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Learning Objectives
Recognize treatment thresholds for hypertension in pregnancy
Discuss pregnancy outcomes following medical treatment of chronic hypertension
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 faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:
Jeffrey D. Sperling, MD, MS has nothing to disclose The PIM and ObGProject planners and others have nothing to disclose
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 live activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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.
Disclaimer
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.
Thyroid Disease in Pregancy
May 27, 2022 at 10 am ET
FREE for ObGFirst® Members and ObG Resident CORE™Members!
Includes CME | Event will be recorded
Faculty: Jeffrey D. Sperling, MD, MS Moderator: Ashley Comfort, MD, FACOG
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Available exclusively for ObGFirst membersand OBG Resident CORE Members
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Learning Objectives
Discuss the diagnosis and management of common thyroid diseases in pregnancy
Identify discrepancies (there are many) in the guidelines on management of thyroid disease in pregnancy
Describe the recent ACOG Practice Bulletin on thyroid disease in pregnancy
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 faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:
Jeffrey D. Sperling, MD, MS has nothing to disclose The PIM and ObGProject planners and others have nothing to disclose
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 live activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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.
Disclaimer
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.
Is Paternal Metformin Use Associated with Higher Odds of Birth Defects in Offspring?
BACKGROUND AND PURPOSE:
Diabetes medications, such as metformin, have effects on the male reproductive system
Reduces serum testosterone levels independently of glycemic control
Unclear if this association can impact offspring
Wensink et al. (Annals of Internal Medicine, 2022) evaluated whether the risk for birth defects in offspring varies with preconceptional pharmacologic treatment of fathers with diabetes
METHODS:
Nationwide prospective registry-based cohort study
Medical Birth Registry (1997 to 2016)
Contains all registered pregnancies in Denmark >20 weeks
Participants
All liveborn singletons
Mothers without a history of diabetes or hypertension
Exposures
Paternal diabetes medication exposure
Father filled ≥1 prescriptions for a diabetes drug during the development of fertilizing sperm
Study design
Associations were adjusted for
Birth year | Paternal age, income, and education | Maternal age, smoking status, and education
The primary outcomes were compared
Across drugs | Times of exposure | Siblings
Primary outcomes
Offspring sex
Frequencies of major birth defects
RESULTS:
1,116,779 offspring
Insulin exposure: 5298 | metformin exposure: 1451
Offspring with ≥1 major birth defects: 3.3%
Insulin-exposed offspring were not at higher odds of having birth defects than non-exposed offspring
Adjusted odds ratio (aOR) 0.98 (95% CI, 0.85 to 1.14)
Metformin-exposed offspring had an elevated birth defect frequency
aOR 1.40 (95% CI, 1.08 to 1.82)
There were no differences in birth defect frequencies if fathers filled a metformin prescription in the year before or the year after sperm development
Before: aOR 0.88 (95% CI, 0.59 to 1.31)
After: aOR 0.92 (95% CI, 0.68 to 1.26)
Unexposed siblings of exposed offspring also had no differences in birth defect frequencies
Exposed: 3.2%
OR 1.54 (95% CI, 0.94 to 2.53)
Among metformin-exposed offspring, genital birth defects, all in boys, were more common
aOR 3.39 (95% CI, 1.82 to 6.30)
Proportion of male offspring was lower among metformin-exposed offspring but not significant
Exposed: 49.4%
Non-exposed: 51.4%
P=0.073
CONCLUSION:
The paternal use of metformin prior to conception is associated with increased odds of major birth defects, especially genital birth defects in boys
