ASRM Video article: Hysteroscopic removal of IUD in pregnancy

The use of Intrauterine Devices (IUD) has increased in recent years. Used correctly, the failure rate for IUD is less than 1%. If a patient gets pregnant with IUD in place, the risk of adverse outcomes like spontaneous abortion and preterm birth increases many-fold.

WHO advises removal of IUD at the earliest gestational age possible if strings are visible on vaginal examination. If strings are not visible there are 3 ways to manage a case of IUD with pregnancy:

Expectant management

Removal with a grasper under ultrasound guidance

Removal under hysteroscopic visualization

Here is a recent video-article published in December issue of Journal Fertility and Sterility, showing step by step procedure of hysteroscopic removal of IUD in 4 patients. In all four cases, the strings were not visible during a vaginal examination. After removal of IUD, all patients had uneventful live term delivery.

All patients were informed about the risk of the procedure, although negligible–– including rupture of gestation sac and pregnancy loss, consent obtained, viability and location of IUD confirmed by pre-op ultrasound and prophylactic antibiotics given. The actual procedure includes:

Vaginoscopic hysteroscopy

IUD localization with or without imaging guidance

Removal of the IUD with the help of hysteroscopic grasper

The key is to use slender hysteroscope and use the minimal amount of distention media. The method is safe with minimum procedure-related complications and > 90% ongoing pregnancy rate.

Here is the American Society for Reproductive Medicine (ASRM) video showing step by step procedure of hysteroscopic removal of IUD in 4 patients. 

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GE Healthcare new fetalHQ software streamlines evaluation of congenital heart diseases

The ultrasonologist can now assess the size, shape, and function of the fetal heart in less than 3 minutes with the GE Healthcare new fetalHQ software. Evaluating fetal heart and ruling out congenital heart anomalies is complicated at 18-20 weeks. This condition is not uncommon and affects one out of every 110 babies around the world.

At this gestational age, the fetal heart is exceptionally complex, just the size of a grape and the rate is near twice the adult heart rate. GE new tool – fetalHQ runs on GE Healthcare’s Voluson ultrasound systems and is the first tool to simultaneously examine the size, shape, and function of the fetal heart.

fetalHQ is the brainchild of Greggory DeVore, M.D., a specialist in maternal-fetal medicine at Huntington Hospital, Pasadena, California. He got inspired to develop the software from another software that used speckle tracking analysis to map the motion of tissues in the heart. This software was regularly used by adult and pediatric cardiologist to assess the function of the heart.

Dr. DeVore installed the software and reprogrammed it to visualize the fetal heart in 24 segments and map it in a way that was never done earlier.

“This was the genesis of the creativity behind using this software,” DeVore said. “From this, we made several measurements of the heart’s size, shape, and contractility – or how it’s squeezing. We immediately got to work and published 13 peer-reviewed articles that described the clinical value of this software.”

Here is a video showing the fetalHQ‘s automatic delineation of the fetal heart’s shape

GE Healthcare news release

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CDC: Meeting the Challenges of Measuring and Preventing Maternal Mortality in the United States

Women in the United States are more likely to die from childbirth or pregnancy-related causes than other women in high-income countries. More evidence is needed to understand the actual causes of death better, but research suggests that half of these deaths may be preventable. Racial disparities persist. The risk of pregnancy-related deaths for black women is three to four times higher than those of white women.

Watch this session of Grand Rounds to learn about efforts to analyze and prevent future deaths. Hear our speakers discuss the effects maternal deaths have on the family and on the community. You will also learn about how CDC has collaborated and intervened through public-private partnership efforts to prevent deaths associated with childbirth and pregnancy.

About CDC Public Health Grand Rounds

CDC Public Health Grand Rounds is a monthly scientific presentation featuring the important work that CDC is doing in the United States and around the world to protect people and save lives.  Experts discuss major public health issues, key challenges, cutting-edge scientific evidence, potential solutions, and recent developments. Each session is the result of a rigorous process which takes months to prepare. This attention to detail ensures that our audiences receive up-to-date, scientifically accurate, and usable information. Grand Rounds welcomes clinicians, researchers, students of public health, medicine and nursing, and the public that we serve to attend in person or watch the live webcast.

