Amniotic Fluid Embolism: What are the Outcomes and Maternal Mortality Rates?

BACKGROUND AND PURPOSE:

  • Mazza et al. (JAMA Network Open, 2022) examined the clinical, pregnancy, and delivery characteristics and maternal outcomes related to amniotic fluid embolism (AFE)

METHODS:

  • Retrospective cohort study
  • Population
    • Vaginal or cesarean deliveries from January 2016, to December 2019
    • Data obtained from the Healthcare Cost and Utilization Project’s National Inpatient Sample (NIS)
    • NIS represents hospital discharge data for more than 90% of the US population | Based on survey weights based on a random sampling of 20% of hospitalized patients annually
  • Exposure
    • AFE
  • Study design
    • The role of AFE on outcomes was assessed using a  logistic regression model
  • Primary outcome
    • Clinical, pregnancy and delivery characteristics of AFE
    • Maternal mortality after AFE
  • Secondary outcomes
    • Severe maternal morbidity indicators
    • Maternal mortality per clinical and pregnancy characteristics

RESULTS:

  • 14,684,135 deliveries
    • Median age: 29 (IQR, 25 to 33 years)
  • AFE diagnoses: 880
    • Incidence rate: 6.0 per 100,000 deliveries
  • In the multivariable analysis the following factors were associated with AFE
    • Patient factors
      • Older age | Asian and Black race | Western US region | Pregestational hypertension | Asthma | Illicit substance use | Grand multiparity
    • Pregnancy factors
      • Placental accreta spectrum (PAS) | Placental abruption | Uterine rupture | Polyhydramnios | Chorioamnionitis | Preeclampsia | Fetal growth restriction | Fetal demise
    • Delivery factors
      • Early gestational age | Cervical ripening | Cesarean delivery | Operative delivery | Manual removal
  • Among these, placental accreta spectrum had the largest association with AFE
    • Adjusted odds ratio (aOR) 10.01 (95% CI, 7.03 to 14.24)
  • When stratified by the PAS subtypes, more severe forms of PAS had a greater association with AFE
    • Increta and percreta: aOR 17.35 (95% CI, 10.21 to 28.48)
    • Accreta: aOR 7.62 (95% CI, 4.8 to 12.01)
  • Patients who had AFE were more likely to experience
    • Coagulopathy
      • aOR 24.68 (95% CI, 19.38 to 31.44)
    • Cardiac arrest
      • aOR 24.56 (95% CI, 17.84 to 33.81)
    • Adult respiratory distress syndrome
      • aOR 10.72 (95% CI, 8.09 to 14.20)
  • The maternal mortality rate after AFE: 17.0%
  • This rate exceeded 30% when AFE co-occurred with other severe maternal morbidity indicators
    • AFE, cardiac arrest, and coagulopathy: 45.8%
    • AFE, shock, and cardiac rhythm conversion: 43.2%
    • AFE, cardiac arrest, coagulopathy, and shock: 38.6%
  • The maternal mortality rate also exceeded 30% when AFE occurred in the setting of placental pathology
    • AFE and PAS: 42.9%
    • AFE and placental abruption: 31.3%

CONCLUSION:

  • In this population, AFE occurred in 6.0 of every 100,000 deliveries
  • Risk factors associated with AFE were identified
    • Placenta accreta spectrum had the largest associated with AFE
  • Maternal mortality after AFE was high, at 17.0%
    • This rate increased if AFE co-occurred with other maternal morbidity indicators or placental pathology
  • The authors state

It is unknown whether adherence to the Society for Maternal-Fetal Medicine checklist for initial management of AFE is associated with improved maternal outcome

Other studies suggested the importance of high-quality cardiopulmonary resuscitation; correction of coagulopathy, including tranexamic acid use; and extracorporeal membrane oxygenation use for AFE management, but these procedures were not assessed in this study

Learn More – Primary Sources:

Association of Pregnancy Characteristics and Maternal Mortality With Amniotic Fluid Embolism

RCT Results: Does Foot Massage Improve Symptoms for Postmenopausal Women?

