Prophylactic use of aspirin can considerably bring down the incidence of preterm SGA

Use of prophylactic aspirin in high-risk group identified by first trimester screening for preeclampsia would considerably lower the incidence of preterm and early SGA by about 20% and 40%, respectively report the results of a data analysis published July 2018 in ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) journal Ultrasound in Obstetrics and Gynecology.

The researchers analyzed the data from two multicentric trials: Screening program for pre-eclampsia (SPREE) study and the Aspirin for Evidence-Based Preeclampsia Prevention trial (ASPRE). SPREE is a prospective multicenter cohort study that screened women for PE during 11-13 weeks by measuring Mean arterial pressure (MAP), Uterine artery pulsatility index (UtA‐PI), Serum placental growth factor (PlGF), and Serum pregnancy‐associated plasma protein‐A (PAPP‐A).

ASPRE trial examined the prophylactic effect of low-dose aspirin started at 11-14 weeks for prevention of PE in women at increased risk for preterm PE.  The results demonstrated that aspirin reduces the incidence of early-PE by 89% and pre-term PE by 62% but does not much reduce the incidence of term PE.

The combined use of maternal factors mean arterial pressure, uterine artery pulsatility index and serum placental growth factor for the screening for preterm preeclampsia identifies a high proportion of patients who will develop small for gestational age (SGA) babies.

Screening in SPREE trial identified 46% of SGA <10th Percentile neonate born before 37 weeks and 56% of those born before 32 weeks with a screen positive rate of 12.2%. Analysis of data from ASPRE trial showed that aspirin reduced the rate of SGA <10th Percentile by 40% in babies born at or before 37 weeks and by 73% in babies born before 32 weeks.

The decrease in the incidence of SGA infants was mainly due to a substantial decrease in the incidence of PE to the amount of 90% in babies born before 32 weeks and 70% in babies born at or before 37 weeks.

Hence, the authors concluded that first-trimester screening of PE identifies a high proportion of patients with who will develop preterm-SGA as the pregnancy progresses further and the prophylactic use of aspirin can prevent that.

Here is a Video abstract of the above study

Abstract

Ob/Gyn Updated Facebook page

ACOG/AHA calls for including a ‘Heart-talk’ during the annual well-woman visit

A joint advisory issued by American College of Obstetrician and Gynecologists (ACOG) and American Heart Association(AHA) calls for all gynecologist to screen women for signs of cardiovascular disease and risk factors during their annual ‘well-woman’ visit.

The presidential advisory published 10 May in Journal Circulation calls for a collaboration between cardiologists and Ob/Gyn physicians to use these visits as an opportunity to screen, counsel and educate women about lifestyle factors that influence the risk of heart diseases.

This is important because, for more than 50% of women, their Ob/Gyn physician is the only primary care doctor they visit every year.

“OB/GYNs are primary care providers for many women, and the annual ‘well woman’ visit provides a powerful opportunity to counsel patients about achieving and maintaining a heart-healthy lifestyle, which is a cornerstone of maintaining heart health” said John Warner, M.D. president of the American Heart Association, executive vice president for Health System Affairs at University of Texas Southwestern Medical Center in Dallas, Texas.

Dr. Stacey Rosen, MD, a cardiologist, co-author of the advisory and vice president of The Katz Institute for Women's Health at Northwell Health said, "We know that 90 percent of women have at least one risk factor for heart disease and that 80 percent of heart disease is preventable through a heart-healthy lifestyle.”

A post-partum visit is an ideal opportunity to identify women with pregnancy complications like pre-eclampsia, eclampsia, chronic hypertension, gestational diabetes, gestational hypertension, pre-term delivery, and low-for-estimated-gestational-age birth weight which all indicate a subsequent increase in the mother’s cardiovascular risk.

Preeclampsia and gestational hypertension impart a three- to six-fold excess risk of subsequent hypertension and a two-fold risk for subsequent heart disease.

In 2001, the Institute of Medicine now the National Academy of Sciences, issued a monograph" Exploring the Biological Contributions to Human Health: Does Sex Matter?" This initiated research on gender-specific risk factors for chronic diseases and development of guidelines that are distinct for men and women based on their unique health risks.

This has considerably helped in bringing down the morbidity and mortality associated with cardiac disease in women in last two decades.

Despite this progress, gender-specific inequalities continue when it comes to managing risk factors for cardiac disease. For example, women who have diabetes are at increased risk of CVD as compared to men (19% vs 10%) but they are far less likely to receive preventive treatment as compared to men.

