Sherry Boschert

KAILUA KONA, HAWAII — Three-dimensional ultrasound is less helpful for diagnosing fetal abnormalities than for counseling patients, Dr. Dolores H. Pretorius said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always performed as an adjunct to two-dimensional prenatal ultrasound, never as a replacement for it, 3-D ultrasound can help visualize and evaluate certain fetal abnormalities, give clinicians more confidence about what they're identifying, and help explain the problem to patients, she said.

Rarely does 3-D ultrasound identify additional abnormalities, said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The most helpful medical use of 3-D ultrasound may be for imaging facial anomalies, especially small cleft lips and cleft palates that are difficult to see with 2-D ultrasound, according to a 2005 consensus panel convened by the American Institute of Ultrasound in Medicine.

Because 3-D ultrasound can provide consistent symmetrical views, unlike 2-D ultrasound, it may help diagnose micrognathia (small chin), but further research is needed to confirm that, she said at the conference, which was sponsored by Boston University. It also may be helpful for imaging brain and spinal anomalies, identifying sutures on the fetal skull, and for research studies of cardiac anomalies, the consensus panel suggested.

Anomalies of the ear or the extremities can be seen with 3-D ultrasound. A diagnosis of club feet by 3-D ultrasound is false 12%–22% of the time, however, so patients must be warned of the false-positive rate, she cautioned. “We've had patients terminate the pregnancy for club feet and then have normal feet at autopsy.”

Referrals to check for central nervous system anomalies include cases of craniosynostosis or of mild ventriculomegaly, to look for the corpus callosum. A 3-D ultrasound of a neural tube defect can localize the level of the defect. “Most of the time this does not impact patient care” except when surgical treatment is planned, she said. Scoliosis is much more apparent on 3-D than on 2-D ultrasound to the parents and clinicians.

Trying to get parents to understand a fetal movement disorder can be difficult with just a 2-D image of an outstretched arm. Show them a 3-D image, however, “and all of a sudden the light bulb goes off in their head and they can understand it. Sometimes for patients the visual appearance of these can be very helpful,” Dr. Pretorius said.

Parents love to see 3-D images of the fetal face, which has led some nonmedical businesses to offer controversial “entertainment” 3-D ultrasound services in shopping malls and elsewhere. “I've already seen several lawsuits coming through related to 3-D ultrasounds that missed anomalies. The key question is, did the patient know that this was for entertainment, not diagnosis?” said Dr. Pretorius, who has studied 3-D ultrasound for 17 years.

A 3-D exam can be a frustrating experience for sonographers. Even experts only manage to image the face in 80% of midtrimester fetuses and 50% of third-trimester fetuses. The fetus must be in the right position without anything obscuring the face, and with plenty of amniotic fluid around it. The results are affected by gestational age and other factors.

At the start of a 3-D exam, “there's no predicting whether I'm going to make a good picture or not. If the parents don't get a good picture, they think that I'm not a good doctor,” Dr. Pretorius said.

As 3-D ultrasound gets used more and more, clinicians must become familiar with a slew of new imaging artifacts. To the untrained eye, a 3-D ultrasound may seem to show a fetus with a single nostril, or a black eye. Motion artifacts can simulate a cleft lip. Rendering artifacts can look like terrible ventriculomegaly. What seems to be a missing arm bone may be a shadow artifact.

KAILUA KONA, HAWAII — Three-dimensional ultrasound is less helpful for diagnosing fetal abnormalities than for counseling patients, Dr. Dolores H. Pretorius said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always performed as an adjunct to two-dimensional prenatal ultrasound, never as a replacement for it, 3-D ultrasound can help visualize and evaluate certain fetal abnormalities, give clinicians more confidence about what they're identifying, and help explain the problem to patients, she said.

Rarely does 3-D ultrasound identify additional abnormalities, said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The most helpful medical use of 3-D ultrasound may be for imaging facial anomalies, especially small cleft lips and cleft palates that are difficult to see with 2-D ultrasound, according to a 2005 consensus panel convened by the American Institute of Ultrasound in Medicine.

Because 3-D ultrasound can provide consistent symmetrical views, unlike 2-D ultrasound, it may help diagnose micrognathia (small chin), but further research is needed to confirm that, she said at the conference, which was sponsored by Boston University. It also may be helpful for imaging brain and spinal anomalies, identifying sutures on the fetal skull, and for research studies of cardiac anomalies, the consensus panel suggested.

Anomalies of the ear or the extremities can be seen with 3-D ultrasound. A diagnosis of club feet by 3-D ultrasound is false 12%–22% of the time, however, so patients must be warned of the false-positive rate, she cautioned. “We've had patients terminate the pregnancy for club feet and then have normal feet at autopsy.”

Referrals to check for central nervous system anomalies include cases of craniosynostosis or of mild ventriculomegaly, to look for the corpus callosum. A 3-D ultrasound of a neural tube defect can localize the level of the defect. “Most of the time this does not impact patient care” except when surgical treatment is planned, she said. Scoliosis is much more apparent on 3-D than on 2-D ultrasound to the parents and clinicians.

Trying to get parents to understand a fetal movement disorder can be difficult with just a 2-D image of an outstretched arm. Show them a 3-D image, however, “and all of a sudden the light bulb goes off in their head and they can understand it. Sometimes for patients the visual appearance of these can be very helpful,” Dr. Pretorius said.

Parents love to see 3-D images of the fetal face, which has led some nonmedical businesses to offer controversial “entertainment” 3-D ultrasound services in shopping malls and elsewhere. “I've already seen several lawsuits coming through related to 3-D ultrasounds that missed anomalies. The key question is, did the patient know that this was for entertainment, not diagnosis?” said Dr. Pretorius, who has studied 3-D ultrasound for 17 years.

A 3-D exam can be a frustrating experience for sonographers. Even experts only manage to image the face in 80% of midtrimester fetuses and 50% of third-trimester fetuses. The fetus must be in the right position without anything obscuring the face, and with plenty of amniotic fluid around it. The results are affected by gestational age and other factors.

At the start of a 3-D exam, “there's no predicting whether I'm going to make a good picture or not. If the parents don't get a good picture, they think that I'm not a good doctor,” Dr. Pretorius said.

As 3-D ultrasound gets used more and more, clinicians must become familiar with a slew of new imaging artifacts. To the untrained eye, a 3-D ultrasound may seem to show a fetus with a single nostril, or a black eye. Motion artifacts can simulate a cleft lip. Rendering artifacts can look like terrible ventriculomegaly. What seems to be a missing arm bone may be a shadow artifact.

KAILUA KONA, HAWAII — Three-dimensional ultrasound is less helpful for diagnosing fetal abnormalities than for counseling patients, Dr. Dolores H. Pretorius said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Always performed as an adjunct to two-dimensional prenatal ultrasound, never as a replacement for it, 3-D ultrasound can help visualize and evaluate certain fetal abnormalities, give clinicians more confidence about what they're identifying, and help explain the problem to patients, she said.

Rarely does 3-D ultrasound identify additional abnormalities, said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The most helpful medical use of 3-D ultrasound may be for imaging facial anomalies, especially small cleft lips and cleft palates that are difficult to see with 2-D ultrasound, according to a 2005 consensus panel convened by the American Institute of Ultrasound in Medicine.

Because 3-D ultrasound can provide consistent symmetrical views, unlike 2-D ultrasound, it may help diagnose micrognathia (small chin), but further research is needed to confirm that, she said at the conference, which was sponsored by Boston University. It also may be helpful for imaging brain and spinal anomalies, identifying sutures on the fetal skull, and for research studies of cardiac anomalies, the consensus panel suggested.

Anomalies of the ear or the extremities can be seen with 3-D ultrasound. A diagnosis of club feet by 3-D ultrasound is false 12%–22% of the time, however, so patients must be warned of the false-positive rate, she cautioned. “We've had patients terminate the pregnancy for club feet and then have normal feet at autopsy.”

Referrals to check for central nervous system anomalies include cases of craniosynostosis or of mild ventriculomegaly, to look for the corpus callosum. A 3-D ultrasound of a neural tube defect can localize the level of the defect. “Most of the time this does not impact patient care” except when surgical treatment is planned, she said. Scoliosis is much more apparent on 3-D than on 2-D ultrasound to the parents and clinicians.

Trying to get parents to understand a fetal movement disorder can be difficult with just a 2-D image of an outstretched arm. Show them a 3-D image, however, “and all of a sudden the light bulb goes off in their head and they can understand it. Sometimes for patients the visual appearance of these can be very helpful,” Dr. Pretorius said.

Parents love to see 3-D images of the fetal face, which has led some nonmedical businesses to offer controversial “entertainment” 3-D ultrasound services in shopping malls and elsewhere. “I've already seen several lawsuits coming through related to 3-D ultrasounds that missed anomalies. The key question is, did the patient know that this was for entertainment, not diagnosis?” said Dr. Pretorius, who has studied 3-D ultrasound for 17 years.

A 3-D exam can be a frustrating experience for sonographers. Even experts only manage to image the face in 80% of midtrimester fetuses and 50% of third-trimester fetuses. The fetus must be in the right position without anything obscuring the face, and with plenty of amniotic fluid around it. The results are affected by gestational age and other factors.

At the start of a 3-D exam, “there's no predicting whether I'm going to make a good picture or not. If the parents don't get a good picture, they think that I'm not a good doctor,” Dr. Pretorius said.

As 3-D ultrasound gets used more and more, clinicians must become familiar with a slew of new imaging artifacts. To the untrained eye, a 3-D ultrasound may seem to show a fetus with a single nostril, or a black eye. Motion artifacts can simulate a cleft lip. Rendering artifacts can look like terrible ventriculomegaly. What seems to be a missing arm bone may be a shadow artifact.

KAILUA KONA, HAWAII — Clinicians who offer fetal ultrasounds in their offices should ensure that those performing the scans are properly trained and that they explain to patients the limitations of the technology, to reduce the risk of being sued over ultrasound results, several speakers said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

In recent years, sonographers and ultrasound technicians who used to work exclusively for radiologists have been hired by some obstetricians to do ultrasounds in their offices. Many malpractice suits arising from misinterpretation or mismanagement of fetal ultrasound derive from inadequate staffing, training, and education, said Kimberly D. Baker, J.D.

