suppresses ovulation. DMPA is a good choice for this population. “Unlike the amenorrhea produced by the progesterone IUD, where they are still ovulating, the DPMA shot reliably suppresses ovulation,” Dr. Davis said. “This is an important consideration for seizure frequency that's responsive to fluctuations in the menstrual cycle.”

All women of childbearing age—including those with epilepsy—should be offered a prescription for emergency contraception, Dr. Davis said. No studies have assessed any possible interactions with AEDs, but “there's no downside to giving it,” she said.

“Give it anyway. It doesn't interrupt an established pregnancy. There's no harm in giving it and you might prevent something that would be good to prevent.”

NEW ORLEANS — The best contraceptive choices for women on antiepileptic medications are probably a progesterone-eluting intrauterine device or intramuscular medroxyprogesterone, with the higher doses of oral contraceptives running in second place, Anne Davis, M.D., said at the annual meeting of the American Epilepsy Society.

Some antiepileptic drugs—carbamazepine, oxcarbazepine, phenytoin, barbiturates (phenobarbital, mephobarbital and primidone), and topiramate—enhance the P450 cytochrome enzyme system. “This potentially decreases the effectiveness of hormonal methods of contraception,” said Dr. Davis of Columbia University, New York.

The intrauterine device (IUD) and the depot medroxyprogesterone acetate (Depo-Provera) injection are not as prone to these drug interactions. The progesterone-eluting IUD thickens cervical mucus, impairs sperm movement, suppresses endometrial development, and has a slight anovulatory effect. The depot medroxyprogesterone acetate (DMPA) suppresses ovulation, and its progesterone content protects its effect from alterations in the enzyme system, Dr. Davis said.

In addition, the high progesterone content might have antiseizure properties. “This is a little bit of a teaser, something that's out there in the literature. Progesterone decreased seizure frequency in animal models, and DMPA decreased seizure frequency in women with intractable epilepsy.”

The second choice for women on the CYP450-enhancing drugs would be higher-dose oral contraceptives. No OC on the market is “high dose.” “What we're really talking about is differentiating between medium dose, low dose, and very low dose.”

Experts have said that oral contraceptives containing 50 mcg estrogen are probably the most effective for these women, “But there are no real data to back that up,” Dr. Davis said. The contraceptive patch and vaginal ring are comparable in estrogen dose with the 50-mcg pill.

The lower-dose pills are much more prone to failure in these women, as are progesterone-only pills. Neither the six-rod implant currently available nor the soon-to-be-approved single rod implant (Implanon) are good choices for this population, as they are both progesterone-only methods.

Some women may want to consider a barrier method, since this alleviates the concern of failure due to drug interaction. However, the failure rates of barrier methods are so much higher than those of hormonal methods that the chance of pregnancy is vastly increased, even taking into consideration drug interaction failures.

Even women taking medications that don't increase contraceptive failure may have special contraceptive considerations, Dr. Davis said.

Numerous studies point to valproate's teratogenicity. Women on this drug who want to conceive may consider switching to another effective drug. If pregnancy is not in the cards for them, sterilization may be a viable alternative.

Women with catamenial epilepsy should use a form of birth control that reliably suppresses ovulation. DMPA is a good choice for this population. “Unlike the amenorrhea produced by the progesterone IUD, where they are still ovulating, the DPMA shot reliably suppresses ovulation,” Dr. Davis said. “This is an important consideration for seizure frequency that's responsive to fluctuations in the menstrual cycle.”

All women of childbearing age—including those with epilepsy—should be offered a prescription for emergency contraception, Dr. Davis said. No studies have assessed any possible interactions with AEDs, but “there's no downside to giving it,” she said.

“Give it anyway. It doesn't interrupt an established pregnancy. There's no harm in giving it and you might prevent something that would be good to prevent.”

Pelvic floor training during pregnancy appears to facilitate delivery and was associated with a decreased incidence of prolonged second-stage labor, Kjell Salvesen, M.D., and colleagues reported.

The results were observed in a secondary analysis of a randomized, controlled study that compared the rate of postpartum incontinence in women who had done the pelvic floor muscle training during pregnancy with that of women who had not.

The original analysis found less urinary incontinence among patients in the treatment group.

Dr. Salvesen of Trondheim (Norway) University and his associates randomized 301 nulliparous pregnant women to either no training or 1 hour of intensive pelvic floor exercises with a physiotherapist each week for 12 weeks (BMJ 2004;329:378–80).

The training occurred between weeks 20 and 36 of pregnancy. The women were also encouraged to perform 8–10 intense pelvic floor contractions at home twice a day. Women in the control group were not discouraged from doing pelvic floor exercises, but received no specific instructions on how to do so.

Only those who entered spontaneous labor after 37 weeks with a singleton fetus in cephalic position were included in the final analysis: There were 111 women in the control group and 113 women in the treatment group.

Treatment-group women had a lower rate of prolonged (longer than 60 minutes) second stage of labor than women in the control group (21% vs. 34%).

Fewer women in the treatment group had episiotomies (51% vs. 64%), but the rates of operative delivery were not significantly different between the two groups.

Pelvic floor training during pregnancy appears to facilitate delivery and was associated with a decreased incidence of prolonged second-stage labor, Kjell Salvesen, M.D., and colleagues reported.

The results were observed in a secondary analysis of a randomized, controlled study that compared the rate of postpartum incontinence in women who had done the pelvic floor muscle training during pregnancy with that of women who had not.

