Obstetrics

How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.

Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians. 

In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.

Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.

Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
 

Interpregnancy Interval and SGA Risk

The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.

According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.

According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.

Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.

“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
 

Previous and Subsequent Adverse Events

The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.

Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.” 

“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.

There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.

The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.

The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.

“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.

Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians. 

In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.

Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.

Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
 

Interpregnancy Interval and SGA Risk

The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.

According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.

According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.

Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.

“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
 

Previous and Subsequent Adverse Events

The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.

Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.” 

“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.

There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.

The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.

The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.

“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.

Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians. 

In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.

Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.

Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
 

Interpregnancy Interval and SGA Risk

The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.

According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.

According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.

Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.

“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
 

Previous and Subsequent Adverse Events

The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.

Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.” 

“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.

There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.

The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.

The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.

“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Safety concerns persist for out-of-hospital births in the United States with multiple potential risk factors and few safety requirements, according to a paper published in the American Journal of Obstetrics and Gynecology.

In 2022, the Centers for Disease Control and Prevention (CDC) reported the highest number of planned home births in 30 years. The numbers rose 12% from 2020 to 2021, the latest period for which complete data are available. Home births rose from 45,646 (1.26% of births) in 2020 to 51,642 (1.41% of births).

Amos Grünebaum, MD, and Frank A. Chervenak, MD, with Northwell Health, and the Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine in New Hyde Park, New York, reviewed the latest safety data surrounding community births in the United States along with well-known perinatal risks and safety requirements for safe out-of-hospital births.

“Most planned home births continue to have one or more risk factors that are associated with an increase in adverse pregnancy outcomes,” they wrote.
 

Birth Certificate Data Analyzed

The researchers used the CDC birth certificate database and analyzed deliveries between 2016 and 2022 regarding the incidence of perinatal risks in community births. The risks included were prior cesarean, first baby, mother older than 35 years, twins, breech presentation, gestational age of less than 37 weeks or more than 41 weeks, newborn weight over 4,000 grams, adequacy of prenatal care, grand multiparity (5 or more prior pregnancies), and a prepregnancy body mass index of at least 35.

The incidence of perinatal risks for out-of-hospital births ranged individually from 0.2% to 28.54% among birthing center births and 0.32% to 24.4% for planned home births.

“The ACOG committee opinion on home births states that for every 1000 home births, 3.9 babies will die,” the authors noted, or about twice the risk of hospital births. The deaths are “potentially avoidable with easy access to an operating room,” they wrote.

Among the safety concerns for perinatal morbidity and mortality in community births, the authors cited the lack of:

• Appropriate patient selection for out-of-hospital births through standardized guidelines.
• Availability of a Certified Nurse Midwife, a Certified Midwife, or midwife whose education and licensure meet International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education.
• Providers practicing obstetrics within an integrated and regulated health system with ready access and availability of board-certified obstetricians to provide consultation for qualified midwives.
• Standardized guidelines on when transport to a hospital is necessary.

“While prerequisites for a safe out-of-hospital delivery may be in place in other high-income countries, these prerequisites have not been actualized in the United States,” the authors wrote.

Incorporating Patient Preferences Into Delivery Models

Yalda Afshar, MD, PhD, maternal-fetal medicine subspecialist and a physician-scientist at UCLA Health in California, said obstetricians are responsible for offering the most evidence-based care to pregnant people.

“What this birth certificate data demonstrates,” she said, “is a tendency among birthing people to opt for out-of-hospital births, despite documented risks to both the pregnant person and the neonate. This underscores the need to persist in educating on risk stratification, risk reduction, and safe birthing practices, while also fostering innovation. Innovation should stem from our commitment to incorporate the preferences of pregnant people into our healthcare delivery model.”

Dr. Afshar, who was not part of the study, said clinicians should develop innovative ways to effectively meet the needs of pregnant patients while ensuring their safety and well-being.

“Ideally, we would establish safe environments within hospital systems and centers that emulate home-like birthing experiences, thereby mitigating risks for these families,” she said.

Though not explicitly stated in the data, she added, it is crucial to emphasize the need for continuous risk assessment throughout pregnancy and childbirth, “with a paramount focus on the safety of the pregnant individual.”

The authors and Dr. Afshar have no relevant financial disclosures.

Safety concerns persist for out-of-hospital births in the United States with multiple potential risk factors and few safety requirements, according to a paper published in the American Journal of Obstetrics and Gynecology.

In 2022, the Centers for Disease Control and Prevention (CDC) reported the highest number of planned home births in 30 years. The numbers rose 12% from 2020 to 2021, the latest period for which complete data are available. Home births rose from 45,646 (1.26% of births) in 2020 to 51,642 (1.41% of births).

Amos Grünebaum, MD, and Frank A. Chervenak, MD, with Northwell Health, and the Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine in New Hyde Park, New York, reviewed the latest safety data surrounding community births in the United States along with well-known perinatal risks and safety requirements for safe out-of-hospital births.

“Most planned home births continue to have one or more risk factors that are associated with an increase in adverse pregnancy outcomes,” they wrote.
 

Birth Certificate Data Analyzed

The researchers used the CDC birth certificate database and analyzed deliveries between 2016 and 2022 regarding the incidence of perinatal risks in community births. The risks included were prior cesarean, first baby, mother older than 35 years, twins, breech presentation, gestational age of less than 37 weeks or more than 41 weeks, newborn weight over 4,000 grams, adequacy of prenatal care, grand multiparity (5 or more prior pregnancies), and a prepregnancy body mass index of at least 35.

The incidence of perinatal risks for out-of-hospital births ranged individually from 0.2% to 28.54% among birthing center births and 0.32% to 24.4% for planned home births.

“The ACOG committee opinion on home births states that for every 1000 home births, 3.9 babies will die,” the authors noted, or about twice the risk of hospital births. The deaths are “potentially avoidable with easy access to an operating room,” they wrote.

Among the safety concerns for perinatal morbidity and mortality in community births, the authors cited the lack of:

• Appropriate patient selection for out-of-hospital births through standardized guidelines.
• Availability of a Certified Nurse Midwife, a Certified Midwife, or midwife whose education and licensure meet International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education.
• Providers practicing obstetrics within an integrated and regulated health system with ready access and availability of board-certified obstetricians to provide consultation for qualified midwives.
• Standardized guidelines on when transport to a hospital is necessary.

“While prerequisites for a safe out-of-hospital delivery may be in place in other high-income countries, these prerequisites have not been actualized in the United States,” the authors wrote.

Incorporating Patient Preferences Into Delivery Models

Yalda Afshar, MD, PhD, maternal-fetal medicine subspecialist and a physician-scientist at UCLA Health in California, said obstetricians are responsible for offering the most evidence-based care to pregnant people.

“What this birth certificate data demonstrates,” she said, “is a tendency among birthing people to opt for out-of-hospital births, despite documented risks to both the pregnant person and the neonate. This underscores the need to persist in educating on risk stratification, risk reduction, and safe birthing practices, while also fostering innovation. Innovation should stem from our commitment to incorporate the preferences of pregnant people into our healthcare delivery model.”

Dr. Afshar, who was not part of the study, said clinicians should develop innovative ways to effectively meet the needs of pregnant patients while ensuring their safety and well-being.

“Ideally, we would establish safe environments within hospital systems and centers that emulate home-like birthing experiences, thereby mitigating risks for these families,” she said.

Though not explicitly stated in the data, she added, it is crucial to emphasize the need for continuous risk assessment throughout pregnancy and childbirth, “with a paramount focus on the safety of the pregnant individual.”

The authors and Dr. Afshar have no relevant financial disclosures.

Safety concerns persist for out-of-hospital births in the United States with multiple potential risk factors and few safety requirements, according to a paper published in the American Journal of Obstetrics and Gynecology.

In 2022, the Centers for Disease Control and Prevention (CDC) reported the highest number of planned home births in 30 years. The numbers rose 12% from 2020 to 2021, the latest period for which complete data are available. Home births rose from 45,646 (1.26% of births) in 2020 to 51,642 (1.41% of births).

Amos Grünebaum, MD, and Frank A. Chervenak, MD, with Northwell Health, and the Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine in New Hyde Park, New York, reviewed the latest safety data surrounding community births in the United States along with well-known perinatal risks and safety requirements for safe out-of-hospital births.

“Most planned home births continue to have one or more risk factors that are associated with an increase in adverse pregnancy outcomes,” they wrote.
 

Birth Certificate Data Analyzed

The researchers used the CDC birth certificate database and analyzed deliveries between 2016 and 2022 regarding the incidence of perinatal risks in community births. The risks included were prior cesarean, first baby, mother older than 35 years, twins, breech presentation, gestational age of less than 37 weeks or more than 41 weeks, newborn weight over 4,000 grams, adequacy of prenatal care, grand multiparity (5 or more prior pregnancies), and a prepregnancy body mass index of at least 35.

The incidence of perinatal risks for out-of-hospital births ranged individually from 0.2% to 28.54% among birthing center births and 0.32% to 24.4% for planned home births.

“The ACOG committee opinion on home births states that for every 1000 home births, 3.9 babies will die,” the authors noted, or about twice the risk of hospital births. The deaths are “potentially avoidable with easy access to an operating room,” they wrote.

Among the safety concerns for perinatal morbidity and mortality in community births, the authors cited the lack of:

• Appropriate patient selection for out-of-hospital births through standardized guidelines.
• Availability of a Certified Nurse Midwife, a Certified Midwife, or midwife whose education and licensure meet International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education.
• Providers practicing obstetrics within an integrated and regulated health system with ready access and availability of board-certified obstetricians to provide consultation for qualified midwives.
• Standardized guidelines on when transport to a hospital is necessary.

“While prerequisites for a safe out-of-hospital delivery may be in place in other high-income countries, these prerequisites have not been actualized in the United States,” the authors wrote.

Incorporating Patient Preferences Into Delivery Models

Yalda Afshar, MD, PhD, maternal-fetal medicine subspecialist and a physician-scientist at UCLA Health in California, said obstetricians are responsible for offering the most evidence-based care to pregnant people.

“What this birth certificate data demonstrates,” she said, “is a tendency among birthing people to opt for out-of-hospital births, despite documented risks to both the pregnant person and the neonate. This underscores the need to persist in educating on risk stratification, risk reduction, and safe birthing practices, while also fostering innovation. Innovation should stem from our commitment to incorporate the preferences of pregnant people into our healthcare delivery model.”

Dr. Afshar, who was not part of the study, said clinicians should develop innovative ways to effectively meet the needs of pregnant patients while ensuring their safety and well-being.

“Ideally, we would establish safe environments within hospital systems and centers that emulate home-like birthing experiences, thereby mitigating risks for these families,” she said.

Though not explicitly stated in the data, she added, it is crucial to emphasize the need for continuous risk assessment throughout pregnancy and childbirth, “with a paramount focus on the safety of the pregnant individual.”

The authors and Dr. Afshar have no relevant financial disclosures.

BUDAPEST, Hungary — A single dose of intravenous esketamine during delivery or cesarean section appears to reduce the risk for postpartum depression (PPD) by more than 50% in the first 6 weeks, a new meta-analysis suggested. However, the long-term safety and efficacy of the drug are still unclear.

Study investigator Angelina Kozhokar, MD, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Sant Cugat del Valles, Spain, told this news organization she was “surprised” by the size of the PPD risk reduction associated with the drug.

However, she added, “it’s important to consider that preliminary studies on a lot of medications used for postpartum depression have also shown very big effect sizes.”

Dr. Kozhokar believes that as more studies examining esketamine for PPD are conducted, “we will see more definitive effect sizes, and the safety profile for this new treatment” will become clearer.

The findings were presented at the European Psychiatric Association (EPA) Congress.
 

Significant Reduction

As previously reported by this news organization, intranasal esketamine (Spravato, Janssen) was shown to be superior to extended-release quetiapine (Seroquel, AstraZeneca), an atypical antipsychotic, for treatment-resistant depression.

With up to 13% of women experiencing PPD in the perinatal period, the researchers sought to examine the impact of esketamine administered prophylactically during labor or cesarean section on the incidence of the disorder.

They searched the PubMed, Scopus, and Google Scholar databases for randomized controlled trials examining the efficacy of esketamine and screened for PPD using the Edinburgh Postpartum Depression Scale (EPDS).

While the intranasal spray is the only form of esketamine approved by the US Food and Drug Administration, an injectable solution is also available. The researchers identified seven eligible trials that included a total of 1287 women. Of these participants, 635 (49.3%) received esketamine. Esketamine was delivered as either patient-controlled intravenous analgesia or a single intravenous dose during delivery or cesarean section.

Across the seven trials, esketamine was associated with a significant reduction in PPD at 1 week after delivery at a risk ratio vs placebo of 0.459 (P < .05). At 6 weeks, the reduction in PPD incidence was maintained, at a risk ratio of 0.470 (P < .01).

However, Dr. Kozhokar pointed out that the EPDS is a subjective measure of PPD, and the studies used different cutoff scores for depression, ranging from 9 to 13 points.
 

Unanswered Questions

She also cautioned that the adverse effects of esketamine on maternal and neonatal health need to be assessed, as well as the long-term cost/benefit ratio of prophylactic treatment.

All seven studies included in the meta-analysis were conducted in China, which limits the generalizability of the findings.

“I suppose they were quicker to get to the topic than the rest of the world,” Dr. Kozhokar said, while also suggesting that, potentially, “we are more regulated here in Europe.”

She pointed out that there is “an important safety concern about the use of medications such as ketamine and esketamine” in terms of the potential for addiction and the effect on babies over the long term, which is currently unknown.

Session chair Linda Rubene, MD, a psychiatrist in the Department of Psychiatry and Narcology at Riga Stradinš University, Riga, Latvia, welcomed the study.

“If we had more options to treat postpartum depression and to treat depression during pregnancy, it would be a great improvement,” she said.

However, she noted, because there are no long-term outcome data for esketamine in PPD, more study is needed. It is possible, said Dr. Rubene, that esketamine may not work for all women.

The investigators and Dr. Rubene reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com .

BUDAPEST, Hungary — A single dose of intravenous esketamine during delivery or cesarean section appears to reduce the risk for postpartum depression (PPD) by more than 50% in the first 6 weeks, a new meta-analysis suggested. However, the long-term safety and efficacy of the drug are still unclear.