BACKGROUND AND PURPOSE:

  • Gökbulut et al. (Menopause, 2022) assessed the impact of foot massage on anxiety, fatigue, and sleep in postmenopausal women

METHODS:

  • Randomized-controlled trial
    • Northern Turkey
    • Between November 1, 2021, and November 30, 2021
  • Participants
    • Gone through menopause naturally in the last year
  • Intervention
    • Foot massage once every day for 7 days
    • No treatment
  • Study design
    • The Fatigue Severity Scale (FSS) and the Beck Anxiety Inventory (BAI) were used to assess outcomes
    • Details of foot massage
      • One of the researchers was internationally certified
      • Quiet and comfortable environment with room temperature approximately 23°C to 26°C
      • Thumb pressure application, swiping, patting, rubbing, and squeezing movements were applied to each foot for 10 minutes same time everyday
    • Sample size: 70 total based on effect size of 0.40, an error level of 0.05, and a power of 0.95
  • Primary outcome
    • Fatigue score
    • Anxiety score
    • Sleep hours achieved

RESULTS:

  • Foot massage: 35 women | Control: 35 women
    • Women in the control group had lower pretest BAI scores than those in the experimental group (P<0.05)
    • Preintervention FSS scores and sleep hours were similar between the groups
  • After the foot massage treatment, women in the intervention group had lower (P
  • FSS scores
    • Foot massage: 2.3 (IQR, 1.6 to 3.4)
    • Control: 5.5 (IQR, 4.6 to 6.2)
  • BAI scores
    • Foot massage: 26.0 (IQR, 23.0 to 29.0)
    • Control: 36.0 (IQR, 31.0 to 43.0)
  • Women in the foot massage group also achieved a greater number of sleep hours after treatment (P
  • Foot massage: 8.0 (IQR, 8.0 to 10.0) hours
    • Control: 7.0 (IQR, 6.0 to 8.0) hours

    CONCLUSION:

    • Postmenopausal women who received foot massage daily achieved a greater number of sleep hours and had lower anxiety and fatigue scores than women who did not receive treatment
    • Limitations include that data came from a specific geographic region
    • Previous studies have noted benefits of reflexology
    • The authors state

    In this study, according to the posttest BAI scores of the participants, the anxiety levels of the women who underwent the foot massage intervention were significantly lower than those who did not undergo the intervention

    Considering that the anxiety levels of the control group before the intervention were significantly lower than those in the experimental group it may be argued that foot massage applied during menopause is a very effective method of reducing anxiety

    Learn More – Primary Sources:

    The impact of foot massage given to postmenopausal women on anxiety, fatigue, and sleep: a randomized-controlled trial

    How Long to Maintain Medical Records?

    Providers keep medical charts for the purpose of providing good care, retaining accurate notes and, when necessary, sharing valuable information with colleagues.  Even after a patient has left care, it is not unusual to receive a request for records.  Patients may move or there may be important medical history that can help diagnose another family member at some point in the future (e.g., heritable cancer syndromes).  Additionally, a well-documented medical record is always the best defense against a medical malpractice lawsuit.  As courtroom adage goes, if it isn’t documented, it didn’t happen.

    Notes made in the medical record at or near the time of treatment are regarded as highly reliable evidence. Without medical records, healthcare providers might not be able to show what care was provided and whether it met the standard of care. Simply stating the level of care and treatment rendered without providing documentation will often not succeed in a court of law, thus leaving the provider liable for the patient’s alleged injuries.

    State and Federal Laws

    State and federal laws regarding mandatory record retention requirements for hospitals or similar facilities differ from the laws for physician practices. The retention period for a minor’s records also varies. This variation exists to allow minors to bring suit for medical malpractice after they reach the age of majority for injuries that occurred when they were under age.

