Role of progesterone in
preventing recurrent preterm births (PTB)
It is widely accepted that progesterone supplementation in pregnancy
reduces the risk of recurrent preterm birth. But, according to a
secondary analysis of data from
Maternal-Fetal Medicine Units Network Trial of hydroxyprogesterone caproate for
prevention of recurrent preterm birth before 37wks concluded that the drug may
not be effective in women with a BMI>30 kg/m2. The
cut off weight is 168 pounds or 75 kg. This finding may be due to
subtherapeutic serum levels in women with increased BMI or weight. Further
larger and planned studies in women with BMI >30 kg/m2
are warranted and also the universal use of progesterone in women
independent of BMI also deserves reassessment.
Heyborne KD et al - Does 17-alpha hydroxyprogesterone
caproate prevent recurrent preterm birth in obese women?
Am J Obstet Gynecol. 2015 Aug;
Maternal
Hypertension in Pregnancy predisposes the offspring for higher risks of
Congenital Heart Disease
According to a systemic review and metaanalysis published in
the journal of pediatric cardiology robust associations were observed between maternal
hypertension and overall CHDs, irrespective of being treated or untreated. The authors
identified 16 studies that met the study criteria. The effect was also uniform
across all the subtypes of CHDs. The results were also similar for various type
of antihypertensive medications used.
The authors propose to understand the mechanisms to design
strategies to reduce the risks..
Ramakrishnan A et al- Maternal Hypertension During Pregnancy
and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and
Meta-analysis.
Pediatr Cardiol. 2015 Oct;36(7):1442-51. Epub 2015 May 8.
The downside
of improved control of malaria.
We are recently seeing improved malaria control
in many endemic areas worldwide, leading to a decrease in immunity in the
population. A large observational study carried out in Mozambique assessed the
prevalence of Plasmodium falciparum infection among 1819 Mozambican women who
delivered infants between 2003 and 2012.
A major decline in maternal level of antimalarial IgG
antibodies were seen in pregnant women both for pregnancy specific parasitic
lines as well as general parasitic lines.
It was also seen that those women who developed malaria
antenatally had a larger reduction in hemoglobin levels as well as the neonatal
birthweight as the immunity declined.
Mayor A
et al- Changing Trends in P. falciparum Burden, Immunity, and Disease in
Pregnancy. N Engl J Med. 2015 Oct
22;373(17):1607-17.
Uterine
exteriorization at cesarean delivery
Uterine exteriorization vs in situ repair has always been a
topic of debate among obstetricians. In A
large meta-analysis of 16 studies amounting to a total of 19,439 subjects 9,736
underwent exteriorization, 9,703 had in situ uterine repair. It was seen that
the estimated blood loss was not statistically significant between the two
groups as well as other perioperative outcomes. Individual preferences and
individual intraoperative circumstances should guide the decision.
Zaphiratos V et al- Uterine exteriorization compared with in
situ repair for Cesarean delivery: a systematic review and meta-analysis.
Can J Anaesth. 2015 Nov;62(11):1209-1220.
The best time to perform
External Cephalic Version (ECV)
The optimum age to perform ECV has always been a debatable
issue.
External cephalic version (ECV) of the breech fetus at term
(after 37 weeks) has been shown to be effective in reducing the number of
breech presentations and caesarean sections, but the rates of success are
relatively low. This systemic review of Cochrane Data base examines studies
initiating ECV prior to term (before 37 weeks' gestation).
Pooled results suggested that early ECV reduced the risk of
non-cephalic presentation at birth, failure to achieve vaginal cephalic birth,
and vaginal breech delivery. However there was no statistical significant difference
in Caesarean Section rate between the two groups. There was evidence that risk
of preterm labour was increased with early ECV compared with ECV after 37
weeks. Future research reporting infant morbidity outcomes in these late
preterm births is warranted.
Hutton E.K et al- External cephalic version for breech
presentation before term.
Cochrane Database Syst Rev.
2015 Jul 29;7:CD000084.
Limited
value of fetal ST-segment analysis
STAN S31 is a one-of-a-kind fetal
monitor which exclusively combines standard CTG technology with ST-Analysis of
the fetal ECG (FECG) during labour. The combined analysis of the CTG and fetal
ECG helps to detect a fetus that is exposed to hypoxia and which needs remedial
action, and also provides reassurance when no intervention is required.
However, It is not clear whether use of
STAN 31 as an adjunct to other conventional fetal heart rate monitor improves the
intrapartum and neonatal outcome.
This Multicenter RCT of about 11,108 subjects included women with a
single fetus undergoing vaginal delivery at more than 36 weeks of gestation with
cervical dilation of 2 to 7 cm. They were randomly assigned to "open"
or "masked" monitoring with fetal ST-segment analysis. The masked
system functioned as a normal fetal heart-rate monitor (FHR). The open system functioned
as both FHR as well as fetal ECG monitor.
The primary outcome was a composite of intrapartum fetal
death, neonatal death, an Apgar score of 3 or less at 5 minutes, neonatal
seizure, an umbilical-artery blood pH of 7.05 or less with a base deficit of 12
mmol per liter or more, intubation for ventilation at delivery, or neonatal
encephalopathy.
It was observed that fetal ECG monitoring along with
FHR did not improve perinatal outcome or
decreased the rate of caesarean delivery. The primary outcome occurred in 52
fetuses or neonates of women in the Fetal ECG group and 40 fetuses or neonates of women in the FHR
group.
Belfort
M.A- A Randomized Trial of Intrapartum Fetal ECG ST-Segment Analysis.
N Engl J Med. 2015
Aug 13;373(7):632-41.
Expectant
management of mild preeclampsia near term is feasible.
There is little guidelines for the management of women with
mild preeclampsia with stable maternal and fetal conditions at 34 to 36 weeks
of gestation. The study by Broekhuijsen K et al in Lancet 2015, investigated the
effect of immediate delivery versus expectant monitoring on maternal and
neonatal outcomes in such women. This open-label, randomised controlled trial,
in seven academic hospitals and 44 non-academic hospitals in the Netherlands
confirmed that most patients will reach term without progressing into severe
disease and the expectant management buys us valuable time for optimum neonatal
maturity without any harm to the mother.
References:
- Relation of body mass index to frequency of recurrent preterm birth in women treated with 17-alpha hydroxyprogesterone caproate.Co AL, Walker HC, Hade EM, Iams JD. Am J Obstet Gynecol. 2015 Aug; 213(2):233.e1-5
- Ramakrihnan A et al- Maternal Hypertension During Pregnancy and the Risk of Congenital Heart Defects in Offspring: A Systematic Review and Meta-analysis.Pediatr Cardiol. 2015 Oct;36(7):1442-51
- Mayor A et al- Changing Trends in P. falciparum Burden, Immunity, and Disease in Pregnancy. N Engl J Med. 2015 Oct 22;373(17):1607-17.
- Zaphiratos V et al- Uterine exteriorization compared with in situ repair for Cesarean delivery: a systematic review and meta-analysis.Can J Anaesth. 2015 Nov;62(11):1209-1220.
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