Study investigator Angelina Kozhokar, MD, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Sant Cugat del Valles, Spain, told this news organization she was “surprised” by the size of the PPD risk reduction associated with the drug.

However, she added, “it’s important to consider that preliminary studies on a lot of medications used for postpartum depression have also shown very big effect sizes.”

Dr. Kozhokar believes that as more studies examining esketamine for PPD are conducted, “we will see more definitive effect sizes, and the safety profile for this new treatment” will become clearer.

The findings were presented at the European Psychiatric Association (EPA) Congress.
 

Significant Reduction

As previously reported by this news organization, intranasal esketamine (Spravato, Janssen) was shown to be superior to extended-release quetiapine (Seroquel, AstraZeneca), an atypical antipsychotic, for treatment-resistant depression.

With up to 13% of women experiencing PPD in the perinatal period, the researchers sought to examine the impact of esketamine administered prophylactically during labor or cesarean section on the incidence of the disorder.

They searched the PubMed, Scopus, and Google Scholar databases for randomized controlled trials examining the efficacy of esketamine and screened for PPD using the Edinburgh Postpartum Depression Scale (EPDS).

While the intranasal spray is the only form of esketamine approved by the US Food and Drug Administration, an injectable solution is also available. The researchers identified seven eligible trials that included a total of 1287 women. Of these participants, 635 (49.3%) received esketamine. Esketamine was delivered as either patient-controlled intravenous analgesia or a single intravenous dose during delivery or cesarean section.

Across the seven trials, esketamine was associated with a significant reduction in PPD at 1 week after delivery at a risk ratio vs placebo of 0.459 (P < .05). At 6 weeks, the reduction in PPD incidence was maintained, at a risk ratio of 0.470 (P < .01).

However, Dr. Kozhokar pointed out that the EPDS is a subjective measure of PPD, and the studies used different cutoff scores for depression, ranging from 9 to 13 points.
 

Unanswered Questions

She also cautioned that the adverse effects of esketamine on maternal and neonatal health need to be assessed, as well as the long-term cost/benefit ratio of prophylactic treatment.

All seven studies included in the meta-analysis were conducted in China, which limits the generalizability of the findings.

“I suppose they were quicker to get to the topic than the rest of the world,” Dr. Kozhokar said, while also suggesting that, potentially, “we are more regulated here in Europe.”

She pointed out that there is “an important safety concern about the use of medications such as ketamine and esketamine” in terms of the potential for addiction and the effect on babies over the long term, which is currently unknown.

Session chair Linda Rubene, MD, a psychiatrist in the Department of Psychiatry and Narcology at Riga Stradinš University, Riga, Latvia, welcomed the study.

“If we had more options to treat postpartum depression and to treat depression during pregnancy, it would be a great improvement,” she said.

However, she noted, because there are no long-term outcome data for esketamine in PPD, more study is needed. It is possible, said Dr. Rubene, that esketamine may not work for all women.

The investigators and Dr. Rubene reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com .

BUDAPEST, Hungary — A single dose of intravenous esketamine during delivery or cesarean section appears to reduce the risk for postpartum depression (PPD) by more than 50% in the first 6 weeks, a new meta-analysis suggested. However, the long-term safety and efficacy of the drug are still unclear.

Study investigator Angelina Kozhokar, MD, Department of Medicine, Universitat Internacional de Catalunya, Barcelona, Sant Cugat del Valles, Spain, told this news organization she was “surprised” by the size of the PPD risk reduction associated with the drug.

However, she added, “it’s important to consider that preliminary studies on a lot of medications used for postpartum depression have also shown very big effect sizes.”

Dr. Kozhokar believes that as more studies examining esketamine for PPD are conducted, “we will see more definitive effect sizes, and the safety profile for this new treatment” will become clearer.

The findings were presented at the European Psychiatric Association (EPA) Congress.
 

Significant Reduction

As previously reported by this news organization, intranasal esketamine (Spravato, Janssen) was shown to be superior to extended-release quetiapine (Seroquel, AstraZeneca), an atypical antipsychotic, for treatment-resistant depression.

With up to 13% of women experiencing PPD in the perinatal period, the researchers sought to examine the impact of esketamine administered prophylactically during labor or cesarean section on the incidence of the disorder.

They searched the PubMed, Scopus, and Google Scholar databases for randomized controlled trials examining the efficacy of esketamine and screened for PPD using the Edinburgh Postpartum Depression Scale (EPDS).

While the intranasal spray is the only form of esketamine approved by the US Food and Drug Administration, an injectable solution is also available. The researchers identified seven eligible trials that included a total of 1287 women. Of these participants, 635 (49.3%) received esketamine. Esketamine was delivered as either patient-controlled intravenous analgesia or a single intravenous dose during delivery or cesarean section.

Across the seven trials, esketamine was associated with a significant reduction in PPD at 1 week after delivery at a risk ratio vs placebo of 0.459 (P < .05). At 6 weeks, the reduction in PPD incidence was maintained, at a risk ratio of 0.470 (P < .01).

However, Dr. Kozhokar pointed out that the EPDS is a subjective measure of PPD, and the studies used different cutoff scores for depression, ranging from 9 to 13 points.
 

Unanswered Questions

She also cautioned that the adverse effects of esketamine on maternal and neonatal health need to be assessed, as well as the long-term cost/benefit ratio of prophylactic treatment.

All seven studies included in the meta-analysis were conducted in China, which limits the generalizability of the findings.

“I suppose they were quicker to get to the topic than the rest of the world,” Dr. Kozhokar said, while also suggesting that, potentially, “we are more regulated here in Europe.”

She pointed out that there is “an important safety concern about the use of medications such as ketamine and esketamine” in terms of the potential for addiction and the effect on babies over the long term, which is currently unknown.

Session chair Linda Rubene, MD, a psychiatrist in the Department of Psychiatry and Narcology at Riga Stradinš University, Riga, Latvia, welcomed the study.

“If we had more options to treat postpartum depression and to treat depression during pregnancy, it would be a great improvement,” she said.

However, she noted, because there are no long-term outcome data for esketamine in PPD, more study is needed. It is possible, said Dr. Rubene, that esketamine may not work for all women.

The investigators and Dr. Rubene reported no relevant financial disclosures.

A version of this article first appeared on Medscape.com .

Premenstrual disorders (PMDs) and perinatal depression (PND) appear to have a bidirectional association, a Swedish national registry-based analysis found.

In women with PND, 2.9% had PMDs before pregnancy vs 0.6% in a matched cohort of unaffected women, according to an international team led by Quian Yang, MD, PhD, of the Institute of Environmental Medicine at the Karolinska Institutet in Stockholm, Sweden. Their study appears in PLoS Medicine.

“Preconception and maternity care providers should be aware of the risk of developing perinatal depression among women with a history of PMDs,” Dr. Yang said in an interview. “Healthcare providers may inform women with perinatal depression about the potential risk of PMDs when menstruation returns after childbirth.” She recommended screening as part of routine perinatal care to identify and treat the condition at an early stage. Counseling and medication may help prevent adverse consequences.

In other findings, the correlation with PMDs held for both prenatal and postnatal depression, regardless of any history of psychiatric disorders and also in full-sister comparisons, the authors noted, with a stronger correlation in the absence of psychiatric disorders (P for interaction <.001).

“Interestingly, we noted a stronger association between PMDs and subsequent PND than the association in the other direction, Dr. Yang said. And although many experience PMD symptom onset in adolescence, symptom worsening has been reported with increasing age and parity. “It is possible that women with milder premenstrual symptoms experienced worse symptoms after pregnancy and are therefore first diagnosed with PMD after pregnancy,” the authors hypothesized.

Both PMDs and PND share depressive symptomatology and onset coinciding with hormonal fluctuations, particularly estrogen and progesterone, suggesting a shared etiology, Dr. Yang explained. “It’s plausible that an abnormal response to natural hormone fluctuations predisposes women to both PMDs and PND. However, the underlying mechanism is complex, and future research is needed to reveal the underlying etiology.”

Affecting a majority of women of reproductive age to some degree, PMDs in certain women can cause significant functional impairment and, when severe, have been linked to increased risks of accidents and suicidal behavior. The psychological symptoms of the more serious form, premenstrual dysphoric disorder, for example, are associated with a 50%-78% lifetime risk for psychiatric disorders, including major depressive, dysthymic, seasonal affective, and generalized anxiety disorders, as well as suicidality.

Mood disorders are common in pregnancy and the postpartum period.

The Swedish Study

In 1.8 million singleton pregnancies in Sweden during 2001-2018, the investigators identified 84,949 women with PND and 849,482 unaffected women and individually matched them 10:1 by age and calendar year. Incident PND and PMDs were identified through clinical diagnoses or prescribed medications, and adjustment was made for such demographics as country of birth, educational level, region of residency, and cohabitation status.

In an initial matched-cohort case-control study with a mean follow-up of 6.9 years, PMDs were associated with a nearly five times higher risk of subsequent PND (odds ratio, 4.76; 95% CI, 4.52-5.01; P <.001).

In another matched cohort with a mean follow-up of 7.0 years, there were 4227 newly diagnosed PMDs in women with PND (incidence rate [IR], 7.6/1000 person-years) and 21,326 among controls (IR, 3.8/1000). Compared with matched controls, women with PND were at almost twice the risk of subsequent PMDs (hazard ratio, 1.81; 95% CI, 1.74-1.88; P <.001).

Dr. Bernard_Harlow_2_web.jpg

Commenting on the study but not involved in it, Bernard L. Harlow, PhD, a professor of epidemiology at Boston University School of Public Health in Massachusetts who specializes in epidemiologic studies of female reproductive disorders, said he was not surprised at these findings, which clearly support the need for PMD screening in mothers-to-be. “Anything that is easy to measure and noninvasive that will minimize the risk of postpartum depression should be part of the standard of care during the prenatal period.” As to safety: If treatment is indicated, he added, “studies have shown that the risk to the mother and child is much greater if the mother’s mood disorder is not controlled than any risk to the baby due to depression treatment.” But though PMDs may be predictive of PND, there are still barriers to actual PND care. A 2023 analysis reported that 65% of mothers-to-be who screened positive for metal health comorbidities were not referred for treatment.

Dr. Yang and colleagues acknowledged that their findings may not be generalizable to mild forms of these disorders since the data were based on clinical diagnoses and prescriptions.

The study was supported by the Chinese Scholarship Council, the Swedish Research Council for Health, Working Life and Welfare, the Karolinska Institutet, and the Icelandic Research Fund. The authors and Dr. Harlow had no relevant competing interests to disclose.

Premenstrual disorders (PMDs) and perinatal depression (PND) appear to have a bidirectional association, a Swedish national registry-based analysis found.

In women with PND, 2.9% had PMDs before pregnancy vs 0.6% in a matched cohort of unaffected women, according to an international team led by Quian Yang, MD, PhD, of the Institute of Environmental Medicine at the Karolinska Institutet in Stockholm, Sweden. Their study appears in PLoS Medicine.

“Preconception and maternity care providers should be aware of the risk of developing perinatal depression among women with a history of PMDs,” Dr. Yang said in an interview. “Healthcare providers may inform women with perinatal depression about the potential risk of PMDs when menstruation returns after childbirth.” She recommended screening as part of routine perinatal care to identify and treat the condition at an early stage. Counseling and medication may help prevent adverse consequences.

In other findings, the correlation with PMDs held for both prenatal and postnatal depression, regardless of any history of psychiatric disorders and also in full-sister comparisons, the authors noted, with a stronger correlation in the absence of psychiatric disorders (P for interaction <.001).

“Interestingly, we noted a stronger association between PMDs and subsequent PND than the association in the other direction, Dr. Yang said. And although many experience PMD symptom onset in adolescence, symptom worsening has been reported with increasing age and parity. “It is possible that women with milder premenstrual symptoms experienced worse symptoms after pregnancy and are therefore first diagnosed with PMD after pregnancy,” the authors hypothesized.

Both PMDs and PND share depressive symptomatology and onset coinciding with hormonal fluctuations, particularly estrogen and progesterone, suggesting a shared etiology, Dr. Yang explained. “It’s plausible that an abnormal response to natural hormone fluctuations predisposes women to both PMDs and PND. However, the underlying mechanism is complex, and future research is needed to reveal the underlying etiology.”

Affecting a majority of women of reproductive age to some degree, PMDs in certain women can cause significant functional impairment and, when severe, have been linked to increased risks of accidents and suicidal behavior. The psychological symptoms of the more serious form, premenstrual dysphoric disorder, for example, are associated with a 50%-78% lifetime risk for psychiatric disorders, including major depressive, dysthymic, seasonal affective, and generalized anxiety disorders, as well as suicidality.

Mood disorders are common in pregnancy and the postpartum period.

The Swedish Study

In 1.8 million singleton pregnancies in Sweden during 2001-2018, the investigators identified 84,949 women with PND and 849,482 unaffected women and individually matched them 10:1 by age and calendar year. Incident PND and PMDs were identified through clinical diagnoses or prescribed medications, and adjustment was made for such demographics as country of birth, educational level, region of residency, and cohabitation status.

In an initial matched-cohort case-control study with a mean follow-up of 6.9 years, PMDs were associated with a nearly five times higher risk of subsequent PND (odds ratio, 4.76; 95% CI, 4.52-5.01; P <.001).

In another matched cohort with a mean follow-up of 7.0 years, there were 4227 newly diagnosed PMDs in women with PND (incidence rate [IR], 7.6/1000 person-years) and 21,326 among controls (IR, 3.8/1000). Compared with matched controls, women with PND were at almost twice the risk of subsequent PMDs (hazard ratio, 1.81; 95% CI, 1.74-1.88; P <.001).

Dr. Bernard_Harlow_2_web.jpg

Commenting on the study but not involved in it, Bernard L. Harlow, PhD, a professor of epidemiology at Boston University School of Public Health in Massachusetts who specializes in epidemiologic studies of female reproductive disorders, said he was not surprised at these findings, which clearly support the need for PMD screening in mothers-to-be. “Anything that is easy to measure and noninvasive that will minimize the risk of postpartum depression should be part of the standard of care during the prenatal period.” As to safety: If treatment is indicated, he added, “studies have shown that the risk to the mother and child is much greater if the mother’s mood disorder is not controlled than any risk to the baby due to depression treatment.” But though PMDs may be predictive of PND, there are still barriers to actual PND care. A 2023 analysis reported that 65% of mothers-to-be who screened positive for metal health comorbidities were not referred for treatment.

