1. Decreased fetal movement protocol did not
reduce fetal death (October 2018)
2. Timing of Tdap vaccination during pregnancy
(October 2018)
3. Low-dose aspirin and spontaneous preterm
birth (October 2018)
4. Choice of follow-up testing after a positive
first-trimester Down syndrome screening test (August 2018)
5. Maternal antenatal exposure to sildenafil
and risk for neonatal death (August 2018)
6. Cervical pessary after arrested preterm
labour does not improve neonatal outcome (July 2018)
7. Nonsteroidal anti-inflammatory drugs and
risk of miscarriage (July 2018)
8. Platelet counts in pregnancy (July 2018)
9. AASLD/IDSA recommendations on HCV screening
during pregnancy (June 2018)
10. Targets for blood pressure control during
pregnancy (May 2018)
11. Glyburide versus insulin for treatment of
gestational diabetes (May 2018)
12. Prenatal caffeine consumption and postnatal growth in
offspring (April 2018)
13. Immediate versus delayed pushing (October 2018)
14. Intravenous versus intramuscular oxytocin for prevention
of postpartum hemorrhage (September 2018)
15. Discontinuation of oxytocin in the active phase during
induction (September 2018)
16. Guidelines for regional anaesthesia in patients
receiving antithrombotic or thrombolytic medications (August
2018)
17. Prophylactic use of tranexamic acid at vaginal delivery
(August 2018)
18. Uterotonic drugs for preventing postpartum hemorrhage
(August 2018)
19. Balloon catheter volume for cervical ripening (August
2018)
20. ACOG endorses shared decision-making for elective
induction at 39 weeks (August 2018)
21. Neuraxial analgesia and risk of operative vaginal
delivery (August 2018)
22. Heat-stable carbetocin for prevention of postpartum
hemorrhage (July 2018)
23. Pregnancy-related hypertensive disorders and risk for
cardiovascular disease (July 2018)
1. Decreased fetal movement protocol did not
reduce fetal death (October 2018)
Pregnant women are routinely counselled to report
decreased fetal movement (DFM) because it is considered a
marker for pregnancies at increased risk for fetal death. In
a cluster randomized trial (AFFIRM, n>400,000 pregnancies)
that evaluated a protocol that increased women's awareness
for promptly reporting DFM coupled with comprehensive fetal
assessment and selective labour induction in affected
pregnancies, the protocol did not reduce stillbirth or
perinatal death rates compared with rates before the
protocol was implemented. Similar trials are in progress and
may help to determine whether these results were due to
chance or inadequate statistical power to detect a small
difference. In the meantime, our approach to counselling
women about DFM and managing these pregnancies has not
changed and is similar to that in the AFFIRM protocol.
2. Timing of Tdap vaccination during
pregnancy (October 2018)
Administration of the tetanus toxoid, reduced diphtheria
toxoid, and acellular pertussis vaccine (Tdap) to pregnant
women provides passive protection against pertussis in
infants during the first few months of life. In a cohort
study of over 600 pregnant women, Tdap vaccination between
27 and 36 weeks of gestation was associated with higher
neonatal cord blood pertussis antibody titers compared with
no vaccination; vaccination between 27 and 30 weeks was
associated with the highest titers. This study lends further
observational support to the Advisory Committee on
Immunization Practices (ACIP) recommendation in the United
States to administer Tdap vaccine during each pregnancy at
27 through 36 weeks of gestation and ideally during the
earlier part of that interval.
3. Low-dose aspirin and spontaneous
preterm birth (October 2018)
Use of low-dose aspirin in pregnant women at high risk
for preeclampsia reduces the risk of preeclampsia, fetal
growth restriction, and preterm birth (PTB) related to these
disorders. Secondary analysis of data from a randomized
trial comparing low-dose aspirin with placebo in healthy,
nulliparous women at low risk of preeclampsia found that
aspirin reduced the rate of spontaneous PTB <34 weeks.
Although promising, the role of low-dose aspirin needs to be
further studied in large randomized trials with spontaneous
PTB as a primary outcome in women at high and low risk for
spontaneous PTB. Until such data are available, we agree
with recommendations by the American College of
Obstetricians and Gynaecologists to not use low-dose aspirin
in an attempt to prevent spontaneous PTB.
4. Choice of follow-up testing after a
positive first-trimester Down syndrome screening test
(August 2018)
Pregnant women who screen positive for Down syndrome on
the first-trimester combined test may choose to undergo
secondary screening with a cell-free DNA test or proceed to
an invasive test for definitive diagnosis. In a multicentre
trial including over 2000 women comparing the two
approaches, no Down syndrome pregnancies were missed, but
two foetuses with microdeletions were detected in the
invasive testing group that would not have been detected by
cell free DNA testing. Although the number of invasive
procedures performed was dramatically lower in the cell free
DNA group, the miscarriage rate was similar for both groups.