    Generally, the Medicare Conditions of Participation (COP) require hospitals to retain records for five years (six years for critical access hospitals).  HIPAA privacy regulations require records to be retained for six years from when the record was created to adhere to the federal statute of limitations for civil penalties for HIPAA violations.  See record retention requirements from the healthit.gov site in ‘Learn More – Primary Sources’ below.

    Medical Board and Medical Association Policies and Recommendations

    When a direct state or federal law does not specify the retention period for physicians, medical boards may be able to provide policies or recommendations on how long a physician should keep records. For example, the Colorado State Board of Medical Examiners Policy 40-07 requires retaining all patient records for a minimum of 7 years after the last date of treatment, or 7 years after the patient reaches age 18 – whichever occurs later.

    Storage and Safety Considerations

    With the near mandatory use of electronic medical records, the storage of paper records will slowly be eliminated. However, attendant with the use of EMR comes the ever increasing need to prevent loss of data, or worse, hacking and cyber attacks on the electronic data across all industries.  Antiquated infrastructure and uncorrected network vulnerabilities are frequent causes of successful attacks.

    Learn More – Primary Sources

    HealthIT.gov: State Medical Record Laws: Minimum Medical Record Retention Periods for Records Held by Medical Doctors and Hospital

    County of San Bernardino/California Code

    From papyrus to the electronic tablet: a brief history of the clinical medical record with lessons for the digital age

    Patient experiences with electronic medical records: Lessons learned

    Barriers and Facilitators to Online Portal Use Among Patients and Caregivers in a Safety Net Health Care System: A Qualitative Study

    How Has Cervical Cancer Incidence Changed Over the Past 10 Years in the US?

    BACKGROUND AND PURPOSE:

    • Incidence of cervical cancer may have plateaued between 2012 and 2017
    • A decline in cancer screening uptake has been reported, particularly among younger women
    • Shahmoradi et al. (JAMA, 2022) evaluated calendar trends in cervical cancer incidence by age at diagnosis 

    METHODS:

    • Time series data analysis
    • Data
      • National Program of Cancer Registries (NPCR) and Surveillance, Epidemiology, and End Results (SEER) from 2001 to 2019
    • Population
      • Cervical cancer cases
    • Study design
      • Hysterectomy-corrected incidence trends were assessed by removing the proportion of women with hysterectomy from the denominator
      • For age groups with increasing incidence, trends were examined by race and ethnicity, stage, and histology
    • Primary outcome
      • Incidence rates of cervical cancer
      • Trends in cases
      • Annual percentage changes (APCs) by 5-year age group

    RESULTS:

    • 227,062 reported cervical cancer cases
    • Overall, hysterectomy-corrected cervical cancer incidence declined
      • 2001: 12.39 per 100,000
      • 2019: 9.80 per 100,000
      • APC −1.2% (95% CI, −1.6 to −0.9)
    • Among women aged 30 to 34 years, after an initial decline from 2001 to 2012, incidence increased after 2012
      • 2001: 12.77 per 100,000
      • 2012: 10.14 per 100,000
      • 2019: 11.60 per 100,000
      • 2001 to 2012: APC −2.3% (95% CI, −2.8 to −1.7)
      • 2012 to 2019: APC 2.5% (95% CI, 1.4 to 3.6)
    • Among this age group, hysterectomy-corrected cervical cancer incidence increased significantly for
      • Hispanic
        • APC 3.0% (95% CI, 0.3 to 5.7)
      • Non-Hispanic White
        • APC 2.8% (95% CI, 0.6 to 5.0)
      • Other racial and ethnic groups
        • APC 5.0% (95% CI, 2.7 to 7.4)
    • The APC for Black women was relatively stable from 2012 to 2019
      • APC −0.8% (95% CI, −2.8 to 1.2)
    • Increases occurred for
      • Localized stage cervical cancer
        • APC 2.8% (95% CI, 1.3 to 4.3)
      • Regional stage cervical cancer
        • APC 1.9% (95% CI, 0.7 to 3.1)
      • Squamous cell carcinoma
        • APC 2.6% (95% CI, 1.0 to 4.2)
      • Adenocarcinoma
        • APC 3.0% (95% CI, 0.9 to 5.1)