Global cesarean section rates almost double since the turn of the century

Globally, the cesarean section rate has almost doubled since 2000, with wide geographical variations based on economic prosperity. The rate is unprecedently high, reaching almost 60% in some parts of Latin America and as low as 5% in southern Africa. The intervention is often overused unnecessarily in some parts of the world and denied to mothers in the area where it is needed the most. The linear increases in rates make it highly unlikely that it will be reversed soon.

The considerable variation in C-section rates indicates that the increase is not backed by scientific evidence, as evident by a whopping 6·2 million unnecessary caesareans performed each year, half of which are done in Brazil and China.

Lancet launched a three-part series on optimizing the cesarean section rates at the World Congress of Gynecology and Obstetrics (FIGO) on Oct 18. Simultaneously, the World Health Organization (WHO) also published guidelines on October 11 to reduce the incidence of unnecessary cesarean sections. 

The WHO guidance is unique because it includes the first ever non-clinical interventions to decrease the rising cesarean rates. The guidance consists of 3 sets of separate recommendations targeted at women, healthcare professionals, and health organization and systems.

Those addressed at women, stress the importance of health education to allay fear of childbirth and misconceptions. The WHO guidance states, comprehensive health education, including tailored information and support about childbirth fear, pain relief, and the advantages and disadvantages of cesarean sections, should be provided to all women.

Providers guidance is crucial in a sense it includes a mandatory second opinion for cesarean section indication, audit and timely feedback in good resource settings to bring down the cesarean rates. Another significant recommendation is the equal remuneration for the vaginal birth and cesarean deliveries.

The guidance also acknowledges other barriers towards practicing evidence-based medicines such as cultural beliefs, litigations, increased surgical skills of younger providers with decreasing confidence in conducting difficult vaginal births.

As the part of the Lancet series, the editorial by Wiklund and colleagues highlights the importance of investing in midwives and midwives-led care in bringing down the global cesarean section rate. Trained midwives can provide continuous and watchful support during labor, creating an atmosphere of trust that may calm the patients resulting in more natural births.

The series further analyzed the significant trends of cesarean section in Brazil and China. Both are emerging economies with the highest cesarean section rates seen in wealthier, educated women in private clinics as compared to less well-educated women (54.4% of births versus 19.4%). Wealthier women are 6 times more likely to have surgical delivery as compared to women from a low socioeconomic background.

FIGO also issued a position paper on how to curb the recent cesarean section epidemic. Gerard Visser, MD, from the University Medical Centre, Utrecht, the Netherlands, and chair of FIGO's Committee on Safe Motherhood and Newborn Health, and colleagues note, “Worldwide there is an alarming increase in C-section rates. The medical profession on its own cannot reverse this trend.

Drivers for the increasing C-section rates can vary between countries and include a loss of medical skills to confidently and competently attend a (potentially tricky) vaginal delivery, as well as medico-legal issues."

In the position paper, FIGO calls upon governmental bodies, UN partners, professional organizations, women's groups, and other stakeholders to join hands to bring down the global cesarean section rates.

The six recommendations by FIGO includes:

• Educating the women about benefits and harm of operative delivery
• Matching the rates of surgical and vaginal deliveries, especially in private practice
• Making mandatory for hospitals to publish their Cesarean section rates
• Ensuring that all hospitals adopt a uniform classification system for CS
• Reinvesting the money saved from lower cesarean section to improve the infrastructure
• Increasing access to skilled care, fetal monitoring and assisted births in low-income, rural areas

The authors further note that the only aspect that has consistently resulted in a significant reduction in CS rates has been an altered reimbursement model for doctors and hospitals that favor vaginal delivery. This has been shown in Portugal following wide dissemination of information on the increased risks of CS, as well as in governmental hospitals in Iran and in a large hospital setting in Shanghai.

WHO recommendations non-clinical interventions to reduce unnecessary caesarean sections

Lancet series: Optimising caesarean section use

Global epidemiology of use of and disparities in caesarean sections

Short-term and long-term effects of caesarean section on the health of women and children

Interventions to reduce unnecessary caesarean sections in healthy women and babies

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FIGO position paper: how to stop the caesarean section epidemic

Appropriate use of caesarean section globally requires a different approach

Strategic measures to reduce the caesarean section rate in Brazil

Editorial

Stemming the global caesarean section epidemic

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Ana Pilar Betrán: seeking the optimum use of caesarean section

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Hyperemesis gravidarum does not usually recur in each pregnancy

Women who have suffered from Hyperemesis gravidarum can now be reassured that severe morning sickness does not necessarily recur in each pregnancy according to the results of the study published August 16 in the American Journal of Obstetrics & Gynecology.