The original analysis found less urinary incontinence among patients in the treatment group.

Dr. Salvesen of Trondheim (Norway) University and his associates randomized 301 nulliparous pregnant women to either no training or 1 hour of intensive pelvic floor exercises with a physiotherapist each week for 12 weeks (BMJ 2004;329:378–80).

The training occurred between weeks 20 and 36 of pregnancy. The women were also encouraged to perform 8–10 intense pelvic floor contractions at home twice a day. Women in the control group were not discouraged from doing pelvic floor exercises, but received no specific instructions on how to do so.

Only those who entered spontaneous labor after 37 weeks with a singleton fetus in cephalic position were included in the final analysis: There were 111 women in the control group and 113 women in the treatment group.

Treatment-group women had a lower rate of prolonged (longer than 60 minutes) second stage of labor than women in the control group (21% vs. 34%).

Fewer women in the treatment group had episiotomies (51% vs. 64%), but the rates of operative delivery were not significantly different between the two groups.

Pelvic floor training during pregnancy appears to facilitate delivery and was associated with a decreased incidence of prolonged second-stage labor, Kjell Salvesen, M.D., and colleagues reported.

The results were observed in a secondary analysis of a randomized, controlled study that compared the rate of postpartum incontinence in women who had done the pelvic floor muscle training during pregnancy with that of women who had not.

The original analysis found less urinary incontinence among patients in the treatment group.

Dr. Salvesen of Trondheim (Norway) University and his associates randomized 301 nulliparous pregnant women to either no training or 1 hour of intensive pelvic floor exercises with a physiotherapist each week for 12 weeks (BMJ 2004;329:378–80).

The training occurred between weeks 20 and 36 of pregnancy. The women were also encouraged to perform 8–10 intense pelvic floor contractions at home twice a day. Women in the control group were not discouraged from doing pelvic floor exercises, but received no specific instructions on how to do so.

Only those who entered spontaneous labor after 37 weeks with a singleton fetus in cephalic position were included in the final analysis: There were 111 women in the control group and 113 women in the treatment group.

Treatment-group women had a lower rate of prolonged (longer than 60 minutes) second stage of labor than women in the control group (21% vs. 34%).

Fewer women in the treatment group had episiotomies (51% vs. 64%), but the rates of operative delivery were not significantly different between the two groups.

NEW ORLEANS — Regardless of glycemic control, vardenafil significantly improves intercourse success rates, compared with placebo, for diabetic men who do not respond to sildenafil, Culley Carson, M.D., reported in a series of posters presented at the annual meeting of the Endocrine Society.

Men with the worst control with hemoglobin A_1c (HbA_1c) greater than 8%–12% had the biggest increase in successful intercourse attempts, said Dr. Carson, chief of urology at the University of North Carolina at Chapel Hill.

Dr. Carson, who is a paid investigator for GlaxoSmithKline and a member of its advisory board, presented a posthoc subgroup analysis of the Patient Response With Vardenafil in Sildenafil Nonresponders (PROVEN) trial. The trial assessed the improvement of erectile function in 463 men with moderate to severe erectile dysfunction who were not responsive to sildenafil therapy. The subgroup analysis applied to 153 men in the group who had diabetes. The mean age of the patients was 60 years; 90% of the group was white.

After a 1-month treatment-free run-in period, the men were randomized to either placebo or one 10-mg vardenafil tablet/day, taken 1 hour before intercourse. They had the option to maintain that dose over the 12-week study, or, at weeks 4 and 8, to titrate to 5 mg or 20 mg based on the efficacy and tolerability of the drug.

After 12 weeks, diabetic men in the active group reported a fivefold increase in the number of successful intercourse attempts over baseline (33% vs. 6%). Men in the placebo group reported a nonsignificant increase in successful attempts of 13% over 11% at baseline.

Improvements in successful intercourse attempts were noted across all levels of glycemic control, Dr. Carson said. The greatest increase occurred in men with the worst glycemic control, who had nearly a sevenfold increase in successful intercourse attempts, from 6% of attempts at baseline to 41% at the study's end. Men with the best control (HbA_1c less than 6.5%) had about a fourfold increase in successful attempts, from about 12% of attempts at baseline to 53% of attempts at the study's end.

Men with intermediate control (HbA_1c 6.5%–8%) also had about a fourfold increase in successful attempts, from about 6% at baseline to 26% at the study's end.

The most frequently reported adverse events in the study were dyspepsia (8% of active group vs. 0% placebo), flushing (6% active group vs. 2% placebo), nasal congestion (6% active group vs. 0% placebo), headache (5% active group vs. 2% placebo), and upper respiratory tract infection (5% active group vs. 2% placebo). Three patients in the placebo group and five in the active group withdrew due to adverse events.

NEW ORLEANS — Regardless of glycemic control, vardenafil significantly improves intercourse success rates, compared with placebo, for diabetic men who do not respond to sildenafil, Culley Carson, M.D., reported in a series of posters presented at the annual meeting of the Endocrine Society.

Men with the worst control with hemoglobin A_1c (HbA_1c) greater than 8%–12% had the biggest increase in successful intercourse attempts, said Dr. Carson, chief of urology at the University of North Carolina at Chapel Hill.