She said too many clinicians want to have a fully equipped office technologically but are unwilling to pay for the education and training needed to maximize use of the technology. Turf wars make it more common for radiologists and other experts to criticize obstetricians or general practitioners whose use of ultrasound contributes to a legal case, said Ms. Baker, a defense lawyer in Seattle who also holds a BS degree in nursing.

“If you are going to have someone in your office who does this, you need to make sure that they are adequately trained, that their status is updated, that they are educated, and that you have a quality review process for your staff,” she advised.

Dr. Dolores H. Pretorius noted during a question-and-answer session that the American Institute of Ultrasound in Medicine offers a voluntary set of credentialing mechanisms for physicians who perform ultrasound. “I think it is helpful to have that to defend yourself,” said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The expertise of the sonographer is especially important with multifetal pregnancies, Dr. Michael A. Belfort said in a separate presentation. “It's not easy to scan twins and exponentially more difficult with triplets” or quadruplets. I can't understand why some doctors, without specific experience in managing high-order multiples, will choose to follow quadruplets in their office with a small, low-tech ultrasound machine and no consultation with a maternal and fetal medicine specialist. I just don't think it's worth the risk,” said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

In particular, when scanning multifetal pregnancies, it's important to get an early and accurate estimation of gestational age, determine amnionicity and chorionicity, and advise the patient of their implications.

Later in a twin pregnancy, one should consider following cervical length by ultrasound, because a woman with a cervix shorter than 25 mm at 24 weeks is more likely to deliver before 32–37 weeks than a woman with a longer cervix, Dr. Belfort advised. And definitely consider following cervical length in higher-order multiples. An anatomic survey by a maternal-fetal medicine specialist is also advisable. It's easy to miss an anomaly or scan the same fetus or parts of the fetus three times and think all three triplets are normal, he said.

One should reduce one's legal risk by explaining the benefits and the limitations of ultrasound to patients, Ms. Baker said at the meeting, sponsored by Boston University. Document in the chart that you explained the technology's limitations as they apply to the particular patient instead of relying on one-size-fits-all consent forms, she advised.

Document that you explained the technology's limitations as they apply to the particular patient. MS. BAKER

A short cervix, such as this one, in a woman with a multifetal pregnancy connotes a higher risk for preterm delivery, which ultrasound could detect early on. Courtesy Dr. Michael A. Belfort

KAILUA KONA, HAWAII — Clinicians who offer fetal ultrasounds in their offices should ensure that those performing the scans are properly trained and that they explain to patients the limitations of the technology, to reduce the risk of being sued over ultrasound results, several speakers said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

In recent years, sonographers and ultrasound technicians who used to work exclusively for radiologists have been hired by some obstetricians to do ultrasounds in their offices. Many malpractice suits arising from misinterpretation or mismanagement of fetal ultrasound derive from inadequate staffing, training, and education, said Kimberly D. Baker, J.D.

She said too many clinicians want to have a fully equipped office technologically but are unwilling to pay for the education and training needed to maximize use of the technology. Turf wars make it more common for radiologists and other experts to criticize obstetricians or general practitioners whose use of ultrasound contributes to a legal case, said Ms. Baker, a defense lawyer in Seattle who also holds a BS degree in nursing.

“If you are going to have someone in your office who does this, you need to make sure that they are adequately trained, that their status is updated, that they are educated, and that you have a quality review process for your staff,” she advised.

Dr. Dolores H. Pretorius noted during a question-and-answer session that the American Institute of Ultrasound in Medicine offers a voluntary set of credentialing mechanisms for physicians who perform ultrasound. “I think it is helpful to have that to defend yourself,” said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The expertise of the sonographer is especially important with multifetal pregnancies, Dr. Michael A. Belfort said in a separate presentation. “It's not easy to scan twins and exponentially more difficult with triplets” or quadruplets. I can't understand why some doctors, without specific experience in managing high-order multiples, will choose to follow quadruplets in their office with a small, low-tech ultrasound machine and no consultation with a maternal and fetal medicine specialist. I just don't think it's worth the risk,” said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

In particular, when scanning multifetal pregnancies, it's important to get an early and accurate estimation of gestational age, determine amnionicity and chorionicity, and advise the patient of their implications.

Later in a twin pregnancy, one should consider following cervical length by ultrasound, because a woman with a cervix shorter than 25 mm at 24 weeks is more likely to deliver before 32–37 weeks than a woman with a longer cervix, Dr. Belfort advised. And definitely consider following cervical length in higher-order multiples. An anatomic survey by a maternal-fetal medicine specialist is also advisable. It's easy to miss an anomaly or scan the same fetus or parts of the fetus three times and think all three triplets are normal, he said.

One should reduce one's legal risk by explaining the benefits and the limitations of ultrasound to patients, Ms. Baker said at the meeting, sponsored by Boston University. Document in the chart that you explained the technology's limitations as they apply to the particular patient instead of relying on one-size-fits-all consent forms, she advised.

Document that you explained the technology's limitations as they apply to the particular patient. MS. BAKER

A short cervix, such as this one, in a woman with a multifetal pregnancy connotes a higher risk for preterm delivery, which ultrasound could detect early on. Courtesy Dr. Michael A. Belfort

KAILUA KONA, HAWAII — Clinicians who offer fetal ultrasounds in their offices should ensure that those performing the scans are properly trained and that they explain to patients the limitations of the technology, to reduce the risk of being sued over ultrasound results, several speakers said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

In recent years, sonographers and ultrasound technicians who used to work exclusively for radiologists have been hired by some obstetricians to do ultrasounds in their offices. Many malpractice suits arising from misinterpretation or mismanagement of fetal ultrasound derive from inadequate staffing, training, and education, said Kimberly D. Baker, J.D.

She said too many clinicians want to have a fully equipped office technologically but are unwilling to pay for the education and training needed to maximize use of the technology. Turf wars make it more common for radiologists and other experts to criticize obstetricians or general practitioners whose use of ultrasound contributes to a legal case, said Ms. Baker, a defense lawyer in Seattle who also holds a BS degree in nursing.

“If you are going to have someone in your office who does this, you need to make sure that they are adequately trained, that their status is updated, that they are educated, and that you have a quality review process for your staff,” she advised.

Dr. Dolores H. Pretorius noted during a question-and-answer session that the American Institute of Ultrasound in Medicine offers a voluntary set of credentialing mechanisms for physicians who perform ultrasound. “I think it is helpful to have that to defend yourself,” said Dr. Pretorius, professor of radiology and director of imaging at the University of California, San Diego.

The expertise of the sonographer is especially important with multifetal pregnancies, Dr. Michael A. Belfort said in a separate presentation. “It's not easy to scan twins and exponentially more difficult with triplets” or quadruplets. I can't understand why some doctors, without specific experience in managing high-order multiples, will choose to follow quadruplets in their office with a small, low-tech ultrasound machine and no consultation with a maternal and fetal medicine specialist. I just don't think it's worth the risk,” said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

In particular, when scanning multifetal pregnancies, it's important to get an early and accurate estimation of gestational age, determine amnionicity and chorionicity, and advise the patient of their implications.

Later in a twin pregnancy, one should consider following cervical length by ultrasound, because a woman with a cervix shorter than 25 mm at 24 weeks is more likely to deliver before 32–37 weeks than a woman with a longer cervix, Dr. Belfort advised. And definitely consider following cervical length in higher-order multiples. An anatomic survey by a maternal-fetal medicine specialist is also advisable. It's easy to miss an anomaly or scan the same fetus or parts of the fetus three times and think all three triplets are normal, he said.

One should reduce one's legal risk by explaining the benefits and the limitations of ultrasound to patients, Ms. Baker said at the meeting, sponsored by Boston University. Document in the chart that you explained the technology's limitations as they apply to the particular patient instead of relying on one-size-fits-all consent forms, she advised.

Document that you explained the technology's limitations as they apply to the particular patient. MS. BAKER

A short cervix, such as this one, in a woman with a multifetal pregnancy connotes a higher risk for preterm delivery, which ultrasound could detect early on. Courtesy Dr. Michael A. Belfort

KAILUA KONA, HAWAII — An important step in detecting preterm labor in a multifetal pregnancy is to increase the patient's awareness of contractions and pelvic pressure and the need to report these symptoms, Dr. Michael A. Belfort said.

Most women who are pregnant for the first time don't know what contractions feel like or what to do if they get them. Spend time describing the sensations and instruct the patient about who to call, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City, said medicolegal issues related to preterm birth in multifetal pregnancies tend to fall in the following categories:

▸ Prevention and diagnosis. There is little benefit from routine bed rest or hospitalization to prevent preterm labor in a multifetal pregnancy, the published evidence shows. It may make sense to hospitalize a woman with a high-risk pregnancy if there is a reason to continuously monitor contractions or fetal heart rate, but admitting someone with only occasional contractions just to have that person in the hospital generally is not helpful, he said. For patients with regular contractions, admission for a full evaluation may be the safest initial step.

Home uterine monitoring has not been shown to help improve outcomes in preterm birth, and the American College of Obstetricians and Gynecologists does not recommend its use. If you plan to follow cervical length measurements by ultrasound, consider also obtaining fetal fibronectin measurements. Some data are available that combine the two measures to estimate the risk of preterm birth, Dr. Belfort said at the meeting, which was sponsored by Boston University.

▸ Steroids. For singletons, it's the standard of care to give a single course of antenatal steroids when there's a high risk of preterm birth between 24 and 34 weeks' gestation if the membranes are intact or between 24 and 32 weeks when the membranes are ruptured and there is no infection. Although no prospective studies specifically recommend the same course of action for twins or higher-order multiples, it makes sense to give steroids in multifetal pregnancies at high risk of preterm birth in those time periods, and most physicians do, he said. Do not give more than one course of steroids, he added. Repeat courses may have harmful effects on fetal brain growth, according to emerging data.

▸ Tocolytics. At least seven prospective studies show there is no clear benefit to giving prophylactic tocolytic therapy to try to stop contractions. This strategy will not prevent preterm birth, improve birth weight, or reduce the risk of neonatal mortality. Probably the best one can hope for is to slow down labor for 48 hours, he said. The terbutaline pump has been associated with maternal cardiac arrhythmia, and ACOG does not support its use.

▸ Cerclage. Two prospective trials in twins found no benefit from prophylactic cerclage in preventing preterm birth. No prospective, randomized, controlled trials have been conducted with triplets.

