Antenatal Corticosteroids – When to Administer?

The appropriate use of antenatal corticosteroids improves neonatal outcomes, including decreased severity and/or frequency of respiratory distress syndrome (RDS), intracranial hemorrhage, necrotizing enterocolitis and death. Antenatal corticosteroids, when appropriate, are administered in a clinical setting where patients are at risk for preterm delivery within 7 days, irrespective of membrane status and fetal number.

Clinical Actions:

Risk of preterm delivery within 7 days

Between 24w0d to 33w6d – ‘Recommended’

    • Single course of corticosteroids

Between 22w0d and 23w6d – ‘May be Considered’

  • 23w0d to 23w6d
    • Single course of corticosteroids
  • 22w0d to 22w6d
    • Single course of corticosteroids

Note: ACOG and SMFM revised recommendation states

Antenatal corticosteroids may be considered at 22 0/7 weeks to 22 6/7 weeks of gestation if neonatal resuscitation is planned and after appropriate counseling

Some families may choose to forgo resuscitation and support after appropriate counseling

Between 20w0d and 21w6d – ‘Not Recommended’

  • Antenatal corticosteroids are not recommended due to lack of data suggesting benefit

Late preterm (34w0d – 36w6d)

ACOG 

  • If no previous corticosteroids
    • Single course of betamethasone
    • Not indicated in women diagnosed with clinical chorioamnionitis

SMFM 

  • Single course of betamethasone in specific populations
    • Population included in ALPS trial: Recommended
      • Nonanomalous singleton gestation
      • High risk for preterm delivery (medically indicated or spontaneous)
      • No prior antenatal steroids
    • Select populations not in the original ALPS trial: Suggest consideration for use in the following clinical scenarios
      • Multiple gestations reduced to a singleton gestation ≥14w0d
      • Fetal anomalies
      • Expected to deliver in less than 12 hours
    • Low likelihood of delivery <37 weeks: Recommend against
    • Pregestational diabetes: Recommend against due to risk for worsening neonatal hypoglycemia

Repeat or Rescue Courses

  • Regularly scheduled repeat courses or serial (> 2) courses
    • Not recommended
  • If a patient has received one prior course of corticosteroids > 14 days ago, is less than 34w0d gestation and is at risk of preterm delivery within 7 days
    • a single repeat course of corticosteroids should be considered (change from previous ‘may’)
    • Rescue course corticosteroids could be provided as early as 7 days from the prior dose, if indicated by the clinical scenario (based on Cochrane meta-analysis)
  • Preterm prelabor rupture of membranes (PPROM)
    • There is insufficient evidence to make a recommendation for or against repeat or rescue courses

Dose and Regimen: give first dose even if 2nd dose unlikely

  • Betamethasone: 12 mg IM, 2 doses 24 hours apart
  • Dexamethasone:  6 mg IM, 4 doses 12 hours apart

Learn More – Primary Sources

ACOG Committee Opinion 713: Antenatal Corticosteroid Therapy for Fetal Maturation

ACOG Practice Advisory: Use of Antenatal Corticosteroids at 22 Weeks of Gestation

ACOG Practice Bulletin No. 171 : Management of Preterm Labor

Society for Maternal-Fetal Medicine (SMFM) Consult #58: Use of Antenatal Corticosteroids for Individuals at Risk for Late Preterm Delivery

Society for Maternal-Fetal Medicine Special Statement: Quality metrics for optimal timing of antenatal corticosteroid administration – American Journal of Obstetrics & Gynecology (ajog.org)

Meta-analysis Results: Do Shoulder Dystocia Simulations Reduce the Prevalence of Neonatal Brachial Plexus Palsy?