The Finnish study provides evidence that 3 out of 4 women who suffered from hyperemesis gravidarum will not experience it in the subsequent pregnancy. The incidence of hyperemesis is 0.5-2.0% and is the most common cause of first-trimester hospital admissions.

The exact etiology of hyperemesis is still unknown, and both maternal and paternal genetics, family history and environmental causes have all been implicated in its causation. Hyperemesis recently hit the headlines when Kate Middleton, the Duchess of Cambridge and wife of Britain's Prince William, was hospitalized with hyperemesis gravidarum during her first pregnancy.

Finnish researchers identified 1836 women over a period of 7 years who were diagnosed with hyperemesis during their first pregnancy and who had at least one more subsequent delivery. The first pregnancy with hyperemesis was considered as an index pregnancy, and the recurrence rate was calculated based on the incidence of hyperemesis and the total number of subsequent pregnancies. 

There were 2,267 later pregnancies, of whom hyperemesis occurred in 544 or 24% of pregnancies, while in 1723 pregnancies no morning sickness was noted. In case of more than 1 subsequent pregnancy, 333 (11%) of women suffered from hyperemesis in all of their pregnancies.

Women who were second para during the index pregnancy were 33% more likely to suffer from hyperemesis as compared to those who were para one (adjusted odds ratio, 1.33, P = .046).

Being overweight and smokers were at decreased odds of recurrence of hyperemesis in subsequent pregnancy. Women with female fetuses were also at 29% increased odds of recurring hyperemesis (adjusted odds ratio, 1.29, P = .012).

Miina Nurmi, lead author of the study, told Reuters Health by email, “It is good to know that hyperemesis gravidarum (HG) is not a ‘lifelong sentence’ to everyone - sometimes HG patients have been told that HG would be with them in every pregnancy.”

 “It is reassuring to know that hyperemesis does not appear to become more likely with each pregnancy and that after 1 pregnancy with hyperemesis, the following pregnancy may be different,” the authors concluded, admitting that comparison of recurrence is difficult given the lack of universal definition of hyperemesis gravidarum.

The authors further suggested that "Large prospective studies concentrating on HG patients' future pregnancies, studied with both symptom diaries and medical records, would be an ideal way, though slow and somewhat expensive, to come as close to the actual recurrence rate as possible."

Abstract

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FDA clears the first smartphone camera-based clinical grade at-home urine test

An Israel-based Healthy.io has received FDA 510(k) clearance for Dip.io, a home-based urinalysis kit that transforms the smartphone into a clinical-grade urine diagnostic device. It is the first smartphone-based urine test to secure clearance as a Class 2 device.

Millions of people around the globe such as pregnant women, those suffering from kidney disease, diabetes, high blood pressure and others are required to get their urine tested very frequently- but going to the lab every day is very cumbersome and time-consuming. Dip.io let patient perform urine test in the privacy of their home with results that are equivalent to a hospital-based lab urine test.

The Dip.io kit comes with a cup, dipsticks and patented colorboard. The user simply opens the smartphone apps and is guided step-by-step through the kit by the chatbot nurse named Emily. After peeing in the cup, the user dips the stick and places it on the colorboard. After a lapse of 60 seconds the dipstick and the board are scanned, the image normalized, and data points are sent to the cloud platform to be analyzed and turned into clinical results.

The results are conveyed to the health care provider or directly stored as a part of the patient’s medical record.

The app is straightforward to use as apparent from the tagline “If you can text, you can test,” and has achieved more than 99 percent usability across age groups ranging from 18-80 because of rapid prototyping and repeated user testing. 

The dipstick measures 10 parameters including blood, protein, and glucose in urine and is enormously useful for patients with chronic kidney disease, diabetes, and high-risk pregnancies.

The FDA approval is based on the demonstration of the significant rise in the use of the Dip.io platform by patients of chronic kidney disease as reported by the results of a study initiated by the National Kidney Foundation (NKF) and Geisinger Health.

The Dip.io technology has already been approved by the National Health Trust of UK and is nationally available through the G-Cloud procurement framework. It is also a part of NHS first 'virtual renal clinic' to improve patient convenience and improve cost.

Already commercialized in Europe and Israel since 2016, it is estimated that it will be utilized by 100,000 users by the end of 2018 through different patient pathways, shifting more and more urine testing from labs to homes.