Results demonstrate association but not causation, which would require further studies
Limitations include lack of data on important confounders such glycemic control or obesity
However, birth defects were not found among insulin group or preconception type 2 diabetes and not receiving metformin
The authors state
The observed effect size is similar to that of maternal age greater than 45 years, a recognized risk factor, with 4.8% birth defects among liveborn singletons in our data
The sheer size of the diabetes pandemic suggests that treatment of prospective fathers with diabetes, including pharmacologic management and counseling on diet, physical exercise, and weight loss, should be subject to further study
Meta-Analysis: Risks and Benefits of LMWH vs Direct Oral Anticoagulants for Thromboprophylaxis Prior to Surgery
BACKGROUND AND PURPOSE:
The best method of thromboprophylaxis for non-cardiac surgery is still uncertain
Marcucci et al. (BMJ, 2022) systematically compared the effect of direct oral anticoagulants vs low-molecular weight heparin (LMWH) as thromboprophylaxis for patients undergoing non-cardiac surgery
METHODS:
Systematic review and network meta-analysis
Inclusion criteria
RCTs
Studies in adults undergoing non-cardiac surgery that compared prophylactic LMWH (low or higher dose) with direct oral anticoagulants or with no active treatment
Study design
Network meta-analysis with multivariate random effects models used to assess odds ratios for primary outcomes
GRADE criteria used to evaluate certainty of the evidence
All treatments reduced symptomatic venous thromboembolism, compared to no active treatment
Low-dose LMWH: OR 0.33 (95% CI, 0.16 to 0.67)
High-dose LMWH: OR 0.19 (95% CI, 0.07 to 0.54)
Direct oral anticoagulants: OR 0.17 (95% CI, 0.07 to 0.41)
Certainty of evidence: Moderate to high
Absolute risk differences varied between 1 and 100 per 1000 patients, depending on baseline risks
None of the active agents reduced symptomatic pulmonary embolism
Certainty of evidence: Low to moderate
Compared with no treatment, direct oral anticoagulants and LMWH were both associated with a 2- to 3-fold increase in the odds of major bleeding
Certainty of evidence: Moderate to high
Absolute risk differences were as high as 50 per 1000 in patients at high risk
Compared with low dose LMWH, high dose LMWH
Did not reduce symptomatic venous thromboembolism
OR 0.57 (95% CI, 0.26 to 1.27)
Did increase major bleeding
OR 1.87 (95% CI, 1.06 to 3.31)
Direct oral anticoagulants
Reduced symptomatic venous thromboembolism
OR 0.53 (95% CI, 0.32 to 0.89)
Did not increase major bleeding
OR 1.23 (95% CI, 0.89 to 1.69)
CONCLUSION:
Compared to no treatment, both LMWH and direct oral anticoagulants reduced the odds of venous thromboembolism
However, both treatments probably increased the odds of bleeding
Direct oral anticoagulants probably prevent symptomatic venous thromboembolism better than prophylactic LMWH
The authors conclude
We showed that direct oral anticoagulants and LMWH probably reduce symptomatic venous thromboembolism in major non-cardiac surgery, and that direct oral anticoagulants probably have a relatively greater efficacy than LMWH at the standard prophylactic dose
Is Chorioamnionitis Associated with Increased Risk for Neurodevelopmental Disorders?
BACKGROUND AND PURPOSE:
Tsamantioti et al. (AJOG, 2022) examined the association between chorioamnionitis and neurodevelopmental disorders in offspring
METHODS:
Retrospective population-based cohort study
Swedish Medical Birth Register
Between 1998 and 2019
Population
Singleton live births and stillbirths
All singleton births ≥22 weeks
Exposures
Chorioamnionitis
Study design
Multivariable Cox proportional hazards regression was used to estimate associations with adjusted hazard ratios (aHR)
Additional analysis of the relationship between chorioamnionitis and neurodevelopmental disorders with preterm delivery (<37 weeks) was performed
Primary outcomes
Cerebral palsy
Autism
Attention deficit hyperactivity disorder