Dr. Carson, who is a paid investigator for GlaxoSmithKline and a member of its advisory board, presented a posthoc subgroup analysis of the Patient Response With Vardenafil in Sildenafil Nonresponders (PROVEN) trial. The trial assessed the improvement of erectile function in 463 men with moderate to severe erectile dysfunction who were not responsive to sildenafil therapy. The subgroup analysis applied to 153 men in the group who had diabetes. The mean age of the patients was 60 years; 90% of the group was white.

After a 1-month treatment-free run-in period, the men were randomized to either placebo or one 10-mg vardenafil tablet/day, taken 1 hour before intercourse. They had the option to maintain that dose over the 12-week study, or, at weeks 4 and 8, to titrate to 5 mg or 20 mg based on the efficacy and tolerability of the drug.

After 12 weeks, diabetic men in the active group reported a fivefold increase in the number of successful intercourse attempts over baseline (33% vs. 6%). Men in the placebo group reported a nonsignificant increase in successful attempts of 13% over 11% at baseline.

Improvements in successful intercourse attempts were noted across all levels of glycemic control, Dr. Carson said. The greatest increase occurred in men with the worst glycemic control, who had nearly a sevenfold increase in successful intercourse attempts, from 6% of attempts at baseline to 41% at the study's end. Men with the best control (HbA_1c less than 6.5%) had about a fourfold increase in successful attempts, from about 12% of attempts at baseline to 53% of attempts at the study's end.

Men with intermediate control (HbA_1c 6.5%–8%) also had about a fourfold increase in successful attempts, from about 6% at baseline to 26% at the study's end.

The most frequently reported adverse events in the study were dyspepsia (8% of active group vs. 0% placebo), flushing (6% active group vs. 2% placebo), nasal congestion (6% active group vs. 0% placebo), headache (5% active group vs. 2% placebo), and upper respiratory tract infection (5% active group vs. 2% placebo). Three patients in the placebo group and five in the active group withdrew due to adverse events.

NEW ORLEANS — Regardless of glycemic control, vardenafil significantly improves intercourse success rates, compared with placebo, for diabetic men who do not respond to sildenafil, Culley Carson, M.D., reported in a series of posters presented at the annual meeting of the Endocrine Society.

Men with the worst control with hemoglobin A_1c (HbA_1c) greater than 8%–12% had the biggest increase in successful intercourse attempts, said Dr. Carson, chief of urology at the University of North Carolina at Chapel Hill.

Dr. Carson, who is a paid investigator for GlaxoSmithKline and a member of its advisory board, presented a posthoc subgroup analysis of the Patient Response With Vardenafil in Sildenafil Nonresponders (PROVEN) trial. The trial assessed the improvement of erectile function in 463 men with moderate to severe erectile dysfunction who were not responsive to sildenafil therapy. The subgroup analysis applied to 153 men in the group who had diabetes. The mean age of the patients was 60 years; 90% of the group was white.

After a 1-month treatment-free run-in period, the men were randomized to either placebo or one 10-mg vardenafil tablet/day, taken 1 hour before intercourse. They had the option to maintain that dose over the 12-week study, or, at weeks 4 and 8, to titrate to 5 mg or 20 mg based on the efficacy and tolerability of the drug.

After 12 weeks, diabetic men in the active group reported a fivefold increase in the number of successful intercourse attempts over baseline (33% vs. 6%). Men in the placebo group reported a nonsignificant increase in successful attempts of 13% over 11% at baseline.

Improvements in successful intercourse attempts were noted across all levels of glycemic control, Dr. Carson said. The greatest increase occurred in men with the worst glycemic control, who had nearly a sevenfold increase in successful intercourse attempts, from 6% of attempts at baseline to 41% at the study's end. Men with the best control (HbA_1c less than 6.5%) had about a fourfold increase in successful attempts, from about 12% of attempts at baseline to 53% of attempts at the study's end.

Men with intermediate control (HbA_1c 6.5%–8%) also had about a fourfold increase in successful attempts, from about 6% at baseline to 26% at the study's end.

The most frequently reported adverse events in the study were dyspepsia (8% of active group vs. 0% placebo), flushing (6% active group vs. 2% placebo), nasal congestion (6% active group vs. 0% placebo), headache (5% active group vs. 2% placebo), and upper respiratory tract infection (5% active group vs. 2% placebo). Three patients in the placebo group and five in the active group withdrew due to adverse events.

NEW ORLEANS–Valproate should not be prescribed as first-line therapy for any indication in women of childbearing age because it significantly increases the risk of major malformations in exposed infants, the American Epilepsy Society's pregnancy outcomes forum panel recommended.

Converging data from six studies presented at the annual meeting of the American Epilepsy Society and two recently published studies prompted the recommendation, said Kimford Meador, M.D., director of the epilepsy program at the University of Florida, Gainesville, and a member of the panel.

“This isn't class I evidence–we're never going to have that–but what is the chance that these different studies in different populations would all come to this same conclusion?” Dr. Meador asked. “In my opinion, this drug should not be used as first-line therapy for this population.”

The studies presented linked valproate with up to a sevenfold increased relative risk of major malformation, compared with the general population; the rate of malformations was 10% for these infants and 1.6% in the general population.

Cardiac, neural tube, and multiple anomalies were among the malformations noted. None of the registries had high enough power to determine the risks for any particular malformation, however, said Lewis Holmes, M.D., chief of the genetics and teratology unit at Massachusetts General Hospital, Boston, and the director of the North American Anti-epileptic Drug Pregnancy Registry, which is managed by the hospital.

