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In the News, Parenting, Pregnancy, Public Health, Public Safety, Women's Health

Exploring new recommendations to diagnose prenatal and postpartum depression

Exploring new recommendations to diagnose prenatal and postpartum depression

Although having a child is usually considered a happy event, an estimated 10 to 15 percent of women living in the U.S. develop some form of maternal depression. In response to new research and increased awareness about the problem, the U.S. Preventive Services Task Force revised their 2009 recommendations for screening procedures to diagnose and treat prenatal and postpartum depression.

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The guidelines, published last week in the Journal of the American Medical Association, now recommend screening for depression in the general adult population and they highlight the potential benefits of screening for pregnant and postpartum women.

Earlier this week, KQED Forum delved into the basis and potential implications of these new recommendations by exploring the topic with a panel of experts including Katherine Williams, MD, director  of Stanford’s Women’s Wellness Clinic.

Williams (who begins speaking at the 10:25 mark) stated that one of the most important aspects of the revised recommendations is its discussion of psychotherapy and how it can and, as Williams says, should be used as the first form of treatment for pregnant or nursing moms who are suffering from depression. The entire hour-long discussion is worth a listen.

Previously: A telephone lifeline for moms with postpartum depression“2020 Mom Project” promotes awareness of perinatal mood disordersAh…OM: Study shows prenatal yoga may relieve anxiety in pregnant women and Helping moms emerge from the darkness of postpartum depression
Photo by Sarah Zucca

Cardiovascular Medicine, Patient Care, Pediatrics, Pregnancy, Stanford News

World-first treatment for rare heart defect saves baby born at Packard Children’s

World-first treatment for rare heart defect saves baby born at Packard Children's

Group shot Liam and doctorsLinda Luna was five months pregnant with her first child when she got the bad news: Ultrasound scans showed a deadly defect in her baby boy’s heart. He had a 90 percent chance of dying before or just after birth. But thanks to a groundbreaking treatment at Lucile Packard Children’s Hospital Stanford, two-month-old baby Liam, who just went home to San Jose last week, is beating those odds.

He is the first baby in the world successfully treated with prenatal maternal hyper-oxygenation for his rare heart defect: congenital Ebstein’s anomaly. This week, several local news outlets report on the success of Liam’s case.

The problem at diagnosis? Due to severe leaks in two heart valves, blood flowed backward through the right half of Liam’s heart. His heart became dangerously enlarged. Too little blood reached his lungs and the rest of his body. Left untreated, the defect would cause irreparable heart and lung damage.

“Once you see type of leakage Liam had, it’s usually a progressive process,” said Theresa Tacy, MD, the fetal cardiology specialist who treated Liam in concert with his mom’s high-risk obstetrician, Katherine Bianco, MD, and a team of other specialists from across the hospital. “It just gets worse,” Tacy said. “The fetus eventually develops heart failure and dies.”

The team gave expectant mom Luna 12 hours per day of oxygen therapy for the last three weeks of her pregnancy. The idea was to relax Liam’s lung blood vessels with the extra oxygen he’d get from his mom. This would make it easier for his heart to pump blood forward into his lungs and, the doctors hoped, let him survive until birth and surgery.

Ebsteins vs normal by Tacy“We were trying to offer Liam’s parents hope but also remain realistic that their baby had a very high chance of not making it,” said cardiologist David Axelrod, MD, who cared for Liam in the cardiovascular intensive care unit after he was born. “We knew that even if he made it through pregnancy, his risk of dying during his first few days of life was very high.”

Immediately after his Nov. 22 birth, the doctors put Liam on an ECMO machine that delivered oxygen to his blood. Cardiothoracic surgeon Frank Hanley, MD, also closed a blood vessel near the heart to help Liam’s blood to flow forward. Finally, 11 days later, Liam was strong enough for a Dec. 3 surgery in which Hanley fully repaired his heart.

“It was a huge operation for a tiny baby fighting for his life,” Luna said. “The seven-hour wait during surgery was the longest wait of my life, but when they finally wheeled him out, he was a different baby. We were so thankful.”

