38 AUGUST 2009 • OB.GYN. NEWS Epidural Choice Appears Pregnant Women’s Snoring Independent of Ethnicity May Not Affect Fetal Outcomes

BY HEIDI SPLETE not (8.8 vs. 3.7). But there was no signifi- BY HEIDI SPLETE that maternal SDB may not be associ- cant difference in epidural use among the ated with adverse fetal outcomes. But WASHINGTON — When equal access ethnic groups, and patients in all groups WASHINGTON — Pregnant women’s the study is ongoing, and data that to epidural anesthesia is available, patient reported similarly effective pain relief af- snoring has no apparent negative impact haven’t yet been fully analyzed suggest ethnicity is not a factor in choosing ter epidural placement. on fetal outcomes, despite some differ- a possible association. “We’re not sure whether to have an epidural, according to The ethnic groups were defined as ences in fetal umbilical arterial gas- how [maternal SDB] might affect fetal results of a study of 797 consecutive white (103 patients), black (78 patients), es, based on data from two studies in- outcome,” Dr. Bullough said in a poster women with singleton at a Hispanic (150 patients), Chinese or Kore- cluding more than 600 women. presentation at the annual meeting of hospital in Flushing, N.Y. an (338 patients), Indian (67 patients), and Previous research has suggested that the Society for Obstetric Anesthesia Although epidural anesthesia is widely other ethnicities (61 patients). habitual snoring in pregnant women and Perinatology. available in the United States, previous Socioeconomic factors and maternal may be a risk factor for poor fetal out- Habitual snoring was not significant- studies have suggested education were not fac- comes, but the available data were pri- ly associated with low or that ethnic disparities Chinese or Korean tors in the use of an marily from case studies, said Dr. Alexan- Apgar scores, based on a second study of persist in the provision of epidural, Dr. Lowenwirt dra Bullough and Louise O’Brien, Ph.D., 429 women with uncomplicated single- epidurals, according to patients averaged reported. of the University of Michigan in Ann ton pregnancies. In this study, also con- Dr. Isaac P. Lowenwirt of the shortest duration In addition, nulli- Arbor. ducted by Dr. O’Brien and Dr. Bullough, the New York Hospital of analgesia, and parous women were As part of a larger study of the impact 35% of the women reported habitual Queens, Flushing. four times more likely to of sleep-disordered breathing (SDB) on snoring (at least 3 nights each week) and To describe the use of black patients choose an epidural than both maternal and fetal outcomes, the 25% were obese (with a BMI of at least 2 epidural anesthesia dur- averaged the longest multiparous women, re- researchers recruited 380 women aged 30 kg/m ). The women’s snoring was as- ing labor in a multiethnic gardless of ethnicity. 18 years and older in the third trimester sessed through sleep questionnaires, and population, Dr. Lowen- duration (141 vs. On further analysis, of singleton, uncomplicated pregnan- fetal outcomes were determined by re- wirt and his colleagues 185 minutes). Chinese or Korean pa- cies to complete sleep questionnaires. viewing obstetric records. conducted a prospective tients averaged the short- This study is the first known to exam- Overall, habitual snoring was not study of 800 consecutive est duration of analge- ine the impact of maternal SDB on fe- significantly associated with low birth singleton pregnancies at a single hospital. sia, and black patients averaged the longest tal outcomes after delivery, based on weight and Apgar scores. These results The average age of the women across duration (141 minutes vs. 185 minutes). umbilical blood gas values for arterial held after controlling for variables in- all ethnic groups ranged from 27 to 32 And there was a significant difference in pH, partial pressure of carbon dioxide cluding maternal diabetes, age, and years. Women who had multiples, mal- average bupivacaine use between the (PCO2), HCO3, and base excess. race. Only the gestational age at deliv- presentation, or planned cesarean deliv- group with the highest use (Hispanic pa- Overall, 129 women met the criteria ery and the mother’s BMI before preg- eries were excluded from the study. tients) and the lowest use (Chinese or Ko- for SDB, and they were compared with nancy were independent significant Complete data from 797 women were rean patients). 