▸ Follow-up. A multifetal pregnancy in preterm labor should be followed closely, whether in or out of the hospital. Giving hydration or antibiotics is not helpful in preventing preterm labor, although antibiotics should not be withheld if there is an infection. Studies are underway on the use of progesterone to reduce the risk of preterm birth in multifetal pregnancies, but this is not yet the standard of care. For singletons, two studies suggest that a weekly intramuscular injection of progesterone may be helpful when given to a pregnant woman with a history of preterm delivery that did not involve cervical incompetence or an abruption.

▸ Experience. Do not delay transferring a patient with a multifetal pregnancy at high risk for preterm delivery to a level 3 facility. Continue to manage only the pregnancies that you're equipped to handle to avoid a postbirth injury that might have been avoided with specialized neonatal care.

KAILUA KONA, HAWAII — An important step in detecting preterm labor in a multifetal pregnancy is to increase the patient's awareness of contractions and pelvic pressure and the need to report these symptoms, Dr. Michael A. Belfort said.

Most women who are pregnant for the first time don't know what contractions feel like or what to do if they get them. Spend time describing the sensations and instruct the patient about who to call, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City, said medicolegal issues related to preterm birth in multifetal pregnancies tend to fall in the following categories:

▸ Prevention and diagnosis. There is little benefit from routine bed rest or hospitalization to prevent preterm labor in a multifetal pregnancy, the published evidence shows. It may make sense to hospitalize a woman with a high-risk pregnancy if there is a reason to continuously monitor contractions or fetal heart rate, but admitting someone with only occasional contractions just to have that person in the hospital generally is not helpful, he said. For patients with regular contractions, admission for a full evaluation may be the safest initial step.

Home uterine monitoring has not been shown to help improve outcomes in preterm birth, and the American College of Obstetricians and Gynecologists does not recommend its use. If you plan to follow cervical length measurements by ultrasound, consider also obtaining fetal fibronectin measurements. Some data are available that combine the two measures to estimate the risk of preterm birth, Dr. Belfort said at the meeting, which was sponsored by Boston University.

▸ Steroids. For singletons, it's the standard of care to give a single course of antenatal steroids when there's a high risk of preterm birth between 24 and 34 weeks' gestation if the membranes are intact or between 24 and 32 weeks when the membranes are ruptured and there is no infection. Although no prospective studies specifically recommend the same course of action for twins or higher-order multiples, it makes sense to give steroids in multifetal pregnancies at high risk of preterm birth in those time periods, and most physicians do, he said. Do not give more than one course of steroids, he added. Repeat courses may have harmful effects on fetal brain growth, according to emerging data.

▸ Tocolytics. At least seven prospective studies show there is no clear benefit to giving prophylactic tocolytic therapy to try to stop contractions. This strategy will not prevent preterm birth, improve birth weight, or reduce the risk of neonatal mortality. Probably the best one can hope for is to slow down labor for 48 hours, he said. The terbutaline pump has been associated with maternal cardiac arrhythmia, and ACOG does not support its use.

▸ Cerclage. Two prospective trials in twins found no benefit from prophylactic cerclage in preventing preterm birth. No prospective, randomized, controlled trials have been conducted with triplets.

▸ Follow-up. A multifetal pregnancy in preterm labor should be followed closely, whether in or out of the hospital. Giving hydration or antibiotics is not helpful in preventing preterm labor, although antibiotics should not be withheld if there is an infection. Studies are underway on the use of progesterone to reduce the risk of preterm birth in multifetal pregnancies, but this is not yet the standard of care. For singletons, two studies suggest that a weekly intramuscular injection of progesterone may be helpful when given to a pregnant woman with a history of preterm delivery that did not involve cervical incompetence or an abruption.

▸ Experience. Do not delay transferring a patient with a multifetal pregnancy at high risk for preterm delivery to a level 3 facility. Continue to manage only the pregnancies that you're equipped to handle to avoid a postbirth injury that might have been avoided with specialized neonatal care.

KAILUA KONA, HAWAII — An important step in detecting preterm labor in a multifetal pregnancy is to increase the patient's awareness of contractions and pelvic pressure and the need to report these symptoms, Dr. Michael A. Belfort said.

Most women who are pregnant for the first time don't know what contractions feel like or what to do if they get them. Spend time describing the sensations and instruct the patient about who to call, he said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City, said medicolegal issues related to preterm birth in multifetal pregnancies tend to fall in the following categories:

▸ Prevention and diagnosis. There is little benefit from routine bed rest or hospitalization to prevent preterm labor in a multifetal pregnancy, the published evidence shows. It may make sense to hospitalize a woman with a high-risk pregnancy if there is a reason to continuously monitor contractions or fetal heart rate, but admitting someone with only occasional contractions just to have that person in the hospital generally is not helpful, he said. For patients with regular contractions, admission for a full evaluation may be the safest initial step.

Home uterine monitoring has not been shown to help improve outcomes in preterm birth, and the American College of Obstetricians and Gynecologists does not recommend its use. If you plan to follow cervical length measurements by ultrasound, consider also obtaining fetal fibronectin measurements. Some data are available that combine the two measures to estimate the risk of preterm birth, Dr. Belfort said at the meeting, which was sponsored by Boston University.

▸ Steroids. For singletons, it's the standard of care to give a single course of antenatal steroids when there's a high risk of preterm birth between 24 and 34 weeks' gestation if the membranes are intact or between 24 and 32 weeks when the membranes are ruptured and there is no infection. Although no prospective studies specifically recommend the same course of action for twins or higher-order multiples, it makes sense to give steroids in multifetal pregnancies at high risk of preterm birth in those time periods, and most physicians do, he said. Do not give more than one course of steroids, he added. Repeat courses may have harmful effects on fetal brain growth, according to emerging data.

▸ Tocolytics. At least seven prospective studies show there is no clear benefit to giving prophylactic tocolytic therapy to try to stop contractions. This strategy will not prevent preterm birth, improve birth weight, or reduce the risk of neonatal mortality. Probably the best one can hope for is to slow down labor for 48 hours, he said. The terbutaline pump has been associated with maternal cardiac arrhythmia, and ACOG does not support its use.

▸ Cerclage. Two prospective trials in twins found no benefit from prophylactic cerclage in preventing preterm birth. No prospective, randomized, controlled trials have been conducted with triplets.

▸ Follow-up. A multifetal pregnancy in preterm labor should be followed closely, whether in or out of the hospital. Giving hydration or antibiotics is not helpful in preventing preterm labor, although antibiotics should not be withheld if there is an infection. Studies are underway on the use of progesterone to reduce the risk of preterm birth in multifetal pregnancies, but this is not yet the standard of care. For singletons, two studies suggest that a weekly intramuscular injection of progesterone may be helpful when given to a pregnant woman with a history of preterm delivery that did not involve cervical incompetence or an abruption.

▸ Experience. Do not delay transferring a patient with a multifetal pregnancy at high risk for preterm delivery to a level 3 facility. Continue to manage only the pregnancies that you're equipped to handle to avoid a postbirth injury that might have been avoided with specialized neonatal care.

KAILUA KONA, HAWAII — Consider the worst thing that can happen when managing preeclampsia and then do the logical thing to avoid that outcome, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He highlighted some confusing aspects in current practice and gave his “logical” alternatives for managing mild and severe preeclampsia.

▸ Mild preeclampsia. Dr. Belfort challenged those who say that it is appropriate to delay delivery in a mildly preeclamptic patient with a preterm fetus (35–37 weeks' gestation). “We've got to get out of the mind-set that it's terrible to deliver somebody earlier than 37 weeks” in the face of a potentially disastrous disease process, he said at the conference sponsored by Boston University. At 35–37 weeks' gestation, deliver the baby if the benefits outweigh the risks to both mother and baby, he said.

He reminded the audience of the American College of Obstetricians and Gynecologists' recommendation to manage mild preeclampsia in the hospital initially, and he supported subsequent outpatient management under certain conditions. Ideally, patients managed on an outpatient basis should have a blood pressure monitor at home so that they can take measurements up to four times daily. The patient also needs clearly defined, written instructions for when to call the physician, he said. The frequency and type of prenatal surveillance in preeclamptic patients are areas open to clinical judgment. Weekly nonstress tests, biophysical profiles, or both, are recommended by ACOG, said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

He suggested increasing the frequency of these tests in hospitalized patients. Dr. Belfort orders a nonstress test, amniotic fluid index, and lab tests every 3–4 days or more often depending on the clinical circumstances. If intrauterine growth restriction (IUGR) is identified in someone with preeclampsia beyond 32 weeks, ACOG guidelines say that the baby should be delivered because the mother is now in the realm of severe preeclampsia. He recommends doing daily fetal movement counting in these patients; fetal movement counting is important not only in preeclampsia, but also in every pregnancy, he added.

When managing mild preeclampsia on an outpatient basis, Dr. Belfort prefers to do twice weekly nonstress testing with amniotic fluid index, the so-called modified biophysical profile. This gives him frequent opportunities not only to check the fetus but also to question patients about headache, abdominal pain, visual disturbances, or other complications.

In women with mild preeclampsia and the potential for developing IUGR, a growth ultrasound should be done every 2–3 weeks. Consider getting a weekly Doppler ultrasound, he added. Dr. Belfort repeats lab tests weekly as long as there's no progression and admits the patient if he suspects progression of disease.

▸ Severe preeclampsia. Beyond 32 weeks' gestation, delivery of the baby, as recommended by ACOG, is usually the safest option, Dr. Belfort said. ACOG guidelines say it's reasonable to deliver the babies of women with hemolysis, elevated liver enzymes, and low platelet count (HELPP) syndrome regardless of gestational age.

“The outcomes for 32-week babies are good in the average level 2 or level 3 neonatal unit. The outcomes for women with progressive, severe HELPP syndrome who have delayed delivery are usually not good,” he explained.

Do an elective cesarean if the cervix is unripe because 80% of women with severe preeclampsia and an unripe cervix will end up having a C-section anyway, he added. Attempting a vaginal delivery may deplete the baby's reserves and result in an emergency C-section. In women with severe preeclampsia, Dr. Belfort orders continuous electronic fetal monitoring and gets lab tests every 6–8 hours to watch for worsening condition.