The registry was established in 1977; as of July 2004, it included 3,708 women. Sixteen infants with major malformations have been born to 149 valproate-exposed women (10.7% and a relative risk of 7.3).

In light of these findings, the panel agreed, physicians should offer safer medications for epilepsy, migraine, and mood disorders to fertile women. “There are lots of other equally effective medications for many of these women,” said panelist Martha Morrell, M.D., of Stanford (Calif.) University.

For women with epilepsy, one such alternative is lamotrigine. “Several studies have indicated that the rate of major malformations associated with this drug is about 3%–similar to what we see in the general population,” Dr. Morrell said.

The panel acknowledged that for some women, valproate's benefits outweigh the risks. “There may be patients for whom this is the only effective drug,” said panelist Gregory Barkley, M.D., chair of the Epilepsy Foundation's professional advisory board. “These women should be counseled to avoid pregnancy,” said Dr. Barkley, professor of neurology at Wayne State University, Detroit.

Valproate is the most frequently prescribed antiepileptic drug, with 12 million prescriptions written annually to women of childbearing years. Only about 20% of those prescriptions are for epilepsy–the rest are for migraine and mood disorders.

But many primary care providers and psychiatrists appear unaware of valproate's significant teratogenicity. Treatment guidelines for mood disorders, which recommend the use of valproate, don't include warnings of its effect on developing fetuses, Dr. Morrell said.

Even neurologists may not fully appreciate the problem, Dr. Holmes said. A patient referred to him said her neurologist told her that folic acid supplements would counteract valproate's increased risk of neural tube defects.

“There are no published data supporting that,” he said. Anecdotal evidence indicates that the normal 1-mg dose of folate does not change the increased risk.

The recommendation to decrease valproate exposure makes “intuitive sense,” said Lee Cohen, M.D., director of the perinatal and reproductive psychiatry clinic at Massachusetts General Hospital.

“It's an ugly drug for reproductive-aged women,” he said. Numerous published and ongoing studies have documented behavioral abnormalities and developmental delay in children prenatally exposed to the drug; it also increases the risk of polycystic ovary disease in women who take it.

Panel members want to encourage U.S. and Canadian physicians to have pregnant patients who are taking any antiepileptic drug join the Antiepileptic Drug Pregnancy Registry. More information is available by calling 888-233-2334 or by going to www.aedpregnancyregistry.org

NEW ORLEANS–Valproate should not be prescribed as first-line therapy for any indication in women of childbearing age because it significantly increases the risk of major malformations in exposed infants, the American Epilepsy Society's pregnancy outcomes forum panel recommended.

Converging data from six studies presented at the annual meeting of the American Epilepsy Society and two recently published studies prompted the recommendation, said Kimford Meador, M.D., director of the epilepsy program at the University of Florida, Gainesville, and a member of the panel.

“This isn't class I evidence–we're never going to have that–but what is the chance that these different studies in different populations would all come to this same conclusion?” Dr. Meador asked. “In my opinion, this drug should not be used as first-line therapy for this population.”

The studies presented linked valproate with up to a sevenfold increased relative risk of major malformation, compared with the general population; the rate of malformations was 10% for these infants and 1.6% in the general population.

Cardiac, neural tube, and multiple anomalies were among the malformations noted. None of the registries had high enough power to determine the risks for any particular malformation, however, said Lewis Holmes, M.D., chief of the genetics and teratology unit at Massachusetts General Hospital, Boston, and the director of the North American Anti-epileptic Drug Pregnancy Registry, which is managed by the hospital.

The registry was established in 1977; as of July 2004, it included 3,708 women. Sixteen infants with major malformations have been born to 149 valproate-exposed women (10.7% and a relative risk of 7.3).

In light of these findings, the panel agreed, physicians should offer safer medications for epilepsy, migraine, and mood disorders to fertile women. “There are lots of other equally effective medications for many of these women,” said panelist Martha Morrell, M.D., of Stanford (Calif.) University.

For women with epilepsy, one such alternative is lamotrigine. “Several studies have indicated that the rate of major malformations associated with this drug is about 3%–similar to what we see in the general population,” Dr. Morrell said.

The panel acknowledged that for some women, valproate's benefits outweigh the risks. “There may be patients for whom this is the only effective drug,” said panelist Gregory Barkley, M.D., chair of the Epilepsy Foundation's professional advisory board. “These women should be counseled to avoid pregnancy,” said Dr. Barkley, professor of neurology at Wayne State University, Detroit.

Valproate is the most frequently prescribed antiepileptic drug, with 12 million prescriptions written annually to women of childbearing years. Only about 20% of those prescriptions are for epilepsy–the rest are for migraine and mood disorders.

But many primary care providers and psychiatrists appear unaware of valproate's significant teratogenicity. Treatment guidelines for mood disorders, which recommend the use of valproate, don't include warnings of its effect on developing fetuses, Dr. Morrell said.

Even neurologists may not fully appreciate the problem, Dr. Holmes said. A patient referred to him said her neurologist told her that folic acid supplements would counteract valproate's increased risk of neural tube defects.

“There are no published data supporting that,” he said. Anecdotal evidence indicates that the normal 1-mg dose of folate does not change the increased risk.

The recommendation to decrease valproate exposure makes “intuitive sense,” said Lee Cohen, M.D., director of the perinatal and reproductive psychiatry clinic at Massachusetts General Hospital.