    CONCLUSION:

    • Cervical cancer rates declined or were stable from 2012 to 2019, except among women aged 30 to 34
      • Among this age group the incidence increased by 2.5% per year after 2012

    Possible Explanations for the Increased Incidence Include Guideline Changes in 2012

    • Co-testing (HPV and cytology): Could lead to increased detection of early-stage cancers 
    • Increased screening interval: The authors state

    In 2012, the US Preventive Services Task Force recommended an increase in screening interval in 21- to 65-year-old women with cytology every 3 years or in 30- to 65-year-old women with a combination of cytology and human papillomavirus testing every 5 years

    Beginning in 2013, declines in screening participation among 21- to 29-year-old women were observed

    Future studies are needed to assess factors that underlie the increase in cervical cancer incidence among 30- to 34-year-old women

    Learn More – Primary Sources:

    Cervical Cancer Incidence Among US Women, 2001-2019

    Emergency Contraception: What, When and How?

    Emergency contraception interventions are intended to prevent an unplanned pregnancy after unprotected or inadequately protected intercourse. Contraceptive failure or failure to use contraception are common indications for use.

    CLINICAL ACTIONS:

    • Offer emergency contraception (EC) to all women who have had unprotected or inadequately protected intercourse and who do not desire pregnancy
      • There are no exclusionary health conditions –women who have contraindications to oral contraceptives can be given EC
    • Offer EC to all reproductive-aged women who have sustained sexual assault
    • No clinical examination or pregnancy testing is necessary
    • Treatment should be initiated as soon as possible, and should be made available up to 5 days after unprotected or inadequately protected intercourse
    • If menses are delayed by a week or more, a woman who has received EC should have a pregnancy test and clinical evaluation
    • EC may be used more than once even in the same menstrual cycle
    • Regular contraception should be started immediately after EC and women should abstain or use barrier contraception for 14 days or until onset of next menses
      • Those receiving uripristal acetate should delay starting hormonal contraception until 5 days after use

    SYNOPSIS:

    All of the methods below are effective only before a pregnancy is established. Hormonal EC does not pose a risk to an established pregnancy and is not associated with embryonal developmental abnormalities. Adverse effects for all of the oral methods include nausea and headache as well as irregular bleeding. Adverse effects for the copper IUD include perforation, changes in menses or dysmenorrhea. Pregnancy rates after EC range from 0% to 2.2% and may be impacted by body weight.

    KEY POINTS:

    • Uripristal acetate, a selective progesterone receptor modulator, is given as a single 30 mg dose
      • Requires a prescription
      • Efficacy may be reduced in women with BMI ≥30
      • Effective up to 5 days after unprotected intercourse
      • FDA approved for EC
    • Progestin only EC, either 1 tablet Levonorgestrel in a single dose (1.5 mg) or as a split dose (1 dose of 0.75 mg of levonorgestrel followed by a second dose of 0.75 mg of levonorgestrel 12 hours later)
      • May be less effective in women with BMI ≥25
      • 1 tablet formulation available over the counter without age restriction
      • 2 tablet formulation available over the counter to women ≥17 years with photo ID
      • Effective for up to 3 days after unprotected intercourse
      • FDA approved for EC
    • Copper IUD insertion
      • Requires office visit and insertion by a clinician
      • Efficacy not impacted by body weight
      • Effective up to 5 days after unprotected intercourse
      • Safe and effective but not FDA labeled for use as EC
      • LNG-IUDs “are currently being investigated” (ACOG PB) | Recent RCT suggests LNG-IUD is not inferior to copper IUD (see ‘Related ObG Topics’)
    • Combined progestin-estrogen pills
      • Can use a variety of formulations (see ‘Learn More – Primary Sources’ WHO entry below for a list of appropriate formulations)
      • Two doses every 12 hours
      • All aim for 100 to 120 micrograms of ethinyl estradiol and 0.5 to 0.6 milligrams of levonorgestrel per dose
      • Requires a prescription
      • Effective up to 5 days after unprotected intercourse
      • Safe and effective but not FDA labeled for use as EC