Dr. Yang and colleagues acknowledged that their findings may not be generalizable to mild forms of these disorders since the data were based on clinical diagnoses and prescriptions.

The study was supported by the Chinese Scholarship Council, the Swedish Research Council for Health, Working Life and Welfare, the Karolinska Institutet, and the Icelandic Research Fund. The authors and Dr. Harlow had no relevant competing interests to disclose.

Premenstrual disorders (PMDs) and perinatal depression (PND) appear to have a bidirectional association, a Swedish national registry-based analysis found.

In women with PND, 2.9% had PMDs before pregnancy vs 0.6% in a matched cohort of unaffected women, according to an international team led by Quian Yang, MD, PhD, of the Institute of Environmental Medicine at the Karolinska Institutet in Stockholm, Sweden. Their study appears in PLoS Medicine.

“Preconception and maternity care providers should be aware of the risk of developing perinatal depression among women with a history of PMDs,” Dr. Yang said in an interview. “Healthcare providers may inform women with perinatal depression about the potential risk of PMDs when menstruation returns after childbirth.” She recommended screening as part of routine perinatal care to identify and treat the condition at an early stage. Counseling and medication may help prevent adverse consequences.

In other findings, the correlation with PMDs held for both prenatal and postnatal depression, regardless of any history of psychiatric disorders and also in full-sister comparisons, the authors noted, with a stronger correlation in the absence of psychiatric disorders (P for interaction <.001).

“Interestingly, we noted a stronger association between PMDs and subsequent PND than the association in the other direction, Dr. Yang said. And although many experience PMD symptom onset in adolescence, symptom worsening has been reported with increasing age and parity. “It is possible that women with milder premenstrual symptoms experienced worse symptoms after pregnancy and are therefore first diagnosed with PMD after pregnancy,” the authors hypothesized.

Both PMDs and PND share depressive symptomatology and onset coinciding with hormonal fluctuations, particularly estrogen and progesterone, suggesting a shared etiology, Dr. Yang explained. “It’s plausible that an abnormal response to natural hormone fluctuations predisposes women to both PMDs and PND. However, the underlying mechanism is complex, and future research is needed to reveal the underlying etiology.”

Affecting a majority of women of reproductive age to some degree, PMDs in certain women can cause significant functional impairment and, when severe, have been linked to increased risks of accidents and suicidal behavior. The psychological symptoms of the more serious form, premenstrual dysphoric disorder, for example, are associated with a 50%-78% lifetime risk for psychiatric disorders, including major depressive, dysthymic, seasonal affective, and generalized anxiety disorders, as well as suicidality.

Mood disorders are common in pregnancy and the postpartum period.

The Swedish Study

In 1.8 million singleton pregnancies in Sweden during 2001-2018, the investigators identified 84,949 women with PND and 849,482 unaffected women and individually matched them 10:1 by age and calendar year. Incident PND and PMDs were identified through clinical diagnoses or prescribed medications, and adjustment was made for such demographics as country of birth, educational level, region of residency, and cohabitation status.

In an initial matched-cohort case-control study with a mean follow-up of 6.9 years, PMDs were associated with a nearly five times higher risk of subsequent PND (odds ratio, 4.76; 95% CI, 4.52-5.01; P <.001).

In another matched cohort with a mean follow-up of 7.0 years, there were 4227 newly diagnosed PMDs in women with PND (incidence rate [IR], 7.6/1000 person-years) and 21,326 among controls (IR, 3.8/1000). Compared with matched controls, women with PND were at almost twice the risk of subsequent PMDs (hazard ratio, 1.81; 95% CI, 1.74-1.88; P <.001).

Dr. Bernard_Harlow_2_web.jpg

Commenting on the study but not involved in it, Bernard L. Harlow, PhD, a professor of epidemiology at Boston University School of Public Health in Massachusetts who specializes in epidemiologic studies of female reproductive disorders, said he was not surprised at these findings, which clearly support the need for PMD screening in mothers-to-be. “Anything that is easy to measure and noninvasive that will minimize the risk of postpartum depression should be part of the standard of care during the prenatal period.” As to safety: If treatment is indicated, he added, “studies have shown that the risk to the mother and child is much greater if the mother’s mood disorder is not controlled than any risk to the baby due to depression treatment.” But though PMDs may be predictive of PND, there are still barriers to actual PND care. A 2023 analysis reported that 65% of mothers-to-be who screened positive for metal health comorbidities were not referred for treatment.

Dr. Yang and colleagues acknowledged that their findings may not be generalizable to mild forms of these disorders since the data were based on clinical diagnoses and prescriptions.

The study was supported by the Chinese Scholarship Council, the Swedish Research Council for Health, Working Life and Welfare, the Karolinska Institutet, and the Icelandic Research Fund. The authors and Dr. Harlow had no relevant competing interests to disclose.

A longtime Kaiser Permanente surgeon is suing a fellow physician for allegedly submitting false medical board complaints against him in an attempt to get him fired.

Joseph Stalfire III, MD, claims Ming Hsieh, MD, began a campaign to harm his reputation after Dr. Stalfire hurt his leg and went on medical leave. Dr. Stalfire, a board-certified ob.gyn., has worked for Kaiser Permanente in western Oregon for more than 20 years, including several years as a regional chief surgical officer.

Dr. Stalfire is accusing Dr. Hsieh of defamation and intentional emotional distress, according to the March 25 lawsuit filed in Marion County Circuit Court. Northwest Permanente P.C., a Kaiser subsidiary, is also named as a defendant.

Dr. Stalfire is asking for $1.2 million in economic damages and $300,000 in noneconomic damages. Dr. Hsieh has not yet responded to the legal complaint.

Dr. Stalfire’s attorney did not respond to a message seeking comment. Dr. Hsieh is representing himself, according to court records. A Kaiser Permanente spokeswoman told this news organization that Kaiser does not comment on pending litigation.

The conflict began in February 2023, after Dr. Stalfire underwent surgery to correct issues stemming from severe injuries when a tree fell on his leg, according to court records. 

Dr. Hsieh, a Kaiser ob.gyn., senior physician, and quality assurance lead, allegedly contacted Dr. Stalfire after the surgery and demanded he return to work earlier than medically recommended. Dr. Stalfire claims Dr. Hsieh questioned his retirement plans and his ability to continue working to pressure him into quitting. 

Dr. Stalfire reported Dr. Hsieh’s conduct to Kaiser’s human resources department. However, the complaint contends Dr. Hsieh’s actions only escalated after the report was made. According to the complaint, Dr. Hsieh began telling coworkers Dr. Stalfire was “lying” about his injuries. Dr. Hsieh also allegedly contacted administrators and schedulers to ask about Dr. Stalfire’s injuries and suggested that he was not “legitimately recovering from serious injuries.” The complaint claims that Dr. Hsieh told Dr. Stalfire’s colleagues that he was a “con man,” a “criminal,” and “despicable.”

According to Dr. Stalfire’s complaint, in August 2023, Dr. Hsieh submitted numerous anonymous complaints about Dr. Stalfire to the Washington Medical Commission, the Oregon Medical Board, and other governmental agencies. Dr. Stalfire defended himself against the complaints, and they were dismissed. The lawsuit does not specify the nature of the complaints.

Dr. Stalfire later made public record requests for the complaints and discovered Dr. Hsieh had used his deceased mother-in-law’s phone number as his contact information, according to the lawsuit. 

Despite multiple reports about Dr. Hsieh’s conduct, Dr. Stalfire claims Kaiser retained Dr. Hsieh as an employee and took no action to prevent him from making false statements about Dr. Stalfire. 

He claims Dr. Hsieh’s harassment and Kaiser’s inaction harmed his professional reputation, caused lost work time, and resulted in severe emotional distress that required mental health treatment. The harm caused continues to impact his ability to work, the suit contends. 
 

A version of this article appeared on Medscape.com.

A longtime Kaiser Permanente surgeon is suing a fellow physician for allegedly submitting false medical board complaints against him in an attempt to get him fired.

Joseph Stalfire III, MD, claims Ming Hsieh, MD, began a campaign to harm his reputation after Dr. Stalfire hurt his leg and went on medical leave. Dr. Stalfire, a board-certified ob.gyn., has worked for Kaiser Permanente in western Oregon for more than 20 years, including several years as a regional chief surgical officer.

Dr. Stalfire is accusing Dr. Hsieh of defamation and intentional emotional distress, according to the March 25 lawsuit filed in Marion County Circuit Court. Northwest Permanente P.C., a Kaiser subsidiary, is also named as a defendant.

Dr. Stalfire is asking for $1.2 million in economic damages and $300,000 in noneconomic damages. Dr. Hsieh has not yet responded to the legal complaint.

Dr. Stalfire’s attorney did not respond to a message seeking comment. Dr. Hsieh is representing himself, according to court records. A Kaiser Permanente spokeswoman told this news organization that Kaiser does not comment on pending litigation.

The conflict began in February 2023, after Dr. Stalfire underwent surgery to correct issues stemming from severe injuries when a tree fell on his leg, according to court records. 

Dr. Hsieh, a Kaiser ob.gyn., senior physician, and quality assurance lead, allegedly contacted Dr. Stalfire after the surgery and demanded he return to work earlier than medically recommended. Dr. Stalfire claims Dr. Hsieh questioned his retirement plans and his ability to continue working to pressure him into quitting. 

Dr. Stalfire reported Dr. Hsieh’s conduct to Kaiser’s human resources department. However, the complaint contends Dr. Hsieh’s actions only escalated after the report was made. According to the complaint, Dr. Hsieh began telling coworkers Dr. Stalfire was “lying” about his injuries. Dr. Hsieh also allegedly contacted administrators and schedulers to ask about Dr. Stalfire’s injuries and suggested that he was not “legitimately recovering from serious injuries.” The complaint claims that Dr. Hsieh told Dr. Stalfire’s colleagues that he was a “con man,” a “criminal,” and “despicable.”

According to Dr. Stalfire’s complaint, in August 2023, Dr. Hsieh submitted numerous anonymous complaints about Dr. Stalfire to the Washington Medical Commission, the Oregon Medical Board, and other governmental agencies. Dr. Stalfire defended himself against the complaints, and they were dismissed. The lawsuit does not specify the nature of the complaints.

Dr. Stalfire later made public record requests for the complaints and discovered Dr. Hsieh had used his deceased mother-in-law’s phone number as his contact information, according to the lawsuit. 

Despite multiple reports about Dr. Hsieh’s conduct, Dr. Stalfire claims Kaiser retained Dr. Hsieh as an employee and took no action to prevent him from making false statements about Dr. Stalfire. 

He claims Dr. Hsieh’s harassment and Kaiser’s inaction harmed his professional reputation, caused lost work time, and resulted in severe emotional distress that required mental health treatment. The harm caused continues to impact his ability to work, the suit contends. 
 

A version of this article appeared on Medscape.com.

A longtime Kaiser Permanente surgeon is suing a fellow physician for allegedly submitting false medical board complaints against him in an attempt to get him fired.

Joseph Stalfire III, MD, claims Ming Hsieh, MD, began a campaign to harm his reputation after Dr. Stalfire hurt his leg and went on medical leave. Dr. Stalfire, a board-certified ob.gyn., has worked for Kaiser Permanente in western Oregon for more than 20 years, including several years as a regional chief surgical officer.

Dr. Stalfire is accusing Dr. Hsieh of defamation and intentional emotional distress, according to the March 25 lawsuit filed in Marion County Circuit Court. Northwest Permanente P.C., a Kaiser subsidiary, is also named as a defendant.

Dr. Stalfire is asking for $1.2 million in economic damages and $300,000 in noneconomic damages. Dr. Hsieh has not yet responded to the legal complaint.

Dr. Stalfire’s attorney did not respond to a message seeking comment. Dr. Hsieh is representing himself, according to court records. A Kaiser Permanente spokeswoman told this news organization that Kaiser does not comment on pending litigation.

The conflict began in February 2023, after Dr. Stalfire underwent surgery to correct issues stemming from severe injuries when a tree fell on his leg, according to court records. 

Dr. Hsieh, a Kaiser ob.gyn., senior physician, and quality assurance lead, allegedly contacted Dr. Stalfire after the surgery and demanded he return to work earlier than medically recommended. Dr. Stalfire claims Dr. Hsieh questioned his retirement plans and his ability to continue working to pressure him into quitting. 

Dr. Stalfire reported Dr. Hsieh’s conduct to Kaiser’s human resources department. However, the complaint contends Dr. Hsieh’s actions only escalated after the report was made. According to the complaint, Dr. Hsieh began telling coworkers Dr. Stalfire was “lying” about his injuries. Dr. Hsieh also allegedly contacted administrators and schedulers to ask about Dr. Stalfire’s injuries and suggested that he was not “legitimately recovering from serious injuries.” The complaint claims that Dr. Hsieh told Dr. Stalfire’s colleagues that he was a “con man,” a “criminal,” and “despicable.”

According to Dr. Stalfire’s complaint, in August 2023, Dr. Hsieh submitted numerous anonymous complaints about Dr. Stalfire to the Washington Medical Commission, the Oregon Medical Board, and other governmental agencies. Dr. Stalfire defended himself against the complaints, and they were dismissed. The lawsuit does not specify the nature of the complaints.

Dr. Stalfire later made public record requests for the complaints and discovered Dr. Hsieh had used his deceased mother-in-law’s phone number as his contact information, according to the lawsuit. 

Despite multiple reports about Dr. Hsieh’s conduct, Dr. Stalfire claims Kaiser retained Dr. Hsieh as an employee and took no action to prevent him from making false statements about Dr. Stalfire. 

He claims Dr. Hsieh’s harassment and Kaiser’s inaction harmed his professional reputation, caused lost work time, and resulted in severe emotional distress that required mental health treatment. The harm caused continues to impact his ability to work, the suit contends. 
 