Major limitations of the trial were differences between
groups in patient compliance with the study protocol and
lack of statistical power to identify a very small
difference in miscarriage rate. We continue to offer both
options to women who screen positive for Down syndrome on
the first-trimester combined test.
5.
Maternal antenatal exposure to sildenafil and risk for
neonatal death (August 2018)
Maternal administration of sildenafil citrate is an
investigational approach for management of severe
oligohydramnios. Although a pilot trial in pregnancies with
idiopathic oligohydramnios reported benefits, a subsequent
multicentre trial of sildenafil for treatment of poor
prognosis early onset growth restriction (STRIDER) using the
same dose was halted early because of higher than expected
rates of lung disease and death of new-borns in the
intervention group [7]. Until more data are available about
the postnatal effects of antenatal administration of
sildenafil, the use of sildenafil in pregnancy should be
restricted to carefully design clinical trials monitored by
data and safety monitoring boards.
6. Cervical pessary after arrested
preterm labour does not improve neonatal outcome (July 2018)
Whether a cervical pessary prolongs pregnancy in women
with a short cervix is unclear. The first clinical trial to
evaluate its use versus routine care in women with singleton
pregnancies and short cervical length after an episode of
arrested preterm labour reported a trend toward reduction in
spontaneous preterm birth <34 weeks, and statistically
significant reductions in spontaneous preterm birth <37
weeks and preterm prelabor rupture of membranes; however,
neonatal morbidity and mortality were similar in both
groups. A subsequent smaller trial, which was halted early
for futility, observed no reduction in preterm birth <32,
34, or 37 weeks. Until a benefit is confirmed in additional
and larger trials, particularly for neonatal outcome, we
suggest utilizing a pessary for this purpose only in the
context of a clinical trial.
7. Nonsteroidal anti-inflammatory drugs
and risk of miscarriage (July 2018)
Several studies have suggested that nonsteroidal
anti-inflammatory drugs (NSAIDs) may increase the risk of
miscarriage, but there are conflicting data. A recent
prospective cohort study of almost 1100 women showed that,
after adjusting for potential confounders, the risk of a
miscarriage was increased in those women who used NSAIDs
within the first two weeks of gestation, compared with
unexposed controls and with women who used acetaminophen.
Women planning to conceive should be cautioned that NSAIDs
taken in the first trimester, especially in the several
weeks following conception, may increase the risk of
miscarriage. Although the evidence is limited, it is
reasonable to suggest that women trying to conceive avoid
use of NSAIDS to minimize the risk of miscarriage,
particularly when effective alternatives (e.g.,
acetaminophen) are available.
8. Platelet counts in pregnancy (July
2018)
The scope and magnitude of gestational thrombocytopenia
(GT) have been unclear. A new study that documented serial
platelet counts in thousands of pregnant women found that
platelet counts decreased progressively from a mean count of
237,000/microL before pregnancy to 217,000/microL at
delivery and returned to the non-pregnant level several
weeks postpartum. Mean platelet counts were slightly lower
in twin pregnancies and in Hispanic and non-Hispanic white
women. Less than 1 percent had platelet counts <100,000/microL.
Based on these findings, we evaluate pregnant women with
platelet counts <100,000/microL for causes other than GT.
Decisions about whether to evaluate pregnant women with
platelet counts between 100,000 and 150,000/microL for
causes other than GT should be made in the context of the
pre-pregnancy platelet count and other medical diagnoses.
9. AASLD/IDSA recommendations on HCV
screening during pregnancy (June 2018)
The rate of hepatitis C virus (HCV) transmission from a
woman with chronic HCV infection to her infant is
approximately 5 percent; risk-based HCV screening of
pregnant women is a standard recommendation in the United
States. The American Association of the Study of Liver
Disease (AASLD) and the Infectious Diseases Society of
America (IDSA) recently updated their joint HCV guidelines
to recommend screening all pregnant women, ideally at the
initial prenatal visit. The rationale includes the
limitations of risk-based screening, the increasing
incidence of HCV among women of child-bearing age, and the
potential to facilitate infant follow-up and postpartum HCV
care for the mother. Arguments against it include the likely
low prevalence of HCV among pregnant women overall and the
lack of interventions to prevent perinatal transmission.
Some, but not all Up-to-date contributors endorse the new
recommendations; obstetric expert groups have not revised
their screening approach.