    Learn More – Primary Sources:

    Practice Bulletin No. 152: Emergency Contraception

    CDC: Emergency Contraception

    Emergency contraception | Office on Women’s Health (womenshealth.gov)

    WHO: Emergency contraception

    Second Trimester Nuchal Fold – What Does It Mean?

    CLINICAL ACTIONS:

    The nuchal fold (NF) thickness is a measurement performed on prenatal ultrasound, and is the distance from the outer edge of the occipital bone to the outer edge of the skin in the midline. While both measurements are at the level of the fetal head or neck, a nuchal fold thickness, which is only performed in the second trimester, should not be confused with a first trimester nuchal translucency (NT) measurement.

    If an enlarged second trimester nuchal fold measurement is obtained, next steps should include

    • Detailed anatomic study
    • If isolated finding
      • Offer NIPS screening (or Quad if NIPS unavailable or too expensive) or diagnostic testing (amniocentesis)
      • If NIPS is negative, no further aneuploidy evaluation is required

    Note: ACOG guidance recommends offering prenatal screening for aneuploidy or invasive, diagnostic testing for all pregnant women regardless of age or aneuploidy risk

    SYNOPSIS:

    Second trimester thickened nuchal fold has a high specificity for aneuploidy.  ACOG and SMFM define an abnormal nuchal fold as 6mm in the 2nd trimester (typically performed between 15w0d and 22w6d). It is the most powerful second trimester sonographic marker for Trisomy 21.

    KEY POINTS:

    • Can be differentiated from a cystic hygroma by the lack of fluid filled loculations
    • Trisomy 21 risk is increased by a factor of 17 when the nuchal fold is thickened
    • Can also be associated with single gene abnormalities

    Learn More – Primary Sources:

    ACOG Practice Bulletin 226: Screening for Fetal Chromosomal Abnormalities

    ACOG Practice Bulletin No. 162: Prenatal Diagnostic Testing for Genetic Disorders

    Society for Maternal-Fetal Medicine Consult Series #57: Evaluation and management of isolated soft ultrasound markers for aneuploidy in the second trimester

    Locate a genetic counselor or genetics services:

    Genetic Services Locator-ACMG

    Genetic Services Locator-NSGC

    Genetic Services Locator-CAGC

    Practical obstetrics info for your women's healthcare practice

    Use of CT Scans During Pregnancy

    CLINICAL ACTIONS:

    If a CT (computed tomography) scan is being considered or has been ordered and the patient is pregnant, consider the following questions

    • Would a CT be ordered if the patient was not pregnant?

    If the answer to the above is ‘yes’

    • Is there another option available that would provide the equivalent information on which to base management?
      • If yes
        • Consider an MRI, which is a safe alternative to CT imaging in cases where they are equivalent for the diagnosis in question
      • If no, and there is not an equal or better alternative
        • CT scan should be performed
        • Do not withhold associated contrast material if clinically indicated
    • In addition to a discussion of the risks and benefits with the patient, there are additional resources that can be accessed if necessary, including
      • Genetic counseling services
      • Clinical physicists: some centers have these individuals on staff and they can assist in calculating actual radiation dose and risks associated with exposure in pregnancy

    SYNOPSIS:

    The radiation exposure in pregnancy from CT procedures varies depending on the number and spacing of adjacent imaging sections. It is very unusual for a patient to be exposed to sufficient radiation to cause any significant adverse events. Clinically documented intellectual disability requires at least 610 mGy and growth restriction and anomalies have been reported at levels greater than 50mGy.

