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I341 Obesity: The metabolic syndrome and diabetes in pregnancy
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Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
I338 A project of the pharmacy access partnership in California
I340 Second trimester medical abortion
B. Taylor-McGhee. Pacific Institute for Women’s Health, USA
A. Templeton. University of Aberdeen, UK
It’s been more than forty years since the birth control pill was introduced in the United States. Yet four decades later, the pill remains a prescription-only product – presenting an access barrier for many underserved women. Additionally, the U.S. fractured healthcare system has left millions of Americans without a healthcare provider, making it difficult for many women to access affordable and effective birth control. Pharmacy Access Partnership, a center of the Pacific Institute for Women’s Health, is celebrating a decade of innovation, cultivation and program development to improve access to hormonal contraception, particularly in pharmacies. New strategies include Pharmacy Forward, a Leadership Development Institute that seeks to build a skilled cadre of pharmacists who can effectively champion emerging reproductive health issues. The Partnership also launched the first U.S.-based Youth Friendly Pharmacy Initiative to make pharmacies a useful access point to meet the reproductive health needs of youth, including improved access to hormonal contraception. After conducting national research documenting women’s and pharmacists’ interest and attitudes toward pharmacy access to hormonal contraception, a pilot program to offer direct pharmacy access to pills, patches and rings without a prescription is in development. These strategies offer real policy change toward the long-term goal of demedicalizing birth control in the U.S. Learning Objectives: At session’s end, participants will be able to: 1. Identify strategies that can be replicated for successful policy change. 2. Understand the steps necessary to garner stakeholder support for these policy initiatives.
This lecture addresses medical abortion in the late first trimester and second trimester, focusing on outcomes of treatment with mifepristone and misoprostol. At 10–13 weeks about half of women have a preference for medical treatment, where both are available, whereas in the second trimester more women prefer surgery, although the situation is less clear. Medical methods have changed considerably since the introduction of mifepristone, more than 20 years ago, such that the majority of medical abortions in the second trimester can be done on a day care basis. Mifepristone given at least 24 hours prior to the administration of prostaglandin reduces the induction to abortion interval, the dose of prostaglandin required, and the need for analgesia. The major problem with medical abortion in the late first trimester is the continuing pregnancy rate, which is gestation dependent (increasing ten-fold from early to late first trimester) and which necessitates strict protocols and follow up. In the second trimester there is still the need to complete the abortion surgically (usually removal of placenta) in 8% of cases, and this is related also to the induction abortion interval. The need for analgesia increases with gestation, but even at over 16 weeks gestation, oral analgesia suffices for 75% of women, with 8% needing opiates and 17% not requiring analgesia. The only clinically relevant correlate with analgesia use is previous birth. Sublingual administration of prostaglandin is as effective as vaginal administration for abortion at all gestations, but is associated with more side effects. It is hoped that a recent trial comparing medical and surgical abortion in the second trimester can be discussed.
I339 The role of diet, exercise and lifestyle in the management of PCOS H. Teede. Research, Jean Hailes Foundation for Women’s Health; Diabetes Southern Health, Professorial Chair Women’s Health, Monash University, Australia Obesity is increasing, especially in young women, at an unprecedented rate. In women, complications of obesity include reproductive complications as well as metabolic consequences of insulin resistance, metabolic syndrome, polycystic ovarian syndrome, gestational diabetes, impaired glucose tolerance, diabetes and CVD. For many women these represent a progressive continuum. In this context, the role of lifestyle including diet and exercise change in the management of PCOS will be discussed. Results of a recent international systematic review and position statement on weight loss and lifestyle intervention will be presented [1]. The impact of weight loss, as well as potential for changes in dietary composition including lowered carbohydrate and glycaemic index diets will be reviewed. Also, the need to deal with demoralisation, low self esteem and depression that frequently coincides with PCOS will be considered as it is important in optimizing self management including effective lifestyle change. Ultimately more research is needed in this area. Reference(s) [1] Moran LJ, Pasquali R, Teede HJ, Hoeger K, Norman R. Androgen Excess and Polycystic Ovary Syndrome International Position Statement: Treatment of obesity in Polycystic Ovary Syndrome. Fertility and Sterility In press, Epub ahead of print.
I341 Obesity: The metabolic syndrome and diabetes in pregnancy K. Teramo Obesity has reached epidemic proportions worldwide during the last 3 decades and it increases both short-term and longterm complications in offspring of obese mothers. Obesity is increasing also among type 1 diabetic patients, which increases complications further and could at least partly explain why the outcomes have not been satisfactory in these pregnancies. Obesity itself predisposes to gestational diabetes (GDM) and increases in the prevalence of GDM have been reported. Maternal diabetes results in fetal hyperglycemia, which stimulates fetal pancreatic insulin production. Insulin is a strong growth promoting hormone in the fetus. Birth weight correlates directly with fetal insulin concentrations. Fetal macrosomia is one of the main complications of diabetic pregnancy increasing maternal and fetal trauma in both vaginal and cesarean section deliveries. Fetal macrosomia predisposes also to intrauterine chronic hypoxia, which is the main cause of “unexplained” stillbirths during the last weeks of diabetic pregnancies. Several epidemiological studies have shown a direct relationship between birth weight and the body mass index of the offspring later in life. However, the mechanisms explaining this relationship are unknown. Offspring of GDM mothers have also an increased risk of subsequent overweight, but it is not clear whether GDM is only a risk marker or an etiological factor in programming the fetus for obesity in adulthood. Good glycemic control throughout pregnancy should be achieved in pregestational diabetic pregnancies in order to reduce short-term complications. Whether long-term complications of the offspring can be influenced by improving glycemic control in diabetic pregnancies needs further studies.