10. Targets for blood pressure control
during pregnancy (May 2018)
Whether it is possible to delay initiation of blood
pressure management until later in pregnancy to offset the
effect of antihypertensive treatment on birth weight was
explored in a post-hoc analysis of data from the CHIPS
trial. Less tight (diastolic target 100 mmHg) versus tight
(diastolic target 85 mmHg) control at <24 weeks was
associated with fewer new-born weights <10th percentile, but
an increase in iatrogenic preterm birth and development of
severe maternal hypertension, with no overall effect on
perinatal death or morbidity. In pregnant women with chronic
hypertension, our treatment target throughout pregnancy is
systolic pressure 130 to 150 mmHg and diastolic pressure 80
to 100 mmHg.
11. Glyburide versus insulin for
treatment of gestational diabetes (May 2018)
Oral antihyperglycemic drugs are increasingly being
prescribed instead of insulin for women with gestational
diabetes. In the largest trial to date comparing glyburide
and insulin in this population, the overall frequency of the
composite outcome of macrosomia, neonatal hypoglycaemia, or
hyperbilirubinemia was similar in both treatment groups, but
maternal and neonatal hypoglycaemia rates were higher in the
glyburide group. We continue to recommend insulin rather
than an oral antihyperglycemic drug for glucose control in
women with gestational diabetes.
12. Prenatal caffeine consumption and
postnatal growth in offspring (April 2018)
Maternal caffeine consumption during pregnancy has been
associated with low birth weight, but long-term data on
childhood growth are limited. In the largest prospective
study to date, increasing maternal prenatal caffeine intake
was associated with excessive growth in infancy and
increasing risk of being overweight at three and five years
of age; however, by eight years of age, the increased risk
of being overweight was limited to children of women with
the highest prenatal intake (???300 mg/day). Although the
mechanisms are not understood, this study further supports
limiting caffeine consumption during pregnancy.
13. INTRAPARTUM AND POSTPARTUM OBSTETRICS
Immediate versus delayed pushing (October 2018)
Whether immediate or delayed pushing results in better
outcomes is controversial. The largest randomized trial
comparing these approaches in nulliparous women at term
receiving neuraxial analgesia reported similar rates of
spontaneous vaginal delivery, caesarean delivery, operative
vaginal delivery, composite neonatal morbidity, and maternal
satisfaction for both groups. Advantages of immediate
pushing were lower rates of chorioamnionitis and postpartum
hemorrhage and a shorter second stage, but disadvantages
included more third-and fourth-degree perineal lacerations
and more time pushing. These data do not provide compelling
evidence for recommending immediate versus delayed pushing.
Either approach is reasonable for most patients, and the
choice is best made as a shared decision.
14. Intravenous versus intramuscular
oxytocin for prevention of postpartum hemorrhage (September
2018)
In the first large randomized trial comparing intravenous
(IV) versus intramuscular (IM) oxytocin administration for
prevention of postpartum hemorrhage in women undergoing
vaginal delivery, the IV group had less postpartum blood
loss, hemorrhage ???1000 mL, and need for blood transfusion.
The frequency of side effects was similar in both groups. We
suggest IV administration of oxytocin, but IM injection is
an acceptable alternative for women without IV access. We
prefer IV infusion to bolus injection.
15. Discontinuation of oxytocin in the active phase during
induction (September 2018)
In patients undergoing induction of labor, there is no
consensus regarding discontinuation of oxytocin when the
active phase is reached. In a previous meta-analysis of
randomized trials comparing discontinuation with
continuation until delivery, discontinuation resulted in
lower rates of cesarean delivery and tachysystole, but
increased the duration of the active phase. A recent
meta-analysis reported similar findings in the intention to
treat analysis, but the difference in the cesarean delivery
rate was no longer significant when the analysis was
restricted to women who reached the active phase of labor.
Both reviews emphasized the significant design limitations
and high risk of bias among the trials. Pending additional
and stronger evidence for best practice, we believe it is
reasonable for clinicians to continue, discontinue, or
reduce the oxytocin dose when patients reach the active
phase.
16. Guidelines for regional anaesthesia in patients receiving
antithrombotic or thrombolytic medications (August 2018)
The American Society of Regional Anesthesia and Pain
Medicine (ASRA) has issued updated guidelines for the use of
regional anesthesia in patients on antithrombotic and
thrombolytic medications. The guidelines make new
recommendations for timing of neuraxial anesthesia for
patients receiving unfractionated heparin (UFH), direct oral
anti-factor Xa agents, dabigatran, warfarin, and
thienopyridines. Recommendations specific to obstetric
patients are a new feature of these guidelines. One
significant change from previous guidelines is a
recommendation to delay neuraxial anesthesia for four to six
hours after the last dose of low-dose subcutaneous UFH (5000
units twice daily or thrice daily). Up-to-date generally
agrees with these guidelines.
17.