A version of this article appeared on Medscape.com.

When her obstetrician-gynecologist recommended a mammogram, Emily Legg didn’t hesitate to schedule an appointment for the screening.

Her grandmother had been diagnosed with breast cancer and her father died of prostate cancer in his mid-50s. Ms. Legg also has polycystic ovary syndrome (PCOS), which increases the risk of some cancers.

Having just turned 40, Ms. Legg said she was determined to be as proactive as possible with cancer screenings.

Before the mammogram, she arranged for childcare for her 6-month-old daughter and filled out a required questionnaire online that asked about her history and health conditions. When the appointment day arrived, Ms. Legg made the 30-minute drive to the clinic where she was prepped for the procedure and escorted to the mammography room.

But just before the screening started, Ms. Legg happened to mention to the technician that she was breastfeeding. The surprised tech immediately halted the procedure, Ms. Legg said. Because of increased breast density caused by nursing, Ms. Legg was told to wait at least 6 weeks after weaning for a mammogram.

“I didn’t even consider that breastfeeding might prevent me from getting a mammogram,” said Ms. Legg, a writing professor from Hamilton, Ohio. “I had to go home. I was frustrated, mostly because I had driven all that way. I had hyped myself up. I had childcare in line. And now I had to wait until my daughter weaned? At the time, I didn’t know if my daughter was going to breastfeed for 2 years or be done at 6 months.”

Considering her family background, Ms. Legg worried about not receiving the screening. Her sister had recently undergone a mammogram while she was breastfeeding without any problems.

When she did research, Ms. Legg found conflicting information about the subject online so she turned to Reddit, where she started a thread asking if other moms over 40 had experienced similar issues. Dozens of moms responded with questions and concerns on the subject. Some wrote about being denied a mammogram while breastfeeding, while others wrote they received the procedure without question. Guidance from health professionals on the topic appeared to vastly differ.

“That’s why I turned to [social media] because I wasn’t finding anything else,” Ms. Legg said. “There’s just a lack of clear information. As an older mom, there’s less information out there for being postpartum and being over 40.”

Confusion over screenings during breastfeeding comes at the intersection of national guidelines lowering the recommended age for first mammograms, more women having babies later in life, and women getting breast cancer earlier.

167549_Legg_and_child_web.JPG

Most physician specialty associations agree that mammography is safe for breastfeeding patients and that they need not delay routine screenings. However, the safety of breast imaging during pregnancy and lactation is not well advertised, said Molly Peterson, MD, a radiologist based in St. Frances, Wisconsin, and lead author of a 2023 article about breast imaging during pregnancy and lactation in RadioGraphics, a journal of the Radiological Society of North America.

Conflicting information from nonscientific resources adds to the confusion, Dr. Peterson said. At the same time, health providers along the care spectrum may be uncertain about what imaging is safe and reasonable. Recommendations about mammography and lactation can also vary by institution, screening experts say.

“I’ve talked with pregnant and breastfeeding patients, both younger and older, who were unsure if they could have mammograms,” Dr. Peterson said. “I’ve also fielded questions from technologists, unclear what imaging we can offer these patients. ... Educating health professionals about evidence-based guidelines for screening and diagnostic imaging and reassuring patients about the safety of breast imaging during pregnancy and lactation is thus more important than ever.”
 

Differing Guidelines, Case-by-Case Considerations

The RadioGraphics paper emphasizes that both screening and diagnostic imaging can be safely performed using protocols based on age, breast cancer risk, and whether the patient is pregnant or lactating.

The American College of Radiology (ACR) Appropriateness Criteria also support mammography for certain patients during lactation. The guidelines state there is no contraindication to performing mammography during lactation, but note that challenges in evaluation can arise because of the unique physiological and structural breast changes that can occur.

“Hormones can change breast density and size of the breast, which could limit the clinical examination, mimic pathology, and obscure mammographic findings,” said Stamatia V. Destounis, MD, FACR, chair of the ACR Breast Imaging Commission. “It is important the patient pumps right before the mammogram or brings the baby to breastfeed prior to the imaging examination to offer the best imaging evaluation and reduce breast density as much as possible.”

In those patients who choose to prolong breastfeeding and are of the age to be screened, it is important they undergo yearly clinical breast exams, perform breast self-exams, and discuss breast cancer screening with their healthcare provider, she said. “They should not delay a routine screening mammogram. Most patients have dense breast tissue at this time, and frequently a breast ultrasound may be performed also.”

The American College of Obstetricians and Gynecologists (ACOG) does not have specific guidelines about breastfeeding mothers and mammography recommendations. Breastfeeding patients should discuss with their physicians or midwives the pros and cons of mammography, taking into account personal risk factors and how long they plan to nurse, said Joshua Copel, MD, vice chair of obstetrics, gynecology and reproductive sciences at Yale Medicine, New Haven, Connecticut, and a member of ACOG’s Committee on Obstetric Practice.

“The question for anybody to address with their physician will be, ‘Is my risk of breast cancer high enough that I should take that small risk that they’re going to over- or underread the mammogram because of my nursing status? Or should I wait until I wean the baby and have the mammogram then?’” he said.

Institutional and practice protocols meanwhile, can depend on a patient’s cancer risk.

Guidelines at the University of Wisconsin, for instance, advise that lactating patients 40 or over who are at average risk, wait 6-8 weeks after cessation of breastfeeding, said Alison Gegios, MD, a radiologist and assistant professor in breast imaging at the University of Wisconsin School of Medicine and Public Health. Average risk is defined as less than a 15% lifetime risk of breast cancer, she said.

Dr. Gegios, a coauthor on the RadioGraphics paper, said her institution recommends screening mammography if lactating patients are at intermediate or high risk, and are over 30. In such cases however, screening is generally deferred until 3-6 months after delivery, she noted.

“If patients are high risk, it’s also important to do screening breast MRIs,” Dr. Gegios said. “Studies have shown that screening breast MRIs are effective in breastfeeding patients despite their increased background parenchymal enhancement because breast cancer still stands out on our maximum intensity projections and stands out on the exam from the background.”
 

How to Clear Up Confusion, Promote Consistency

After her experience at the mammography practice, Ms. Legg went home and immediately sent a message to her ob.gyn. about what happened.

The doctor was similarly surprised and frustrated that Ms. Legg wasn’t able to get the mammogram, she said. To get around the difference in protocols, Ms. Legg’s ob.gyn. referred her to a high-risk clinic in Cincinnati. Ms. Legg’s history qualified her as high risk and she received genetic testing and a breast ultrasound at the clinic, she said.

“The ultrasound showed some shady spots,” Ms. Legg recalled. “They weren’t quite sure what they were. Another ultrasound later, they determined the spots were symmetrical and it ended up not being anything [serious]. Genetic-wise, I did not have any markers for cancer.”

Ms. Legg was relieved and she eventually received a mammogram when she finished breastfeeding, she said. However, she feels the overlap of older, breastfeeding moms and mammography guidelines deserves more attention.

“I would encourage all of us in the ‘geriatric mother’s club,’ to advocate for yourself, do your research, and also turn to your medical professionals and ask questions,” she said. “Make sure you know what they recommend for moms who are older and just had a baby.”

On the provider side, Dr. Destounis said physicians should revisit with patients the most updated guidelines about breastfeeding and mammography at routine appointments.

“Patients and their physicians have to have communication about screening for breast cancer if they are of screening age,” she said.

Dr. Copel advises physicians to run through the risks and benefits of mammograms with older, breastfeeding patients and make a shared decision. “It’s all going to vary with the individual circumstances,” he said. “If someone [has] a BRCA gene and their sister and mother had breast cancer, maybe it’s worth it. If somebody has absolutely no family history and just crossed the threshold for meeting a mammogram [recommendation], then sure, wait.”

Ms. Legg would like to see more professional literature and educational material directed toward the older, breastfeeding population about mammograms.

“At minimum, work together across departments to create an intake form, a questionnaire that is inclusive of everything,” she said. “There should be a question before you even get to the tech that asks, ‘Are you breastfeeding?’ ”

When her obstetrician-gynecologist recommended a mammogram, Emily Legg didn’t hesitate to schedule an appointment for the screening.

Her grandmother had been diagnosed with breast cancer and her father died of prostate cancer in his mid-50s. Ms. Legg also has polycystic ovary syndrome (PCOS), which increases the risk of some cancers.

Having just turned 40, Ms. Legg said she was determined to be as proactive as possible with cancer screenings.

Before the mammogram, she arranged for childcare for her 6-month-old daughter and filled out a required questionnaire online that asked about her history and health conditions. When the appointment day arrived, Ms. Legg made the 30-minute drive to the clinic where she was prepped for the procedure and escorted to the mammography room.

But just before the screening started, Ms. Legg happened to mention to the technician that she was breastfeeding. The surprised tech immediately halted the procedure, Ms. Legg said. Because of increased breast density caused by nursing, Ms. Legg was told to wait at least 6 weeks after weaning for a mammogram.

“I didn’t even consider that breastfeeding might prevent me from getting a mammogram,” said Ms. Legg, a writing professor from Hamilton, Ohio. “I had to go home. I was frustrated, mostly because I had driven all that way. I had hyped myself up. I had childcare in line. And now I had to wait until my daughter weaned? At the time, I didn’t know if my daughter was going to breastfeed for 2 years or be done at 6 months.”

Considering her family background, Ms. Legg worried about not receiving the screening. Her sister had recently undergone a mammogram while she was breastfeeding without any problems.

When she did research, Ms. Legg found conflicting information about the subject online so she turned to Reddit, where she started a thread asking if other moms over 40 had experienced similar issues. Dozens of moms responded with questions and concerns on the subject. Some wrote about being denied a mammogram while breastfeeding, while others wrote they received the procedure without question. Guidance from health professionals on the topic appeared to vastly differ.

“That’s why I turned to [social media] because I wasn’t finding anything else,” Ms. Legg said. “There’s just a lack of clear information. As an older mom, there’s less information out there for being postpartum and being over 40.”

Confusion over screenings during breastfeeding comes at the intersection of national guidelines lowering the recommended age for first mammograms, more women having babies later in life, and women getting breast cancer earlier.

167549_Legg_and_child_web.JPG

Most physician specialty associations agree that mammography is safe for breastfeeding patients and that they need not delay routine screenings. However, the safety of breast imaging during pregnancy and lactation is not well advertised, said Molly Peterson, MD, a radiologist based in St. Frances, Wisconsin, and lead author of a 2023 article about breast imaging during pregnancy and lactation in RadioGraphics, a journal of the Radiological Society of North America.

Conflicting information from nonscientific resources adds to the confusion, Dr. Peterson said. At the same time, health providers along the care spectrum may be uncertain about what imaging is safe and reasonable. Recommendations about mammography and lactation can also vary by institution, screening experts say.

“I’ve talked with pregnant and breastfeeding patients, both younger and older, who were unsure if they could have mammograms,” Dr. Peterson said. “I’ve also fielded questions from technologists, unclear what imaging we can offer these patients. ... Educating health professionals about evidence-based guidelines for screening and diagnostic imaging and reassuring patients about the safety of breast imaging during pregnancy and lactation is thus more important than ever.”
 

Differing Guidelines, Case-by-Case Considerations

The RadioGraphics paper emphasizes that both screening and diagnostic imaging can be safely performed using protocols based on age, breast cancer risk, and whether the patient is pregnant or lactating.

The American College of Radiology (ACR) Appropriateness Criteria also support mammography for certain patients during lactation. The guidelines state there is no contraindication to performing mammography during lactation, but note that challenges in evaluation can arise because of the unique physiological and structural breast changes that can occur.

“Hormones can change breast density and size of the breast, which could limit the clinical examination, mimic pathology, and obscure mammographic findings,” said Stamatia V. Destounis, MD, FACR, chair of the ACR Breast Imaging Commission. “It is important the patient pumps right before the mammogram or brings the baby to breastfeed prior to the imaging examination to offer the best imaging evaluation and reduce breast density as much as possible.”

In those patients who choose to prolong breastfeeding and are of the age to be screened, it is important they undergo yearly clinical breast exams, perform breast self-exams, and discuss breast cancer screening with their healthcare provider, she said. “They should not delay a routine screening mammogram. Most patients have dense breast tissue at this time, and frequently a breast ultrasound may be performed also.”

The American College of Obstetricians and Gynecologists (ACOG) does not have specific guidelines about breastfeeding mothers and mammography recommendations. Breastfeeding patients should discuss with their physicians or midwives the pros and cons of mammography, taking into account personal risk factors and how long they plan to nurse, said Joshua Copel, MD, vice chair of obstetrics, gynecology and reproductive sciences at Yale Medicine, New Haven, Connecticut, and a member of ACOG’s Committee on Obstetric Practice.

“The question for anybody to address with their physician will be, ‘Is my risk of breast cancer high enough that I should take that small risk that they’re going to over- or underread the mammogram because of my nursing status? Or should I wait until I wean the baby and have the mammogram then?’” he said.

Institutional and practice protocols meanwhile, can depend on a patient’s cancer risk.

Guidelines at the University of Wisconsin, for instance, advise that lactating patients 40 or over who are at average risk, wait 6-8 weeks after cessation of breastfeeding, said Alison Gegios, MD, a radiologist and assistant professor in breast imaging at the University of Wisconsin School of Medicine and Public Health. Average risk is defined as less than a 15% lifetime risk of breast cancer, she said.

Dr. Gegios, a coauthor on the RadioGraphics paper, said her institution recommends screening mammography if lactating patients are at intermediate or high risk, and are over 30. In such cases however, screening is generally deferred until 3-6 months after delivery, she noted.

“If patients are high risk, it’s also important to do screening breast MRIs,” Dr. Gegios said. “Studies have shown that screening breast MRIs are effective in breastfeeding patients despite their increased background parenchymal enhancement because breast cancer still stands out on our maximum intensity projections and stands out on the exam from the background.”
 

How to Clear Up Confusion, Promote Consistency

After her experience at the mammography practice, Ms. Legg went home and immediately sent a message to her ob.gyn. about what happened.