Healthy.io is currently working on expanding the technology for at home assessment of chronic wound through ‘medical-selfies.’

Arming patients with the capability to conduct the critical tests at home with the same accuracy as the lab will curb the tide of many chronic diseases, simplify their daily routine and bring down the healthcare cost significantly.

Press Release

Healthy.io homepage

National Kidney Foundation study

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Here is a short video about how the product works

Here is an animation describing the company’s intention behind developing the product

Healthy IO (Full Version) from Peepshow on Vimeo.

Use of antimycotics in early pregnancy is not linked to spontaneous abortion

Exposure to antifungals Clotrimazole and miconazole during pregnancy for Vulvovaginal candidiasis (VVC) is not associated with increased risk of spontaneous abortion says the results of a cohort study published in June issue of American Journal of Obstetrics and Gynecology.

VVC is more frequent in pregnancy possibly because of higher estrogen levels and higher glycogen content in vaginal secretions; thereby, creating a favorable environment for the yeast to thrive and grow. It is estimated that about 10% of pregnant women in the USA will have a yeast infection at any given time.

Topical clotrimazole and miconazole are the treatment of choice for VVC in pregnancy. They are easily available over the counter and are known to be safe in pregnancy. A recent study has suggested an increased risk of miscarriage by using these azoles.

The researchers from Beer-Sheva, Israel conducted this historical study to investigate the risk of spontaneous abortion after treatment with vaginal antimycotics.

Data was gathered on all clinically apparent pregnancies over a period of 6 years (2003-2009) at the Soroka Medical Center, Clalit Health Services, Beer-Sheva, Israel. Databases with information on medicines dispensed to these patients and information on births and spontaneous abortions were linked together.

Statistical analysis was done by time-varying Cox regression models adjusted for maternal demographics like age, ethnicity, tobacco use, and the year of admission; the presence of chronic diseases like diabetes mellitus, hypothyroidism, obesity, hypercoagulable or inflammatory conditions; and reproductive and contraceptive history.

A total of 65,457 pregnancies were included in the analysis of which 58,949 (90.1%) ended with birth and 6508 (9.9%) with a spontaneous abortion.

Out of which 3246 (5%) pregnancies received vaginal antifungal drugs until the 20^th week of gestation: (2712 (4.2%) were exposed to clotrimazole and 633 (1%) to miconazole.

Exposure to vaginal antifungals as a group was not linked to spontaneous abortion (adjusted hazard ratio, 1.11; 95% confidence interval, 0.96–1.29). Individually clotrimazole and miconazole were also not associated with spontaneous abortion.  

There was no dose-response relationship observed between the antifungals and spontaneous miscarriages.

The authors concluded that vaginal use of antimycotics is not linked to spontaneous abortion.

Abstract

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UTI in pregnancy: nitrofurantoin and trimethoprim-sulfamethoxazole overprescribed despite potential risks.

Nitrofurantoin and trimethoprim-sulfamethoxazole were commonly prescribed for pregnant women during first trimester in 2014, despite the potential risk associated with these antibiotics, reports the results of analysis of large insurance database by Center for Disease Control(CDC). These findings were reported in the Morbidity and Mortality Weekly Report(MMWR) by CDC issued January 12, 2018.

Pregnant women are routinely screened for UTI in pregnancy and receive antibiotics if they screen positive, because of foreseen serious complication later in pregnancy like pyelonephritis, preterm labor, low birth weight, and sepsis.

ACOG recommends to being selective in prescribing antibiotics during first trimester because of potential of birth defects with certain antibiotics. ACOG recommends that nitrofurantoin and trimethoprim-sulfamethoxazole should only be prescribed in early pregnancy when other antibiotics are found ineffective.

CDC gathered data of about 482,917 pregnancies from Truven Health MarketScan Commercial Database and analyzed it for prescription filled for antibiotics during the first trimester.

All pregnant women between aged 15–44 years with a diagnosis of a UTI from 90 days before LMP through the end of pregnancy were identified to be included in the study. UTI was defined according to the International Classification of Diseases Ninth Revision, Clinical Modification (ICD-9 CM) diagnosis code or presence of cystitis with an outpatient prescription filled.

Women with recurrent UTI or those who were admitted were excluded from study.

The data showed that 34,864 (7.2%) pregnant women had an initial outpatient UTI claim 90 days before or during pregnancy.  UTI was most common during the first trimester (40%) and least common in the third trimester of pregnancy.

