Morning Sickness Treatments

Review Shows Little Evidence

Jennifer P Hellwig, MS, RD, ELS .

There are currently no reliably safe and effective treatments for morning sicknessthats the conclusion of a group of Cochrane researchers who conducted a systematic review of the available evidence on pharmaceutical and alternative treatments for morning sickness. The review, published in September in the Cochrane Database of Systematic Reviews, included 27 randomized controlled trials, which together involved 4,041 women who were up to 20 weeks pregnant. Benefit was measured by various scales commonly used to gauge the severity of nausea at a time as close as possible to 3 days after treatment. In six studies of acupressure and two of acupuncture, there were no significant differences in benefit compared with control groups. One study of acustimulation did, however, report some improvement over 3 weeks. There was limited evidence of an

effect of ginger in relieving nausea, as there was for vitamin B6, antihistamines and antiemetic (antivomiting) drugs, including the antenatal drug Debendox. In addition, some of the treatments caused adverse effects, including drowsiness in those taking antiemetics. Ginger caused heartburn in some people. A number of the studies we looked at appeared to show benefits, but in general the results were inconsistent and it was difficult to draw firm conclusions about any one treatment in particular, said lead researcher Dr. Anne Matthews, of the School of Nursing at Dublin City University in Dublin, Ireland. We were also unable to obtain much information about whether these treatments are actually making a difference to womens quality of life. The researchers point to the need for additional and more rigorous trials in this area.

HPV Vaccine Recommendations

The American College of Obstetricians and Gynecologists (ACOG) is recommending that girls ages 11 to 12 should receive either of the two FDA-approved vaccines to prevent cervical cancer, ideally before they become sexually active. In its recommendations, ACOG emphasizes that routine Pap screening is still necessary for all women beginning at age 21, including those who have had the cervical cancer vaccine. The Committee Opinion (#467) was published in the September 2010 issue of Obstetrics and Gynecology.

http://nwh.awhonn.org

2010, AWHONN

447

Cognition and Gender

Older men may be at risk of developing mild cognitive impairment (MCI), often a precursor to Alzheimers disease, earlier in life than older women, according to a study appearing online in the journal Neurology. The researchers conducted in-person evaluations of 1,969 randomly selected people from all 70- to 89-year-olds living in Olmsted County, MN. The group was evenly split between men and women. Each participant received a neurologic evaluation and neuropsychologic testing. A panel then reviewed those data plus other information, such as health history and occupation/education levels, to reach a diagnosis. Sixteen percent were diagnosed with MCI; these individuals displayed either amnestic MCI, where memory is impaired, or nonamnestic MCI, where different cognitive problems arise, such as with language. Overall, MCI was more prevalent in men (19 percent) than in women (14 percent), even after adjusting for several demographic variables and clinical factors, such as hypertension and coronary artery disease. Of the 16 percent affected with MCI, more than twice as many people had the amnestic form that usually progresses to Alzheimers disease and the prevalence rate was higher in men than in women. MCI prevalence was higher among people with the APOE e4 gene, a known risk factor for late-onset Alzheimers, a form of the disease that usually occurs at age 65 or older. A greater number of years spent in school was significantly associated with decreased MCI prevalence, from 30 percent among participants with less than 9 years of education to just 11 percent in those with more than 16 years of education. MCI prevalence was higher in participants who never married, as opposed to those currently or previously married.

Jennifer P. Hellwig, MS, RD, ELS, is managing editor of Nursing for Womens Health.
DOI: 10.1111/j.1751-486X.2010.01591.x

Breastfeeding Rates
Seventy-five percent of babies born in the United States in 2007more than 3 millionstarted life breastfeeding, according to the Centers for Disease Control and Preventions 2010 Breastfeeding Report Card. The 75 percent breastfeeding initiation rate meets the nations Healthy People 2010 goal, and half of the states have breastfeeding initiation rates above 75 percent. State by state breastfeeding initiation rates ranged from nearly 90 percent in Utah to 52.5 percent in Mississippi. But while initiation rates have risen steadily, the number of babies who continue breastfeeding until 6 and 12 months remains stagnant for the third consecutive year, with only 43 percent (1.8 million) still breastfeeding at 6 months and 22 percent (fewer than 1 million) breastfeeding at 12 months. The CDCs Breastfeeding Report Card is available at http://www.cdc.gov/breastfeeding/ data/reportcard.htm.