“It's an ugly drug for reproductive-aged women,” he said. Numerous published and ongoing studies have documented behavioral abnormalities and developmental delay in children prenatally exposed to the drug; it also increases the risk of polycystic ovary disease in women who take it.

Panel members want to encourage U.S. and Canadian physicians to have pregnant patients who are taking any antiepileptic drug join the Antiepileptic Drug Pregnancy Registry. More information is available by calling 888-233-2334 or by going to www.aedpregnancyregistry.org

NEW ORLEANS–Valproate should not be prescribed as first-line therapy for any indication in women of childbearing age because it significantly increases the risk of major malformations in exposed infants, the American Epilepsy Society's pregnancy outcomes forum panel recommended.

Converging data from six studies presented at the annual meeting of the American Epilepsy Society and two recently published studies prompted the recommendation, said Kimford Meador, M.D., director of the epilepsy program at the University of Florida, Gainesville, and a member of the panel.

“This isn't class I evidence–we're never going to have that–but what is the chance that these different studies in different populations would all come to this same conclusion?” Dr. Meador asked. “In my opinion, this drug should not be used as first-line therapy for this population.”

The studies presented linked valproate with up to a sevenfold increased relative risk of major malformation, compared with the general population; the rate of malformations was 10% for these infants and 1.6% in the general population.

Cardiac, neural tube, and multiple anomalies were among the malformations noted. None of the registries had high enough power to determine the risks for any particular malformation, however, said Lewis Holmes, M.D., chief of the genetics and teratology unit at Massachusetts General Hospital, Boston, and the director of the North American Anti-epileptic Drug Pregnancy Registry, which is managed by the hospital.

The registry was established in 1977; as of July 2004, it included 3,708 women. Sixteen infants with major malformations have been born to 149 valproate-exposed women (10.7% and a relative risk of 7.3).

In light of these findings, the panel agreed, physicians should offer safer medications for epilepsy, migraine, and mood disorders to fertile women. “There are lots of other equally effective medications for many of these women,” said panelist Martha Morrell, M.D., of Stanford (Calif.) University.

For women with epilepsy, one such alternative is lamotrigine. “Several studies have indicated that the rate of major malformations associated with this drug is about 3%–similar to what we see in the general population,” Dr. Morrell said.

The panel acknowledged that for some women, valproate's benefits outweigh the risks. “There may be patients for whom this is the only effective drug,” said panelist Gregory Barkley, M.D., chair of the Epilepsy Foundation's professional advisory board. “These women should be counseled to avoid pregnancy,” said Dr. Barkley, professor of neurology at Wayne State University, Detroit.

Valproate is the most frequently prescribed antiepileptic drug, with 12 million prescriptions written annually to women of childbearing years. Only about 20% of those prescriptions are for epilepsy–the rest are for migraine and mood disorders.

But many primary care providers and psychiatrists appear unaware of valproate's significant teratogenicity. Treatment guidelines for mood disorders, which recommend the use of valproate, don't include warnings of its effect on developing fetuses, Dr. Morrell said.

Even neurologists may not fully appreciate the problem, Dr. Holmes said. A patient referred to him said her neurologist told her that folic acid supplements would counteract valproate's increased risk of neural tube defects.

“There are no published data supporting that,” he said. Anecdotal evidence indicates that the normal 1-mg dose of folate does not change the increased risk.

The recommendation to decrease valproate exposure makes “intuitive sense,” said Lee Cohen, M.D., director of the perinatal and reproductive psychiatry clinic at Massachusetts General Hospital.

“It's an ugly drug for reproductive-aged women,” he said. Numerous published and ongoing studies have documented behavioral abnormalities and developmental delay in children prenatally exposed to the drug; it also increases the risk of polycystic ovary disease in women who take it.

Panel members want to encourage U.S. and Canadian physicians to have pregnant patients who are taking any antiepileptic drug join the Antiepileptic Drug Pregnancy Registry. More information is available by calling 888-233-2334 or by going to www.aedpregnancyregistry.org

ROME – A pediatric atopic dermatitis treatment plan is not complete without a psychological element, Dr. Caroline Koblenzer said at the 10th World Congress of Pediatric Dermatology.

“Without adding a psychological component to treatment, patients with atopic dermatitis can stay in a chronic course of remission and exacerbation,” said Dr. Koblenzer of the University of Pennsylvania, Philadelphia.

“Most patients do respond well to treatment, but in recalcitrant patients, you need to explore the experience of early infancy.”

Studies have shown that up to 60% of dermatology patients have at least one coexisting psychiatric condition, she said.

Atopic children tend to be more emotionally and behaviorally immature than do controls.

Often, these children use their scratching behavior as a tool to manipulate their parents, define weak boundaries, or express anger and aggression.

The foundation for these behaviors is laid in infancy, when the atopic infant, itchy and restless, fails to perceive empathic touch while absorbing negative psychic energy from an anxious, guilt-ridden mother.

This initiates a self-renewing cycle of emotionally and physically related events that trigger more atopic flares for the infant.

In infancy, Dr. Koblenzer said, empathic touch, usually from the mother, helps develop the infant's capacity to release and regulate tension.

This release is modulated by nonverbal two-way communication with the mother: The infant uses the mother as a mirror of his/her feelings until he/she develops emotional self-regulation.

“The relaxed mother will have a soothing effect, while the anxious, unhappy mother will increase the infant's distress,” Dr. Koblenzer said.

“Failure to internalize this emotional control can lead to continued tension discharge through physical pathways.