The doctor was similarly surprised and frustrated that Ms. Legg wasn’t able to get the mammogram, she said. To get around the difference in protocols, Ms. Legg’s ob.gyn. referred her to a high-risk clinic in Cincinnati. Ms. Legg’s history qualified her as high risk and she received genetic testing and a breast ultrasound at the clinic, she said.

“The ultrasound showed some shady spots,” Ms. Legg recalled. “They weren’t quite sure what they were. Another ultrasound later, they determined the spots were symmetrical and it ended up not being anything [serious]. Genetic-wise, I did not have any markers for cancer.”

Ms. Legg was relieved and she eventually received a mammogram when she finished breastfeeding, she said. However, she feels the overlap of older, breastfeeding moms and mammography guidelines deserves more attention.

“I would encourage all of us in the ‘geriatric mother’s club,’ to advocate for yourself, do your research, and also turn to your medical professionals and ask questions,” she said. “Make sure you know what they recommend for moms who are older and just had a baby.”

On the provider side, Dr. Destounis said physicians should revisit with patients the most updated guidelines about breastfeeding and mammography at routine appointments.

“Patients and their physicians have to have communication about screening for breast cancer if they are of screening age,” she said.

Dr. Copel advises physicians to run through the risks and benefits of mammograms with older, breastfeeding patients and make a shared decision. “It’s all going to vary with the individual circumstances,” he said. “If someone [has] a BRCA gene and their sister and mother had breast cancer, maybe it’s worth it. If somebody has absolutely no family history and just crossed the threshold for meeting a mammogram [recommendation], then sure, wait.”

Ms. Legg would like to see more professional literature and educational material directed toward the older, breastfeeding population about mammograms.

“At minimum, work together across departments to create an intake form, a questionnaire that is inclusive of everything,” she said. “There should be a question before you even get to the tech that asks, ‘Are you breastfeeding?’ ”

When her obstetrician-gynecologist recommended a mammogram, Emily Legg didn’t hesitate to schedule an appointment for the screening.

Her grandmother had been diagnosed with breast cancer and her father died of prostate cancer in his mid-50s. Ms. Legg also has polycystic ovary syndrome (PCOS), which increases the risk of some cancers.

Having just turned 40, Ms. Legg said she was determined to be as proactive as possible with cancer screenings.

Before the mammogram, she arranged for childcare for her 6-month-old daughter and filled out a required questionnaire online that asked about her history and health conditions. When the appointment day arrived, Ms. Legg made the 30-minute drive to the clinic where she was prepped for the procedure and escorted to the mammography room.

But just before the screening started, Ms. Legg happened to mention to the technician that she was breastfeeding. The surprised tech immediately halted the procedure, Ms. Legg said. Because of increased breast density caused by nursing, Ms. Legg was told to wait at least 6 weeks after weaning for a mammogram.

“I didn’t even consider that breastfeeding might prevent me from getting a mammogram,” said Ms. Legg, a writing professor from Hamilton, Ohio. “I had to go home. I was frustrated, mostly because I had driven all that way. I had hyped myself up. I had childcare in line. And now I had to wait until my daughter weaned? At the time, I didn’t know if my daughter was going to breastfeed for 2 years or be done at 6 months.”

Considering her family background, Ms. Legg worried about not receiving the screening. Her sister had recently undergone a mammogram while she was breastfeeding without any problems.

When she did research, Ms. Legg found conflicting information about the subject online so she turned to Reddit, where she started a thread asking if other moms over 40 had experienced similar issues. Dozens of moms responded with questions and concerns on the subject. Some wrote about being denied a mammogram while breastfeeding, while others wrote they received the procedure without question. Guidance from health professionals on the topic appeared to vastly differ.

“That’s why I turned to [social media] because I wasn’t finding anything else,” Ms. Legg said. “There’s just a lack of clear information. As an older mom, there’s less information out there for being postpartum and being over 40.”

Confusion over screenings during breastfeeding comes at the intersection of national guidelines lowering the recommended age for first mammograms, more women having babies later in life, and women getting breast cancer earlier.

167549_Legg_and_child_web.JPG

Most physician specialty associations agree that mammography is safe for breastfeeding patients and that they need not delay routine screenings. However, the safety of breast imaging during pregnancy and lactation is not well advertised, said Molly Peterson, MD, a radiologist based in St. Frances, Wisconsin, and lead author of a 2023 article about breast imaging during pregnancy and lactation in RadioGraphics, a journal of the Radiological Society of North America.

Conflicting information from nonscientific resources adds to the confusion, Dr. Peterson said. At the same time, health providers along the care spectrum may be uncertain about what imaging is safe and reasonable. Recommendations about mammography and lactation can also vary by institution, screening experts say.

“I’ve talked with pregnant and breastfeeding patients, both younger and older, who were unsure if they could have mammograms,” Dr. Peterson said. “I’ve also fielded questions from technologists, unclear what imaging we can offer these patients. ... Educating health professionals about evidence-based guidelines for screening and diagnostic imaging and reassuring patients about the safety of breast imaging during pregnancy and lactation is thus more important than ever.”
 

Differing Guidelines, Case-by-Case Considerations

The RadioGraphics paper emphasizes that both screening and diagnostic imaging can be safely performed using protocols based on age, breast cancer risk, and whether the patient is pregnant or lactating.

The American College of Radiology (ACR) Appropriateness Criteria also support mammography for certain patients during lactation. The guidelines state there is no contraindication to performing mammography during lactation, but note that challenges in evaluation can arise because of the unique physiological and structural breast changes that can occur.

“Hormones can change breast density and size of the breast, which could limit the clinical examination, mimic pathology, and obscure mammographic findings,” said Stamatia V. Destounis, MD, FACR, chair of the ACR Breast Imaging Commission. “It is important the patient pumps right before the mammogram or brings the baby to breastfeed prior to the imaging examination to offer the best imaging evaluation and reduce breast density as much as possible.”

In those patients who choose to prolong breastfeeding and are of the age to be screened, it is important they undergo yearly clinical breast exams, perform breast self-exams, and discuss breast cancer screening with their healthcare provider, she said. “They should not delay a routine screening mammogram. Most patients have dense breast tissue at this time, and frequently a breast ultrasound may be performed also.”

The American College of Obstetricians and Gynecologists (ACOG) does not have specific guidelines about breastfeeding mothers and mammography recommendations. Breastfeeding patients should discuss with their physicians or midwives the pros and cons of mammography, taking into account personal risk factors and how long they plan to nurse, said Joshua Copel, MD, vice chair of obstetrics, gynecology and reproductive sciences at Yale Medicine, New Haven, Connecticut, and a member of ACOG’s Committee on Obstetric Practice.

“The question for anybody to address with their physician will be, ‘Is my risk of breast cancer high enough that I should take that small risk that they’re going to over- or underread the mammogram because of my nursing status? Or should I wait until I wean the baby and have the mammogram then?’” he said.

Institutional and practice protocols meanwhile, can depend on a patient’s cancer risk.

Guidelines at the University of Wisconsin, for instance, advise that lactating patients 40 or over who are at average risk, wait 6-8 weeks after cessation of breastfeeding, said Alison Gegios, MD, a radiologist and assistant professor in breast imaging at the University of Wisconsin School of Medicine and Public Health. Average risk is defined as less than a 15% lifetime risk of breast cancer, she said.

Dr. Gegios, a coauthor on the RadioGraphics paper, said her institution recommends screening mammography if lactating patients are at intermediate or high risk, and are over 30. In such cases however, screening is generally deferred until 3-6 months after delivery, she noted.

“If patients are high risk, it’s also important to do screening breast MRIs,” Dr. Gegios said. “Studies have shown that screening breast MRIs are effective in breastfeeding patients despite their increased background parenchymal enhancement because breast cancer still stands out on our maximum intensity projections and stands out on the exam from the background.”
 

How to Clear Up Confusion, Promote Consistency

After her experience at the mammography practice, Ms. Legg went home and immediately sent a message to her ob.gyn. about what happened.

The doctor was similarly surprised and frustrated that Ms. Legg wasn’t able to get the mammogram, she said. To get around the difference in protocols, Ms. Legg’s ob.gyn. referred her to a high-risk clinic in Cincinnati. Ms. Legg’s history qualified her as high risk and she received genetic testing and a breast ultrasound at the clinic, she said.

“The ultrasound showed some shady spots,” Ms. Legg recalled. “They weren’t quite sure what they were. Another ultrasound later, they determined the spots were symmetrical and it ended up not being anything [serious]. Genetic-wise, I did not have any markers for cancer.”

Ms. Legg was relieved and she eventually received a mammogram when she finished breastfeeding, she said. However, she feels the overlap of older, breastfeeding moms and mammography guidelines deserves more attention.

“I would encourage all of us in the ‘geriatric mother’s club,’ to advocate for yourself, do your research, and also turn to your medical professionals and ask questions,” she said. “Make sure you know what they recommend for moms who are older and just had a baby.”

On the provider side, Dr. Destounis said physicians should revisit with patients the most updated guidelines about breastfeeding and mammography at routine appointments.

“Patients and their physicians have to have communication about screening for breast cancer if they are of screening age,” she said.

Dr. Copel advises physicians to run through the risks and benefits of mammograms with older, breastfeeding patients and make a shared decision. “It’s all going to vary with the individual circumstances,” he said. “If someone [has] a BRCA gene and their sister and mother had breast cancer, maybe it’s worth it. If somebody has absolutely no family history and just crossed the threshold for meeting a mammogram [recommendation], then sure, wait.”

Ms. Legg would like to see more professional literature and educational material directed toward the older, breastfeeding population about mammograms.

“At minimum, work together across departments to create an intake form, a questionnaire that is inclusive of everything,” she said. “There should be a question before you even get to the tech that asks, ‘Are you breastfeeding?’ ”

Infants born to women with obesity showed improved measures of cardiovascular health when their mothers adopted healthier lifestyles before and during pregnancy, based on data from a systematic review presented at the annual meeting of the Society for Reproductive Investigation.

Previous research has shown that children born to mothers with a high body mass index (BMI) are more likely to die from cardiovascular disease in later life, said presenting author Samuel J. Burden, PhD, in an interview.

“Surprisingly, early signs of these heart issues can start before birth and continue into childhood,” said Dr. Burden, a research associate in the Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom.

To examine the effect of interventions such as a healthy diet and exercise in pregnant women with obesity on the heart health of their infants, Dr. Burden and colleagues reviewed data from eight randomized, controlled trials involving diet and exercise for pregnant women with obesity. Of these, two used antenatal exercise, two used diet and physical activity, and one used preconception diet and physical activity. The studies ranged in size from 18 to 404 participants. Two studies included infants younger than 2 months of age, and four studies included children aged 3-7 years.

Overall, lifestyle interventions before conception and before birth were associated with significant changes in cardiac remodeling, specifically reduced interventricular septal wall thickness.

In addition, one of three studies of cardiac diastolic function and four of five studies of systolic function showed significant improvements. The five studies of cardiac systolic function and three studies of diastolic function also showed improvement in systolic and diastolic blood pressure in infants of mothers who took part in the interventions. The studies were limited mainly by large attrition rates, the researchers wrote in their presentation. However, more studies in larger populations that also include older children could confirm the findings and inform public health strategies to promote healthy lifestyles for pregnant women, they noted.

Encourage Healthy Lifestyle Before and During Pregnancy

The evidence supports the findings from animal studies showing that an offspring’s health is influenced by maternal lifestyle before and during pregnancy, Dr. Burden said in an interview. The data suggest that healthcare providers should encourage women with a high BMI who want to become pregnant to eat healthfully and become more active as a way to enhance the future cardiovascular health of their children, he said.

The full results of the current study are soon to be published, but more work is needed, said Dr. Burden. “While we observed a protective effect from these lifestyle programs, there is a need for more extensive studies involving a larger number of women (and their children) who were part of the initial research,” he said. “Additionally, it will be crucial to track these children into adulthood to determine whether these antenatal lifestyle interventions persist in lowering the risk of future cardiovascular disease.”

Beginning healthy lifestyle programs prior to pregnancy might yield the best results for promoting infant cardiovascular health, and more prepregnancy interventions for women with obesity are needed, Dr. Burden added.

The current study adds to the growing body of evidence that the in utero environment can have lifelong effects on offspring, Joseph R. Biggio Jr, MD, system chair of maternal fetal medicine at Ochsner Health, New Orleans, Louisiana, said in an interview.

“Several studies have previously shown that the children of mothers with diabetes, hypertension, or obesity are at increased risk for developing signs of metabolic syndrome and cardiovascular changes during childhood or adolescence,” said Dr. Biggio.

The data from this systematic review support the potential value of interventions aimed at improving maternal weight gain and cardiovascular performance before and during pregnancy that may result in reduced cardiovascular remodeling and myocardial thickening in infants, he said.   

The study was supported by a British Heart Foundation Special Project Grant. The researchers had no financial conflicts to disclose. Dr. Biggio had no financial conflicts to disclose.

Infants born to women with obesity showed improved measures of cardiovascular health when their mothers adopted healthier lifestyles before and during pregnancy, based on data from a systematic review presented at the annual meeting of the Society for Reproductive Investigation.

Previous research has shown that children born to mothers with a high body mass index (BMI) are more likely to die from cardiovascular disease in later life, said presenting author Samuel J. Burden, PhD, in an interview.

“Surprisingly, early signs of these heart issues can start before birth and continue into childhood,” said Dr. Burden, a research associate in the Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom.

To examine the effect of interventions such as a healthy diet and exercise in pregnant women with obesity on the heart health of their infants, Dr. Burden and colleagues reviewed data from eight randomized, controlled trials involving diet and exercise for pregnant women with obesity. Of these, two used antenatal exercise, two used diet and physical activity, and one used preconception diet and physical activity. The studies ranged in size from 18 to 404 participants. Two studies included infants younger than 2 months of age, and four studies included children aged 3-7 years.

Overall, lifestyle interventions before conception and before birth were associated with significant changes in cardiac remodeling, specifically reduced interventricular septal wall thickness.

In addition, one of three studies of cardiac diastolic function and four of five studies of systolic function showed significant improvements. The five studies of cardiac systolic function and three studies of diastolic function also showed improvement in systolic and diastolic blood pressure in infants of mothers who took part in the interventions. The studies were limited mainly by large attrition rates, the researchers wrote in their presentation. However, more studies in larger populations that also include older children could confirm the findings and inform public health strategies to promote healthy lifestyles for pregnant women, they noted.