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Autoimmune Disease, Pregnancy, Research, Stanford News, Women's Health

The latest on the pregnancy risks for women with lupus

The latest on the pregnancy risks for women with lupus

2892182827_accf82f274_zWomen with lupus, an autoimmune disorder that can attack a variety of tissues, were once counseled to avoid pregnancy. Now, physicians tailor their advice to each patient’s case. In many instances, however, it’s difficult for physicians to gauge what types of risk their patient might be facing.

A new study designed to clarify those risks found that women with lupus during pregnancy — and even women who may soon be diagnosed with lupus — are more likely to experience preeclampsia, stroke and infection than women without lupus. Infants born to mothers with lupus or pre-lupus are also more likely to be born preterm, have infections, or be small for gestational age, according to the paper, which was published today in Arthritis Care and Research.

“We’ve confirmed previous findings while strengthening the data to show that lupus is associated with a variety of adverse pregnancy outcomes both to the mother, and to the infant,” said senior author Julia Simard, ScD, assistant professor of health research and policy at Stanford.

The research team, which included collaborators in Sweden and at several U.S. universities, examined data from population-based Swedish registers. That data set allowed the researchers to identify patients who had babies several years before being diagnosed with lupus.  From 13,598 single, first-time births, the team identified 551 women with existing lupus and 198 who presented with lupus within five years after giving birth.

For women who have not yet been diagnosed, it’s possible that autoantibodies implicated in the disease may lead to some of the adverse outcomes, but the exact mechanisms remain unknown, Simard said.

She and others are also working to clarify the clinical ramifications of the work, which may help refine physicians’ recommendations and care of pregnant women with lupus, and may lead to earlier diagnoses.

This is a descriptive study, Simard cautioned. Lupus is a challenging condition to study, because it can manifest differently in every patient. As with other chronic diseases, it’s also difficult to distinguish between conditions that could strike anyone, and conditions that might be caused by lupus, she said.

Previously: Empowered is as empowered does: Making a choice about living with lupus, Women and men’s immune system genes operate differently, Stanford study shows Lupus and rheumatoid arthritis may mean fewer children for female patients and Why some autoimmune diseases go into remission during pregnancy
Photo by J.K. Califf

Ask Stanford Med, Pregnancy, Women's Health

A look at hypertension in pregnancy

A look at hypertension in pregnancy

Most people know that hypertension, or high blood pressure, is a common condition. What many might not know is that it’s also one of the most common complications in pregnancy: It is prevalent in 5-10 percent of pregnant women.

In a recent Q&A session, Sandra Tsai, MD, MPH, spoke with BeWell at Stanford about this condition and its effects:

Hypertension in pregnancy — especially the more severe forms (preeclampsia and eclampsia) — increases the risk for complications such as placenta abruption, acute kidney injury, and death. Longer-term, women diagnosed with hypertension in pregnancy are at risk for future cardiometabolic diseases — including hypertension, diabetes, stroke, and heart attacks.

Tsai also delved into ways to prevent hypertension and discussed her own work in this area:

Lifestyle behaviors — such as a healthy diet, regular exercise, starting pregnancy with a normal weight — may reduce, but may not entirely prevent, a woman’s risk for developing hypertension in pregnancy.

I am interested in helping women maintain a healthy weight throughout pregnancy. Women who start their pregnancy with excess weight are at increased risk for gaining more weight than the Institute of Medicine recommends. If these women can remain within the weight gain guidelines, they may be at less risk of developing pregnancy complications such as gestational hypertension and preeclampsia.

Alex Giacomini is a social media intern in the medical school’s Office of Communication and Public Affairs. 

Previously: Attending to signs of preeclampsia in late-stage pregnancy and The importance of knowing your blood pressure level in preventing hypertension

Fertility, Pregnancy, Sexual Health, Women's Health

Fertility quiz: How well do you know your body?

Fertility quiz: How well do you know your body?

2364734203_937bfdfe48_zRemember all the rumors that you heard about sexuality and fertility as a teen (or even a 20-something or a 30-something)? It’s hard to sort fact from fiction.

According to the Institute for Reproductive Health (IRH) at the Georgetown University Medical Center, an accurate understanding of sexuality and fertility is surprisingly low around the world. That’s why IRH has created an online quiz to probe fertility awareness, called “Know Your Bod,” which poses the challenge: “You live with your body everyday. Do you really know it? Find out.”