Types of antibiotics prescribed differed according to pregnancy status of women, with fluoroquinolones and sulfonamides more commonly prescribed to women within 90 days before their LMP while nitrofurantoin, cephalosporins and penicillins were the drugs of choice during pregnancy.

The most common antibiotics prescribed during the first trimester were nitrofurantoin (34.7%), ciprofloxacin (10.5%), cephalexin (10.3%), and trimethoprim-sulfamethoxazole (7.6%).

This report has its own limitations because UTI was identified only based on codes and not lab reports, some women may have other concomitant infections for which these antibiotics were prescribed, the MarketScan sample was a convenient sample hence could not be generalized to whole of US populations and out of pocket payee women were not included in the study.

Inspite of these limitations,  the report shows that it is important for all healthcare providers to be aware of antibiotic recommendations in pregnancy and be aware that they are prescribing for two in women who are pregnant or who might get pregnant in coming months.   

CDC MMWR Report 

Clomiphene compared with other drugs in terms of ovulation, EMT, pregnancy and live births: systematic review and meta-analysis

Ovulation induction with Clomiphene Citrate (CC) in women with WHO group II ovulatory disorders results in lower endometrial thickness (EMT) as compared to other regimens. The regimen also resulted in lower number of pregnancies and live births reports the results of systematic review and meta-analysis published in Journal Ultrasound in Obstetrics and Gynecology.

WHO group II ovulation disorders are defined as dysfunctions of the hypothalamic-pituitary-ovarian axis. This category includes conditions such as polycystic ovary syndrome (PCOS) and hyperprolactinaemic amenorrhoea. Around 85% of women with ovulation disorders have a group II ovulation disorder.

This systematic review and meta-analysis only focused on randomized control trials(RCTs) and included all those studies comparing CC with any other regimens and looked at EMT and rates of ovulation, pregnancy and live births.

The other regimens included in the study were Letrozole, CC plus metformin, CC plus N-acetyl cysteine (NAC), CC + nitric oxide (NO) donor and Tamoxifen.

The researchers selected 33 RCTs from 1718 articles that fitted the inclusion criteria amounting a total of 4349 women and 7210 ovulation induction cycle.

Maximum number (15) of RCTs compared CC with Letrozole. Overall the mean EMT was 1.39mm lower in CC group as compared to Letrozole. (WMD, −1.39; 95% CI, −2.27 to −0.51; I² = 100%), and women on CC had a 22% lower chance of pregnancy and 30% lower chance of live births. The ovulation rates were comparable between the two groups.

Only 2 RCTS were found comparing CC with CC plus metformin and no significant difference were noted in any of the outcome parameters between the groups.

When comparing CC with CC plus N-acetyl cysteine (NAC) and CC plus nitric oxide (NO) donor, EMT was lower in CC only group, along with ovulation and pregnancy rates.

When the CC regimen was compared with Tamoxifen, lower EMT and comparable ovulation and pregnancy rates were noted.

The authors concluded that in women with WHO group II ovulatory disorders, Letrozole seems to benefit these women more in terms of increased EMT, ovulation, pregnancy rates and live births. 

Whether the increase pregnancy rates and live births rates are due to increase in EMT has not been looked at in this study.

Abstract

Adequate vitamin D levels result in higher live birth rate in women undergoing ART

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Women undergoing ART with adequate levels of Vitamin D have a 30% increase chances of live birth as compared to women who were found deficient in Vitamin D says the results of a systematic review and meta-analysis published November 15, 2017 in Journal Human Reproduction.

The lead researcher was  Dr Justin Chu, an Academic Clinical Lecturer and Specialist Registrar in Obstetrics and Gynaecology for Tommy's National Centre for Miscarriage Research at the University of Birmingham and Birmingham Women's and Children's NHS Foundation Trust.

It is known that every nearly 20%-50% of women of reproductive age are deficient in Vitamin D and many mechanisms are suggested. This meta-analysis found a higher prevalence of women with Vit D deficiency (34.6%) and insufficiency (34.6%). 

A total of 11 studies conducted over a period of 5 years (2010-2015) were included in the review, amounting to 2700 women receiving ART. Vitamin D levels were labelled as adequate or deficient according to Endocrine Society classification (<50 nmol/l deficient, 50–75 nmol/l insufficient and greater than 75nmol/l replete).