Encourage Healthy Lifestyle Before and During Pregnancy

The evidence supports the findings from animal studies showing that an offspring’s health is influenced by maternal lifestyle before and during pregnancy, Dr. Burden said in an interview. The data suggest that healthcare providers should encourage women with a high BMI who want to become pregnant to eat healthfully and become more active as a way to enhance the future cardiovascular health of their children, he said.

The full results of the current study are soon to be published, but more work is needed, said Dr. Burden. “While we observed a protective effect from these lifestyle programs, there is a need for more extensive studies involving a larger number of women (and their children) who were part of the initial research,” he said. “Additionally, it will be crucial to track these children into adulthood to determine whether these antenatal lifestyle interventions persist in lowering the risk of future cardiovascular disease.”

Beginning healthy lifestyle programs prior to pregnancy might yield the best results for promoting infant cardiovascular health, and more prepregnancy interventions for women with obesity are needed, Dr. Burden added.

The current study adds to the growing body of evidence that the in utero environment can have lifelong effects on offspring, Joseph R. Biggio Jr, MD, system chair of maternal fetal medicine at Ochsner Health, New Orleans, Louisiana, said in an interview.

“Several studies have previously shown that the children of mothers with diabetes, hypertension, or obesity are at increased risk for developing signs of metabolic syndrome and cardiovascular changes during childhood or adolescence,” said Dr. Biggio.

The data from this systematic review support the potential value of interventions aimed at improving maternal weight gain and cardiovascular performance before and during pregnancy that may result in reduced cardiovascular remodeling and myocardial thickening in infants, he said.   

The study was supported by a British Heart Foundation Special Project Grant. The researchers had no financial conflicts to disclose. Dr. Biggio had no financial conflicts to disclose.

Infants born to women with obesity showed improved measures of cardiovascular health when their mothers adopted healthier lifestyles before and during pregnancy, based on data from a systematic review presented at the annual meeting of the Society for Reproductive Investigation.

Previous research has shown that children born to mothers with a high body mass index (BMI) are more likely to die from cardiovascular disease in later life, said presenting author Samuel J. Burden, PhD, in an interview.

“Surprisingly, early signs of these heart issues can start before birth and continue into childhood,” said Dr. Burden, a research associate in the Department of Women & Children’s Health, School of Life Course & Population Sciences, King’s College London, London, United Kingdom.

To examine the effect of interventions such as a healthy diet and exercise in pregnant women with obesity on the heart health of their infants, Dr. Burden and colleagues reviewed data from eight randomized, controlled trials involving diet and exercise for pregnant women with obesity. Of these, two used antenatal exercise, two used diet and physical activity, and one used preconception diet and physical activity. The studies ranged in size from 18 to 404 participants. Two studies included infants younger than 2 months of age, and four studies included children aged 3-7 years.

Overall, lifestyle interventions before conception and before birth were associated with significant changes in cardiac remodeling, specifically reduced interventricular septal wall thickness.

In addition, one of three studies of cardiac diastolic function and four of five studies of systolic function showed significant improvements. The five studies of cardiac systolic function and three studies of diastolic function also showed improvement in systolic and diastolic blood pressure in infants of mothers who took part in the interventions. The studies were limited mainly by large attrition rates, the researchers wrote in their presentation. However, more studies in larger populations that also include older children could confirm the findings and inform public health strategies to promote healthy lifestyles for pregnant women, they noted.

Encourage Healthy Lifestyle Before and During Pregnancy

The evidence supports the findings from animal studies showing that an offspring’s health is influenced by maternal lifestyle before and during pregnancy, Dr. Burden said in an interview. The data suggest that healthcare providers should encourage women with a high BMI who want to become pregnant to eat healthfully and become more active as a way to enhance the future cardiovascular health of their children, he said.

The full results of the current study are soon to be published, but more work is needed, said Dr. Burden. “While we observed a protective effect from these lifestyle programs, there is a need for more extensive studies involving a larger number of women (and their children) who were part of the initial research,” he said. “Additionally, it will be crucial to track these children into adulthood to determine whether these antenatal lifestyle interventions persist in lowering the risk of future cardiovascular disease.”

Beginning healthy lifestyle programs prior to pregnancy might yield the best results for promoting infant cardiovascular health, and more prepregnancy interventions for women with obesity are needed, Dr. Burden added.

The current study adds to the growing body of evidence that the in utero environment can have lifelong effects on offspring, Joseph R. Biggio Jr, MD, system chair of maternal fetal medicine at Ochsner Health, New Orleans, Louisiana, said in an interview.

“Several studies have previously shown that the children of mothers with diabetes, hypertension, or obesity are at increased risk for developing signs of metabolic syndrome and cardiovascular changes during childhood or adolescence,” said Dr. Biggio.

The data from this systematic review support the potential value of interventions aimed at improving maternal weight gain and cardiovascular performance before and during pregnancy that may result in reduced cardiovascular remodeling and myocardial thickening in infants, he said.   

The study was supported by a British Heart Foundation Special Project Grant. The researchers had no financial conflicts to disclose. Dr. Biggio had no financial conflicts to disclose.

A longer time between hysteroscopic polypectomy and frozen embryo transfer may improve the odds of successful pregnancy, based on data from a new analysis presented at the annual meeting of the Society for Reproductive Investigation.

Although uterine polyps have a negative effect on pregnancy rates, data supporting a specific time interval between hysteroscopic polypectomy (HP) and frozen embryo transfer (FET) are limited, according to Audrey Messelt, MD, of Baylor College of Medicine, Houston, Texas, and colleagues.

“Hysteroscopic polypectomy is a common procedure performed before embryo transfer to optimize the receptivity of the endometrium. Currently, there is no ideal recovery time lapse between surgery and an embryo transfer,” said senior author Laura Detti, MD, professor of obstetrics and gynecology at Baylor, in an interview. “This is often the last step prior to embryo transfer, and identifying a recovery time that allows the best outcome is important.”

In a retrospective analysis, the researchers examined the effect of the time between HP and FET on pregnancy outcomes. They identified 65 patients with uterine pathology based on saline-infusion sonogram who underwent hysteroscopy and FET between June 1, 2022, and September 30, 2023.

The endometrial preparation for FET included sequential administration of oral or transdermal estradiol and intramuscular progesterone.

Overall, 46 patients were diagnosed with endometrial polyps at the time of surgery; three had endometritis, one had a uterine septum that was resected, 15 had no abnormal pathology or had normal endometrium at the time of examination. No cases of hyperplasia or malignancy were identified.

A total of 58 patients underwent FET with a single euploid embryo, four with a single untested embryo, one with a low-mosaic embryo, and two with a double-embryo transfer (one euploid and one low mosaic).

After FET, 50 patients conceived and 15 did not. Patients with ongoing pregnancies who had a history of endometrial polyps had significantly more days from surgery to FET, compared to patients with a history of polyps who failed to conceive (median 70 days vs 45 days, P = .01).

By contrast, the time between hysteroscopy and FET was similar among patients with no endometrial pathology who did and did not have ongoing pregnancies (median 45 vs 52.5 days, P = .95).

The findings were limited by the relatively small sample size and exclusion of patients with pathologies other than polyps, as well as a lack of data on age group breakdowns. However, the results suggest that patients with uterine polyps may benefit from more time between HP and FET, while patients with normal surgical findings could undergo FET sooner, the researchers concluded.
 

Postpolypectomy Timing May Affect Pregnancy Outcomes

“We used to think that having had the first menses from surgery would be enough recovery time for the uterine cavity, even if it was just 2 weeks,” Dr. Detti said in an interview. “This still holds true when no endometrial polyps are diagnosed in the pathological specimen; however, we learned that if endometrial polyps are removed at the time of hysteroscopy, the ideal recovery time prior to an embryo transfer should be longer,” she said.

The current study is important because approximately 15% of women are diagnosed with endometrial polyps during their reproductive years, said Mark P. Trolice, MD, professor at the University of Central Florida, Orlando, and founder/medical director of the IVF Center of Central Florida in Winter Park, in an interview.

“Abnormalities of the uterine cavity have been shown to reduce embryo implantation and increase the risk of miscarriage,” said Dr. Trolice. Although the impact of small endometrial polyps on fertility and pregnancy are uncertain, most infertility specialists recommend removal of endometrial polyps via hysteroscopic polypectomy in general and prior to IVF embryo transfer in particular, he said.

Although infertility patients are anxious to undergo embryo transfer, the current study suggests a benefit in delaying the procedure following the removal of any polyps identified during the pretransfer evaluation, Dr. Trolice said in an interview. As for additional research, “it would be helpful to know the age group breakdown of patients and if the results were consistent among all categories,” he said.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Trolice had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.

A longer time between hysteroscopic polypectomy and frozen embryo transfer may improve the odds of successful pregnancy, based on data from a new analysis presented at the annual meeting of the Society for Reproductive Investigation.

Although uterine polyps have a negative effect on pregnancy rates, data supporting a specific time interval between hysteroscopic polypectomy (HP) and frozen embryo transfer (FET) are limited, according to Audrey Messelt, MD, of Baylor College of Medicine, Houston, Texas, and colleagues.

“Hysteroscopic polypectomy is a common procedure performed before embryo transfer to optimize the receptivity of the endometrium. Currently, there is no ideal recovery time lapse between surgery and an embryo transfer,” said senior author Laura Detti, MD, professor of obstetrics and gynecology at Baylor, in an interview. “This is often the last step prior to embryo transfer, and identifying a recovery time that allows the best outcome is important.”

In a retrospective analysis, the researchers examined the effect of the time between HP and FET on pregnancy outcomes. They identified 65 patients with uterine pathology based on saline-infusion sonogram who underwent hysteroscopy and FET between June 1, 2022, and September 30, 2023.

The endometrial preparation for FET included sequential administration of oral or transdermal estradiol and intramuscular progesterone.

Overall, 46 patients were diagnosed with endometrial polyps at the time of surgery; three had endometritis, one had a uterine septum that was resected, 15 had no abnormal pathology or had normal endometrium at the time of examination. No cases of hyperplasia or malignancy were identified.

A total of 58 patients underwent FET with a single euploid embryo, four with a single untested embryo, one with a low-mosaic embryo, and two with a double-embryo transfer (one euploid and one low mosaic).

After FET, 50 patients conceived and 15 did not. Patients with ongoing pregnancies who had a history of endometrial polyps had significantly more days from surgery to FET, compared to patients with a history of polyps who failed to conceive (median 70 days vs 45 days, P = .01).

By contrast, the time between hysteroscopy and FET was similar among patients with no endometrial pathology who did and did not have ongoing pregnancies (median 45 vs 52.5 days, P = .95).

The findings were limited by the relatively small sample size and exclusion of patients with pathologies other than polyps, as well as a lack of data on age group breakdowns. However, the results suggest that patients with uterine polyps may benefit from more time between HP and FET, while patients with normal surgical findings could undergo FET sooner, the researchers concluded.
 

Postpolypectomy Timing May Affect Pregnancy Outcomes

“We used to think that having had the first menses from surgery would be enough recovery time for the uterine cavity, even if it was just 2 weeks,” Dr. Detti said in an interview. “This still holds true when no endometrial polyps are diagnosed in the pathological specimen; however, we learned that if endometrial polyps are removed at the time of hysteroscopy, the ideal recovery time prior to an embryo transfer should be longer,” she said.

The current study is important because approximately 15% of women are diagnosed with endometrial polyps during their reproductive years, said Mark P. Trolice, MD, professor at the University of Central Florida, Orlando, and founder/medical director of the IVF Center of Central Florida in Winter Park, in an interview.

“Abnormalities of the uterine cavity have been shown to reduce embryo implantation and increase the risk of miscarriage,” said Dr. Trolice. Although the impact of small endometrial polyps on fertility and pregnancy are uncertain, most infertility specialists recommend removal of endometrial polyps via hysteroscopic polypectomy in general and prior to IVF embryo transfer in particular, he said.

Although infertility patients are anxious to undergo embryo transfer, the current study suggests a benefit in delaying the procedure following the removal of any polyps identified during the pretransfer evaluation, Dr. Trolice said in an interview. As for additional research, “it would be helpful to know the age group breakdown of patients and if the results were consistent among all categories,” he said.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Trolice had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.

A longer time between hysteroscopic polypectomy and frozen embryo transfer may improve the odds of successful pregnancy, based on data from a new analysis presented at the annual meeting of the Society for Reproductive Investigation.

Although uterine polyps have a negative effect on pregnancy rates, data supporting a specific time interval between hysteroscopic polypectomy (HP) and frozen embryo transfer (FET) are limited, according to Audrey Messelt, MD, of Baylor College of Medicine, Houston, Texas, and colleagues.

“Hysteroscopic polypectomy is a common procedure performed before embryo transfer to optimize the receptivity of the endometrium. Currently, there is no ideal recovery time lapse between surgery and an embryo transfer,” said senior author Laura Detti, MD, professor of obstetrics and gynecology at Baylor, in an interview. “This is often the last step prior to embryo transfer, and identifying a recovery time that allows the best outcome is important.”

In a retrospective analysis, the researchers examined the effect of the time between HP and FET on pregnancy outcomes. They identified 65 patients with uterine pathology based on saline-infusion sonogram who underwent hysteroscopy and FET between June 1, 2022, and September 30, 2023.

The endometrial preparation for FET included sequential administration of oral or transdermal estradiol and intramuscular progesterone.

Overall, 46 patients were diagnosed with endometrial polyps at the time of surgery; three had endometritis, one had a uterine septum that was resected, 15 had no abnormal pathology or had normal endometrium at the time of examination. No cases of hyperplasia or malignancy were identified.

A total of 58 patients underwent FET with a single euploid embryo, four with a single untested embryo, one with a low-mosaic embryo, and two with a double-embryo transfer (one euploid and one low mosaic).

After FET, 50 patients conceived and 15 did not. Patients with ongoing pregnancies who had a history of endometrial polyps had significantly more days from surgery to FET, compared to patients with a history of polyps who failed to conceive (median 70 days vs 45 days, P = .01).