“This stress may cause physical symptoms.”

In addition to promoting the atopic cycle, this dance between the mother and infant has the ability to blunt the child's behavioral and emotional growth. “The itchy, restless infant whose anxiety continues to rise and who is difficult to soothe results in a mother who feels anxious and frustrated,” Dr. Koblenzer said.

These feelings of anxiety and frustration can raise the mother's anxiety even more, leading to a corresponding increase in the infant's anxiety, she said.

The mother may feel inadequate and then guilty about her perceived inadequacy. As a result, the mother may fail to set boundaries, thereby retarding the child's emotional development and perpetuating the negative emotional cycle.

Other family members also feel the impact of this problematic relationship, she said.

“The emotional and financial costs of atopic dermatitis are actually greater for the family than if the child has insulin-dependent diabetes,” Dr. Koblenzer said. “And because the mother's time is monopolized, siblings may act out with attention-seeking behavior.”

Additionally, she said, atopic children, whose sense of body integrity is poorly developed, may interpret treatments as assaults. That is particularly the case when treatments, involve the face, neck, and genital areas.

It is crucial that physicians recognize and bring to the surface the emotional aspects that influence atopic dermatitis, particularly with patients who don't readily respond to conventional therapy, Dr. Koblenzer said.

The value of the doctor-patient relationship with these families can't be understated, she stressed.

“It's really important for us to empathize and understand the burdens on the parents, the patient, and the family.”

ROME – A pediatric atopic dermatitis treatment plan is not complete without a psychological element, Dr. Caroline Koblenzer said at the 10th World Congress of Pediatric Dermatology.

“Without adding a psychological component to treatment, patients with atopic dermatitis can stay in a chronic course of remission and exacerbation,” said Dr. Koblenzer of the University of Pennsylvania, Philadelphia.

“Most patients do respond well to treatment, but in recalcitrant patients, you need to explore the experience of early infancy.”

Studies have shown that up to 60% of dermatology patients have at least one coexisting psychiatric condition, she said.

Atopic children tend to be more emotionally and behaviorally immature than do controls.

Often, these children use their scratching behavior as a tool to manipulate their parents, define weak boundaries, or express anger and aggression.

The foundation for these behaviors is laid in infancy, when the atopic infant, itchy and restless, fails to perceive empathic touch while absorbing negative psychic energy from an anxious, guilt-ridden mother.

This initiates a self-renewing cycle of emotionally and physically related events that trigger more atopic flares for the infant.

In infancy, Dr. Koblenzer said, empathic touch, usually from the mother, helps develop the infant's capacity to release and regulate tension.

This release is modulated by nonverbal two-way communication with the mother: The infant uses the mother as a mirror of his/her feelings until he/she develops emotional self-regulation.

“The relaxed mother will have a soothing effect, while the anxious, unhappy mother will increase the infant's distress,” Dr. Koblenzer said.

“Failure to internalize this emotional control can lead to continued tension discharge through physical pathways.

“This stress may cause physical symptoms.”

In addition to promoting the atopic cycle, this dance between the mother and infant has the ability to blunt the child's behavioral and emotional growth. “The itchy, restless infant whose anxiety continues to rise and who is difficult to soothe results in a mother who feels anxious and frustrated,” Dr. Koblenzer said.

These feelings of anxiety and frustration can raise the mother's anxiety even more, leading to a corresponding increase in the infant's anxiety, she said.

The mother may feel inadequate and then guilty about her perceived inadequacy. As a result, the mother may fail to set boundaries, thereby retarding the child's emotional development and perpetuating the negative emotional cycle.

Other family members also feel the impact of this problematic relationship, she said.

“The emotional and financial costs of atopic dermatitis are actually greater for the family than if the child has insulin-dependent diabetes,” Dr. Koblenzer said. “And because the mother's time is monopolized, siblings may act out with attention-seeking behavior.”

Additionally, she said, atopic children, whose sense of body integrity is poorly developed, may interpret treatments as assaults. That is particularly the case when treatments, involve the face, neck, and genital areas.

It is crucial that physicians recognize and bring to the surface the emotional aspects that influence atopic dermatitis, particularly with patients who don't readily respond to conventional therapy, Dr. Koblenzer said.

The value of the doctor-patient relationship with these families can't be understated, she stressed.

“It's really important for us to empathize and understand the burdens on the parents, the patient, and the family.”

ROME – A pediatric atopic dermatitis treatment plan is not complete without a psychological element, Dr. Caroline Koblenzer said at the 10th World Congress of Pediatric Dermatology.

“Without adding a psychological component to treatment, patients with atopic dermatitis can stay in a chronic course of remission and exacerbation,” said Dr. Koblenzer of the University of Pennsylvania, Philadelphia.

“Most patients do respond well to treatment, but in recalcitrant patients, you need to explore the experience of early infancy.”

Studies have shown that up to 60% of dermatology patients have at least one coexisting psychiatric condition, she said.

Atopic children tend to be more emotionally and behaviorally immature than do controls.

Often, these children use their scratching behavior as a tool to manipulate their parents, define weak boundaries, or express anger and aggression.

The foundation for these behaviors is laid in infancy, when the atopic infant, itchy and restless, fails to perceive empathic touch while absorbing negative psychic energy from an anxious, guilt-ridden mother.

This initiates a self-renewing cycle of emotionally and physically related events that trigger more atopic flares for the infant.