The online quiz asks ten questions including the true-or-false query, “A woman will get pregnant only if she has sex on the same day she ovulates? ” After you select an answer, the quiz provides a simple educational summary that explains the correct answer. At the end, it shows your score and how you compare to the general population.

The quiz was officially introduced this week at the International Conference on Family Planning in Indonesia. It was developed as part of IRH’s Fertility Awareness for Community Transformation Project, which strives to increase fertility awareness and the use of family planning.

Victoria Jennings, PhD, director of IRH, explained in a recent Georgetown press release:

Accurate understanding and awareness about human fertility is surprisingly low around the world, regardless of age, sex or education level. If we could lift the taboos and improve fertility awareness, would people be informed and empowered to make better sexual and reproductive health decisions? At IRH, we believe the answer to this question is ‘yes.’

So why not take the challenge? How well do you know your bod?

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor.

Previously:Ask Stanford Med: Expert in reproductive medicine responds to questions on infertilitySex without babies, and visa versa: Stanford panel explores issues surrounding reproductive technologies, and Med students want more sexual-health training
Photo by Scott Maxwell

Global Health, Health Policy, In the News, Pediatrics, Pregnancy, Women's Health

Ending preventable stillbirth: A Q&A with Stanford global-health expert Gary Darmstadt

Ending preventable stillbirth: A Q&A with Stanford global-health expert Gary Darmstadt

Today, prominent medical journal The Lancet publishes “Ending Preventable Stillbirth,” a series of articles calling for global efforts to greatly reduce fetal deaths that occur late in pregnancy or during labor. The series brings much-needed attention to a medical and societal problem that often goes ignored.

“Millions of women and families around the world have suffered the pain of stillbirth in silence,” said series adviser Gary Darmstadt, MD, a Stanford global-health expert who studies how to improve medical care for pregnant women, infants and children in developing countries.

Darmstadt recently answered my questions about why we should break the silence and work to lower stillbirth rates. “Many of the interventions that avert stillbirths also avert deaths of mothers and newborns,” he said. An edited version of his responses is below.

What’s the biggest misconception about stillbirth?

Perhaps the biggest misconception is that stillbirths don’t matter. There is a tradition of social stigma and lack of awareness of stillbirths that makes it easy to keep them out of sight and out of mind. But an estimated 1.2 million women around the world every year have an intrapartum stillbirth: They enter into labor after a normal pregnancy, with great expectations for a healthy baby and one of the most joyous experiences of a lifetime, only to face sudden devastation when the baby dies during birth. Their experiences matter.

A related misconception is that nothing much can be done to prevent stillbirth, or that prevention will divert scarce resources from other important issues. In fact, three fourths of intrapartum stillbirths around the world could be prevented through means that we take for granted in high income societies — such as skilled medical care before and during delivery — and that also benefit mothers, surviving newborns and children.

Why did the scientists involved in The Lancet’s new series think it was important to break the common pattern of silence, stigma and fatalism around stillbirth?

Stillbirth is a taboo topic in many societies, or worse yet, mothers are blamed for failing to deliver a healthy baby and feel intense social pressure to keep quiet about stillbirth. Their sense of loss and isolation may lead to depression, which in turn has many adverse consequences, including for subsequent pregnancies. On the other hand, many women who have the opportunity to talk about their experience with stillbirth and work through their grief express great relief and renewed hope. When the last Lancet stillbirth series came out five years ago, and women shared their experiences online or in parent support groups — often the first time they had ever shared their experience with stillbirth with anyone — many found this to be immensely healing and empowering. Thus, it was both the science showing the adverse effects of unexpressed and unresolved grief, and the testimonials of women who had experienced the benefits of breaking the silence that I believe influenced the scientists involved in The Lancet series to highlight this issue.

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Pregnancy, Public Health, Women's Health

Reducing cesarean delivery rates, without jeopardizing safety

Reducing cesarean delivery rates, without jeopardizing safety

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Approximately one-third of all babies born in the United States are currently delivered by cesarean section, according to the Centers for Disease Control and Prevention. Although cesarean delivery can be life saving for both the mother and child, the rapid increase in the cesarean birth rate between 1996 and 2011 raised significant concern that cesarean delivery is being overused.

This concern has led to initiatives to lower the c-section rates, including a new plan funded by the Oakland-based California HealthCare Foundation (CHCF) to lower California’s c-section rate for low-risk mothers to 23.9 percent in the next five years — in alignment with the federal government’s Healthy People 2020’s national target.