448

Nursing for Womens Health

Volume 14

Issue 6

Aerobic Exercise for Insomnia

Regular aerobic exercise improves the quality of sleep, mood and vitality in middle-aged and older adults, according to study published in Sleep Medicine. The study included 23 sedentary adults, primarily women, age 55 and older who had difficulty falling asleep and/or staying asleep and impaired daytime functioning. After a conditioning period, the aerobic physical activity group exercised for two 20-minute sessions four times per week or one 30- to 40-minute session four times per week, both for 16 weeks. Participants worked at 75 percent of their maximum heart rate on at least two activities including walking or using a stationary bicycle or treadmill. Participants in the nonphysical activity group participated in recreational or educational activities, such as a cooking class or a museum lecture, which met for about 45 minutes three to five times per

Gestational Age and Cerebral Palsy

While preterm birth is a known risk factor for cerebral palsy (CP), an examination of data for infants born at term or later finds that compared with delivery at 40 weeks, birth at 37 or 38 weeks or at 42 weeks or later was associated with an increased risk of CP, according to a study in the September 1 issue of JAMA. Dag Moster, MD, PhD, of the University of Bergen, Norway, and colleagues examined the relation of CP risk with gestational age among term and post-term births using the Medical Birth Registry of Norway, which identified 1,682,441 children born in the years 1967 to 2001 with a gestational age of 37 through 44 weeks and no congenital anomalies. The group was followed up through 2005 by linkage to other national registries. Of the group of term and post-term children, 1,938 were identified as having CP. The researchers found that infants born at 40 weeks had the lowest risk of CP, with a prevalence of 0.99/1,000 births. Risk for CP was higher with earlier or later delivery, with a prevalence at 37 weeks of 1.91/1,000 (90 percent increased risk), a prevalence at 38 weeks of 1.25/1,000 (30 percent higher risk), a prevalence at 42 weeks of 1.36/1,000 (40 percent increased risk) and a prevalence after 42 weeks of 1.44/1,000 (40 percent higher risk). The authors add that these associations were stronger in a subset with gestational age based on ultrasound measurements, with a gestational age of 37 weeks associated with a 3.7 times higher risk of CP; and 42 weeks, a 2.4 times higher risk. Adjustment for infant sex, maternal age, and various socioeconomic measures had little effect. Until the biological mechanisms for these patterns of risk in term and post-term births are better understood, it would be hasty to assume that interventions on gestational age at delivery could reduce the occurrence of CP, the authors write.

week for 16 weeks. Both groups received education about good sleep hygiene, which includes sleeping in a cool, dark and quiet room, going to bed the same time every night and not staying in bed too long if unable to fall asleep. Exercise improved the participants self-reported sleep quality, elevating them from a diagnosis of poor sleeper to good sleeper. They also reported fewer depressive symptoms, more vitality and less daytime sleepiness. The participants scores on the Pittsburgh Sleep Quality Index dropped an average of 4.8 points (a higher score indicates worse sleep).

Stress and Menstruation

Women who reported feeling stressed 2 weeks before the beginning of menstruation were two to four times more likely to report moderate to severe premenstrual and menstrual symptoms than were women who didnt feel stressed, according to a study published online in the Journal of Womens Health. Researchers administered questionnaires to 259 women ages 18 to 44 who didnt have any long-term health conditions and who were not using oral contraceptives or taking any other hormonal formulations. Each woman was provided with an at-home fertility monitor to follow the phases of her monthly cycle, and completed a questionnaire about stress levels for each of the 4 weeks of her cycle. Most of the women (250) took part in the study for two menstrual cycles. Women whose responses indicated they felt stressed were more likely to report moderate or severe levels of psychological symptoms, such as depression or sadness, crying spells, anger, irritability, and anxiety associated with menstruation. Similarly, women who felt stressed were also more likely to report moderate or severe levels of physical symptoms such as body aches, abdominal bloating, lower back pain, fatigue, abdominal cramping, headache and cravings for sweet or salty foods. The researchers couldnt rule out that anticipation of pain and other symptoms might add to a womans stress level and result in more severe symptoms. However, they sought to compensate for this possibility by administering the questionnaires on stress early, during the symptom-free parts of the womens cycles, when they were less likely to be anticipating severe symptoms.
December 2010 | January 2011