251 nonsnoring controls. The women predictors of birth weight and 1-minute presented in a poster at the annual meet- The Hispanic patients who chose bupi- with SDB averaged a significantly high- Apgar scores, and only gestational age ing of the Society for Obstetric Anesthesia vacaine averaged 7.3 mg/hr, compared er than controls both at delivery was an independent and and Perinatology. with an average of 5.5 mg/hr for the Chi- before (35 kg/m2 vs. 25 significant predictor of 5-minute Apgar The women were offered three options: nese or Korean patients who chose bupi- kg/m2) and during pregnancy (35 scores. Regardless of sleep apnea status, parenteral fentanyl, patient-controlled vacaine, he said.. kg/m2 vs. 28 kg/m2 ). “women with high BMI were going to anesthesia (bupivacaine), or no medica- The results suggest that when equal In this study, there were no signifi- have bigger babies,” Dr. Bullough said. tion. The severity of pain was measured access to epidural analgesia is available, cant differences between the SDB and These results contrasted with previ- with a visual analog scale. women of all ethnic groups choose it in control groups in average measures of ous studies suggesting that maternal Overall, 82% of the patients chose an similar proportions, compared with no arterial pH (7.3 vs. 7.3), PCO2 (54.4 mm sleep apnea may predict poor infant epidural. , the researchers wrote in the Hg vs. 57.4 mm Hg), HCO3 (23.6 outcomes, and more research is need- The average baseline pain scores were poster. mmol/L vs. 24.4 mmol/L), and base ed to evaluate the association. higher among the women who chose an Dr. Lowenwirt said he had no financial excess (–1.82 mmol vs. –1.85 mmol). The researchers said they had no fi- epidural, compared with those who did conflicts to disclose. ■ These preliminary findings suggest nancial conflicts to disclose. ■ Hyperemesis Gravidarum Symptoms May Persist Post Partum

BY BETSY BATES These symptoms included: Clearly, more needs to be known term food aversion—to physical, includ- Ǡ Food aversions (34% vs. 6%). about what is different about the sub- ing theories about long-term conse- C HICAGO — Many women with Ǡ Gastroesophageal reflux (23% vs. 5%). group of women with severe HG, par- quences of “the marked nutritional severe hyperemesis gravidarum experi- Ǡ Digestive problems (21% vs. 3%). ticularly those with long-lasting post- deprivation that these women under- ence clinical symptoms that persist well Ǡ Continued (13% vs. 5%). partum symptoms, he added. go,” Dr. Hernandez noted. beyond delivery, a survey shows. Ǡ Gallbladder problems (9% vs. 2%). “We do know that there is something A 2-year online survey coordinated Ǡ Persistent (52% vs. 25%). different about them that makes them through the nonprofit Hyperemesis Ǡ Muscle weakness (24% vs. 8%). Fatigue persisted still have problems after pregnancy,” he Education & Research Foundation com- The subgroup of women who re- beyond a year said. pared postpartum symptoms in 891 quired during preg- in 23% of these A goal of the research team is to focus women diagnosed with hyperemesis nancy had the highest prevalence of per- women, and on ways to identify women most at risk gravidarum (HG) (162 of whom received sistent postpartum nausea, fatigue, and food aversions, for severe HG and to develop and im- parenteral nutrition) and 541 controls muscle weakness—symptoms that in in 17%. plement a comprehensive management who did not experience dur- some cases lasted months or even plan for them during and after their preg- ing pregnancy from severe nausea and longer. DR. HERNANDEZ nancies, said Dr. Hernandez. , researchers reported at the an- Fatigue, for example, persisted beyond He was assisted in the research by nual meeting of the American College of a year in 23% of these women, and food “The etiology of these symptoms, as associates from the USC department of Obstetricians and Gynecologists. aversions, in 17%. well as the cause of their intensity and obstetrics and gynecology and division Highly significant differences were seen “It has been the common clinical im- duration in this subgroup of the preg- of maternal-fetal medicine in Los Ange- in both the prevalence and duration of nu- pression that all symptoms associated nant population remains unknown,” he les, and the Hyperemesis Education & merous postpartum symptoms between with HG resolve after pregnancy. This is said. Research Foundation of Leesburg, Va. women with HG and controls, reported the case for the majority of HG cases, Hypotheses range from psychologi- None of the investigators reported Dr. Gerson D. Hernandez of the Univer- but not all, as we can see in our results,” cal—behavior modification during conflicts of interest relevant to the sity of Southern California, Los Angeles. Dr. Hernandez said in an interview. months of pregnancy leading to long- study. ■