A recent KQED Science article describes these efforts to reduce the state’s c-section rates. The story also explores the controversial issue that a healthy pregnant woman’s likelihood of having a cesarean birth varies depending on the hospital, based on a recent analysis of maternity care. For instance, the CHCF’s assessment report found that Lucile Packard Children’s Hospital Stanford has a c-section rate of 23.0 percent and the Coastal Communities Hospital in Santa Ana has a rate of 42.9 percent.

Deirdre Lyell, MD, professor of obstetrics and gynecology, clarified the issue in a recent email:

Nationally and internationally, there is concern that cesarean rates as a whole are too high. CHCF and others have shown a wide range in cesarean rates by hospital around the country, and even within hospitals among individual physicians. Hospitals with very high rates should examine the underlying reasons. However, the “ideal rate” depends on the characteristics of the patient population, and it would be inappropriate to apply one goal to all women. For example, a non-obese 25-year old who has had a prior vaginal delivery has a better likelihood of delivering her baby vaginally than does an obese 45-year old first-time mom.

At Stanford, we follow the “Safe Prevention of the Primary Cesarean Delivery” guidelines outlined by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. We care for a higher risk maternal and higher risk fetal population, and share with our patients a common goal for delivery: a safe mom and a safe baby, while not performing cesareans unnecessarily. Avoidance of the first cesarean helps reduce the potential risks in the future.

Jennifer Huber, PhD, is a science writer with extensive technical communications experience as an academic research scientist, freelance science journalist, and writing instructor.

Previously: C-section rates up to 19 percent help save women and their newborns, global study findsUnneeded cesareans are risky and expensive, and  “The mama Sherpas”: Exploring the work of nurse-midwives and their collaborations with doctors
Photo by Salim Fadhley

Genetics, Pregnancy, Research, Stanford News

Mouse placental cells contain dozens, even hundreds, of copies of genes key for pregnancy

Mouse placental cells contain dozens, even hundreds, of copies of genes key for pregnancy

19452628685_98cca6511f_zPeering inside a mouse placental cell is a bit like looking at a fun-house mirror. Rather than the standard two copies of each chromosome (mice have 20), there are as many as 900 copies of each genome segment.

What gives?

A team led by Julie Baker, PhD, associate professor of genetics, has found one clue: Genes that produce critical developmental proteins supporting the pregnancy are among the replicated regions. Baker, and first author Roberta Hannibal, PhD, published their results today in Current Biology.

“The placenta is a really fascinating organ,” Baker told me. “It’s a transient organ, so it doesn’t need to invest that much energy in conserving the genome. What it really needs is to get proteins and (placental) attachment molecules up and running really, really fast.”

And the best way to do that, rather than wasting energy cleaving the genome and producing a new cell with each division, may be to just jam many copies of the critical genes in one cell, Baker says.

This is the first time anyone has found genomic amplification of selective regions in mammals, the researchers write. That’s because no one has looked before, Baker said: “The placenta has been largely ignored.”

Next, she and her team are investigating the role of extra genome copies in human placentas. They’re also studying the particular mouse placental cells they examined, called trophoblast giant cells, in the lab, Baker said.

Previously: Species-specific differences among placentas due to long-ago viral infection, say Stanford researchers, Scientists create a placenta-on-a-chip to safely study process and pitfalls of pregnancy and NIH puts focus on the placenta, the “fascinating” and “least understood” organ
Photo by Michael Pardo

Pregnancy, Research

New drug target for treating preterm labor identified in Stanford study

New drug target for treating preterm labor identified in Stanford study

pregnantbelly-4Here’s one of the biggest mysteries of pregnancy: How does the uterus muscle manage to stay quiet for most of gestation, yet shift to big, strong contractions when it’s time for the baby to be born?

The answer is not just a matter of scientific curiosity. Preterm birth recently surpassed infectious disease as the leading cause of death in kids under age 5 worldwide, and doctors urgently need better drugs to halt uterine contractions when a pregnant woman shows up at the hospital in early labor.

Current labor-slowing drugs delay but don’t entirely prevent preterm birth. They also can have bad side effects. Because they work by blocking voltage-gated calcium channels, which are a key widget in the mechanics of muscle contraction, high doses of these drugs have a detrimental effect on other muscles around the body, especially the heart.