Invited presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S1–S92
I338 A project of the pharmacy access partnership in California
I340 Second trimester medical abortion
B. Taylor-McGhee. Pacific Institute for Women’s Health, USA
A. Templeton. University of Aberdeen, UK
It’s been more than forty years since the birth control pill was introduced in the United States. Yet four decades later, the pill remains a prescription-only product – presenting an access barrier for many underserved women. Additionally, the U.S. fractured healthcare system has left millions of Americans without a healthcare provider, making it difficult for many women to access affordable and effective birth control. Pharmacy Access Partnership, a center of the Pacific Institute for Women’s Health, is celebrating a decade of innovation, cultivation and program development to improve access to hormonal contraception, particularly in pharmacies. New strategies include Pharmacy Forward, a Leadership Development Institute that seeks to build a skilled cadre of pharmacists who can effectively champion emerging reproductive health issues. The Partnership also launched the first U.S.-based Youth Friendly Pharmacy Initiative to make pharmacies a useful access point to meet the reproductive health needs of youth, including improved access to hormonal contraception. After conducting national research documenting women’s and pharmacists’ interest and attitudes toward pharmacy access to hormonal contraception, a pilot program to offer direct pharmacy access to pills, patches and rings without a prescription is in development. These strategies offer real policy change toward the long-term goal of demedicalizing birth control in the U.S. Learning Objectives: At session’s end, participants will be able to: 1. Identify strategies that can be replicated for successful policy change. 2. Understand the steps necessary to garner stakeholder support for these policy initiatives.
This lecture addresses medical abortion in the late first trimester and second trimester, focusing on outcomes of treatment with mifepristone and misoprostol. At 10–13 weeks about half of women have a preference for medical treatment, where both are available, whereas in the second trimester more women prefer surgery, although the situation is less clear. Medical methods have changed considerably since the introduction of mifepristone, more than 20 years ago, such that the majority of medical abortions in the second trimester can be done on a day care basis. Mifepristone given at least 24 hours prior to the administration of prostaglandin reduces the induction to abortion interval, the dose of prostaglandin required, and the need for analgesia. The major problem with medical abortion in the late first trimester is the continuing pregnancy rate, which is gestation dependent (increasing ten-fold from early to late first trimester) and which necessitates strict protocols and follow up. In the second trimester there is still the need to complete the abortion surgically (usually removal of placenta) in 8% of cases, and this is related also to the induction abortion interval. The need for analgesia increases with gestation, but even at over 16 weeks gestation, oral analgesia suffices for 75% of women, with 8% needing opiates and 17% not requiring analgesia. The only clinically relevant correlate with analgesia use is previous birth. Sublingual administration of prostaglandin is as effective as vaginal administration for abortion at all gestations, but is associated with more side effects. It is hoped that a recent trial comparing medical and surgical abortion in the second trimester can be discussed.
I339 The role of diet, exercise and lifestyle in the management of PCOS H. Teede. Research, Jean Hailes Foundation for Women’s Health; Diabetes Southern Health, Professorial Chair Women’s Health, Monash University, Australia Obesity is increasing, especially in young women, at an unprecedented rate. In women, complications of obesity include reproductive complications as well as metabolic consequences of insulin resistance, metabolic syndrome, polycystic ovarian syndrome, gestational diabetes, impaired glucose tolerance, diabetes and CVD. For many women these represent a progressive continuum. In this context, the role of lifestyle including diet and exercise change in the management of PCOS will be discussed. Results of a recent international systematic review and position statement on weight loss and lifestyle intervention will be presented [1]. The impact of weight loss, as well as potential for changes in dietary composition including lowered carbohydrate and glycaemic index diets will be reviewed. Also, the need to deal with demoralisation, low self esteem and depression that frequently coincides with PCOS will be considered as it is important in optimizing self management including effective lifestyle change. Ultimately more research is needed in this area. Reference(s) [1] Moran LJ, Pasquali R, Teede HJ, Hoeger K, Norman R. Androgen Excess and Polycystic Ovary Syndrome International Position Statement: Treatment of obesity in Polycystic Ovary Syndrome. Fertility and Sterility In press, Epub ahead of print.
I341 Obesity: The metabolic syndrome and diabetes in pregnancy K. Teramo Obesity has reached epidemic proportions worldwide during the last 3 decades and it increases both short-term and longterm complications in offspring of obese mothers. Obesity is increasing also among type 1 diabetic patients, which increases complications further and could at least partly explain why the outcomes have not been satisfactory in these pregnancies. Obesity itself predisposes to gestational diabetes (GDM) and increases in the prevalence of GDM have been reported. Maternal diabetes results in fetal hyperglycemia, which stimulates fetal pancreatic insulin production. Insulin is a strong growth promoting hormone in the fetus. Birth weight correlates directly with fetal insulin concentrations. Fetal macrosomia is one of the main complications of diabetic pregnancy increasing maternal and fetal trauma in both vaginal and cesarean section deliveries. Fetal macrosomia predisposes also to intrauterine chronic hypoxia, which is the main cause of “unexplained” stillbirths during the last weeks of diabetic pregnancies. Several epidemiological studies have shown a direct relationship between birth weight and the body mass index of the offspring later in life. However, the mechanisms explaining this relationship are unknown. Offspring of GDM mothers have also an increased risk of subsequent overweight, but it is not clear whether GDM is only a risk marker or an etiological factor in programming the fetus for obesity in adulthood. Good glycemic control throughout pregnancy should be achieved in pregestational diabetic pregnancies in order to reduce short-term complications. Whether long-term complications of the offspring can be influenced by improving glycemic control in diabetic pregnancies needs further studies.