Epilepsy
Intellectual disability
RESULTS:
2,228,280 births
Exposed to chorioamnionitis: 0.26%
Incidence of neurodevelopmental disorders across all births during study period
Cerebral palsy: 0.21%
Epilepsy: 0.80%
Autism: 2.27%
Attention deficit hyperactivity disorder: 5.12%
Intellectual disability: 0.65%
After adjusting for potential confounders, exposure to chorioamnionitis increased risk for the following
Cerebral palsy
aHR 7.43 (95% CI, 5.90 to 9.37)
Autism
aHR 1.43 (95% CI, 1.21 to 1.68)
Attention deficit hyperactivity disorder
aHR 1.17 (95% CI, 1.03 to 1.33)
Intellectual disability
aHR 1.99 (95% CI, 1.53 to 2.58)
Chorioamnionitis was not significantly associated with higher rates of epilepsy
Associations were mainly explained through preterm delivery, although increased risk was also observed among term infants
CONCLUSION:
Exposure to chorioamnionitis in utero is associated with increased risks for cerebral palsy, autism, attention deficit hyperactivity disorder, and intellectual disability
These risks are mostly explained through preterm birth
The authors state
Efforts for timely identification and appropriate interventions to treat infections during pregnancy will have sustained benefits in reducing the burden of neurological complications in children at the population level
ALTAR RCT Results: Methenamine Hippurate Prophylaxis for Recurrent UTI
BACKGROUND AND PURPOSE:
Harding et al. (BMJ, 2022) compared the efficacy of methenamine hippurate for prevention of recurrent UTI with the current standard prophylaxis of daily low dose antibiotics
METHODS:
Multicenter, open label, randomized, non-inferiority trial
The ALTAR trial (alternative to prophylactic antibiotics for the treatment of recurrent urinary tract infections in women)
8 centers across the UK
Participants
Women ≥18 years
Recurrent UTI requiring prophylactic treatment
Interventions
Antibiotic prophylaxis for 12 months (standard treatment) | Oral once daily | Choice of antibiotic dependant on urine culture and history of allergy or intolerance
Nitrofurantoin (50 or 100 mg) or
Timethoprim (100 mg) or
Cefalexin (250 mg)
Methenamine hippurate for 12 months
1 g oral twice daily
Study design
Participants were randomly assigned 1:1
Recurrent UTI definition
≥3 episodes of symptomatic UTI in the previous 12 months or
≥2 episodes in the past six months
Treatment allocation was not masked and crossover between arms was allowed
A patient and public involvement group predefined the non-inferiority margin as one episode of UTI per person year
Intention-to-treat analyses
All participants observed for at least six months
Primary outcome
Absolute difference in incidence of symptomatic UTIs requiring antibiotic treatment
RESULTS:
Standard treatment: 102 participants | Methenamine hippurate: 103
Incidence of UTIs requiring antibiotic treatment during the 12-month study period
Standard treatment: 0.89 episodes per person year (95% CI, 0.65 to 1.12)
Methenamine hippurate: 1.38 episodes per person year (95% CI, 1.05 to 1.72)
Methenamine hippurate was confirmed to be non-inferior to the standard treatment of low dose prophylactic antibiotics
Absolute difference in UTI incidence: 0.49 (90% CI, 0.15 to 0.84)
Incidence of adverse reactions
Standard treatment: 24%
Methenamine hippurate: 28%
Most reactions were mild
Only 2 serious adverse reactions (severe abdominal pain and raised alanine transaminase), both in antibiotic group
CONCLUSION:
In this trial, methenamine hippurate was found to be non-inferior to antibiotic prophylaxis for the prevention of recurrent UTI
Methenamine hippurate may be appropriate for some women with recurrent UTI
Limitations of the study include lack of blinding and heterogeneity of prophylactic antibiotics prescribed
The authors state
The range of a priori outcomes reported confirm clinical utility of methenamine hippurate as a non-antibiotic option for prevention of urinary tract infection in this pragmatic trial, which allows generalisability of results
Diagnosing Hypertension: How Do Clinic, Home and Kiosk BP Measurements Compare?