So a Stanford team led by David Cornfield, MD, went back to the lab bench to learn more about the biology of uterine contractions. Today, they report in Science Translational Medicine on how their findings may yield a new way to stop early labor.

The researchers focused their work on a calcium channel that they suspected fine-tuned the action of the uterine muscle. They demonstrated that this channel, called the “transient receptor potential vanilloid 4 channel,” has effects that are specific to the uterus during pregnancy.

For instance, their data show greater expression of the Trpv4 gene and higher levels of the TRPV4 protein in the uterus of pregnant than non-pregnant rats. The levels fall off again after the rats give birth. Trpv4 gene expression levels were also higher in uterine tissue from pregnant than non-pregnant humans. In mouse experiments, the team also found that blocking the TRPV4 channel could reduce the ability of oxytocin, a labor-triggering hormone, to cause uterine contractions. In addition, a TRPV4-blocking chemical delayed birth in a mouse model of preterm labor.

The new findings strongly suggest that the TRPV4 calcium channel fine-tunes the sensitivity of the uterus, helping it shift from the quiet state that persists through most of pregnancy to the very strong contractions needed before birth. That means the channel could be a great target for new labor-stopping drugs. Cornfield and his colleagues are eager to continue their work to see if it can be used to develop a medication that’s safe for humans and will help more pregnancies continue all the way to term.

Previously: Stanford microbiome research offers new clues to the mystery of preterm birth, Stanford/VA study finds link between PTSD and premature birth and Maternal obesity linked to earliest premature births, says Stanford study
Photo by Teza Harinaivo Ramiandrisoa

 

Global Health, Health Policy, Pregnancy, Stanford News, Women's Health

C-section rates up to 19 percent help save women and their newborns, global study finds

C-section rates up to 19 percent help save women and their newborns, global study finds

321699721_9002c5cebd_zCesarean sections are the most commonly performed operations around the world. But just how effective are these procedures, which have their own risks and complications, in saving the lives of women and their newborns?

To help answer that question, researchers at Stanford and Harvard’s Ariadne Labs examined C-section delivery rates in 2012 for 194 countries – all the member states of the World Health Organization. In that year, an estimated 22.9 million C-sections were performed in these countries.

The researchers found that maternal and child deaths declined when the C-section rate was up to 19 percent. When the number of C-sections was higher than that, there was no reduction in these mortality rates, the researchers report today in the online issue of the Journal of the American Medical Association.

Those numbers are higher than current WHO guidelines, which recommend that national C-section rates be no greater than 10 to 15 percent of deliveries. Worldwide, the number of C-sections varies widely from region to region, from .6 percent (South Sudan) to 56.6 percent (Brazil). In the United States, the C-section rate is roughly 30 percent.

Stanford surgeon Tom Weiser, MD, MPH, co-lead author, said the study “certainly presents a compelling argument for improved surgical capacity,” particularly in poor countries where there is limited capacity for surgical care. In parts of the developing world, women routinely die of obstructed labor and other pregnancy-related complications because there is no surgical infrastructure and personnel to provide advanced care, including C-section deliveries, he said.

Weiser and his co-authors argue for improving access to these potentially life-saving procedures, which could have many spillover effects, including improved facility infrastructure such as clean water and electricity – both needed for a functioning operating room – as well as improvements in healthcare systems as a whole.

“All the things you need to do to build up surgical capacity, like personnel training, improving supply chains, providing clean water and sterile environments, all contribute to general strengthening of health-care systems,” said Weiser, an assistant professor of surgery. “If you were to build a strong and robust surgical capacity, you’d have a health-care system more resilient and more resistant to catastrophic events, including Ebola or other infectious outbreaks.”

He noted, however, that new surgical services have to be provided within a safe environment to avoid potentially fatal complications, such as infection and bleeding.

“We cannot just advocate for increased access, as services have to be safe and they have to adhere to basic standards of surgical care,” he said.

Previously: Stanford microbiome research offers new clues to the mystery of preterm birth, From womb to world: Stanford Medicine magazine explores new work on having a baby and Study shows women prefer less-intense pain at the cost of a prolonged labor
Photo by Bonbon

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