Outcomes for women with HELPP syndrome who have delayed delivery are usually not good. DR. BELFORT

KAILUA KONA, HAWAII — Consider the worst thing that can happen when managing preeclampsia and then do the logical thing to avoid that outcome, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He highlighted some confusing aspects in current practice and gave his “logical” alternatives for managing mild and severe preeclampsia.

▸ Mild preeclampsia. Dr. Belfort challenged those who say that it is appropriate to delay delivery in a mildly preeclamptic patient with a preterm fetus (35–37 weeks' gestation). “We've got to get out of the mind-set that it's terrible to deliver somebody earlier than 37 weeks” in the face of a potentially disastrous disease process, he said at the conference sponsored by Boston University. At 35–37 weeks' gestation, deliver the baby if the benefits outweigh the risks to both mother and baby, he said.

He reminded the audience of the American College of Obstetricians and Gynecologists' recommendation to manage mild preeclampsia in the hospital initially, and he supported subsequent outpatient management under certain conditions. Ideally, patients managed on an outpatient basis should have a blood pressure monitor at home so that they can take measurements up to four times daily. The patient also needs clearly defined, written instructions for when to call the physician, he said. The frequency and type of prenatal surveillance in preeclamptic patients are areas open to clinical judgment. Weekly nonstress tests, biophysical profiles, or both, are recommended by ACOG, said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

He suggested increasing the frequency of these tests in hospitalized patients. Dr. Belfort orders a nonstress test, amniotic fluid index, and lab tests every 3–4 days or more often depending on the clinical circumstances. If intrauterine growth restriction (IUGR) is identified in someone with preeclampsia beyond 32 weeks, ACOG guidelines say that the baby should be delivered because the mother is now in the realm of severe preeclampsia. He recommends doing daily fetal movement counting in these patients; fetal movement counting is important not only in preeclampsia, but also in every pregnancy, he added.

When managing mild preeclampsia on an outpatient basis, Dr. Belfort prefers to do twice weekly nonstress testing with amniotic fluid index, the so-called modified biophysical profile. This gives him frequent opportunities not only to check the fetus but also to question patients about headache, abdominal pain, visual disturbances, or other complications.

In women with mild preeclampsia and the potential for developing IUGR, a growth ultrasound should be done every 2–3 weeks. Consider getting a weekly Doppler ultrasound, he added. Dr. Belfort repeats lab tests weekly as long as there's no progression and admits the patient if he suspects progression of disease.

▸ Severe preeclampsia. Beyond 32 weeks' gestation, delivery of the baby, as recommended by ACOG, is usually the safest option, Dr. Belfort said. ACOG guidelines say it's reasonable to deliver the babies of women with hemolysis, elevated liver enzymes, and low platelet count (HELPP) syndrome regardless of gestational age.

“The outcomes for 32-week babies are good in the average level 2 or level 3 neonatal unit. The outcomes for women with progressive, severe HELPP syndrome who have delayed delivery are usually not good,” he explained.

Do an elective cesarean if the cervix is unripe because 80% of women with severe preeclampsia and an unripe cervix will end up having a C-section anyway, he added. Attempting a vaginal delivery may deplete the baby's reserves and result in an emergency C-section. In women with severe preeclampsia, Dr. Belfort orders continuous electronic fetal monitoring and gets lab tests every 6–8 hours to watch for worsening condition.

Outcomes for women with HELPP syndrome who have delayed delivery are usually not good. DR. BELFORT

KAILUA KONA, HAWAII — Consider the worst thing that can happen when managing preeclampsia and then do the logical thing to avoid that outcome, Dr. Michael A. Belfort said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law.

He highlighted some confusing aspects in current practice and gave his “logical” alternatives for managing mild and severe preeclampsia.

▸ Mild preeclampsia. Dr. Belfort challenged those who say that it is appropriate to delay delivery in a mildly preeclamptic patient with a preterm fetus (35–37 weeks' gestation). “We've got to get out of the mind-set that it's terrible to deliver somebody earlier than 37 weeks” in the face of a potentially disastrous disease process, he said at the conference sponsored by Boston University. At 35–37 weeks' gestation, deliver the baby if the benefits outweigh the risks to both mother and baby, he said.

He reminded the audience of the American College of Obstetricians and Gynecologists' recommendation to manage mild preeclampsia in the hospital initially, and he supported subsequent outpatient management under certain conditions. Ideally, patients managed on an outpatient basis should have a blood pressure monitor at home so that they can take measurements up to four times daily. The patient also needs clearly defined, written instructions for when to call the physician, he said. The frequency and type of prenatal surveillance in preeclamptic patients are areas open to clinical judgment. Weekly nonstress tests, biophysical profiles, or both, are recommended by ACOG, said Dr. Belfort, professor of obstetrics and gynecology at the University of Utah, Salt Lake City.

He suggested increasing the frequency of these tests in hospitalized patients. Dr. Belfort orders a nonstress test, amniotic fluid index, and lab tests every 3–4 days or more often depending on the clinical circumstances. If intrauterine growth restriction (IUGR) is identified in someone with preeclampsia beyond 32 weeks, ACOG guidelines say that the baby should be delivered because the mother is now in the realm of severe preeclampsia. He recommends doing daily fetal movement counting in these patients; fetal movement counting is important not only in preeclampsia, but also in every pregnancy, he added.

When managing mild preeclampsia on an outpatient basis, Dr. Belfort prefers to do twice weekly nonstress testing with amniotic fluid index, the so-called modified biophysical profile. This gives him frequent opportunities not only to check the fetus but also to question patients about headache, abdominal pain, visual disturbances, or other complications.

In women with mild preeclampsia and the potential for developing IUGR, a growth ultrasound should be done every 2–3 weeks. Consider getting a weekly Doppler ultrasound, he added. Dr. Belfort repeats lab tests weekly as long as there's no progression and admits the patient if he suspects progression of disease.

▸ Severe preeclampsia. Beyond 32 weeks' gestation, delivery of the baby, as recommended by ACOG, is usually the safest option, Dr. Belfort said. ACOG guidelines say it's reasonable to deliver the babies of women with hemolysis, elevated liver enzymes, and low platelet count (HELPP) syndrome regardless of gestational age.

“The outcomes for 32-week babies are good in the average level 2 or level 3 neonatal unit. The outcomes for women with progressive, severe HELPP syndrome who have delayed delivery are usually not good,” he explained.

Do an elective cesarean if the cervix is unripe because 80% of women with severe preeclampsia and an unripe cervix will end up having a C-section anyway, he added. Attempting a vaginal delivery may deplete the baby's reserves and result in an emergency C-section. In women with severe preeclampsia, Dr. Belfort orders continuous electronic fetal monitoring and gets lab tests every 6–8 hours to watch for worsening condition.

Outcomes for women with HELPP syndrome who have delayed delivery are usually not good. DR. BELFORT

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.” Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

The clash of cultures in perinatal care doesn't always end so happily. She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who couldn't arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop. Some cultures accept only short-term causes of health problems and don't believe in chronic disease.

Cultural differences go beyond words, Ms. Martin noted. In Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.” Typically, white Americans prefer to keep about 3 or 4 feet between themselves and other people, but Native Americans usually prefer a greater distance.

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” or “The belly blew up,” which can be taken literally.

For the newborn period, ask in advance about expectations for feeding the infant, including the best method and timing of the first feed. Talk with the parents about swaddling practices and about what kinds of caretaking are expected at home. Do they believe babies should be allowed to cry or should be comforted immediately? Do they plan ritual beautification practices? Where will the baby sleep? How will they care for the umbilical stump?

Incorporating new knowledge and experiences of different cultures in your practice will improve perinatal care, Ms. Martin said.

For more information, she recommended the American Academy of Pediatrics' “Transcultural Aspects of Perinatal Health Care: A Resource Guide.”

Evaluate your own attitudes and biases, be open to change, and treat each person with respect. MS. MARTIN

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.” Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

The clash of cultures in perinatal care doesn't always end so happily. She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who couldn't arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop. Some cultures accept only short-term causes of health problems and don't believe in chronic disease.

Cultural differences go beyond words, Ms. Martin noted. In Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.” Typically, white Americans prefer to keep about 3 or 4 feet between themselves and other people, but Native Americans usually prefer a greater distance.

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” or “The belly blew up,” which can be taken literally.

For the newborn period, ask in advance about expectations for feeding the infant, including the best method and timing of the first feed. Talk with the parents about swaddling practices and about what kinds of caretaking are expected at home. Do they believe babies should be allowed to cry or should be comforted immediately? Do they plan ritual beautification practices? Where will the baby sleep? How will they care for the umbilical stump?

Incorporating new knowledge and experiences of different cultures in your practice will improve perinatal care, Ms. Martin said.

For more information, she recommended the American Academy of Pediatrics' “Transcultural Aspects of Perinatal Health Care: A Resource Guide.”

Evaluate your own attitudes and biases, be open to change, and treat each person with respect. MS. MARTIN

STANFORD, CALIF. — The young woman who arrived in labor was accompanied by a large and loud crowd of extended family members who spoke little English. With each contraction, the family yelled louder, Marylouise Martin recalled.

Instead of simply asking them to be quiet or leave, she pulled aside one of the family members and asked why they were all yelling. “Must yell,” the man told her. “Louder you yell, more beautiful baby will be.” Cultural differences made the yelling irritating to staff members but a routine part of the birth process to the family, she said at a conference on perinatal and pediatric nutrition.

After a separate, nearby room was found for the family to carry on in, everyone was satisfied, said Ms. Martin, a nurse educator at McLeod Regional Medical Center, Florence, S.C.

The clash of cultures in perinatal care doesn't always end so happily. She told another tale of a male resident physician at an unnamed hospital who was called to substitute at the last minute for a female physician who couldn't arrive in time to deliver her patient's baby. The mother cried and tried to refuse his care. The woman's husband fought to remove the resident from the room and was taken away by hospital security officers. The baby was delivered, but the parents left the hospital shortly after the birth without the baby. In their eyes, the woman had been violated, and they could not keep the baby.

The stories illustrate why it's important to pursue cultural competence—the accrual of knowledge and skills that enable providers to adapt health care in accordance with the ethnocultural or religious heritage of the individual patient and the patient's family and community, she said at the meeting, jointly sponsored by Symposia Medicus and Stanford University.