Similarly, only 29% of older women have a well-controlled blood pressure as compared to 41% of older men.

In women, the CVD risk factors are often related to hormonal or pregnancy influences, such as pregnancy complications and polycystic ovary syndrome, menopausal status and hormone use, but these are seldom considered when calculating the risk of CVD.

Some of the common recommendations in the advisory include:

• All women should be weighed at every visit and diet assessment should be performed through a predetermined questionnaire.
• Women are advised to perform 150 minutes per week of moderate-intensity physical activity, 75 minutes per week of vigorous-intensity aerobic physical activity or a combination of both levels. Women should also walk 10,000 steps per day.
• Presence of behavioral risk factors like smoking and alcohol should be assessed.
• Screening for Glucose intolerance should be done in women 40 to 70 years with obesity or overweight, a history of gestational diabetes, a family history of diabetes or established CVD.
• All women above 20 years of age with a family history of CVD, should undergo lipid screening. Lifestyle modification followed by statins is advised in those with elevated lipids.
• Women with family history of CVD should also be screened for blood pressure every 2 years and annually after 40 years of age.
• Medical therapy would be considered for women without CVD or elevated risk for the disease and with BP measurements greater than 140 mm Hg/90 mm Hg.
• Ob/Gyn and cardiologist should make sure that patients Electronic Health Record (EHR) is complete during each visit and is something does not look good, patients should be referred to a specialist.

The clinicians and patients can visit the following websites to get patient education material.

AHA Life's Simple 7 

AHA's Go Red for Women

ACOG's patient page

Full Text

Ob/Gyn Updated Facebook page

Here is one video from  AHA series ' Life's Simple 7'

Guidelines issued for standardized care to patients with severe hypertension during pregnancy

The National Partnership for Maternal Safety, under the guidance of the Council on Patient Safety in Women’s Health Care, has issued a patient safety bundle that assists the healthcare professionals in providing a standardized care to patients with severe hypertension during pregnancy and the postpartum period.

The consensus  bundle was published online  ahead of print in Journal of Obstetrics and Gynecology. The safety bundle is organized into 4 domains and outlines clinical practices that should be practiced at every maternity unit.

The four domains are: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning.

Readiness

The readiness domain consists of 5 key components to prepare each maternity unit for prompt and effective management of women with hypertension in pregnancy. It includes:

Each maternity setting should have standardized criteria for recognizing the warning signs, to diagnose, monitor and treat preeclampsia and eclampsia.

The staff should undergo regular drills to practice the protocols.

The maternity unit, along with the OPD and ER should be well equipped for dealing with patients with severe preeclampsia or eclampsia.

All the medications used in emergency treatment should be readily available and stocked continuously.

Appropriate consultations from various concerned department and means of transportation to tertiary center should be available all the time.

Recognition and Prevention

All women should be educated about the warning signs of hypertension in pregnancy.

Standard protocols should be developed for measuring B.P and urine analysis for all women during pregnancy and postpartum period.

Standard protocols should be developed and followed for investigating all women with hypertension in pregnancy. The investigations should include complete blood count with platelets, aspartate transaminase, and alanine transaminase.

Response (Every Case of Severe Hypertension or Preeclampsia)

Each facility should be well equipped with management of severe hypertension, Eclampsia, seizure prophylaxis, and magnesium over dosage and recognizing symptoms of postpartum hypertension.

The concerned physician or primary care provider should be immediately notified if systolic blood pressure is 160 mm Hg or greater or diastolic blood pressure is 110 mm Hg or greater for two measurements within 15 minutes.

If the second blood pressure reading is also high, treatment should be initiated immediately. Guidelines for initiation and maintenance of Magnesium Sulfate should be readily available everywhere.

Escalation measures should be lined out for patients unresponsive to initial treatment along with follow up and education protocols at 7-14 days postpartum.

Reporting and Systems Learning (Every Unit)

All the members of the multidisciplinary team should receive debriefing about the way the emergency was handled, what went well along with areas of improvement.

The team should also review all other patients admitted with severe hypertension and eclampsia about the outcome. Robust data system should be present to report accurate outcomes to all the concerned persons. The review should include all the measures taken since the woman arrived in emergency room till postpartum education and follow-up.

One very important key element in reducing maternal morbidity and mortality and neonatal morbidity and mortality is time to treatment after the recognition of severe hypertension.

The full text of the article can be accessed here.