BACKGROUND AND PURPOSE: 

  • Guidelines aimed at reducing neonatal brachial plexus palsy (NBPP) due to shoulder dystocia suggest use of simulation exercises (with mannequins) 
  • Wagner at al. (AJOG, 2021) evaluated the outcomes associated with the implementation of simulation exercises to reduce NBPP with shoulder dystocia 

METHODS:

  • Systematic review and meta-analysis 
  • Study inclusion criteria 
    • Frequency of shoulder dystocia  
    • Associated complications before and after the implementation of interventional exercises  
  • Study design 
    • Study effects were combined using a Bayesian meta-analysis and were reported as risk ratios and 95% credible intervals (Crs) 
  • Primary outcomes 
    • NBPP diagnosed following deliveries complicated by shoulder dystocia 
    • Presence of brachial palsy at 12 months or later 
  • Secondary outcomes 
    • Frequency of shoulder dystocia 
    • Cesarean delivery 

RESULTS:

  • 16 studies | 428,552 deliveries 
    • Deliveries during preintervention guideline period: 50.8% 
    • Deliveries during postintervention period: 49.2% 
  • The incidence of neonatal brachial plexus palsy after shoulder dystocia decreased from preintervention to postintervention period  
    • Preintervention period: 12.1%  
    • Postintervention period: 5.7% 
    • Risk ratio (RR) 0.37 (95% Cr, 0.26 to 0.57); probability of reduction 100% 
  • The overall proportion of neonatal brachial plexus palsy decreased  
    • Preintervention period: 0.3% 
    • Postintervention period: 0.1% 
    • RR 0.53 (95% Cr, 0.21 to 1.26); probability of reduction 94% 
  • 2 studies followed newborns with brachial plexus palsy for at least 12 months reported conflicting data  
    • Study 1: Reduction in persistent NBPP following integration of guideline interventions 
      • Preintervention: 1.9% 
      • Postintervention: 0.2% 
      • RR 0.13 (95% CI, 0.04 to 0.49) 
    • Study 2: No difference in persistent NBPP 
      • Preintervention: 0.3 per 1000 births 
      • Postintervention: 0.2 per 1000 births 
      • RR 0.77 (95% CI, 0.31 to 1.90) 
  • Following the implementation of shoulder dystocia interventional exercises, the diagnosis of shoulder dystocia increased significantly 
    • Preintervention: 1.2% 
    • Postintervention: 1.7% 
    • RR 1.39 (95% Cr, 1.19 to 1.65); probability of increase 100% 
  • Compared with the preintervention period, the cesarean delivery rate increased postimplementation 
    • Preintervention: 21.2% 
    • Postintervention: 25.9% 
    • RR 1.22 (95% Cr, 0.93 to 1.59); probability of increase 93% 

CONCLUSION: 

  • There was a 63% risk reduction for newborn brachial plexus palsy after the introduction of shoulder dystocia simulation exercises   
  • However, introduction of simulation exercises also increased the diagnosis of shoulder dystocia diagnoses by 39% and cesarean delivery by 22%  
  • Study limitations 
    • In many studies, there was lack of matching and adjustment for confounding  
  • The authors state that the results of this study  

…demonstrate mixed clinical outcomes following introduction of shoulder dystocia simulation, indicate the need for a reassessment of the recommendations calling for the universal implementation of shoulder dystocia interventional exercises 

The uncertainties surrounding the nature of the interventional exercises and the necessary audience, the potential unintended consequences, the questionable improvement in the long-term sequelae of shoulder dystocia along with resource utilization and cost-effectiveness together construct a compelling reason to undertake an adequately powered trial that incorporates long-term follow-ups 

Wagner at al. (AJOG, 2021)

Learn More – Primary Sources:

Interventions to decrease complications after shoulder dystocia: a systematic review and Bayesian meta-analysis 

 

Can High Dose Nitric Oxide Improve Respiratory Function in Pregnant Women with Severe COVID-19?