In the values of traditional American health care, life is sacred, autonomous decision making is paramount, telling the truth is essential, and suffering should be avoided. In some cultures, however, the family may be the primary decision maker. Some patients may not want to hear about health risks, out of the belief that once potential problems are mentioned, the problems are more likely to develop. Some cultures accept only short-term causes of health problems and don't believe in chronic disease.

Cultural differences go beyond words, Ms. Martin noted. In Greece and Bulgaria, shaking the head up and down means “No,” not “Yes.” Typically, white Americans prefer to keep about 3 or 4 feet between themselves and other people, but Native Americans usually prefer a greater distance.

To increase your cultural awareness and competence, evaluate your own attitudes and biases, and be open to change, she advised. Learn to treat each person with respect and equality, and never assume that a person's ethnic identity tells you anything about his or her cultural values or patterns of behavior.

Work with your patients toward common goals by asking questions and communicating effectively. Speak clearly and slowly in short sentences using simple words, not medical jargon. Avoid phrases like, “The baby crashed,” or “The belly blew up,” which can be taken literally.

For the newborn period, ask in advance about expectations for feeding the infant, including the best method and timing of the first feed. Talk with the parents about swaddling practices and about what kinds of caretaking are expected at home. Do they believe babies should be allowed to cry or should be comforted immediately? Do they plan ritual beautification practices? Where will the baby sleep? How will they care for the umbilical stump?

Incorporating new knowledge and experiences of different cultures in your practice will improve perinatal care, Ms. Martin said.

For more information, she recommended the American Academy of Pediatrics' “Transcultural Aspects of Perinatal Health Care: A Resource Guide.”

Evaluate your own attitudes and biases, be open to change, and treat each person with respect. MS. MARTIN

SAN FRANCISCO – Postoperative psychiatric complications in a small percentage of liver donors included three completed or attempted suicides, Dr. James F. Trotter reported in a poster at the annual meeting of the American Association for the Study of Liver Diseases.

Data on the right hepatic lobe donors came from the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL), which followed donors and recipients at nine U.S. transplant centers for at least 5 days and up to nearly 6 years after the surgery.

“Suicide and severe psychiatric complications are of concern in right hepatic lobe donors. We suggest psychiatric assessment and monitoring of liver donors may be helpful to understand and prevent such tragic events,” wrote Dr. Trotter of the University of Colorado Health Sciences Center, Denver, and his associates.

More studies are needed to determine if the psychiatric complications are related to stress from the surgery or to the types of people who choose to donate, or both, he said.

The postoperative psychiatric complications, which occurred in 3% of 390 liver donors, included two completed suicides and one attempted suicide in addition to depression in two donors, substance abuse in two, and the development of worsening obsessive-compulsive disorder, insomnia, or bipolar disorder in one donor each. Detailed questionnaires were used to profile the three suicide events. The recipients of the right hepatic lobe donations in these three cases were alive and well at the time of the suicide attempts.

A 50-year-old man who donated to his niece was treated with clonazepam for bipolar disorder before and after the donation. He developed physical postoperative complications, including a middle hepatic vein thrombosis, abdominal discomfort, and fatigue. He used a shotgun to the head to kill himself 22 months after the donation.

A 35-year-old man who donated to his brother developed a pleural effusion, ileus, and mild urinary retention after the surgery. Prior to donation, he had been in counseling related to a divorce but had no psychiatric history. A fatal, self-induced drug overdose 23 months after donation was recorded as suicide by the transplant center.

A 23-year-old man who donated to his father had no physical complications. Nine months later he was hospitalized twice in a 2-month period for slashing his wrists in attempted suicides after a breakup with his significant other. He is alive and doing well today, Dr. Trotter wrote.

Besides the two donors who committed suicide, two other donors died–one from postdonation surgical complications and one in a train accident.

SAN FRANCISCO – Postoperative psychiatric complications in a small percentage of liver donors included three completed or attempted suicides, Dr. James F. Trotter reported in a poster at the annual meeting of the American Association for the Study of Liver Diseases.

Data on the right hepatic lobe donors came from the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL), which followed donors and recipients at nine U.S. transplant centers for at least 5 days and up to nearly 6 years after the surgery.

“Suicide and severe psychiatric complications are of concern in right hepatic lobe donors. We suggest psychiatric assessment and monitoring of liver donors may be helpful to understand and prevent such tragic events,” wrote Dr. Trotter of the University of Colorado Health Sciences Center, Denver, and his associates.

More studies are needed to determine if the psychiatric complications are related to stress from the surgery or to the types of people who choose to donate, or both, he said.

The postoperative psychiatric complications, which occurred in 3% of 390 liver donors, included two completed suicides and one attempted suicide in addition to depression in two donors, substance abuse in two, and the development of worsening obsessive-compulsive disorder, insomnia, or bipolar disorder in one donor each. Detailed questionnaires were used to profile the three suicide events. The recipients of the right hepatic lobe donations in these three cases were alive and well at the time of the suicide attempts.

A 50-year-old man who donated to his niece was treated with clonazepam for bipolar disorder before and after the donation. He developed physical postoperative complications, including a middle hepatic vein thrombosis, abdominal discomfort, and fatigue. He used a shotgun to the head to kill himself 22 months after the donation.

A 35-year-old man who donated to his brother developed a pleural effusion, ileus, and mild urinary retention after the surgery. Prior to donation, he had been in counseling related to a divorce but had no psychiatric history. A fatal, self-induced drug overdose 23 months after donation was recorded as suicide by the transplant center.

A 23-year-old man who donated to his father had no physical complications. Nine months later he was hospitalized twice in a 2-month period for slashing his wrists in attempted suicides after a breakup with his significant other. He is alive and doing well today, Dr. Trotter wrote.

Besides the two donors who committed suicide, two other donors died–one from postdonation surgical complications and one in a train accident.

SAN FRANCISCO – Postoperative psychiatric complications in a small percentage of liver donors included three completed or attempted suicides, Dr. James F. Trotter reported in a poster at the annual meeting of the American Association for the Study of Liver Diseases.

Data on the right hepatic lobe donors came from the Adult-to-Adult Living Donor Liver Transplant Cohort Study (A2ALL), which followed donors and recipients at nine U.S. transplant centers for at least 5 days and up to nearly 6 years after the surgery.

“Suicide and severe psychiatric complications are of concern in right hepatic lobe donors. We suggest psychiatric assessment and monitoring of liver donors may be helpful to understand and prevent such tragic events,” wrote Dr. Trotter of the University of Colorado Health Sciences Center, Denver, and his associates.

More studies are needed to determine if the psychiatric complications are related to stress from the surgery or to the types of people who choose to donate, or both, he said.

The postoperative psychiatric complications, which occurred in 3% of 390 liver donors, included two completed suicides and one attempted suicide in addition to depression in two donors, substance abuse in two, and the development of worsening obsessive-compulsive disorder, insomnia, or bipolar disorder in one donor each. Detailed questionnaires were used to profile the three suicide events. The recipients of the right hepatic lobe donations in these three cases were alive and well at the time of the suicide attempts.

A 50-year-old man who donated to his niece was treated with clonazepam for bipolar disorder before and after the donation. He developed physical postoperative complications, including a middle hepatic vein thrombosis, abdominal discomfort, and fatigue. He used a shotgun to the head to kill himself 22 months after the donation.

A 35-year-old man who donated to his brother developed a pleural effusion, ileus, and mild urinary retention after the surgery. Prior to donation, he had been in counseling related to a divorce but had no psychiatric history. A fatal, self-induced drug overdose 23 months after donation was recorded as suicide by the transplant center.

A 23-year-old man who donated to his father had no physical complications. Nine months later he was hospitalized twice in a 2-month period for slashing his wrists in attempted suicides after a breakup with his significant other. He is alive and doing well today, Dr. Trotter wrote.

Besides the two donors who committed suicide, two other donors died–one from postdonation surgical complications and one in a train accident.

SAN FRANCISCO — Infectious disease specialists at one institution provided over $93,000 worth of curbside consultations without reimbursement, Dr. Christopher J. Grace said at the annual meeting of the Infectious Diseases Society of America.

Members of the specialty “need to get a handle on this. We're giving away the farm,” said Dr. Grace of the University of Vermont, Burlington.

A 1-year prospective study at Fletcher Allen Health Care, a 500-bed community and tertiary care center in Burlington, found that infectious disease specialists gave 1,001 curbside consultations, defined as advice or suggestions given to another physician without seeing the patient. Curbside consults took place in person or by telephone, letter, or e-mail.

Without the physicians or nurses who requested the curbside consultations knowing it, the infectious disease specialists assigned a CPT code to each event based on whether the patient in question was an inpatient or outpatient, whether the consultation dealt with initial care or subsequent care, and how complex the case was.

They then gave a physician-work relative value unit, or RVU, the standard used by the Centers for Medicare and Medicaid Services (CMS) to calculate reimbursements, to each curbside consultation based on the CPT code and then multiplied the aggregate RVUs by the 2005 CMS conversion factor of $37.89 per RVU to estimate costs.

In 98% of cases, curbside consultations focused on a specific patient, rather than on theoretical patients or general topics. Among consultations for patients, 34% were for inpatients and 66% were for outpatients. Events were coded as initial consultations in 96% of cases.

The main clinical topics of consultations focused on skin disease in 16% of cases, pulmonary disease in 8%, bone or joint infection in 8%, and bacteremia in 7%.

The curbside consultations accounted for 21% of all infectious disease consultations that year and were as complex as formal consultations, Dr. Grace said. The curbside consultations generated a total of 2,462 RVUs, which would have meant $93,285 “if we were paid the standard Medicare reimbursement fee,” he said.

Formal consultations in the same time period generated 9,409 RVUs worth $356,507. The number of RVUs per consultation was higher for curbside (2.46) than for formal consultations (1.22) because the former had a higher proportion of initial consultations.

Who asked for curbside consultations? Questions came about equally from the health center's staff and from community physicians with medical privileges at the center. More questions came from general internists than other specialists.

A physician in the audience urged Dr. Grace to share the results with colleagues in other specialties at his institution. “When you do, they'll be horrified that they're using you this way. It tends to bring your formal consults up,” he said, based on his own experience.

Dr. Grace noted that some physicians requesting the curbside consultations practiced 20–150 miles away, making formal consultations more difficult.

Hospitals, insurers, and others need to integrate curbside consultations into productivity measures and compensation measures, he said.