Pooled data from all the study for clinical pregnancy showed that women with more than 75nmol/l of vitamin D levels have 46% higher chances of clinical pregnancy (OR 1.46; CI 1.05–2.02; P = 0.02).

Similarly, these women with replete Vitamin D levels had a 33% increase chance of live birth rate (OR 1.33; CI 1.08–1.65; P = 0.39) and 34% increased chances of biochemical pregnancy (OR 1.34; CI 1.04–1.73; P = 0.28).

No correlation was found between Vitamin D levels and risk of miscarriages.

The main source of vitamin D for people is sunlight. Foods rich in Vitamin D are oily fish, red meat, liver and egg yolks also provide vitamin D, as well as vitamin D supplements

The researchers say the improved ART success in women replete in vitamin D "could be via the actions of vitamin D on the endometrium promoting embryo implantation or as a surrogate marker for general well-being."

Dr Chu, from the University of Birmingham’s Institute of Metabolism and Systems Research, cautioned that the findings do not mean that vitamin D supplementation necessarily improves women’s chances of having a baby following ART as the research can only show an association.

Dr Chu said: “Although an association has been identified, the beneficial effect of correction of vitamin D deficiency or insufficiency needs to be tested by performing a clinical trial.

“In the meantime, women who want to achieve a successful pregnancy should not rush off to their local pharmacy to buy vitamin D supplements until we know more about its effects. It is possible to overdose on vitamin D and this can lead to too much calcium building up in the body, which can weaken bones and damage the heart and kidneys.”

The researchers are calling for large randomizes studies to confirm the findings of other studies and prove causation.

“Testing for vitamin D concentrations is relatively cheap and widely available and its treatment is not costly,” said Dr Chu. “It could be that correcting vitamin D deficiency could benefit women undergoing assisted reproduction treatment, but further research is needed to test this.”

Full Text

News Release by the University of Birmingham

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ACOG updates recommendations for diagnostic imaging during pregnancy and lactation

http://www.infantrisk.com/content/radiological-procedures-pregnancy

ACOG has issued recommendations addressing the concerns surrounding the use of X-ray, sonography, nuclear medicine, CT and MRI in pregnancy and lactation. The committee opinion was published in October issue of Journal Obstetrics and Gynecology.

These investigative modalities have become an integral part of our diagnostic armamentarium for evaluating acute and chronic conditions. However, there is confusion and fear surrounding these tests among physician and patients alike that many times they are delayed or totally avoided. Many a times breast feeding is stopped while patient undergo these investigations.

The ACOG’s committee on obstetric practice make the following recommendations:

Ultrasonography and MRI are safe and are the imaging modalities of choice in pregnancy and lactation, although they should be availed only when they are expected to answer a relevant clinical dilemma or are provide health benefit to the patient.

Routine radiography, computed tomography (CT) scan, or nuclear medicine imaging techniques exposes the pregnant women to a dose that is much lower than what is associated with fetal harm and so these techniques should be used if deemed necessary in addition to USG or MRI or alone if they answer the relevant clinical question.

The use of gadolinium contrast with MRI is not advised in routine practice and should only be used as contrast if it significantly improve the diagnosis and maternal and fetal outcome during pregnancy.

Breastfeeding need not be interrupted after gadolinium administration.

Nuclear Medicine imaging should be limited to the use of technetium 99m at 5 mGy when indicated during pregnancy. 

Radioactive iodine (iodine 131) readily crosses placenta and is absolutely contraindicated in pregnancy.

Full Text 

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Society for Maternal-Fetal Medicine (SMFM) issues guidelines for HCV in pregnancy

The Society for Maternal-Fetal Medicine (SMFM) has issued guidelines for screening and management of Hepatitis C infection in pregnancy.  

The guidelines were published ahead of print in American Journal of Obstetrics and Gynecology.

It is estimated that on average nearly 1-2.5% of pregnant women in US are infected with the virus and the risk of vertical transmission is 5%.