BACKGROUND AND PURPOSE:
Prior to making a new hypertension diagnosis, the USPSTF recommends blood pressure (BP) monitoring outside of a clinic setting
24 hour ambulatory BP monitoring (ABPM) is one non-clinic option, but its use is infrequent in the US
Home BP monitoring (HBPM) is another possibility, but requires training and the use of validated monitoring systems
BP monitoring at kiosks found in pharmacies or clinic waiting rooms are an alternative, but their use has not been compared to the other monitoring options
Green et al. (Journal of General Internal Medicine, 2022) compared clinic-, home-, and kiosk-based BP measurement to ABPM for diagnosing hypertension
METHODS:
Randomized diagnostic study
12 Washington State primary care centers
Participants
18 to 85 years
Elevated BP: ≥138 mmHg systolic or ≥88 mmHg diastolic at last outpatient visit No hypertension diagnosis in the prior 2 years
No prescribed antihypertensive medications in the prior 12 months
Without diagnosed hypertension or prescribed antihypertensive medications
Interventions
Clinic: Usual care follow-up BPs
Home: Duplicate BPs twice daily for 5 days
Kiosk (pharmacy or clinic waiting area): Triplicate BPs on 3 separate days
Study design
All participants completed ABPM at 3 weeks
Primary outcome
Difference between ABPM daytime mean systolic BP and BP measured with intervention
Secondary outcomes
Difference in diastolic BP
Sensitivity
Specificity
RESULTS:
434 participants
Mean age: 58.7 years
80.2% White
Adjusted mean differences in systolic BP, compared to daytime ABPM
Clinic: −4.7mmHg (95% CI, −7.3 to −2.2); P<0.001
Home: −0.1mmHg (95% CI, −1.6 to 1.5); P=0.92
Kiosk: 9.5mmHg (95% CI, 7.5 to 11.6); P<0.001
Adjusted mean differences in diastolic BP, compared to daytime ABPM
Clinic: −7.2mmHg (95% CI, −8.8 to −5.5); P<0.001
Home: −0.4mmHg (95% CI, −1.4 to 0.7); P=0.52
Kiosk: 5.0mmHg (95% CI, 3.8 to 6.2); P<0.001
Sensitivity and specificity, compared to ABPM
Clinic
Sensitivity: 31.1% (95% CI, 22.9 to 40.6)
Specificity: 79.5% (95% CI, 64.0 to 89.4)
Home
Sensitivity: 82.2% (95% CI, 73.8 to 88.4)
Specificity: 53.3% (95% CI, 38.9 to 67.2)
Kiosk
Sensitivity: 96.0% (95% CI, 90.0 to 98.5)
Specificity: 28.2% (95% CI, 16.4 to 44.1)
CONCLUSION:
Compared to ABPM, clinic BPs that were significantly lower, and kiosk BPs were significantly higher
There was no difference with home BP monitoring
Clinic BP measurements have low sensitivity for detecting hypertension | Kiosk BP measurements have low specificity
The authors state
BP is highly variable, particularly among individuals with untreated hypertension, with systolic often varying by 30–40 mmHg or more during daytime hours
Home provided many more BPs, with average standard deviation smaller than single or duplicate clinic measurements
Findings support utility of home BP monitoring for making a new diagnosis of hypertension
RCT Results: Relugolix Versus Leuprorelin for the Management of Endometriosis-Associated Pelvic Pain
BACKGROUND AND PURPOSE:
Relugolix (REL) is an oral GnRH antagonist medication
Leuprorelin (LEU) is a sustained-released GnRH agonist that downregulates the GnRH receptor
Harada et al. (Fertility and Sterility 2021) evaluated the efficacy and safety of 40-mg REL vs LEU in women with endometriosis-associated pain
METHODS:
Phase 3, multicenter, randomized, double-blind, double-dummy, active-controlled study
42 centers in Japan
Participants
≥20 years
Regular menstrual cycles (25 to 38 days)
Endometriosis or ovarian endometrioma and pelvic pain
Interventions
REL group: 40 mg of REL, orally administered once a day for 24 weeks
LEU group: 3.75 or 1.88 (body weight <50 kg) mg of LEU, subcutaneously injected every 4 weeks for 24 weeks
Primary outcome
Change in the maximum visual analog scale (VAS) score for pelvic pain from baseline until the end of treatment period (last 28 days of the treatment period including those who completed treatment up to 24 weeks or discontinued treatment early)
Secondary outcomes
Change from baseline to the end of treatment for
Mean VAS score | Menstrual pain | Nonmenstrual pelvic pain (NMPP) | Dyspareunia
RESULTS:
REL group: 171 participants | LEU group: 164 participants
REL was found to be noninferior to LEU at reducing maximum visual analog scale score for pelvic pain
Changes in the mean (±SD) maximum visual analog scale score
REL: −52.6 ± 1.3
LEU: −57.5 ± 1.4
Ovarian endometrioma also decreased among both treatment groups
REL: –12.26 ± 17.52 cm3
LEU: –14.10 ± 18.81 cm3
Return of menses
REL: Median, 38 days
LEU: Median 68 days
By approximately 4 months, menstruation had returned to almost all patients
Drug-related treatment emergent adverse events (TEAE) with an incidence of >10% for both groups
Hot flushes
Metrorrhagia
Headache
Genital hemorrhage
Discontinuations due to TEAE
REL: 2.9%
LEU: 4.3%
CONCLUSION:
Relugolix was found to be noninferior to leuprorelin at reducing endometriosis-associated pelvic pain
Both treatment groups experienced similar levels of adverse events
Women in the relugolix group had their menses return earlier than those in the leuprorelin group
The authors state
The recovery of the serum E2 levels and menstruation after EOT occurred earlier for REL than for LEU, a huge advantage for patients who plan to become pregnant
In addition, because REL is an oral drug, patients often recover from a TEAE more quickly after stopping treatment
Have Stage IV Breast Cancer Diagnoses Increased During the COVID-19 Pandemic?