In infancy, Dr. Koblenzer said, empathic touch, usually from the mother, helps develop the infant's capacity to release and regulate tension.

This release is modulated by nonverbal two-way communication with the mother: The infant uses the mother as a mirror of his/her feelings until he/she develops emotional self-regulation.

“The relaxed mother will have a soothing effect, while the anxious, unhappy mother will increase the infant's distress,” Dr. Koblenzer said.

“Failure to internalize this emotional control can lead to continued tension discharge through physical pathways.

“This stress may cause physical symptoms.”

In addition to promoting the atopic cycle, this dance between the mother and infant has the ability to blunt the child's behavioral and emotional growth. “The itchy, restless infant whose anxiety continues to rise and who is difficult to soothe results in a mother who feels anxious and frustrated,” Dr. Koblenzer said.

These feelings of anxiety and frustration can raise the mother's anxiety even more, leading to a corresponding increase in the infant's anxiety, she said.

The mother may feel inadequate and then guilty about her perceived inadequacy. As a result, the mother may fail to set boundaries, thereby retarding the child's emotional development and perpetuating the negative emotional cycle.

Other family members also feel the impact of this problematic relationship, she said.

“The emotional and financial costs of atopic dermatitis are actually greater for the family than if the child has insulin-dependent diabetes,” Dr. Koblenzer said. “And because the mother's time is monopolized, siblings may act out with attention-seeking behavior.”

Additionally, she said, atopic children, whose sense of body integrity is poorly developed, may interpret treatments as assaults. That is particularly the case when treatments, involve the face, neck, and genital areas.

It is crucial that physicians recognize and bring to the surface the emotional aspects that influence atopic dermatitis, particularly with patients who don't readily respond to conventional therapy, Dr. Koblenzer said.

The value of the doctor-patient relationship with these families can't be understated, she stressed.

“It's really important for us to empathize and understand the burdens on the parents, the patient, and the family.”

ST. LOUIS – Homosexual and bisexual youth appear to be overrepresented among teen parents, with 1 in 3 teen fathers and 1 in 10 teen mothers reporting either same- or both-gender sexual partners, Rebekah Forrest, R.N., said at the annual meeting of the Society for Adolescent Medicine.

“The high percentage of teen parents reporting same- or both-gender sexual partners raises important policy and practice considerations,” said Ms. Forrest, a public health nursing master's degree candidate at the University of Minnesota, Minneapolis. “We naturally assume all teen parents are heterosexual, but this is not the case.”

Although overall, births to teenagers have fallen by 30% over the last decade, the risk of pregnancy among homosexual and bisexual teens has increased; these teenagers are 2–4 times more likely to become pregnant or cause a pregnancy than are heterosexual teens.

To explore the sexual orientation of teen parents in Minnesota, Ms. Forrest and Elizabeth Saewyc, Ph.D., also of the University of Minnesota, performed a secondary analysis of a 1998 statewide survey of students in the 9th and 12th grades.

The Minnesota Student Survey covers 97% of the state's public school students in those grades; it includes students in alternative schools and juvenile correction facilities.

Included in this analysis were 1,018 students who reported having primary responsibility for raising a child of their own and who answered questions about the gender of their sexual partners within the previous 12 months–either same gender only, opposite gender only, or both genders.

Of the students included in the analysis, 44% were in ninth grade and 56% were in 12th grade; 77% were white, and 55% were male.

About one in three teen fathers (36.6%) and one in 10 teen mothers (12%) reported same- or both-gender sexual partners within the previous 12 months.

Since this reporting could be confounded by sexual abuse, any teen with a self-reported history of sexual abuse at any time was excluded.

This adjustment lowered the percentages only slightly: 30% of teen fathers and 8.6% of teen mothers still reported sexual minority experiences within the previous 12 months.

Homosexual or bisexual teen parents also tended to be younger than teen parents with opposite-gender-only partners. Two-thirds of the homosexual or bisexual teen parents were in the ninth grade vs. one-third of teen parents with opposite-gender-only partners.

Among all sexually experienced boys, 14% reported same- or both-gender partners, while among teen fathers, 37% reported same- or both-gender partners, a 2.5-fold increase.

Among all sexually experienced girls, about 4% reported same- or both-gender partners, while among teen mothers, 12% reported these experiences–a threefold increase.

No studies have identified the reasons that may put homosexual or bisexual teens at an increased risk for pregnancy and parenthood, Ms. Forrest said.

A lack of preparedness for opposite-gender sexual relations may be one factor. Another factor, she said, may be the desire–either conscious or unconscious–to make a societal statement about their sexuality or to gain social acceptance.

Regardless of the reasons, she said, health care and parenting programs should support the needs of all teen parents.

Future research in this area should focus on the prevention of pregnancy in homosexual and bisexual parents, Ms. Forrest noted.

Ms. Forrest cautioned that the results of this analysis might be confounded by the higher dropout rate among teen parents.

ST. LOUIS – Homosexual and bisexual youth appear to be overrepresented among teen parents, with 1 in 3 teen fathers and 1 in 10 teen mothers reporting either same- or both-gender sexual partners, Rebekah Forrest, R.N., said at the annual meeting of the Society for Adolescent Medicine.

“The high percentage of teen parents reporting same- or both-gender sexual partners raises important policy and practice considerations,” said Ms. Forrest, a public health nursing master's degree candidate at the University of Minnesota, Minneapolis. “We naturally assume all teen parents are heterosexual, but this is not the case.”