The recommendations are:

1) All women who are at increased risk for Hepatitis C should get tested for anti-HCV antibodies at their first prenatal visit. If the risk persists till later in pregnancy or new risk factor arise, the screening should be repeated again. (GRADE 1B)

According to American Liver Foundation the risk of Hepatitis C is increased if:

• Shared needles to inject drugs or straws to inhale them
• Had tattoos or body piercings in an unclean environment using unsterile equipment
• Worked in a place where you came in contact with infected blood or needles, for example, healthcare workers
• Received a blood transfusion or organ transplant before July 1992
• Received a blood product for clotting problems made before 1987
• Needed to have your blood filtered by a machine (hemodialysis) for a long period of time because your kidneys weren’t working
• Were born to a mother with HCV
• Had unprotected sex with multiple partners
• Have or had a sexually transmitted disease
• Have HIV

2) All HCV positive pregnant women should be screened for other sexually transmitted diseases (STDs) including HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV). (GRADE 1B)

3) All patients with HCV, including pregnant women should be advised to refrain from consuming alcohol. (Best Practice)

4) Direct-acting antiviral medications (DAA) are not to be used in pregnancy, except in settings of clinical trials. The treatment should be initiated after the delivery of the patient in the postpartum period. (Grade 1C).

5) If invasive prenatal testing is requested than amniocentesis is preferred over chorionic villus sampling (CVS) because of limited data on the risk of vertical transmission for CVS over amniocentesis. (Grade 2C).

 6) HCV infection solely is not an indication for Cesarean section in absence of other obstetric indications. (GRADE 1B)

7) Internal fetal monitoring, prolonged rupture of membranes, and episiotomy should be avoided during labor in HCV+ women (Grade 1B).

8) Positive HCV status is not a contraindication for breast feeding. (Grade 1A).

Double layer vs single layer uterine closure in cesarean results in stronger uterine scar and increases chances of vaginal birth in future pregnancies.

Transabdominaluterine scar measurement at 36-38 weeks.

Double layer closure of uterus during previous cesarean section results in thicker third-trimester lower uterine segment and decreases rate of uterine rupture by 3 to 5fold during trial of labor after cesarean (TOLAC) and vaginal birth after cesarean reports results of multicenter prospective cohort study published in July issue of Journal obstetrics and gynecology.

In U.S.A, about 1.3 million babies are delivered by Cesarean every year, which roughly equals to every 1 in every 3 children born in US (33%). Decrease in vaginal births after cesarean and TOLAC has significantly contributed to the rising C-section rates. Significant maternal and neonatal mortality and morbidity because of uterine rupture has increased the rate of elective repeat C-section (ERC).

Lower uterine segment thickness (LUST) as measured by ultrasound is routinely used in clinical practice to estimate the risk of uterine rupture during TOLAC.  A value of <2.0 mm measured between 35 and 38 weeks is significantly associated with greater incidence of uterine rupture or scar dehiscence compared with a measurement >2.0 mm.

The researchers performed a secondary analysis of study conducted at 4 hospitals over a period of 5 years. Out of 1856 women originally recruited, records about uterine closure in previous C-section were available for 1613 patients.

Each of the study participant received transvaginal and transabdominal sonography for measuring LUST between 34 weeks to 38 weeks and 6 days of pregnancy.  Each measurement was confirmed at least 3 times.

Thirty-one percent (495) of patients had undergone a single layer closure, whereas 69% (1118) had undergone a double layer closure at the time of previous C-section.

After adjustment of confounding factors, it was observed that patients with double layer uterine closure had 32% less odds of third-trimester LUST <2.0 mm in the next pregnancy (P<.01).

Type of catgut (Chromic vs synthetic) did not have any effect on thickness of lower uterine segment in next pregnancy. Other factors that resulted in LUST < 2 mm were interdelivery interval <18 months; a body mass index >30 kg/m2; and an elective or planned cesarean delivery.

If previous cesarean was performed in labor than it resulted in thicker lower uterine segment as compared to cesarean performed electively. So, double layer closure becomes all the more important in elective cesarean sections.

Patients were followed up till delivery and it was seen that patients with double layer closure were slightly more likely to undergo TOLAC or vaginal birth. Double layer closure was also significantly less likely to be associated with uterine scar defect and dehiscence.

The authors concluded that, “the current study supports the use of double-layer suture of the uterus at cesarean, especially when it is performed before labor, to optimize uterine scar healing. This technique could lead to a reduction of uterine scar defects during a TOLAC.”

Full text can be accessed here.

Source: Single versus double-layer uterine closure at cesarean: impact on lower uterine segment thickness at next pregnancy

Vachon-Marceau, Chantale et al.