Many in the audience agreed. “We all should have done this 30 years ago, and we'd have more leverage with the payers,” one physician said.

Another suggested refusing to do curbside consultations. “At some point we just need to draw the line. If you offend the people who are curbsiding you, you lose nothing,” he suggested.

The definition of curbside consultation in the study excluded consultations for infection control, efforts to restrict antibiotic use, follow-up on formal consultations, education of students or residents, and curbside consultations that converted to formal consultations on the same day.

SAN FRANCISCO — Infectious disease specialists at one institution provided over $93,000 worth of curbside consultations without reimbursement, Dr. Christopher J. Grace said at the annual meeting of the Infectious Diseases Society of America.

Members of the specialty “need to get a handle on this. We're giving away the farm,” said Dr. Grace of the University of Vermont, Burlington.

A 1-year prospective study at Fletcher Allen Health Care, a 500-bed community and tertiary care center in Burlington, found that infectious disease specialists gave 1,001 curbside consultations, defined as advice or suggestions given to another physician without seeing the patient. Curbside consults took place in person or by telephone, letter, or e-mail.

Without the physicians or nurses who requested the curbside consultations knowing it, the infectious disease specialists assigned a CPT code to each event based on whether the patient in question was an inpatient or outpatient, whether the consultation dealt with initial care or subsequent care, and how complex the case was.

They then gave a physician-work relative value unit, or RVU, the standard used by the Centers for Medicare and Medicaid Services (CMS) to calculate reimbursements, to each curbside consultation based on the CPT code and then multiplied the aggregate RVUs by the 2005 CMS conversion factor of $37.89 per RVU to estimate costs.

In 98% of cases, curbside consultations focused on a specific patient, rather than on theoretical patients or general topics. Among consultations for patients, 34% were for inpatients and 66% were for outpatients. Events were coded as initial consultations in 96% of cases.

The main clinical topics of consultations focused on skin disease in 16% of cases, pulmonary disease in 8%, bone or joint infection in 8%, and bacteremia in 7%.

The curbside consultations accounted for 21% of all infectious disease consultations that year and were as complex as formal consultations, Dr. Grace said. The curbside consultations generated a total of 2,462 RVUs, which would have meant $93,285 “if we were paid the standard Medicare reimbursement fee,” he said.

Formal consultations in the same time period generated 9,409 RVUs worth $356,507. The number of RVUs per consultation was higher for curbside (2.46) than for formal consultations (1.22) because the former had a higher proportion of initial consultations.

Who asked for curbside consultations? Questions came about equally from the health center's staff and from community physicians with medical privileges at the center. More questions came from general internists than other specialists.

A physician in the audience urged Dr. Grace to share the results with colleagues in other specialties at his institution. “When you do, they'll be horrified that they're using you this way. It tends to bring your formal consults up,” he said, based on his own experience.

Dr. Grace noted that some physicians requesting the curbside consultations practiced 20–150 miles away, making formal consultations more difficult.

Hospitals, insurers, and others need to integrate curbside consultations into productivity measures and compensation measures, he said.

Many in the audience agreed. “We all should have done this 30 years ago, and we'd have more leverage with the payers,” one physician said.

Another suggested refusing to do curbside consultations. “At some point we just need to draw the line. If you offend the people who are curbsiding you, you lose nothing,” he suggested.

The definition of curbside consultation in the study excluded consultations for infection control, efforts to restrict antibiotic use, follow-up on formal consultations, education of students or residents, and curbside consultations that converted to formal consultations on the same day.

SAN FRANCISCO — Infectious disease specialists at one institution provided over $93,000 worth of curbside consultations without reimbursement, Dr. Christopher J. Grace said at the annual meeting of the Infectious Diseases Society of America.

Members of the specialty “need to get a handle on this. We're giving away the farm,” said Dr. Grace of the University of Vermont, Burlington.

A 1-year prospective study at Fletcher Allen Health Care, a 500-bed community and tertiary care center in Burlington, found that infectious disease specialists gave 1,001 curbside consultations, defined as advice or suggestions given to another physician without seeing the patient. Curbside consults took place in person or by telephone, letter, or e-mail.

Without the physicians or nurses who requested the curbside consultations knowing it, the infectious disease specialists assigned a CPT code to each event based on whether the patient in question was an inpatient or outpatient, whether the consultation dealt with initial care or subsequent care, and how complex the case was.

They then gave a physician-work relative value unit, or RVU, the standard used by the Centers for Medicare and Medicaid Services (CMS) to calculate reimbursements, to each curbside consultation based on the CPT code and then multiplied the aggregate RVUs by the 2005 CMS conversion factor of $37.89 per RVU to estimate costs.

In 98% of cases, curbside consultations focused on a specific patient, rather than on theoretical patients or general topics. Among consultations for patients, 34% were for inpatients and 66% were for outpatients. Events were coded as initial consultations in 96% of cases.

The main clinical topics of consultations focused on skin disease in 16% of cases, pulmonary disease in 8%, bone or joint infection in 8%, and bacteremia in 7%.

The curbside consultations accounted for 21% of all infectious disease consultations that year and were as complex as formal consultations, Dr. Grace said. The curbside consultations generated a total of 2,462 RVUs, which would have meant $93,285 “if we were paid the standard Medicare reimbursement fee,” he said.

Formal consultations in the same time period generated 9,409 RVUs worth $356,507. The number of RVUs per consultation was higher for curbside (2.46) than for formal consultations (1.22) because the former had a higher proportion of initial consultations.

Who asked for curbside consultations? Questions came about equally from the health center's staff and from community physicians with medical privileges at the center. More questions came from general internists than other specialists.

A physician in the audience urged Dr. Grace to share the results with colleagues in other specialties at his institution. “When you do, they'll be horrified that they're using you this way. It tends to bring your formal consults up,” he said, based on his own experience.

Dr. Grace noted that some physicians requesting the curbside consultations practiced 20–150 miles away, making formal consultations more difficult.

Hospitals, insurers, and others need to integrate curbside consultations into productivity measures and compensation measures, he said.

Many in the audience agreed. “We all should have done this 30 years ago, and we'd have more leverage with the payers,” one physician said.

Another suggested refusing to do curbside consultations. “At some point we just need to draw the line. If you offend the people who are curbsiding you, you lose nothing,” he suggested.

The definition of curbside consultation in the study excluded consultations for infection control, efforts to restrict antibiotic use, follow-up on formal consultations, education of students or residents, and curbside consultations that converted to formal consultations on the same day.

SAN FRANCISCO — The extent of hepatitis B viral suppression after 6 months of therapy predicts treatment efficacy and the risk of developing resistance at 1 year, Dr. Ching-Lung Lai said at the annual meeting of the American Association for the Study of Liver Diseases.

A study of 1,367 patients with chronic hepatitis B virus (HBV) infection and viral DNA levels greater than 6 log

Patients with detectable HBV at 6 months had more variable outcomes at 1 year, with higher viral loads at 6 months linked to increased risks for detectable virus, viral breakthrough, and development of drug resistance at 1 year, said Dr. Lai, chief of gastroenterology and hepatology at the University of Hong Kong, and his associates.

“Now we can actually adjust the patient's treatment” by adding or changing drugs if HBV remains detectable at 6 months, he suggested. “Early viral suppression at 6 months is an ideal thing to aim for in the treatment of chronic hepatitis B.”

The main purpose of the phase III, randomized GLOBE study was to compare the efficacy of the investigational anti-HBV drug telbivudine with lamivudine during 2 years of treatment. The temporal relationship between early viral suppression and 1-year outcomes was seen in both treatment groups, but telbivudine worked better to suppress the virus, Dr. Lai said. He is a consultant for and has received funding from Idenix Pharmaceuticals, which is developing telbivudine in collaboration with Novartis Pharma AG.

The relationship between early viral suppression and good 1-year outcomes applied regardless of whether patients were positive or negative for hepatitis B e-antigen (HBeAg) at baseline.

For the analysis, patients were divided into four groups based on viral load at 6 months, as measured with polymerase chain reaction: patients with undetectable levels (below 300 copies/mL), fewer than 3 log

Among HBeAg-positive patients, HBV DNA was undetectable at 1 year in 91% of patients with undetectable levels at 6 months but in only 5% of patients with more than 4 log

Viral breakthrough by 1 year was seen in fewer than 1% of patients who had undetectable HBV DNA at 6 months, regardless of HBeAg status. Breakthrough occurred by 1 year in 14% of HBeAg-positive patients and 24% of HBeAg-negative patients who had more than 4 log

At baseline, all patients had compensated liver disease and ALT levels at 1.3–10 times the upper limit of normal. ALT levels normalized by 1 year in 88% of HBeAg-positive patients and 81% of HBeAg-negative patients who had undetectable HBV DNA at 6 months, indicative of improved liver function. In comparison, ALT levels normalized by 1 year in 53% of HBeAg-positive patients and 41% of HBeAg-negative patients who had a viral load of more than 4 log

In each of the viral load categories, telbivudine achieved greater viral suppression and led to less drug resistance, compared with lamivudine, he added.

SAN FRANCISCO — The extent of hepatitis B viral suppression after 6 months of therapy predicts treatment efficacy and the risk of developing resistance at 1 year, Dr. Ching-Lung Lai said at the annual meeting of the American Association for the Study of Liver Diseases.

A study of 1,367 patients with chronic hepatitis B virus (HBV) infection and viral DNA levels greater than 6 log

Patients with detectable HBV at 6 months had more variable outcomes at 1 year, with higher viral loads at 6 months linked to increased risks for detectable virus, viral breakthrough, and development of drug resistance at 1 year, said Dr. Lai, chief of gastroenterology and hepatology at the University of Hong Kong, and his associates.

“Now we can actually adjust the patient's treatment” by adding or changing drugs if HBV remains detectable at 6 months, he suggested. “Early viral suppression at 6 months is an ideal thing to aim for in the treatment of chronic hepatitis B.”

The main purpose of the phase III, randomized GLOBE study was to compare the efficacy of the investigational anti-HBV drug telbivudine with lamivudine during 2 years of treatment. The temporal relationship between early viral suppression and 1-year outcomes was seen in both treatment groups, but telbivudine worked better to suppress the virus, Dr. Lai said. He is a consultant for and has received funding from Idenix Pharmaceuticals, which is developing telbivudine in collaboration with Novartis Pharma AG.