BACKGROUND AND PURPOSE:
The COVID-19 pandemic has disrupted cancer screening programs, such as mammograms and colonoscopies, and this may have led to an increase in late-stage cancer diagnoses during the pandemic
Zhou et al. (JAMA Network Open, 2022) compared the incidence of early- and late-stage breast and colorectal cancer diagnoses during vs before the COVID-19 pandemic
METHODS:
Quality improvement study
Participants
All patients presenting to a cancer center for a new diagnosis of malignant neoplasm or a second opinion
Exposures
Presentation in 2019
Presentation in 2020
Study design
Fisher exact test used to compare the proportions of stage I or stage IV of cancers between 2019 and 2020
Primary outcome
Stage distribution at presentation for
Cancer overall
Colorectal cancer
Breast cancer
RESULTS:
Men: 55 | Women: 476
Mean age: 58.1 (SD, 13.5) years
The total number of new patient visits for malignant neoplasm was similar in 2019 and 2020
In 2019: 1894 visits
In 2020: 1915 visits
Overall Cancer
The overall stage distribution for all patients with cancer was similar
Stage I
In 2019: 31.9% of patients
In 2020: 29.0% of patients
OR 1.15 (95% CI, 1.00 to 1.32); P=0.05
Stage IV
In 2019: 26.0% of patients
In 2020: 26.4% of patients
OR 0.98 (95% CI, 0.84 to 1.13); P=0.77
Colorectal Cancer
After the start of the COVID-19 pandemic, there was no significant decrease in colorectal cancer
Stage I
In 2019: 17.8%
In 2020: 14.6%
OR 1.26 (95% CI, 0.34 to 4.88); P=0.78
Stage IV
In 2019: 6.7%
In 2020: 19.5%
OR 0.3 (95% CI, 0.05 to 1.37); P=0.11
Breast Cancer
Among patients with breast cancer, a lower percentage of patients presented with stage I disease in 2019 vs 2020
In 2019: 63.9%
In 2020: 51.3%
OR 1.67 (95% CI, 1.13 to 2.47); P=0.008
There was a significantly higher number of patients presenting with stage IV breast cancer in 2020
In 2019: 1.9%
In 2020: 6.2%
OR 0.33 (95% CI, 0.09 to 0.98); P=0.04
Recent data for January through March 2021 demonstrate a continuing trend of a lower percentage of patients with breast cancer presenting with stage I disease and a higher percentage presenting with stage IV disease
Stage I: 41.9%
Stage IV: 8.0%
CONCLUSION:
The percentage of patients presenting with stage IV breast cancer increased in 2020, compared to before the COVID-19 pandemic
Limitations include a single center study | Study design addresses associations but not causality | Colorectal cancer cases were limited
The authors state
There is increasing concern regarding the effect of the COVID-19 pandemic on cancer mortality, as the evidence suggests that the number of patients presenting at late, incurable stages is increasing. Patients who have delayed preventative care during the pandemic should be encouraged to resume treatment as soon as possible
Is Obesity Linked to Weaker Uterine Contractility During Labor?
