G AUGING P REGNANCY R ISK W ITH N O H UMAN DATA ,
Ob.Gyn. News
VO L . 4 3 , N O. 1 6
This coronal T2 image
(top) of a fetus diagnosed
with an aberrant
pulmonary vein shows
agenesis of the corpus
callosum, abnormal and
retarded gyration,
malrotation of both
hippocampi, and
associated signal
abnormalities of the
developing white matter
at 28 weeks.
The brain of a fetus
(bottom) with Fallot’s
tetralogy shows bilateral
germinolytic cysts in the
caudothalamic groove at
25 weeks.
Fetal Cardiac, Brain
Defects Are Linked
BY AMY ROTHMAN
SCHONFELD
Contributing Writer
N E W O R L E A N S — Fetal MRI
shows that almost 60% of fetus-
es with cardiac defects also have
brain abnormalities, according to
the findings of an imaging study
conducted in Vienna.
A total of 57 pregnant women
whose fetuses had cardiac mal-
formations identified by ultra-
sound were studied. The find-
ings were presented by Dr.
Gregor Kasprian at the Ameri-
can Society of Neuroradiology.
The fetuses had a variety of car-
diac malformations, including:
Fallot’s tetralogy (nine cases);
transposition of the great vessels
(three); ventricle septum defect
with or without associated car-
diac malformations (nine); rhab-
domyoma (three); aortic steno-
sis at the isthmus (three);
arteriovenous canal (three); car-
diomegaly (unilateral or bilater-
al) (three); or other pathologies
such as an aneurysm, cardiac
teratoma, missing inferior vena
cava, and double-outlet right
ventricle. In some cases, it was
too early to classify the defect.
When these fetuses then un-
derwent fetal MRI between 20
and 38 gestational weeks (with a
1.5-T superconducting system us-
ing ultrafast T2-weighted, T1-
weighted, diffusion-weighted, and
PAGE 12
THE LEADER
IN NEWS
AND
MEETING
COVERAGE
www.obg ynnews.com
T he Leading Inde p endent Ne wspaper for the Obstetrician/Gynecologist—Since 1966 AU G U S T 1 5 , 2 0 0 8
INSIDE
Induction Effect
HT May Benefit
Declines in mean birth
weight and gestational age
are linked to an increase in
Postmenopausal
labor induction.
PAGE 6 Cognition, Memory
D R . G REGOR K ASPRIAN
Preterm Triggers
Three new studies contradict past results.
Low HDL cholesterol and B Y M I C H E L E G. trolled trials using conjugated
high homocysteine levels may S U L L I VA N equine estrogens have shown no
be keys to preterm delivery. Mid-Atlantic Bureau treatment effects in women at
risk for Alzheimer’s disease, or in
COURTESY
PAGE 10 C H I C A G O — Hormone thera- women who have the illness.”
py might preserve cognition and These concerns, plus her own
I MAGES
memory in postmenopausal hypothesis that the “minidoses”
Trump the Triad women, and even attenuate of hormones used in many ran-
Education and professional some of the cognitive deficits domized trials might be too low
teamwork can prevent the that occur in Alzheimer’s disease, to offer protective benefit,
female athlete triad.
PAGE 16
new research suggests.
Controversy exists over the
possible cognitive benefits of hor-
prompted Dr. Tierney of the
Sunnybrook Health Sciences
Centre, Toronto, and her col-
mone therapy in older women,
Dr. Mary Tierney said at the In-
ternational Conference on
leagues to undertake a new study.
The 2-year trial randomized 142
women aged 61-87 years to either
Alzheimer’s Disease. “While pre- placebo or to 1 mg estradiol dai-
echo-planar sequences in three clinical and observational studies ly plus 0.35 mg progestin 3 days
orthogonal section planes), brain have shown a positive effect of per week.
pathology was found in 33 cases estradiol on the brain and cogni- The primary outcome was the
(59%), said Dr. Kasprian, a radiol- tive function, randomized con- See Cognition page 6
ogist at the Medical University of
Vienna. This rate is generally
higher than that reported using
prenatal ultrasonography First-Trimester Lamotrigine
The study was carried out un-
der the auspices of the Fetal MRI
Work Group, led by Dr. Daniela
Health Politics
Sen. John McCain proposes
Use Linked to Oral Clefts
Prayer, also of the Medical Uni- to replace the tax exclusion BY ROBERT FINN mations, Dr. Lewis B. Holmes
versity of Vienna. for employee health benefits San Francisco Bureau said at the annual meeting of the
Eighteen fetuses demonstrated with a tax credit. Teratology Society. This trans-
brain malformations, such as M O N T E R E Y, C A L I F. — lates to a rate of 2.3%, compared
commissural anomalies (three PAGE 26 Women who take the anticon- with a baseline rate of 1.6% in un-
cases), holoprosencephaly (one), vulsant lamotrigine during their exposed newborn infants (Neu-
See Defects page 7 first trimester of pregnancy have rology 2008;70:2152-8).
a 10-fold greater risk of having a Although this difference in com-
VITAL SIGNS baby with nonsyndromal cleft bined major malformation rates
lip, cleft palate, or both, accord- was not statistically significant, the
ing to a peer-reviewed study. investigators observed a signifi-
Median Income for Ob.Gyns. Among 684 women enrolled cantly increased risk when they re-
in the North American Anti- stricted the analysis to oral clefts.
$300,000 Epileptic Drug (AED) Pregnancy Three of the infants had an iso-
$280,629 Registry who reported taking lated cleft palate, one had an iso-
Actual lamotrigine monotherapy during lated cleft lip, and one had bilater-
their first trimester, there were 16 al cleft lip and palate, for an overall
$250,000 $237,191
infants born with major malfor- See Lamotrigine page 7
$233,066
$221,980 Adjusted*
$200,000
E LSEVIER G LOBAL M EDICAL N EWS
0
2003 2004 2005 2006 2007
*Adjusted for inflation to 2000 dollars.
Source: Medical Group Management Association
 Au g u s t 1 5 , 2 0 0 8 • w w w. o b g y n n e w s . c o m News 7

AMA Apologizes for Past Racial Discrimination

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

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

Brain-Cardio Tie Tenfold Increase in Risk EDITORIAL

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