    KEY POINTS:

    Fetal Radiation Dose and CT Exam Type

    Dosage levels

    • Very low-dose exam: 0.1 mGy
    • Low- to moderate-dose exam: 0.1 on 10 mGy
    • Higher-dose exam: 10 on 50 mGy

    Type of CT Exam 

    • Head or neck CT (very low-dose)
      • 0.001 on 0.01 mGy
    • Chest CT or CT pulmonary angiography (low- to moderate-dose)
      • 0.01 on 0.66 mGy
    •  Limited CT pelvimetry (low- to moderate-dose)
      • <1 mGy
    • Abdominal CT (higher-dose)
      • 1.3 on 35 mGy

    Pulmonary Embolism

    • A CT evaluation of the chest results in a lower dose of fetal exposure to radiation compared with ventilation perfusion scanning
    • Radiation exposure from a spiral CT is comparable to conventional CT
    • The most commonly used contrast material is an iodinated media which carries a low risk of adverse effects
    • Contrast
      • Should be used only if absolutely required to obtain additional diagnostic information
      • Breastfeeding can be continued after the use of iodinated contrast material

    Learn More – Primary Sources:

    ACOG Committee Opinion 723: Guidelines for Diagnostic Imaging During Pregnancy and Lactation

    Locate a Genetic Counselor or Genetics services:

    Genetic Services Locator-ACMG

    Genetic Services Locator-NSGC

    Genetic Services Locator-CAGC

    Is Active Endometriosis Linked to Worse Pregnancy Outcomes?

    BACKGROUND AND PURPOSE:

    • Lafleur et al. (Obstetrics & Gynecology, 2022) evaluated the association between endometriosis and risk of severe maternal morbidity (SMM)

    METHODS:

    • Population-based retrospective cohort study
    • Population
      • All deliveries at a single hospital between 1989 and 2019
    • Exposure
      • Active endometriosis during pregnancy
      • Inactive endometriosis during pregnancy
      • Diagnosis of endometriosis postpregnancy
      • No endometriosis
    • Study design
      • Rates of SMM were computed using regression analysis
      • Adjustments made for maternal characteristics
      • Definitions
        • Active endometriosis: Required clinical management for pelvic pain or other symptoms during pregnancy
        • Inactive endometriosis: Diagnosed before pregnancy but did not require follow-up during or postpregnancy
    • Primary outcome
      • SMM: Life-threatening maternal conditions during pregnancy or up to 42 days postdelivery

    RESULTS:

    • 2,412,823 deliveries
    • Endometriosis was associated with increased risk for SMM
      • With endometriosis: 46.2 per 1000 patients
      • No endometriosis: 30.7 per 1000 patients
      • Risk ratio (RR) 1.43 (95% CI, 1.36 to 1.51)
    • Active endometriosis was associated with a greater risk for SMM
      • RR 1.93 (95% CI, 1.76 to 2.11)
    • Active endometriosis was also associated with a risk of
      • Severe preeclampsia and eclampsia
      • Severe hemorrhage
      • Hysterectomy
      • Cardiac complications
      • Embolism
      • Shock
      • Sepsis
      • Intensive care unit admission
    • Inactive endometriosis was less strongly associated with these outcomes

    CONCLUSION:

    • Endometriosis was associated with a greater risk for severe pregnancy complications, especially if active during pregnancy
    • The authors state

    These findings suggest that endometriosis has implications beyond common delivery complications

    Effective management of active endometriosis and closer follow-up during pregnancy could potentially mitigate these risks

    Learn More – Primary Sources:

    Association of Endometriosis and Severe Maternal Morbidity

    RCT Results: 6 Weeks vs 3 Months of Rivaroxaban for Isolated Distal DVT

    BACKGROUND AND PURPOSE:

    • Ageno et al. (BMJ, 2022) compared 6 weeks to 3 months of rivaroxaban in patients with symptomatic isolated distal deep vein thrombosis (DVT) for recurrence prevention

    METHODS:

    • Randomized, double blind, placebo controlled clinical trial
      • Rivaroxaban for the treatment of symptomatic Isolated Distal deep vein ThrombosiS (RIDTS) study
      • 28 centers
    • Participants
      • Adults with symptomatic isolated distal DVT
    • Intervention
      • Standard dose rivaroxaban for six weeks followed by
        • Rivaroxaban 20 mg daily for an additional 6 weeks
        • Placebo daily for an additional 6 weeks
    • Study design
      • Follow-up: 24 months from study inclusion
      • Eligibility
        • Isolated distal DVT diagnosis ≤72 hours before baseline visit
        • Any type of parenteral or oral anticoagulant treatment was administered at an intermediate dose (eg, 1 mg/kg once daily for low molecular weight heparin) or therapeutic dose for no more than three days
      • Patients with cancer associated isolated distal DVT were excluded
      • Below the knee class II elastic compression stocking in the symptomatic leg and treatment with non-steroidal anti-inflammatory drugs were permitted
    • Primary outcomes
      • Recurrent venous thromboembolism
        • Composite: Isolated distal DVT | Recurrent isolated distal DVT | Proximal DVT | Symptomatic pulmonary embolism | Fatal pulmonary embolism
      • Major bleeding

    RESULTS:

    • Additional rivaroxaban: 200 participants | Placebo: 202 participants
    • Isolated distal DVT
      • Additional rivaroxaban: 40%
      • Placebo: 43%
    • There was a reduced risk of the composite for recurrent venous thromboembolism in the additional rivaroxaban group
      • Additional rivaroxaban: 11%
      • Placebo: 19%
      • Relative risk (RR) 0.59 (95% CI, 0.36 to 0.95); P=0.03
      • Number needed to treat: 13 (95% CI, 7 to 126)
    • Recurrent isolated distal DVT occurred in fewer patients in the additional rivaroxaban group
      • Additional rivaroxaban: 8%
      • Placebo: 15%
      • P=0.02
    • There was no different in proximal DVT or pulmonary embolism
      • Additional rivaroxaban: 3%
      • Placebo: 4%
      • P=0.80
    • There were no major bleeding events

    CONCLUSION:

    • 3 months of rivaroxaban vs 6 weeks for treatment of isolated distal DVT reduced the risk of recurrent venous thromboembolism
      • The risk reduction was mainly through a reduced risk of recurrent isolated distal DVT
    • There was no increased risk of bleeding with this treatment
    • The authors state

    Compared with placebo, rivaroxaban administered for six additional weeks in patients who completed a six week uneventful period of anticoagulation effectively reduces the risk of recurrent thrombosis over two years without increasing the risk of haemorrhage

    The benefit of reduced risk of recurrence and no increased risk of major bleeds was consistent among patient subgroups, such as patients with axial vein thrombosis and patients with unprovoked event 

    Learn More – Primary Sources:

    Rivaroxaban treatment for six weeks versus three months in patients with symptomatic isolated distal deep vein thrombosis: randomised controlled trial

    Does Invasive Prenatal Testing in Twins Increase the Risk of Miscarriage?

    BACKGROUND AND PURPOSE:

    • Navaratnam et al. (Prenatal Diagnosis, 2022) determine fetal losses for dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twin pregnancies following transabdominal CVS or amniocentesis

    METHODS:

    • Retrospective cohort study
    • 6 tertiary fetal medicine centers in the UK and Belgium
    • Population
      • Individuals with DCDA or MCDA twin pregnancies
      • managed between 2000 and 2020
    • Exposures
      • Invasive prenatal testing: CVS (11w0d to 22w0d) or amniocentesis (15w0d to 22w0d)
      • No invasive procedure exposure
    • Primary outcomes
      • Overall fetal losses <24w0d