By contrast, the time between hysteroscopy and FET was similar among patients with no endometrial pathology who did and did not have ongoing pregnancies (median 45 vs 52.5 days, P = .95).

The findings were limited by the relatively small sample size and exclusion of patients with pathologies other than polyps, as well as a lack of data on age group breakdowns. However, the results suggest that patients with uterine polyps may benefit from more time between HP and FET, while patients with normal surgical findings could undergo FET sooner, the researchers concluded.
 

Postpolypectomy Timing May Affect Pregnancy Outcomes

“We used to think that having had the first menses from surgery would be enough recovery time for the uterine cavity, even if it was just 2 weeks,” Dr. Detti said in an interview. “This still holds true when no endometrial polyps are diagnosed in the pathological specimen; however, we learned that if endometrial polyps are removed at the time of hysteroscopy, the ideal recovery time prior to an embryo transfer should be longer,” she said.

The current study is important because approximately 15% of women are diagnosed with endometrial polyps during their reproductive years, said Mark P. Trolice, MD, professor at the University of Central Florida, Orlando, and founder/medical director of the IVF Center of Central Florida in Winter Park, in an interview.

“Abnormalities of the uterine cavity have been shown to reduce embryo implantation and increase the risk of miscarriage,” said Dr. Trolice. Although the impact of small endometrial polyps on fertility and pregnancy are uncertain, most infertility specialists recommend removal of endometrial polyps via hysteroscopic polypectomy in general and prior to IVF embryo transfer in particular, he said.

Although infertility patients are anxious to undergo embryo transfer, the current study suggests a benefit in delaying the procedure following the removal of any polyps identified during the pretransfer evaluation, Dr. Trolice said in an interview. As for additional research, “it would be helpful to know the age group breakdown of patients and if the results were consistent among all categories,” he said.

The study received no outside funding. The researchers had no financial conflicts to disclose. Dr. Trolice had no financial conflicts to disclose and serves on the Editorial Advisory Board of Ob.Gyn. News.

Teen pregnancy is associated with a higher risk for premature mortality, both among those who carry the pregnancies to term and those who miscarry, according to a new study.

Among 2.2 million female teenagers in Ontario, Canada, the risk for premature death by age 31 years was 1.5 times higher among those who had one teen pregnancy and 2.1 times higher among those with two or more teen pregnancies.

“No person should die during childhood or early adulthood. Such deaths, unexpected and tragic, are often from preventable causes, including intentional injury,” lead author Joel Ray, MD, an obstetric medicine specialist and epidemiologist at St. Michael’s Hospital in Toronto, told this news organization. 

“Women who experience teen pregnancy appear more vulnerable, often having experienced a history of adverse experiences in childhood, including abuse and economic challenges,” he said.

The study was published online in JAMA Network Open.
 

Analyzing Pregnancy Associations

The investigators conducted a population-based cohort study of all girls who were alive at age 12 years from April 1991 to March 2021 in Ontario. They evaluated the risk for all-cause mortality from age 12 years onward in association with the number of teen pregnancies between ages 12 and 19 years and the age at first pregnancy. The investigators adjusted the hazard ratios for year of birth, comorbidities at ages 9-11 years, area-level education, income level, and rural status.

Among more than 2.2 million teens, 163,124 (7.3%) had a pregnancy at a median age of 18 years, including 121,276 (74.3%) who had one pregnancy and 41,848 (25.6%) who had two or more. These teens were more likely to live in the lowest neighborhood income quintile and in an area with a lower rate of high school completion. They also had a higher prevalence of self-harm history between ages 12 and 19 years but not a higher prevalence of physical or mental comorbidities.

Among all teens who had a pregnancy, 60,037 (36.8%) ended in a birth, including 59,485 (99.1%) live births. A further 106,135 (65.1%) ended in induced abortion, and 17,945 (11%) ended in miscarriage or ectopic pregnancy.

Overall, there were 6030 premature deaths among those without a teen pregnancy, or 1.9 per 10,000 person-years. There were 701 deaths among those with one teen pregnancy (4.1 per 10,000 person-years) and 345 deaths among those with two or more teen pregnancies (6.1 per 10,000 person-years).

The adjusted hazard ratios (AHRs) for mortality were 1.51 for those with one pregnancy and 2.14 for those with two or more pregnancies. Compared with no teen pregnancy, the AHRs for premature death were 1.41 if the first teen pregnancy ended in an induced abortion and 2.10 if it ended in a miscarriage or birth.

Comparing those with a teen pregnancy and those without, the AHRs for premature death were 1.25 from noninjury, 2.06 from unintentional injury, and 2.02 from intentional injury. Among patients with teen pregnancy, noninjury-related premature mortality was more common, at 2.0 per 10,000 person-years, than unintentional and intentional injuries, at 1.0 per 10,000 person-years and 0.4 per 10,000 person-years, respectively.

A teen pregnancy before age 16 years entailed the highest associated risk for premature death, with an AHR of 2.00.
 

Next Research Steps

“We were not surprised by our findings, but it was new to us to see that the risk for premature death was higher for women who had an induced abortion in their teen years,” said Dr. Ray. “It was even higher in those whose pregnancy ended in a birth or miscarriage.”

The investigators plan to evaluate whether the future risk for premature death after teen pregnancy differs by the type of induced abortion, such as procedural or pharmaceutical, or by whether the pregnancy ended in a live birth, stillbirth, or miscarriage. Among those with a live birth, the researchers will also analyze the risk for premature death in relation to whether the newborn was taken into custody by child protection services in Canada.

Other factors associated with teen pregnancy and overall mortality, particularly adverse childhood experiences, may point to the reasons for premature mortality and should be studied further, the authors wrote. Structural and systems-related factors should be considered as well.
 

Stigmatization and Isolation 

“Some teens choose to become pregnant, but most teen pregnancies are unintended, which exposes shortcomings in the systems that exist to educate, guide, and support young people,” said Elizabeth Cook, a research scientist at Child Trends in Rockville, Maryland.

Dr. Cook, who wasn’t involved with this study, wrote an accompanying editorial in JAMA Network Open. She conducts studies of sexual and reproductive health for Child Trends.

“Teens who become pregnant often experience stigmatization and isolation that can make it more difficult to thrive in adulthood, especially if they lack the necessary support to navigate such a significant decision,” she said. “Fortunately, the systems that youths encounter, such as healthcare, education, and child welfare, are taking on a larger role in prevention efforts than they have in the past.”

These systems are shifting the burden of unintended teen pregnancy from the teens themselves and their behaviors to the health and education systems, Dr. Cook noted, though more work is needed around local policies and lack of access to healthcare facilities. 

“Teen pregnancy may offer an opportunity to intervene in the lives of people at higher risk for premature death, but knowing how best to offer support requires an understanding of the context of their lives,” she said. “As a starting point, we must celebrate and listen to all pregnant young people so they can tell us what they need to live long, fulfilled lives.”

The study was funded by grants from the PSI Foundation and the Canadian Institutes of Health Research, as well as ICES, which is funded by the Ontario Ministry of Health and the Ministry of Long-Term Care. Dr. Ray and Dr. Cook reported no relevant disclosures. 

A version of this article first appeared on Medscape.com.

Teen pregnancy is associated with a higher risk for premature mortality, both among those who carry the pregnancies to term and those who miscarry, according to a new study.

Among 2.2 million female teenagers in Ontario, Canada, the risk for premature death by age 31 years was 1.5 times higher among those who had one teen pregnancy and 2.1 times higher among those with two or more teen pregnancies.

“No person should die during childhood or early adulthood. Such deaths, unexpected and tragic, are often from preventable causes, including intentional injury,” lead author Joel Ray, MD, an obstetric medicine specialist and epidemiologist at St. Michael’s Hospital in Toronto, told this news organization. 

“Women who experience teen pregnancy appear more vulnerable, often having experienced a history of adverse experiences in childhood, including abuse and economic challenges,” he said.

The study was published online in JAMA Network Open.
 

Analyzing Pregnancy Associations

The investigators conducted a population-based cohort study of all girls who were alive at age 12 years from April 1991 to March 2021 in Ontario. They evaluated the risk for all-cause mortality from age 12 years onward in association with the number of teen pregnancies between ages 12 and 19 years and the age at first pregnancy. The investigators adjusted the hazard ratios for year of birth, comorbidities at ages 9-11 years, area-level education, income level, and rural status.

Among more than 2.2 million teens, 163,124 (7.3%) had a pregnancy at a median age of 18 years, including 121,276 (74.3%) who had one pregnancy and 41,848 (25.6%) who had two or more. These teens were more likely to live in the lowest neighborhood income quintile and in an area with a lower rate of high school completion. They also had a higher prevalence of self-harm history between ages 12 and 19 years but not a higher prevalence of physical or mental comorbidities.

Among all teens who had a pregnancy, 60,037 (36.8%) ended in a birth, including 59,485 (99.1%) live births. A further 106,135 (65.1%) ended in induced abortion, and 17,945 (11%) ended in miscarriage or ectopic pregnancy.

Overall, there were 6030 premature deaths among those without a teen pregnancy, or 1.9 per 10,000 person-years. There were 701 deaths among those with one teen pregnancy (4.1 per 10,000 person-years) and 345 deaths among those with two or more teen pregnancies (6.1 per 10,000 person-years).

The adjusted hazard ratios (AHRs) for mortality were 1.51 for those with one pregnancy and 2.14 for those with two or more pregnancies. Compared with no teen pregnancy, the AHRs for premature death were 1.41 if the first teen pregnancy ended in an induced abortion and 2.10 if it ended in a miscarriage or birth.

Comparing those with a teen pregnancy and those without, the AHRs for premature death were 1.25 from noninjury, 2.06 from unintentional injury, and 2.02 from intentional injury. Among patients with teen pregnancy, noninjury-related premature mortality was more common, at 2.0 per 10,000 person-years, than unintentional and intentional injuries, at 1.0 per 10,000 person-years and 0.4 per 10,000 person-years, respectively.

A teen pregnancy before age 16 years entailed the highest associated risk for premature death, with an AHR of 2.00.
 

Next Research Steps

“We were not surprised by our findings, but it was new to us to see that the risk for premature death was higher for women who had an induced abortion in their teen years,” said Dr. Ray. “It was even higher in those whose pregnancy ended in a birth or miscarriage.”

The investigators plan to evaluate whether the future risk for premature death after teen pregnancy differs by the type of induced abortion, such as procedural or pharmaceutical, or by whether the pregnancy ended in a live birth, stillbirth, or miscarriage. Among those with a live birth, the researchers will also analyze the risk for premature death in relation to whether the newborn was taken into custody by child protection services in Canada.

Other factors associated with teen pregnancy and overall mortality, particularly adverse childhood experiences, may point to the reasons for premature mortality and should be studied further, the authors wrote. Structural and systems-related factors should be considered as well.
 

Stigmatization and Isolation 

“Some teens choose to become pregnant, but most teen pregnancies are unintended, which exposes shortcomings in the systems that exist to educate, guide, and support young people,” said Elizabeth Cook, a research scientist at Child Trends in Rockville, Maryland.

Dr. Cook, who wasn’t involved with this study, wrote an accompanying editorial in JAMA Network Open. She conducts studies of sexual and reproductive health for Child Trends.

“Teens who become pregnant often experience stigmatization and isolation that can make it more difficult to thrive in adulthood, especially if they lack the necessary support to navigate such a significant decision,” she said. “Fortunately, the systems that youths encounter, such as healthcare, education, and child welfare, are taking on a larger role in prevention efforts than they have in the past.”

These systems are shifting the burden of unintended teen pregnancy from the teens themselves and their behaviors to the health and education systems, Dr. Cook noted, though more work is needed around local policies and lack of access to healthcare facilities. 

“Teen pregnancy may offer an opportunity to intervene in the lives of people at higher risk for premature death, but knowing how best to offer support requires an understanding of the context of their lives,” she said. “As a starting point, we must celebrate and listen to all pregnant young people so they can tell us what they need to live long, fulfilled lives.”

The study was funded by grants from the PSI Foundation and the Canadian Institutes of Health Research, as well as ICES, which is funded by the Ontario Ministry of Health and the Ministry of Long-Term Care. Dr. Ray and Dr. Cook reported no relevant disclosures. 

A version of this article first appeared on Medscape.com.

Teen pregnancy is associated with a higher risk for premature mortality, both among those who carry the pregnancies to term and those who miscarry, according to a new study.

Among 2.2 million female teenagers in Ontario, Canada, the risk for premature death by age 31 years was 1.5 times higher among those who had one teen pregnancy and 2.1 times higher among those with two or more teen pregnancies.

“No person should die during childhood or early adulthood. Such deaths, unexpected and tragic, are often from preventable causes, including intentional injury,” lead author Joel Ray, MD, an obstetric medicine specialist and epidemiologist at St. Michael’s Hospital in Toronto, told this news organization. 

“Women who experience teen pregnancy appear more vulnerable, often having experienced a history of adverse experiences in childhood, including abuse and economic challenges,” he said.

The study was published online in JAMA Network Open.
 

Analyzing Pregnancy Associations

The investigators conducted a population-based cohort study of all girls who were alive at age 12 years from April 1991 to March 2021 in Ontario. They evaluated the risk for all-cause mortality from age 12 years onward in association with the number of teen pregnancies between ages 12 and 19 years and the age at first pregnancy. The investigators adjusted the hazard ratios for year of birth, comorbidities at ages 9-11 years, area-level education, income level, and rural status.

Among more than 2.2 million teens, 163,124 (7.3%) had a pregnancy at a median age of 18 years, including 121,276 (74.3%) who had one pregnancy and 41,848 (25.6%) who had two or more. These teens were more likely to live in the lowest neighborhood income quintile and in an area with a lower rate of high school completion. They also had a higher prevalence of self-harm history between ages 12 and 19 years but not a higher prevalence of physical or mental comorbidities.

Among all teens who had a pregnancy, 60,037 (36.8%) ended in a birth, including 59,485 (99.1%) live births. A further 106,135 (65.1%) ended in induced abortion, and 17,945 (11%) ended in miscarriage or ectopic pregnancy.