BACKGROUND AND PURPOSE:
Hautakangas et al. (BJOG, 2022) investigated the impact of severe obesity (BMI ≥35 kg/m2) on uterine contractile activity
METHODS:
Exploratory, blinded analysis of a prospective cohort from a previous RCT
Primary RCT compared intrauterine and external tocodynamometries and labor outcomes
Population
Singleton pregnancies
≥ 37 weeks
Cephalic presentation
Intrauterine tocodynamometry during labor
Exposures
Severe obesity: BMI ≥35 kg/m2
Primary outcome
Uterine contractile activity
Assessed as intrauterine pressure, frequency of contractions and basal tonus of uterine muscle
Secondary outcomes
Use of oxytocin
Labor outcomes
RESULTS:
686 participants
BMI ≥35 kg/m2: 84 participants
Participants with obesity reached intrauterine pressure ≥200 MVUs during the first stage of labor more often than those with BMI <35 kg/m2
BMI ≥35 kg/m2: 62%
BMI <35 kg/m2: 49%
OR 1.67 (95% CI, 1.05 to 2.67)
Participants with obesity also had a higher basal tone of uterine muscle
Women with obesity without a previous vaginal delivery
Were more likely to fail to reach the active stage of labor
OR 2.36 (95% CI, 2.39 to 4.37); P=0.005
Were more likely to require cesarean
OR 1.88 (95% CI, 1.08 to 3.27); P=0.024
If a parturient had had previous vaginal delivery
Obesity did not influence uterine activity
There was no increased risk for caesarean
Doses and total oxytocin amounts did not significantly differ between BMI groups
CONCLUSION:
Women with obesity were less likely to reach the active stage of labor and were more likely to require cesarean
However, these outcomes are probably not due to decreased uterine contractile activity as uterine contractility was increased vs leaner participants
The authors state
The uterine contractile activity of obese parturients is equal to or even greater than that of leaner parturients, but obese parturients less often achieve vaginal delivery
However, if the active stage of labour is reached, obese parturients have labours that are as straightforward as those among leaner parturients
CDC Surveillance: ART-Related Birth Outcomes in the US
BACKGROUND AND PURPOSE:
Pregnancies resulting from assisted reproductive technology (ART) are at higher risk of adverse obstetrical outcomes
Sunderam et al. (CDCMMWR, 2022) report on US state-specific ART procedures performed in 2018 and compare ART birth outcomes with outcomes for all infants born in the United States in 2018
METHODS:
Population cohort study
Data derived from all fertility clinics in the US that provide and verify information about the outcomes of the ART cycles through the National ART Surveillance System (NASS), a web-based data collection system developed by CDC
Population
Live births in the US in 2018
Exposures
Conception via ART
State of patient residence
Primary outcomes
Number of ART procedures performed
Incidence of adverse obstetrical outcomes (e.g., small for gestational age)
RESULTS:
ART Procedures Performed
ART procedures performed in 2018: 203,119
Live birth deliveries: 73,831
Infants born: 81,478
Rate of ART procedures performed among women 15 to 44 years old: 3,135 per 1 million women
ART use was 1.5 times higher than the national rate in 7 states and the District of Columbia
Connecticut, Illinois, Maryland, Massachusetts, New Jersey, New York, and Rhode Island
ART Embryo Transfers
Average number of embryos transferred was similar across age groups
Women aged <35 years: 1.3
Women aged 35 to 37 years: 1.3
Women aged >37 years: 1.4
Single-embryo transfer (SET) rate among all embryo-transfer procedures
Women aged <35 years: 74.1%
Women aged 35 to 37 years: 72.8%
Women aged >37 years: 66.4%
ART Conceived Births
In 2018, 2.0% of all infants born the US were conceived with ART
The majority of infants conceived with ART were singletons: 78.6%
Twins: 20.7%
Triplets and higher order multiples: 0.6%
ART contribution to multiple birth
All multiple births attributable to ART: 12.5%
Twins attributable to ART: 12.5%
Triplets and higher order births attributable to ART: 13.3%
The percentage of multiple births was higher among infants conceived with ART
ART: 21.4%
Total birth population: 3.3%
ART Obstetrical Outcomes
Low birthweight (<2,500 g) attributable to ART: 4.2%
The percentage of low birthweight infants was higher in the ART conceived population
ART: 18.3%
Total birth population: 8.3%
Preterm (<37 weeks) births attributable to ART: 5.1%
The percentage of preterm births was higher among infants conceived with ART
ART: 26.1%
Total birth population: 10.0%
CONCLUSION:
Most infants conceived via ART procedures are singletons, though the percentage of multiple births are higher among those conceived with ART
The percentage of low birthweight and preterm births is also higher among infants conceived by ART
The authors state
Since 1995, the number of ART procedures performed and the number of infants born as a result have more than tripled in the United States
With this increasing use, ART-conceived infants represented approximately 2% of infants born in 2018 in the United States and contributed to approximately 4% and 5% of all low birthweight and preterm births, respectively
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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.
Disclaimer
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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