Although overall, births to teenagers have fallen by 30% over the last decade, the risk of pregnancy among homosexual and bisexual teens has increased; these teenagers are 2–4 times more likely to become pregnant or cause a pregnancy than are heterosexual teens.

To explore the sexual orientation of teen parents in Minnesota, Ms. Forrest and Elizabeth Saewyc, Ph.D., also of the University of Minnesota, performed a secondary analysis of a 1998 statewide survey of students in the 9th and 12th grades.

The Minnesota Student Survey covers 97% of the state's public school students in those grades; it includes students in alternative schools and juvenile correction facilities.

Included in this analysis were 1,018 students who reported having primary responsibility for raising a child of their own and who answered questions about the gender of their sexual partners within the previous 12 months–either same gender only, opposite gender only, or both genders.

Of the students included in the analysis, 44% were in ninth grade and 56% were in 12th grade; 77% were white, and 55% were male.

About one in three teen fathers (36.6%) and one in 10 teen mothers (12%) reported same- or both-gender sexual partners within the previous 12 months.

Since this reporting could be confounded by sexual abuse, any teen with a self-reported history of sexual abuse at any time was excluded.

This adjustment lowered the percentages only slightly: 30% of teen fathers and 8.6% of teen mothers still reported sexual minority experiences within the previous 12 months.

Homosexual or bisexual teen parents also tended to be younger than teen parents with opposite-gender-only partners. Two-thirds of the homosexual or bisexual teen parents were in the ninth grade vs. one-third of teen parents with opposite-gender-only partners.

Among all sexually experienced boys, 14% reported same- or both-gender partners, while among teen fathers, 37% reported same- or both-gender partners, a 2.5-fold increase.

Among all sexually experienced girls, about 4% reported same- or both-gender partners, while among teen mothers, 12% reported these experiences–a threefold increase.

No studies have identified the reasons that may put homosexual or bisexual teens at an increased risk for pregnancy and parenthood, Ms. Forrest said.

A lack of preparedness for opposite-gender sexual relations may be one factor. Another factor, she said, may be the desire–either conscious or unconscious–to make a societal statement about their sexuality or to gain social acceptance.

Regardless of the reasons, she said, health care and parenting programs should support the needs of all teen parents.

Future research in this area should focus on the prevention of pregnancy in homosexual and bisexual parents, Ms. Forrest noted.

Ms. Forrest cautioned that the results of this analysis might be confounded by the higher dropout rate among teen parents.

ST. LOUIS – Homosexual and bisexual youth appear to be overrepresented among teen parents, with 1 in 3 teen fathers and 1 in 10 teen mothers reporting either same- or both-gender sexual partners, Rebekah Forrest, R.N., said at the annual meeting of the Society for Adolescent Medicine.

“The high percentage of teen parents reporting same- or both-gender sexual partners raises important policy and practice considerations,” said Ms. Forrest, a public health nursing master's degree candidate at the University of Minnesota, Minneapolis. “We naturally assume all teen parents are heterosexual, but this is not the case.”

Although overall, births to teenagers have fallen by 30% over the last decade, the risk of pregnancy among homosexual and bisexual teens has increased; these teenagers are 2–4 times more likely to become pregnant or cause a pregnancy than are heterosexual teens.

To explore the sexual orientation of teen parents in Minnesota, Ms. Forrest and Elizabeth Saewyc, Ph.D., also of the University of Minnesota, performed a secondary analysis of a 1998 statewide survey of students in the 9th and 12th grades.

The Minnesota Student Survey covers 97% of the state's public school students in those grades; it includes students in alternative schools and juvenile correction facilities.

Included in this analysis were 1,018 students who reported having primary responsibility for raising a child of their own and who answered questions about the gender of their sexual partners within the previous 12 months–either same gender only, opposite gender only, or both genders.

Of the students included in the analysis, 44% were in ninth grade and 56% were in 12th grade; 77% were white, and 55% were male.

About one in three teen fathers (36.6%) and one in 10 teen mothers (12%) reported same- or both-gender sexual partners within the previous 12 months.

Since this reporting could be confounded by sexual abuse, any teen with a self-reported history of sexual abuse at any time was excluded.

This adjustment lowered the percentages only slightly: 30% of teen fathers and 8.6% of teen mothers still reported sexual minority experiences within the previous 12 months.

Homosexual or bisexual teen parents also tended to be younger than teen parents with opposite-gender-only partners. Two-thirds of the homosexual or bisexual teen parents were in the ninth grade vs. one-third of teen parents with opposite-gender-only partners.

Among all sexually experienced boys, 14% reported same- or both-gender partners, while among teen fathers, 37% reported same- or both-gender partners, a 2.5-fold increase.

Among all sexually experienced girls, about 4% reported same- or both-gender partners, while among teen mothers, 12% reported these experiences–a threefold increase.

No studies have identified the reasons that may put homosexual or bisexual teens at an increased risk for pregnancy and parenthood, Ms. Forrest said.

A lack of preparedness for opposite-gender sexual relations may be one factor. Another factor, she said, may be the desire–either conscious or unconscious–to make a societal statement about their sexuality or to gain social acceptance.

Regardless of the reasons, she said, health care and parenting programs should support the needs of all teen parents.

Future research in this area should focus on the prevention of pregnancy in homosexual and bisexual parents, Ms. Forrest noted.

Ms. Forrest cautioned that the results of this analysis might be confounded by the higher dropout rate among teen parents.