    RESULTS:

    • DCDA fetuses
      • CVS: 258 fetuses | Controls: 3406
      • Amniocentesis: 406 | Controls: 3390
    • MCDA fetuses
      • CVS: 98 | Controls: 1124
      • Amniocentesis: 160 | Controls: 1122
    • There were more losses <24w0d with both procedures for both DCDA and MCDA twins
      • DCDA
        • CVS: Relative risk (RR) 5.54 (95% CI, 3.38 to 9.08)
        • Amniocentesis: RR 2.36 (95% CI, 1.22 to 4.56)
      • MCDA
        • CVS: RR 5.14 (95% CI, 2.51 to 10.54)
        • Amniocentesis: RR 7.01 (95% CI, 3.86 to 12.74)
    • Losses of normal (genetic and structural) fetuses were nonsignificant compared to controls
      • DCDA
        • CVS: RR 0.39 (95% CI, 0.05 to 2.83)
        • Amniocentesis: RR 1.16 (95% CI, 0.42 to 3.22)
      • MCDA
        • CVS: RR 2.3 (95% CI, 0.71 to 7.56)
        • Amniocentesis: RR 1.93 (95% CI, 0.59 to 6.38)

    CONCLUSION:

    • Fetal loss is more common among both MCDA and DCDA twin pregnancies following invasive prenatal testing
    • Losses of genetically and structurally normal fetuses were nonsignificant compared to controls
    • The authors state

    The uncertain procedure-related risk to structurally and genetically normal twins persists due to low numbers of adverse outcomes in our cohort and other published analyses

    Any counselling should highlight different baseline risks between MCDA and DCDA twins and the contribution of maternal and pregnancy factors to outcomes for complex twin pregnancies 

    Learn More – Primary Sources:

    Foetal loss after chorionic villus sampling and amniocentesis in twin pregnancies: A multicentre retrospective cohort study

    Beyond ARRIVE: Is Elective Induction Associated with Lower Risk of Cesarean in a Community Hospital Setting?

    BACKGROUND AND PURPOSE:

    • Burrows et al. (Journal of Obstetrics and Gynaecology Canada, 2022) determined the impact of offering elective labor induction at 39 weeks in nulliparous, low-risk pregnancies

    METHODS:

    • Retrospective cohort study
      • Single community hospital in Canada that began offering elective induction at 39 weeks in 2020
      • Study data includes deliveries between September 2018 and December 2021
    • Population
      • Low-risk
      • Nulliparous
      • Singleton pregnancies
      • Delivery at ≥39 weeks
    • Exposures
      • Elective induction at 39w0d to 39w6d
      • Expectant management
    • Primary outcomes
      • Cesarean delivery
      • Adverse perinatal and maternal outcomes

    RESULTS:

    • Elective induction: 56 patients | Expectant management: 118 patients
    • Those in induction group had a significantly lower risk of
      • Cesarean delivery: OR 0.39 (95% CI, 0.15 to 0.99)
      • Composite adverse maternal outcomes: OR 0.34 (95% CI, 0.12 to 0.97)
      • Composite adverse perinatal outcomes: OR 0.26 (95% CI, 0.07 to 0.92)

    CONCLUSION:

    • Performing induction of labor at 39 weeks in nulliparous individuals with low-risk pregnancies was associated with decreased risk for cesarean delivery and adverse maternal and perinatal outcomes vs expectant management
    • The authors state

    The obstetricians at BGH found that most of their patients have appreciated having the option of elective induction at 39+ weeks

    After an informed discussion of the ARRIVE trial results, and most recently the findings from this study, they approximated that 80% to 90% of their patients are currently opting for planned induction at 39+ weeks 

    Learn More – Primary Sources:

    Elective Induction of Labour at 39 Weeks Compared With Expectant Management in Nulliparous Persons Delivering in a Community Hospital