ACOG MFM SOAP SPA & ASA Respond to Epidural/Autism Study – No Evidence to Support Causation
Learning Objectives and CME/Disclosure Information
This activity is intended for healthcare providers delivering care to women and their families.
After completing this activity, the participant should be better able to:
1. Describe the results from the Qui et al. (JAMA Pediatrics, 2020) study that looked at epidural exposure during labor and association with autism spectrum disorders 2. Discuss the limitations of this study
Estimated time to complete activity: 0.25 hours
Ashley Comfort, MD, FACOG is the Director of Medical Content, ObG Project.
Disclosure of Conflicts of Interest
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.
Faculty: Ashley Comfort, MD, has a financial interest in Pfizer and has no other conflicts of interest to disclose.
Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.
Method of Participation and Request for Credit
Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 3/31/2022 through 3/1/2023, participants must read the learning objectives and faculty disclosures and study the educational activity.
If you wish to receive acknowledgment for completing this activity, please complete the test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.
For Pharmacists: Upon successfully completing the test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.
Joint Accreditation Statement
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Physician Continuing Medical Education
Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Continuing Nursing Education
The maximum number of hours awarded for this Continuing Nursing Education activity is 0.25 contact hours.
Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.
ACOG, MFM, Society for Obstetric Anesthesia and Perinatology, American Society for Anesthesiologists and the Society of Pediatric Anesthesia have released a joint statement in response to a retrospective study (Qui et al. JAMA Pediatrics, 2020) that suggests an association between epidural anesthesia and autism. The joint statement states that this study “…does not provide credible scientific evidence that labor epidurals for pain relief cause autism.”
Study Overview (Qui et al. JAMA Pediatrics, 2020)
Retrospective longitudinal cohort study (2008 to 2015)
Kaiser Permanente Southern California
Vaginal delivery (singleton)
28 to 44 weeks’ gestation
Data derived from EMR
Children not enrolled as KPSC health plan members by 1 year of age were not included
Maternal social demographic characteristics (age at delivery, parity, educational level | Self-reported maternal race/ethnicity, and median family household income based on census tract of residence) | Medical center of delivery | History of comorbidity (≥1 diagnoses of heart, lung, kidney, or liver disease or cancer) | Maternal obesity |Diabetes | Preeclampsia or eclampsia | Smoking during pregnancy | Child characteristics at delivery (gestational age at delivery, birth weight, sex, and presence of any birth defect)
147,895 singleton children | males: 50.3% | Mean GA: 38.9 weeks
Exposure to epidural during labor: 74.2%
Autism spectrum disorders
Epidural group: 1.9%
No epidural: 1.3%
Hazard ratio (adjusted): 1.37 (95% CI, 1.23-1.53) | Fever did not affect results
Length of exposure (epidural group vs no epidural group)
<4 hours: Risk was 33% greater
4 to 8 hours: Risk was 35% greater
>8 hours: Risk was 46% greater
There were significant limitations related to this study
Important potential uncontrolled confounders (before, during and after pregnancy) not included in the model, inlcuding
Paternal history | Genetic predisposition | Viral or bacterial infection | Toxic exposures
Epidural information not assessed: Medication | Additives | Dosing
The researchers state that
…our findings should be interpreted with caution given the wide varieties of LEA practice and cannot be interpreted as a demonstration of a causal link between LEA exposure and subsequent development of ASD
Joint Statement by Professional Societies
As noted by researchers, there is no evidence of causation provided by this study
Details regarding the course of labor are not available
There is no evidence for biologic plausibility provided in this study or previous literature for detrimental neurologic effects of very low doses of epidural medications on fetus or infant
Neuraxial analgesia remains the gold standard for labor pain relief
Furthermore, the joint statement reinforces the following points
…if anything, epidurals improve maternal and neonatal outcomes
…five medical societies that represent more than 100,000 physicians want to assure the public that an association between a mother’s use of epidural analgesia during childbirth, and her infant’s risk of developing autism does not imply causation
Millions of women worldwide benefit from epidural pain relief every year and give birth without any complications to mother or baby
Royal College of Anaesthetists
In the statement released by the Royal College of Anaesthetists, they provide a review of study limitations including
Patient characteristics: Children not enrolled with the health insurance scheme by one year of age were excluded | “Lower socioeconomic status is widely recognised to be associated with under diagnosis of autism” | Results may have been different if researchers had included the results from this excluded group
In addition, this document addresses the absence of antepartum and intrapartum clinical information
…one of the surprising aspects of this study is lack of data about pregnancy and delivery complications which are known to increase the risk of autism
Such complications as prolonged duration of labour, fetal distress, fetal malposition and assisted vaginal delivery are also known to be associated with an increased request rate for epidurals. It is possible therefore that birth complications are actually the hidden factor linking epidurals and autism
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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