The relationship between early viral suppression and good 1-year outcomes applied regardless of whether patients were positive or negative for hepatitis B e-antigen (HBeAg) at baseline.

For the analysis, patients were divided into four groups based on viral load at 6 months, as measured with polymerase chain reaction: patients with undetectable levels (below 300 copies/mL), fewer than 3 log

Among HBeAg-positive patients, HBV DNA was undetectable at 1 year in 91% of patients with undetectable levels at 6 months but in only 5% of patients with more than 4 log

Viral breakthrough by 1 year was seen in fewer than 1% of patients who had undetectable HBV DNA at 6 months, regardless of HBeAg status. Breakthrough occurred by 1 year in 14% of HBeAg-positive patients and 24% of HBeAg-negative patients who had more than 4 log

At baseline, all patients had compensated liver disease and ALT levels at 1.3–10 times the upper limit of normal. ALT levels normalized by 1 year in 88% of HBeAg-positive patients and 81% of HBeAg-negative patients who had undetectable HBV DNA at 6 months, indicative of improved liver function. In comparison, ALT levels normalized by 1 year in 53% of HBeAg-positive patients and 41% of HBeAg-negative patients who had a viral load of more than 4 log

In each of the viral load categories, telbivudine achieved greater viral suppression and led to less drug resistance, compared with lamivudine, he added.

SAN FRANCISCO — The extent of hepatitis B viral suppression after 6 months of therapy predicts treatment efficacy and the risk of developing resistance at 1 year, Dr. Ching-Lung Lai said at the annual meeting of the American Association for the Study of Liver Diseases.

A study of 1,367 patients with chronic hepatitis B virus (HBV) infection and viral DNA levels greater than 6 log

Patients with detectable HBV at 6 months had more variable outcomes at 1 year, with higher viral loads at 6 months linked to increased risks for detectable virus, viral breakthrough, and development of drug resistance at 1 year, said Dr. Lai, chief of gastroenterology and hepatology at the University of Hong Kong, and his associates.

“Now we can actually adjust the patient's treatment” by adding or changing drugs if HBV remains detectable at 6 months, he suggested. “Early viral suppression at 6 months is an ideal thing to aim for in the treatment of chronic hepatitis B.”

The main purpose of the phase III, randomized GLOBE study was to compare the efficacy of the investigational anti-HBV drug telbivudine with lamivudine during 2 years of treatment. The temporal relationship between early viral suppression and 1-year outcomes was seen in both treatment groups, but telbivudine worked better to suppress the virus, Dr. Lai said. He is a consultant for and has received funding from Idenix Pharmaceuticals, which is developing telbivudine in collaboration with Novartis Pharma AG.

The relationship between early viral suppression and good 1-year outcomes applied regardless of whether patients were positive or negative for hepatitis B e-antigen (HBeAg) at baseline.

For the analysis, patients were divided into four groups based on viral load at 6 months, as measured with polymerase chain reaction: patients with undetectable levels (below 300 copies/mL), fewer than 3 log

Among HBeAg-positive patients, HBV DNA was undetectable at 1 year in 91% of patients with undetectable levels at 6 months but in only 5% of patients with more than 4 log

Viral breakthrough by 1 year was seen in fewer than 1% of patients who had undetectable HBV DNA at 6 months, regardless of HBeAg status. Breakthrough occurred by 1 year in 14% of HBeAg-positive patients and 24% of HBeAg-negative patients who had more than 4 log

At baseline, all patients had compensated liver disease and ALT levels at 1.3–10 times the upper limit of normal. ALT levels normalized by 1 year in 88% of HBeAg-positive patients and 81% of HBeAg-negative patients who had undetectable HBV DNA at 6 months, indicative of improved liver function. In comparison, ALT levels normalized by 1 year in 53% of HBeAg-positive patients and 41% of HBeAg-negative patients who had a viral load of more than 4 log

In each of the viral load categories, telbivudine achieved greater viral suppression and led to less drug resistance, compared with lamivudine, he added.

SAN FRANCISCO — Antidepressants were safe and moderately effective in a study of 368 patients with end-stage liver disease, Dr. Jayant A. Talwalkar reported.

Little is known about the effects of antidepressants in patients with end-stage liver disease. The prevalence of depression was 41% in this population, higher than the estimated 30% in the general population. The mean age of the depressed patients was 54 years, and 44% were women, Dr. Talwalkar wrote in a poster presented at the annual meeting of the American Association for the Study of Liver Diseases.

The investigators reviewed the records of all patients who underwent a formal psychiatric consultation as part of their evaluation for a liver transplant. The patients were treated at one institution during a 2-year period.

Of the 150 patients identified as depressed, 44% had a prior history of depression and 83% were eligible for pharmacologic therapy for their depression. Antidepressants were prescribed for 83% of the 125 eligible patients, for a mean duration of 13 months.

Treated patients showed no significantly increased rates of worsening serum liver biochemistries, compared with the 264 patients who did not use antidepressants. The rates of development of new complications also did not differ between these two groups, reported Dr. Talwalkar of the Mayo Clinic, Rochester, Minn., and his associates.

“Pharmacologic therapy was not associated with a greater frequency of hepatic decompensation in patients with end-stage liver disease,” he wrote. The most common antidepressants prescribed were selective serotonin reuptake inhibitors, used by 83% of treated patients; 34% of patients required a change in antidepressant therapy or additional drugs for depression. Citalopram was used by 46% of patients, paroxetine by 20%, sertraline by 12%, and trazodone by 10%.

Dr. Talwalkar has received research funding from Pfizer Inc., the manufacturer of sertraline.

Antidepressant-related adverse events, reported in 21% of treated patients, included somnolence in 10%, nausea or diarrhea in 6%, and dry mouth in 3%.

The main causes of liver disease were hepatitis C infection, alcohol abuse, a combination of the two, and nonalcoholic steatohepatitis. The liver disease caused fatigue in 51%, pruritus in 10%, ascites in 70%, hepatic encephalopathy in 40%, hepatocellular carcinoma in 8%, and a prior variceal hemorrhage in 16%. Overall, 24% of patients were using β-blockers.

'Pharmacologic therapy was not associated with a greater frequency of hepatic decompensation.' DR. TALWALKAR

SAN FRANCISCO — Antidepressants were safe and moderately effective in a study of 368 patients with end-stage liver disease, Dr. Jayant A. Talwalkar reported.

Little is known about the effects of antidepressants in patients with end-stage liver disease. The prevalence of depression was 41% in this population, higher than the estimated 30% in the general population. The mean age of the depressed patients was 54 years, and 44% were women, Dr. Talwalkar wrote in a poster presented at the annual meeting of the American Association for the Study of Liver Diseases.

The investigators reviewed the records of all patients who underwent a formal psychiatric consultation as part of their evaluation for a liver transplant. The patients were treated at one institution during a 2-year period.

Of the 150 patients identified as depressed, 44% had a prior history of depression and 83% were eligible for pharmacologic therapy for their depression. Antidepressants were prescribed for 83% of the 125 eligible patients, for a mean duration of 13 months.

Treated patients showed no significantly increased rates of worsening serum liver biochemistries, compared with the 264 patients who did not use antidepressants. The rates of development of new complications also did not differ between these two groups, reported Dr. Talwalkar of the Mayo Clinic, Rochester, Minn., and his associates.

“Pharmacologic therapy was not associated with a greater frequency of hepatic decompensation in patients with end-stage liver disease,” he wrote. The most common antidepressants prescribed were selective serotonin reuptake inhibitors, used by 83% of treated patients; 34% of patients required a change in antidepressant therapy or additional drugs for depression. Citalopram was used by 46% of patients, paroxetine by 20%, sertraline by 12%, and trazodone by 10%.

Dr. Talwalkar has received research funding from Pfizer Inc., the manufacturer of sertraline.

Antidepressant-related adverse events, reported in 21% of treated patients, included somnolence in 10%, nausea or diarrhea in 6%, and dry mouth in 3%.

The main causes of liver disease were hepatitis C infection, alcohol abuse, a combination of the two, and nonalcoholic steatohepatitis. The liver disease caused fatigue in 51%, pruritus in 10%, ascites in 70%, hepatic encephalopathy in 40%, hepatocellular carcinoma in 8%, and a prior variceal hemorrhage in 16%. Overall, 24% of patients were using β-blockers.

'Pharmacologic therapy was not associated with a greater frequency of hepatic decompensation.' DR. TALWALKAR

SAN FRANCISCO — Antidepressants were safe and moderately effective in a study of 368 patients with end-stage liver disease, Dr. Jayant A. Talwalkar reported.

Little is known about the effects of antidepressants in patients with end-stage liver disease. The prevalence of depression was 41% in this population, higher than the estimated 30% in the general population. The mean age of the depressed patients was 54 years, and 44% were women, Dr. Talwalkar wrote in a poster presented at the annual meeting of the American Association for the Study of Liver Diseases.

The investigators reviewed the records of all patients who underwent a formal psychiatric consultation as part of their evaluation for a liver transplant. The patients were treated at one institution during a 2-year period.

Of the 150 patients identified as depressed, 44% had a prior history of depression and 83% were eligible for pharmacologic therapy for their depression. Antidepressants were prescribed for 83% of the 125 eligible patients, for a mean duration of 13 months.

Treated patients showed no significantly increased rates of worsening serum liver biochemistries, compared with the 264 patients who did not use antidepressants. The rates of development of new complications also did not differ between these two groups, reported Dr. Talwalkar of the Mayo Clinic, Rochester, Minn., and his associates.

“Pharmacologic therapy was not associated with a greater frequency of hepatic decompensation in patients with end-stage liver disease,” he wrote. The most common antidepressants prescribed were selective serotonin reuptake inhibitors, used by 83% of treated patients; 34% of patients required a change in antidepressant therapy or additional drugs for depression. Citalopram was used by 46% of patients, paroxetine by 20%, sertraline by 12%, and trazodone by 10%.

Dr. Talwalkar has received research funding from Pfizer Inc., the manufacturer of sertraline.

Antidepressant-related adverse events, reported in 21% of treated patients, included somnolence in 10%, nausea or diarrhea in 6%, and dry mouth in 3%.