American Journal of Obstetrics & Gynecology , Volume 217 , Issue 1 , 65.e1 - 65.e5

Even low levels of prenatal alcohol exposure will be reflected on the baby’s face

https://abtrs.com/

A small amount of drinking by an expectant mother will show itself by changes in child's craniofacial shape at 12 months reports a study published online in JAMA.

Guidelines from physicians and experts around the world advise against drinking in pregnancy.

The ACOG writes that “there is no safe level of alcohol use during pregnancy,” as also UK’s Department of health which previously advised pregnant women to limit themselves to 1 to 2units once or twice per week. Now the updated guidelines in January 2016, advises even against a small amount of drinking.

The concurrent occurrence of 3 classic facial features( small palpebral fissure, a smooth philtrum, and a thin upper lip is hallmark of fetal alcohol syndrome (FAS). If only 2 features are concurrently present, the condition is labelled as partial FAS.

Some fetuses also present with heavy prenatal alcohol exposure (PAE), but no evidence of FAS or partial FAS.

The study by Evelyne Muggli and her colleagues, shed some light on relationship between low alcohol exposure and changes in child craniofacial shape.

The facial measurements were performed at 12 months of age with the help of 3-D images.

A total of 415 white children were included in the study over a period of 3 years. The mothers were recruited early in first trimester and the amount of alcohol consumed was well documented throughout the pregnancy, including records of drinking even before the pregnancy was documented.

Other confounders which can affect the development of face were taken into consideration.

The authors found consistent association between craniofacial shape and PAE, regardless of whether the exposure occurred early in pregnancy or throughout the pregnancy.  

The faces of affected children had difference in midface, nose, lips, and eyes regions. They also had mid-facial hypoplasia, with shorter and upturned nose. Further analysis showed that different regions of face were affected according to level of drinking in first trimester: in low exposure (forehead), moderate to high exposure (eyes, midface, chin, and parietal region), and binge-level exposure (chin) were affected.

According to a survey, 40% of OB-GYN advice the patients that some amount of alcohol in pregnancy is fine. According to CDC’s Morbidity and Mortality Weekly Report (MMWR), One in 10 pregnant women in the United States reports drinking alcohol and 3.1 percent of pregnant women report binge drinking – defined as 4 or more alcoholic beverages on one occasion.

https://www.mofas.org/drinking-pregnancy/trying-to-get-pregnant/what-women-need-to-know/

The study strength’s lies in well documentation of exposure and outcome. The clinical implications of changes in craniofacial features is not yet known but, the study provides evidence in favor of total abstinence of alcohol during pregnancy.

Frequent, loud snoring increases the risk of preterm delivery: News from the sleep conference

Another interesting paper presented at the annual meeting of the Associated Professional Sleep Societies linking obstructive sleep apnea and preterm and early preterm delivery. Women who are frequent, loud snorers during pregnancy and also before they were pregnant have a definite higher risk of preterm delivery as compared to their counterpart who sleep soundly throughout night.

The paper was presented at the 31st Annual Meeting of the Associated Professional Sleep Societies LLC (APSS), Boston. by Galit Levi Dunietz, PhD, MPH, of the University of Michigan.

It is already known that women with Sleep disordered breathing (SDB) do not fare well in pregnancy and many particularly have maternal hypertension and diabetes and possibly fetal growth restriction.

The study looked at 904 non-hypertensive, non-diabetic women, pregnant women in their third trimester, attending a prenatal clinic at a large medical center.

The women were divided into 4 groups based on their snoring pattern: non-snorers, infrequent-quiet, frequent-quiet, or frequent-loud snorers.

Only 6% of women were frequent loud-snorers and about 50% did not snore at all. 

About 25% of women in the pre-pregnancy frequent, loud- snoring category had a preterm delivery.

After adjusting for all pre-pregnancy and pregnancy confounders, those women who were frequent loud-snorers had an 81% increased risk of preterm delivery.  

The mean time to delivery in frequent loud snoring group was 37.1 weeks as compared to 38.6 weeks in controls.

Non-loud, infrequent, or pregnancy-onset snorers did not face the risk for preterm delivery.

Galit Levi Dunietz, PhD, MPH, of the University of Michigan said, “The fact that there is an association between snoring and time to delivery in a cohort which is not hypertensive is alarming, and I think that treatment for snoring earlier on in pregnancy may alleviate some of these outcomes.”

She further added that “The combination of snoring frequency and intensity may be a clinically useful marker to identify otherwise low-risk women who are likely to deliver earlier.”

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