Nursing for Womens Health

449

Mortality in High-Risk Infants

An analysis of data from previously published studies indicates that very low birth weight (VLBW) and very preterm infants not born in highly specialized, level III hospitals have an associated higher likelihood of neonatal and predischarge death compared with similar infants born at level III hospitals, according to an article in the September 1 issue of JAMA. Researchers from the Centers for Disease Control and Prevention conducted a meta-analysis of previous research to examine the relationship between hospital level at birth and neonatal or predischarge mortality for VLBW (1,500 g [53oz] or less) and very preterm (32 weeks or less gestation) infants to determine the importance of level of care at birth to survival. The researchers identified 41 publications that met criteria to be included in the study. Analysis of the 37 studies of 104,944 VLBW infants indicated a 62 percent increase in odds of neonatal/predischarge death for infants born in non-level III hospitals compared with those born in level III hospitals (38 percent vs. 23 percent). When restricted to only higher-quality evidence (nine publications; 46,318 infants), a 60 percent increase in the odds of neonatal and/or predischarge mortality was estimated for VLBW infants born at nonlevel III hospitals (36 percent vs. 21 percent). Also, extremely low-birth-weight infants (1,000 g [35oz] or less) born in non-level III hospitals had an estimated 80 percent increase in odds of neonatal and/or predischarge mortality compared with those born at level III hospitals (59 percent vs. 32 percent). The weighted, combined data from four publications regarding 9,300 very preterm infants indicated that those infants born in lower-level hospitals had a 55 percent increase in odds of neonatal/predischarge mortality compared with those born in level III facilities (15 percent vs. 17 percent). Restricting to the three studies rated as adequate- and high-quality (n = 6,100 infants) reduced the estimate to a 42 percent increased odds of death (7 percent vs. 12 percent).

Cost of Car Accidents

In a 1-year period, the cost of medical care and productivity losses associated with injuries from motor vehicle crashes exceeded $99 billion, with the cost of direct medical care accounting for $17 billion, according to a study by the Centers for Disease Control and Prevention. The total annual cost amounts to nearly $500 for each licensed driver in the United States, said the study in the journal Trac Injury Prevention.

450

Nursing for Womens Health

Volume 14

Issue 6

Cholesterol and Estrogen

Womens cholesterol levels correspond with monthly changes in estrogen levels, according to a study published online in the Journal of Clinical Endocrinology and Metabolism, and the authors suggest that this natural variation might indicate a need to take into account the phases of a womans monthly cycle before evaluating her cholesterol measures. On average, the total cholesterol level of the women in the study varied 19 percent over the course of the menstrual cycle. The researchers found that as the level of estrogen rises, high-density lipoprotein (HDL) cholesterol also rises, peaking at the time of ovulation. HDL cholesterol is believed to be protective against heart disease. In contrast, total cholesterol and low-density lipoprotein (LDL) cholesterol levels, as well as triglycerides, declined as estrogen levels rose. The decline was not immediate, beginning a couple of days after the estrogen peak at ovulation. Total cholesterol, LDL cholesterol and triglyceride levels reached their lowest just before menstruation began.

New Emergency Contraceptive Approved

The U.S. Food and Drug Administration (FDA) has approved ella (ulipristal acetate) tablets for emergency contraception. The prescription-only product prevents pregnancy when taken orally within 120 hours (5 days) after a contraceptive failure or unprotected intercourse. Its not intended for routine use as a contraceptive. ella is a progesterone agonist/antagonist whose likely main effect is to inhibit or delay ovulation. Since May 2009, the prescription product has been available in Europe under the brand name ellaOne. The safety and efficacy of ella were demonstrated in two Phase III clinical trials. One study was a prospective, multicenter, open-label, single-arm trial conducted in the United States; the other was a randomized, multicenter, single-blind comparatorcontrolled trial conducted in the United States, United Kingdom and Ireland. Side effects most frequently observed with ella in the clinical trials included headache, nausea, abdominal pain, pain/discomfort during menstruation (dysmenorrhea), fatigue and dizziness. The profile of side effects for ella is similar to that of FDA-approved levonorgestrel emergency contraceptives. According to the products labeling, women with known or suspected pregnancy and women who are breastfeeding should not use ella. A patient package insert also will be provided to ensure that women are fully informed of the benefits and risks involved in the use of ella.

Fertility and Stress

A new study, published online in Fertility and Sterility, supports the widespread belief that stress inhibits fertility. The study found, in women without a history of fertility problems, an association between high levels of a alpha-amylase (a substance indicative of stress) and a reduced chance of becoming pregnant. Alpha-amylase is secreted when the nervous system produces catecholamines, compounds that initiate a type of stress response. Researchers charted the ovulation cycles of 274 English women ages 18 to 40 years who were trying to conceive, and who participated in the Oxford Conception Study led by Cecilia Pyper, MB, BS. The women were given at-home fertility test kits to track the phases of their monthly cycles. On the sixth day of her cycle, each woman collected a sample of her saliva, which was subsequently tested for alpha-amylase. The womens saliva samples were also analyzed for cortisol, another hormone produced by the adrenal glands in response to stress. Each woman took part in the study until she became pregnant, or at the end of six menstrual cycles. The researchers found that, all other factors being equal, women with high alpha-amylase levels were less likely to conceive than were women with low levels, during the 6 days when conception is most likely to occur. The researchers did not find a correlation between cortisol levels and the chances of conception. Overall, the 25 percent of women in the study who had the highest alpha-amylase levels had roughly an estimated 12 percent reduction in getting pregnant each cycle in comparison to women with the lowest concentrations, said first author, Germaine Buck Louis, PhD, MS. Dr. Buck Louis added that she and her colleagues are currently conducting a study with a larger group of women to confirm the findings, and that additional research may be needed to determine whether relaxation techniques such as meditation, biofeedback, yoga, or increasing social support can assist women having difficulty conceiving.