Prophylactic use of tranexamic acid at vaginal delivery
(August 2018)
Tranexamic acid is a common component of treatment of
postpartum hemorrhage (PPH), but data on its use in the
third stage of labor as prophylaxis against PPH has been
limited. Now, a multicenter randomized trial of over 4000
labouring women ???35 weeks of gestation compared tranexamic
acid with placebo in addition to oxytocin after delivery of
the anterior shoulder. A strong trend toward reduced blood
loss >500 mL (RR 0.83, 95% CI 0.68-1.01) was reported for
the tranexamic acid group. Most secondary outcomes did not
differ significantly between the two groups. These and
previous data support our use of tranexamic acid for
prevention of PPH in high-risk settings (e.g., delivery of
patients who refuse blood products, patients at
significantly increased risk for PPH).
18. Uterotonic drugs for preventing postpartum hemorrhage
(August 2018)
Oxytocin alone has been the standard of care for active
management of the third stage of labor in the United States
and in some other countries. A recent network meta-analysis
of trials of the effectiveness and side-effects of
uterotonic drugs for prevention of postpartum hemorrhage
found that oxytocin plus misoprostol, oxytocin plus
ergometrine, and carbetocin were more effective for reducing
excessive bleeding at childbirth than oxytocin alone,
although side effects were somewhat higher for the
combination therapies. Based on these findings, we suggest
one of these pharmacologic approaches rather than oxytocin
alone in women at high risk for postpartum hemorrhage.
Oxytocin alone or in combination with another uterotonic
agent or carbetocin is an appropriate choice for women at
low risk.
19. Balloon catheter volume for cervical ripening (August
2018)
In a meta-analysis of randomized trials comparing use of
larger (60 to 80 mL) versus smaller (30 mL) volume balloon
catheters for cervical ripening, larger balloon volumes
resulted in a shorter time from induction to delivery, but
the cesarean delivery rate, time to vaginal delivery, time
to catheter expulsion, and maternal and fetal complication
rates were similar for both groups. These data suggest that
either a large or small balloon volume is a reasonable
choice.
20. ACOG endorses shared decision-making for elective
induction at 39 weeks (August 2018)
Elective induction of labor has been controversial. In the
multicenter ARRIVE trial, which evaluated the perinatal and
maternal consequences of planned induction of labor at 39+0
to 39+4 weeks of gestation versus expectant management in
over 6100 low-risk nulliparous women across the United
States, induction reduced the chance of cesarean delivery,
hypertensive disorders of pregnancy, and neonatal
respiratory problems; the frequency of the composite outcome
of perinatal death or severe neonatal complications was
similar in both groups. Based on the results of this trial,
the American College of Obstetricians and Gynecologists (ACOG)
now concludes that offering elective induction of labor to
low-risk nulliparous women at 39 weeks of gestation is a
reasonable option that should be a shared decision of a
woman and her obstetric provider, with consideration of
available resources.
21. Neuraxial analgesia and risk of operative vaginal
delivery (August 2018)
Neuraxial analgesia with higher concentrations of local
anaesthetics (LA), as used historically, has been associated
with an increased risk of operative vaginal delivery.
However, neuraxial analgesia with the lower concentration
LA/opioid solutions that have now become standard obstetric
anesthesia practice does not increase the risk of operative
vaginal delivery. A 2018 meta-analysis of randomized trials
compared epidural with non-epidural analgesia or no
analgesia for labor and found no difference in instrumental
delivery rate in trials conducted after 2005.
22. Heat-stable carbetocin for prevention of postpartum
hemorrhage (July 2018)
Oxytocin is administered routinely after delivery to reduce
the risk of postpartum hemorrhage. However, it must be
refrigerated during transport and storage, which is a
barrier to its use in some areas. Now, a multicenter,
randomized noninferiority trial comparing intramuscular
administration of heat-stable carbetocin with oxytocin
immediately after vaginal birth reported that the frequency
of blood loss ???500 mL, use of additional uterotonic drugs,
and adverse event rates were similar for both drugs. These
data support use of heat-stable carbetocin as the preferred
prophylactic uterotonic drug in parts of the world that lack
appropriate refrigeration. Misoprostol is an alternative if
a non-parenteral route of administration is necessary.
23. Pregnancy-related hypertensive disorders and risk for
cardiovascular disease (July 2018) Previous studies have established an association between
pregnancy-related hypertensive disorders and future
mortality from cardiovascular disease. A cohort study of
long-term outcomes, comparing women with pregnancy-related
hypertensive disorders in their first birth with
normotensive women, found an association between
pregnancy-related hypertension and increased risks for
chronic hypertension, type 2 diabetes, and
hypercholesterolemia, even after correction for multiple
pre-pregnancy confounders. The increased relative risk was
highest in the first five years after delivery but persisted
for decades. These findings add to the body of evidence
supporting assessment of a history of pregnancy-related
hypertension during post-pregnancy clinical care, with
appropriate monitoring for other risk factors for
cardiovascular disease and risk reduction interventions,
when indicated.
|