Overall, there were 6030 premature deaths among those without a teen pregnancy, or 1.9 per 10,000 person-years. There were 701 deaths among those with one teen pregnancy (4.1 per 10,000 person-years) and 345 deaths among those with two or more teen pregnancies (6.1 per 10,000 person-years).

The adjusted hazard ratios (AHRs) for mortality were 1.51 for those with one pregnancy and 2.14 for those with two or more pregnancies. Compared with no teen pregnancy, the AHRs for premature death were 1.41 if the first teen pregnancy ended in an induced abortion and 2.10 if it ended in a miscarriage or birth.

Comparing those with a teen pregnancy and those without, the AHRs for premature death were 1.25 from noninjury, 2.06 from unintentional injury, and 2.02 from intentional injury. Among patients with teen pregnancy, noninjury-related premature mortality was more common, at 2.0 per 10,000 person-years, than unintentional and intentional injuries, at 1.0 per 10,000 person-years and 0.4 per 10,000 person-years, respectively.

A teen pregnancy before age 16 years entailed the highest associated risk for premature death, with an AHR of 2.00.
 

Next Research Steps

“We were not surprised by our findings, but it was new to us to see that the risk for premature death was higher for women who had an induced abortion in their teen years,” said Dr. Ray. “It was even higher in those whose pregnancy ended in a birth or miscarriage.”

The investigators plan to evaluate whether the future risk for premature death after teen pregnancy differs by the type of induced abortion, such as procedural or pharmaceutical, or by whether the pregnancy ended in a live birth, stillbirth, or miscarriage. Among those with a live birth, the researchers will also analyze the risk for premature death in relation to whether the newborn was taken into custody by child protection services in Canada.

Other factors associated with teen pregnancy and overall mortality, particularly adverse childhood experiences, may point to the reasons for premature mortality and should be studied further, the authors wrote. Structural and systems-related factors should be considered as well.
 

Stigmatization and Isolation 

“Some teens choose to become pregnant, but most teen pregnancies are unintended, which exposes shortcomings in the systems that exist to educate, guide, and support young people,” said Elizabeth Cook, a research scientist at Child Trends in Rockville, Maryland.

Dr. Cook, who wasn’t involved with this study, wrote an accompanying editorial in JAMA Network Open. She conducts studies of sexual and reproductive health for Child Trends.

“Teens who become pregnant often experience stigmatization and isolation that can make it more difficult to thrive in adulthood, especially if they lack the necessary support to navigate such a significant decision,” she said. “Fortunately, the systems that youths encounter, such as healthcare, education, and child welfare, are taking on a larger role in prevention efforts than they have in the past.”

These systems are shifting the burden of unintended teen pregnancy from the teens themselves and their behaviors to the health and education systems, Dr. Cook noted, though more work is needed around local policies and lack of access to healthcare facilities. 

“Teen pregnancy may offer an opportunity to intervene in the lives of people at higher risk for premature death, but knowing how best to offer support requires an understanding of the context of their lives,” she said. “As a starting point, we must celebrate and listen to all pregnant young people so they can tell us what they need to live long, fulfilled lives.”

The study was funded by grants from the PSI Foundation and the Canadian Institutes of Health Research, as well as ICES, which is funded by the Ontario Ministry of Health and the Ministry of Long-Term Care. Dr. Ray and Dr. Cook reported no relevant disclosures. 

A version of this article first appeared on Medscape.com.

Breastfeeding by women with multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD) who are taking monoclonal antibodies (mAbs) appears to be safe for infants, new research confirmed.

Registry data showed no differences in health or development in the first 3 years of life among infants exposed to natalizumab, ocrelizumab, rituximab, or ofatumumab, compared with unexposed infants.

“Most monoclonal antibody medications for multiple sclerosis are not currently approved for use while a mother is breastfeeding,” even though the disease can develop during a person’s reproductive years, study investigator Kerstin Hellwig, MD, with Ruhr University in Bochum, Germany, said in a news release.

“Our data show infants exposed to these medications through breastfeeding experienced no negative effects on health or development within the first 3 years of life,” Dr. Hellwig said.

The findings were released ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology.
 

Registry Data and Analysis

Using the German MS and Pregnancy Registry, researchers identified 183 infants born to mothers taking mAbs while breastfeeding — 180 with a diagnosis of MS and three with a diagnosis of NMOSD. The infants were matched to 183 unexposed infants (control group).

Exposure to mAbs during lactation started a median of 19 days postpartum and lasted for a median of 172 days. The most commonly used mAb during lactation was natalizumab (125 women), followed by ocrelizumab (34 women), rituximab (11 women), and ofatumumab (10 women).

Among the entire infant cohort, two were first exposed to natalizumab and then ocrelizumab; one was exposed to rituximab and then ocrelizumab; three had been previously breastfed on glatiramer acetate and two on interferons.

The primary outcomes were hospitalizations, antibiotic use, developmental delay, and weight during the first 3 years of life in mAb-exposed versus unexposed infants.

In adjusted regression analyses, mAb exposure during breastfeeding was not significantly associated with annual hospitalization (rate ratio [RR], 1.23; P = .473), annual systemic antibiotic use (RR, 1.55; P = .093), developmental delay (odds ratio, 1.16; P = .716), or weight.

A limitation of the study was that only about a third of the infants were followed for the full 3 years. Therefore, Dr. Hellwig said, the results for the third year of life are less meaningful than for years 1 and 2.
 

‘Reassuring’ Data

Reached for comment, Edith L. Graham, MD, Department of Neurology, Multiple Sclerosis and Neuroimmunology, Northwestern University, Chicago, Illinois, noted that this is the largest group of breastfed infants exposed to mAbs used to treat MS and said the data provide “reassuring infant outcomes with no increase in hospitalization, antibiotic use, or developmental delay.”

Dr. Graham noted that recent publications have reported more on the use of anti-CD20 mAbs (ocrelizumab/rituximab/ofatumumab) while breastfeeding, “and this study adds data for patients on natalizumab.”

“It will be important to know how infusion timing after birth impacts transfer of monoclonal antibodies depending on the milk stage as it transitions from colostrum to mature milk in the first month postpartum,” Dr. Graham said.

“While infection rates of infants are reassuring, data on allergies in the exposed infants would be interesting to look at as well,” she added. “While these infusions are not orally bioavailable, we do not know the full extent of impact on the neonatal gut microbiome.”

In addition, Dr. Graham said it would be important to know whether drugs administered monthly, such as natalizumab and ofatumumab, accumulate in the breast milk at higher levels than medications such as ocrelizumab and rituximab, which are administered twice a year.

The German MS and pregnancy registry was partly supported by the Innovation Fund of the Federal Joint Committee, Almirall Hermal GmbH, Biogen GmbH Germany, Hexal AG, Merck Serono GmbH, Novartis Pharma GmbH, Roche Deutschland GmbH, Sanofi Genzyme, and Teva GmbH. Dr. Hellwig and Dr. Graham had no relevant disclosures.

A version of this article appeared on Medscape.com.

Breastfeeding by women with multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD) who are taking monoclonal antibodies (mAbs) appears to be safe for infants, new research confirmed.

Registry data showed no differences in health or development in the first 3 years of life among infants exposed to natalizumab, ocrelizumab, rituximab, or ofatumumab, compared with unexposed infants.

“Most monoclonal antibody medications for multiple sclerosis are not currently approved for use while a mother is breastfeeding,” even though the disease can develop during a person’s reproductive years, study investigator Kerstin Hellwig, MD, with Ruhr University in Bochum, Germany, said in a news release.

“Our data show infants exposed to these medications through breastfeeding experienced no negative effects on health or development within the first 3 years of life,” Dr. Hellwig said.

The findings were released ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology.
 

Registry Data and Analysis

Using the German MS and Pregnancy Registry, researchers identified 183 infants born to mothers taking mAbs while breastfeeding — 180 with a diagnosis of MS and three with a diagnosis of NMOSD. The infants were matched to 183 unexposed infants (control group).

Exposure to mAbs during lactation started a median of 19 days postpartum and lasted for a median of 172 days. The most commonly used mAb during lactation was natalizumab (125 women), followed by ocrelizumab (34 women), rituximab (11 women), and ofatumumab (10 women).

Among the entire infant cohort, two were first exposed to natalizumab and then ocrelizumab; one was exposed to rituximab and then ocrelizumab; three had been previously breastfed on glatiramer acetate and two on interferons.

The primary outcomes were hospitalizations, antibiotic use, developmental delay, and weight during the first 3 years of life in mAb-exposed versus unexposed infants.

In adjusted regression analyses, mAb exposure during breastfeeding was not significantly associated with annual hospitalization (rate ratio [RR], 1.23; P = .473), annual systemic antibiotic use (RR, 1.55; P = .093), developmental delay (odds ratio, 1.16; P = .716), or weight.

A limitation of the study was that only about a third of the infants were followed for the full 3 years. Therefore, Dr. Hellwig said, the results for the third year of life are less meaningful than for years 1 and 2.
 

‘Reassuring’ Data

Reached for comment, Edith L. Graham, MD, Department of Neurology, Multiple Sclerosis and Neuroimmunology, Northwestern University, Chicago, Illinois, noted that this is the largest group of breastfed infants exposed to mAbs used to treat MS and said the data provide “reassuring infant outcomes with no increase in hospitalization, antibiotic use, or developmental delay.”

Dr. Graham noted that recent publications have reported more on the use of anti-CD20 mAbs (ocrelizumab/rituximab/ofatumumab) while breastfeeding, “and this study adds data for patients on natalizumab.”

“It will be important to know how infusion timing after birth impacts transfer of monoclonal antibodies depending on the milk stage as it transitions from colostrum to mature milk in the first month postpartum,” Dr. Graham said.

“While infection rates of infants are reassuring, data on allergies in the exposed infants would be interesting to look at as well,” she added. “While these infusions are not orally bioavailable, we do not know the full extent of impact on the neonatal gut microbiome.”

In addition, Dr. Graham said it would be important to know whether drugs administered monthly, such as natalizumab and ofatumumab, accumulate in the breast milk at higher levels than medications such as ocrelizumab and rituximab, which are administered twice a year.

The German MS and pregnancy registry was partly supported by the Innovation Fund of the Federal Joint Committee, Almirall Hermal GmbH, Biogen GmbH Germany, Hexal AG, Merck Serono GmbH, Novartis Pharma GmbH, Roche Deutschland GmbH, Sanofi Genzyme, and Teva GmbH. Dr. Hellwig and Dr. Graham had no relevant disclosures.

A version of this article appeared on Medscape.com.

Breastfeeding by women with multiple sclerosis (MS) or neuromyelitis optica spectrum disorder (NMOSD) who are taking monoclonal antibodies (mAbs) appears to be safe for infants, new research confirmed.

Registry data showed no differences in health or development in the first 3 years of life among infants exposed to natalizumab, ocrelizumab, rituximab, or ofatumumab, compared with unexposed infants.

“Most monoclonal antibody medications for multiple sclerosis are not currently approved for use while a mother is breastfeeding,” even though the disease can develop during a person’s reproductive years, study investigator Kerstin Hellwig, MD, with Ruhr University in Bochum, Germany, said in a news release.

“Our data show infants exposed to these medications through breastfeeding experienced no negative effects on health or development within the first 3 years of life,” Dr. Hellwig said.

The findings were released ahead of the study’s scheduled presentation at the annual meeting of the American Academy of Neurology.
 

Registry Data and Analysis

Using the German MS and Pregnancy Registry, researchers identified 183 infants born to mothers taking mAbs while breastfeeding — 180 with a diagnosis of MS and three with a diagnosis of NMOSD. The infants were matched to 183 unexposed infants (control group).

Exposure to mAbs during lactation started a median of 19 days postpartum and lasted for a median of 172 days. The most commonly used mAb during lactation was natalizumab (125 women), followed by ocrelizumab (34 women), rituximab (11 women), and ofatumumab (10 women).

Among the entire infant cohort, two were first exposed to natalizumab and then ocrelizumab; one was exposed to rituximab and then ocrelizumab; three had been previously breastfed on glatiramer acetate and two on interferons.

The primary outcomes were hospitalizations, antibiotic use, developmental delay, and weight during the first 3 years of life in mAb-exposed versus unexposed infants.

In adjusted regression analyses, mAb exposure during breastfeeding was not significantly associated with annual hospitalization (rate ratio [RR], 1.23; P = .473), annual systemic antibiotic use (RR, 1.55; P = .093), developmental delay (odds ratio, 1.16; P = .716), or weight.

A limitation of the study was that only about a third of the infants were followed for the full 3 years. Therefore, Dr. Hellwig said, the results for the third year of life are less meaningful than for years 1 and 2.
 

‘Reassuring’ Data

Reached for comment, Edith L. Graham, MD, Department of Neurology, Multiple Sclerosis and Neuroimmunology, Northwestern University, Chicago, Illinois, noted that this is the largest group of breastfed infants exposed to mAbs used to treat MS and said the data provide “reassuring infant outcomes with no increase in hospitalization, antibiotic use, or developmental delay.”

Dr. Graham noted that recent publications have reported more on the use of anti-CD20 mAbs (ocrelizumab/rituximab/ofatumumab) while breastfeeding, “and this study adds data for patients on natalizumab.”

“It will be important to know how infusion timing after birth impacts transfer of monoclonal antibodies depending on the milk stage as it transitions from colostrum to mature milk in the first month postpartum,” Dr. Graham said.

“While infection rates of infants are reassuring, data on allergies in the exposed infants would be interesting to look at as well,” she added. “While these infusions are not orally bioavailable, we do not know the full extent of impact on the neonatal gut microbiome.”

In addition, Dr. Graham said it would be important to know whether drugs administered monthly, such as natalizumab and ofatumumab, accumulate in the breast milk at higher levels than medications such as ocrelizumab and rituximab, which are administered twice a year.

The German MS and pregnancy registry was partly supported by the Innovation Fund of the Federal Joint Committee, Almirall Hermal GmbH, Biogen GmbH Germany, Hexal AG, Merck Serono GmbH, Novartis Pharma GmbH, Roche Deutschland GmbH, Sanofi Genzyme, and Teva GmbH. Dr. Hellwig and Dr. Graham had no relevant disclosures.

A version of this article appeared on Medscape.com.