December 2010 | January 2011

Nursing for Womens Health

451

Male Maturity and Nutrition

Rapid weight gain in the first 6 months of life predicts earlier puberty for boys, according to a study in the September 13 issue of the Proceedings of the National Academy of Sciences. Males who experienced rapid growth as babies also were taller, had more muscle and were stronger, and had higher testosterone levels as young adults. They had sex for the first time at a younger age and were more likely to report having had sex in the past month, resulting in more lifetime sex partners. The researchers think that testosterone may hold the key to understanding these long-term effects. Most people are unaware that male infants in the first 6 months of life produce testosterone at approximately the same level as an adult male, said Christopher W. Kuzawa, associate professor of anthropology in the Weinberg College of Arts and Sciences at Northwestern University and author of the study. We looked

at weight gain during this particular window of early life development, because testosterone is very high at this age and helps shape the differences between males and females. The study, which was funded by the National Science Foundation and the Wenner Gren

Most people are unaware that male infants in the first 6 months of life produce testosterone at approximately the same level as an adult male
Foundation, was conducted among a group of 770 Filipino males ages 20 to 22 who have been followed their entire lives. Since 1983, a team of researchers in the United States and the Philippines has been working to understand how early life nutrition influences adult health, such as risk for cardiovascular disease and diabetes.

Antibiotics and Cesarean Delivery

The American College of Obstetricians and Gynecologists (ACOG) has recommended that all pregnant women be given antibiotics before having a cesarean delivery to help prevent infections. It recommends that antibiotics be given within 1 hour of the start of surgery for maximum effectiveness. Infection is the most common complication of cesarean delivery and can occur in 10 percent to 40 percent of women who have a cesarean compared with 1 percent to 3 percent of women who deliver vaginally. Although antibiotics have been given to women having cesareans to reduce their risk of postoperative infections, they have generally been given after the baby was born and the umbilical cord was clamped. Based on the latest data, prophylactic antibiotics given to pregnant women before a cesarean significantly reduce maternal infection and do not appear to harm newborns, said William H. Barth, Jr., MD, chair of ACOGs Committee on Obstetric Practice. An exception to the recommendations, Dr. Barth noted, are pregnant women who are already taking appropriate antibiotics for another problem, such as chorioamnionitis. Women who need an emergency cesarean should be given antibiotics as soon as possible. The Committee Opinion (#465) was published in the September 2010 issue of Obstetrics and Gynecology.
452 Nursing for Womens Health Volume 14 Issue 6

Synergy of Health Behaviors

Its widely known that a healthful lifestyle that includes not smoking, limiting alcohol intake, and maintaining a proper weight reduces disease risk. In the journal PLoS Medicine, researchers from Vanderbilt University Medical Center now report results from a large study quantifying the impact of combining healthy lifestyle factors. They found that a healthy lifestyle pattern reduced mortality. The researchers analyzed data from 71,243 nonsmoking, nondrinking Chinese women ages 40 to 70 years who have been participating in the ongoing population-based Shanghai Womens Health Study. Over the 9-year study period, 2,860 deaths were reported, including 1,351 cancer deaths and 775 deaths from cardiovascular disease. To calculate healthy lifestyle scores, the investigators selected five well-studied healthy lifestyle factors relevant for this population: normal weight (body mass index 18.5-24.99); lower waist-hip ratio (an estimate of abdominal fat); exercise participation; never exposed

to spouses smoking; and higher fruit and vegetable daily intake. For each of the five factors, study subjects were assigned one point for having the healthy factor (and zero for not having the healthy factor), and the points were then summed to generate a cumulative score for each woman, ranging from zero points (least healthy) to five points (most healthy). They found that a higher healthy lifestyle score was significantly associated with reduced risk of mortality from all causes, as well as from cardiovascular diseases and cancer, specifically. Women with four to five healthy lifestyle factors had 43 percent lower risk of all-cause mortality compared with women with a score of zero. The reduction in mortality associated with higher lifestyle scores was strongest for deaths due to cardiovascular disease.

H e l p i n g Wo m e n S t a y We l l
Today we know more than ever about preventing disease and promoting health. For the very latest, read Well Woman, a clinical practice column appearing three times a year in Nursing for Womens Health.
READ IT TO KEEP YOUR PATIENTSAND YOURSELFFEELING HEALTHY, ACTIVE AND VIBRANT.

December 2010 | January 2011

Nursing for Womens Health

453

Copyright of Nursing for Women's Health is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.