The main causes of liver disease were hepatitis C infection, alcohol abuse, a combination of the two, and nonalcoholic steatohepatitis. The liver disease caused fatigue in 51%, pruritus in 10%, ascites in 70%, hepatic encephalopathy in 40%, hepatocellular carcinoma in 8%, and a prior variceal hemorrhage in 16%. Overall, 24% of patients were using β-blockers.

'Pharmacologic therapy was not associated with a greater frequency of hepatic decompensation.' DR. TALWALKAR

KAILUA KONA, HAWAII — Many people—and many jurors—assume that a large pregnant woman has a large birth canal. If shoulder dystocia during delivery leads to neurologic injury of the baby, they reason that the physician must have done something wrong.

Educate patients early on in pregnancy that they way they are built on the outside doesn't necessarily reflect the way they are built on the inside, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law. “That may sound really simplistic, but I can't tell you the number of times I've taken the testimony of the mother, who had shoulders like a football player and said, 'I don't understand. It never occurred to me that my pelvis wouldn't be as big as the rest of me,'” said Ms. Baker, a defense attorney in Seattle who also holds a BS degree in nursing.

In addition, follow the patient's weight, assess her for diabetes, estimate fetal weight, and discuss the potential for a macrosomic infant with the patient and her partner. Talk about the risk for shoulder dystocia and injury and the risks and benefits of choosing a vaginal birth or an elective C-section in the case of a small maternal pelvis or an estimated large baby.

If you get sued for not predicting shoulder dystocia, data in the literature provide a very good defense, she said. Studies show that fetal size, shoulder dystocia, and brachial plexus injury don't necessarily go hand in hand, Ms. Baker said.

That doesn't mean you won't be sued anyway, plaintiffs' attorney Michael F. Becker, J.D., commented during the same session at the meeting sponsored by Boston University. If you can reasonably anticipate that shoulder dystocia might become a problem during vaginal delivery, you may have a duty to discuss the option of a C-section, to allow the mother an informed choice of delivery mode.

Ultrasounds or maternal weight gain suggesting cephalopelvic disproportion or macrosomia may make it reasonable to anticipate shoulder dystocia, he suggested. “We know that women under 5 feet tall have a tendency to have a smaller pelvis,” and physicians should be discussing shoulder dystocia as a possibility with these patients, said Mr. Becker, who practices law in Cleveland.

Other reasons for malpractice suits include improper management of shoulder dystocia, such as applying fundal pressure, or failing to apply suprapubic pressure or the McRoberts maneuver. Shoulder dystocia brings Mr. Becker many clients.

“These are the cases that we see an awful lot of in my office. We must have six or eight currently pending,” he said.

In close to a third of the cases, shoulder dystocia is not documented in the patient's chart. That's no defense for the physician, however. “All we have to do is talk to the family members or look at the videotapes to see what really happened,” he said.

Ms. Baker advised physicians to think long and hard before allowing people to take photos or videos in the delivery room. She also urged them to be candid in their account of events in notes. If shoulder dystocia leads to an injured baby, be compassionate and sympathetic and engaged, she suggested. “It's a very big deal for the mother and the father or partner.”

Get a pediatric neurologist involved in the case. Place a tickler in your file system so that when the mother comes in for postpartum care, you ask about the child. Ask the mother's permission to speak with the neurologist to see how the child is doing.

If you end up in court, remember that jurors respond to visual evidence. Show them your chart notes or photos of the mother's weight gain if you have them.

Ms. Baker defended one case in which a woman ballooned up to 300 pounds during pregnancy but slimmed down to 122 pounds by the time of the trial. The jurors could not believe the argument that her weight gain increased the risk for macrosomia until the defense produced a photo taken 2 weeks before delivery.

You may have a duty to discuss the option of a C-section, to allow the mother an informed choice. MR. BECKER

KAILUA KONA, HAWAII — Many people—and many jurors—assume that a large pregnant woman has a large birth canal. If shoulder dystocia during delivery leads to neurologic injury of the baby, they reason that the physician must have done something wrong.

Educate patients early on in pregnancy that they way they are built on the outside doesn't necessarily reflect the way they are built on the inside, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law. “That may sound really simplistic, but I can't tell you the number of times I've taken the testimony of the mother, who had shoulders like a football player and said, 'I don't understand. It never occurred to me that my pelvis wouldn't be as big as the rest of me,'” said Ms. Baker, a defense attorney in Seattle who also holds a BS degree in nursing.

In addition, follow the patient's weight, assess her for diabetes, estimate fetal weight, and discuss the potential for a macrosomic infant with the patient and her partner. Talk about the risk for shoulder dystocia and injury and the risks and benefits of choosing a vaginal birth or an elective C-section in the case of a small maternal pelvis or an estimated large baby.

If you get sued for not predicting shoulder dystocia, data in the literature provide a very good defense, she said. Studies show that fetal size, shoulder dystocia, and brachial plexus injury don't necessarily go hand in hand, Ms. Baker said.

That doesn't mean you won't be sued anyway, plaintiffs' attorney Michael F. Becker, J.D., commented during the same session at the meeting sponsored by Boston University. If you can reasonably anticipate that shoulder dystocia might become a problem during vaginal delivery, you may have a duty to discuss the option of a C-section, to allow the mother an informed choice of delivery mode.

Ultrasounds or maternal weight gain suggesting cephalopelvic disproportion or macrosomia may make it reasonable to anticipate shoulder dystocia, he suggested. “We know that women under 5 feet tall have a tendency to have a smaller pelvis,” and physicians should be discussing shoulder dystocia as a possibility with these patients, said Mr. Becker, who practices law in Cleveland.

Other reasons for malpractice suits include improper management of shoulder dystocia, such as applying fundal pressure, or failing to apply suprapubic pressure or the McRoberts maneuver. Shoulder dystocia brings Mr. Becker many clients.

“These are the cases that we see an awful lot of in my office. We must have six or eight currently pending,” he said.

In close to a third of the cases, shoulder dystocia is not documented in the patient's chart. That's no defense for the physician, however. “All we have to do is talk to the family members or look at the videotapes to see what really happened,” he said.

Ms. Baker advised physicians to think long and hard before allowing people to take photos or videos in the delivery room. She also urged them to be candid in their account of events in notes. If shoulder dystocia leads to an injured baby, be compassionate and sympathetic and engaged, she suggested. “It's a very big deal for the mother and the father or partner.”

Get a pediatric neurologist involved in the case. Place a tickler in your file system so that when the mother comes in for postpartum care, you ask about the child. Ask the mother's permission to speak with the neurologist to see how the child is doing.

If you end up in court, remember that jurors respond to visual evidence. Show them your chart notes or photos of the mother's weight gain if you have them.

Ms. Baker defended one case in which a woman ballooned up to 300 pounds during pregnancy but slimmed down to 122 pounds by the time of the trial. The jurors could not believe the argument that her weight gain increased the risk for macrosomia until the defense produced a photo taken 2 weeks before delivery.

You may have a duty to discuss the option of a C-section, to allow the mother an informed choice. MR. BECKER

KAILUA KONA, HAWAII — Many people—and many jurors—assume that a large pregnant woman has a large birth canal. If shoulder dystocia during delivery leads to neurologic injury of the baby, they reason that the physician must have done something wrong.

Educate patients early on in pregnancy that they way they are built on the outside doesn't necessarily reflect the way they are built on the inside, Kimberly D. Baker, J.D., said at a conference on obstetrics, gynecology, perinatal medicine, neonatology, and the law. “That may sound really simplistic, but I can't tell you the number of times I've taken the testimony of the mother, who had shoulders like a football player and said, 'I don't understand. It never occurred to me that my pelvis wouldn't be as big as the rest of me,'” said Ms. Baker, a defense attorney in Seattle who also holds a BS degree in nursing.

In addition, follow the patient's weight, assess her for diabetes, estimate fetal weight, and discuss the potential for a macrosomic infant with the patient and her partner. Talk about the risk for shoulder dystocia and injury and the risks and benefits of choosing a vaginal birth or an elective C-section in the case of a small maternal pelvis or an estimated large baby.

If you get sued for not predicting shoulder dystocia, data in the literature provide a very good defense, she said. Studies show that fetal size, shoulder dystocia, and brachial plexus injury don't necessarily go hand in hand, Ms. Baker said.

That doesn't mean you won't be sued anyway, plaintiffs' attorney Michael F. Becker, J.D., commented during the same session at the meeting sponsored by Boston University. If you can reasonably anticipate that shoulder dystocia might become a problem during vaginal delivery, you may have a duty to discuss the option of a C-section, to allow the mother an informed choice of delivery mode.

Ultrasounds or maternal weight gain suggesting cephalopelvic disproportion or macrosomia may make it reasonable to anticipate shoulder dystocia, he suggested. “We know that women under 5 feet tall have a tendency to have a smaller pelvis,” and physicians should be discussing shoulder dystocia as a possibility with these patients, said Mr. Becker, who practices law in Cleveland.

Other reasons for malpractice suits include improper management of shoulder dystocia, such as applying fundal pressure, or failing to apply suprapubic pressure or the McRoberts maneuver. Shoulder dystocia brings Mr. Becker many clients.

“These are the cases that we see an awful lot of in my office. We must have six or eight currently pending,” he said.

In close to a third of the cases, shoulder dystocia is not documented in the patient's chart. That's no defense for the physician, however. “All we have to do is talk to the family members or look at the videotapes to see what really happened,” he said.

Ms. Baker advised physicians to think long and hard before allowing people to take photos or videos in the delivery room. She also urged them to be candid in their account of events in notes. If shoulder dystocia leads to an injured baby, be compassionate and sympathetic and engaged, she suggested. “It's a very big deal for the mother and the father or partner.”

Get a pediatric neurologist involved in the case. Place a tickler in your file system so that when the mother comes in for postpartum care, you ask about the child. Ask the mother's permission to speak with the neurologist to see how the child is doing.

If you end up in court, remember that jurors respond to visual evidence. Show them your chart notes or photos of the mother's weight gain if you have them.

Ms. Baker defended one case in which a woman ballooned up to 300 pounds during pregnancy but slimmed down to 122 pounds by the time of the trial. The jurors could not believe the argument that her weight gain increased the risk for macrosomia until the defense produced a photo taken 2 weeks before delivery.

You may have a duty to discuss the option of a C-section, to allow the mother an informed choice. MR. BECKER