PURPOSE:

  • There is limited data on how best to manage respiratory failure in pregnant women with COVID-19
  • Safaee Fakhr et al. sought to determine if administering high concentrations of nitric oxide could improve the clinical course of pregnant women with respiratory failure  

METHODS:

  • Case series (April to June 2020)
  • 6 pregnant patients admitted with severe or critical COVID-19
  • Patients received high-dose (160–200 ppm) nitric oxide by mask twice daily
    • Treatment sessions lasted 30 minutes to 1 hour
    • For those patients requiring mechanical ventilation, the high dose regimen was stopped and restarted after extubation | During intubation, the patients received continuous low dose nitric oxide through the ventilator

RESULTS:

  • Total of 39 treatments
  • Cardiopulmonary function improved with administration of nitric oxide
    • Systemic oxygenation: Improved following each administration session in hypoxemic patients
    • Tachypnea: Reduced among all patients each session
  • 3 deliveries while in hospital
    • 4 neonates
    • 28-day follow-up: All mothers and infants in good condition at home
  • 3 remaining patients:
    • Discharged home and still pregnant at time of publication  
  • There were no adverse events documented

CONCLUSION:

  • While acknowledging the small cohort size, the authors also conclude that

Nitric oxide at 160–200 ppm is easy to use, appears to be well tolerated, and might be of benefit in pregnant patients with COVID-19 with hypoxic respiratory failure

Learn More – Primary Sources:

High Concentrations of Nitric Oxide Inhalation Therapy in Pregnant Patients With Severe Coronavirus Disease 2019 (COVID-19)

Pregnant Women with COVID-19 at Time of Delivery: NYC Cohort Characteristics and Outcomes

BACKGROUND AND PURPOSE:

  • Khoury et al. (Obstetrics & Gynecology, 2020) characterized clinical features and disease course among the initial cohort of pregnant women during the COVID-19 pandemic in New York City admitted for delivery

METHODS:

  • Prospective cohort study (March 13 to April 12, 2020 with follow-up completed April 20, 2020)
  • Setting
    • Five New York City medical centers
  • Participants
    • Pregnant women admitted for delivery
    • Confirmed COVID-19  
  • Study design
    • Data collected: Demographics | Presentation | Comorbidities | Maternal and Neonatal outcomes | COVID-19 clinical course
  • COVID-19 cases were defined as
    • Asymptomatic
    • Mild: no additional oxygen supplementation required
    • Severe: Dyspnea | Respiratory rate ≥30 breaths | Oxygen saturation ≤93% | Pneumonia
    • Critical: Respiratory failure | Septic shock | Multiple organ dysfunction or failure

RESULTS:

  • 241 women included
    • Asymptomatic on admission: 61.4% | 69% remained asymptomatic
  • Clinical status at time of hospitalization for delivery
    • Mild: 26.5%
    • Severe: 26.1%
    • Critical: 5%
  • Singleton preterm birth rate: 14.6%
  • Critical outcomes
    • ICU admission: 7.1% of women (17 women)
    • Intubation during delivery: 3.7% (9 women)
    • Maternal deaths: 0 women
  • BMI ≥30 associated with COVID-19 severity (P=0.001)
  • Cesarean delivery rates
    • Severe COVID-19: 52.4%
    • Critical COVID-19: 91.7%
    • Linear trend across COVID-19 severity groups for cesarean risk (P<.001)
  • 245 liveborn neonates
    • Resuscitation at delivery beyond normal requirements: 30%
    • NICU admission: 25.7% | Hospitalization <2 days in 62.4%
  • Newborn outcomes
    • Prematurity and low birth weight: 8.7% (most common complications)
    • RDS: 5.8%
    • No complications: 79.3%
  • 97.5% of newborns tested negative for SARS-CoV-2 at 24 to 96 hours  
  • IUFD: 2 cases
    • Case 1: 38 weeks without fetal movement | Symptoms of COVID-19 pneumonia including chest imaging | No supplemental oxygen required | Patient declined autopsy and further work up for COVID-19 | No abnormalities were seen on placental pathology
    • Case 2: 29 weeks of gestation | FGR <1%tile | HELLP syndrome | Severe COVID-19 pneumonia

CONCLUSION:

  • Majority of pregnant women admitted for delivery were asymptomatic for COVID-19  
    • Approximately 1/3 remained asymptomatic
  • Obesity was associated with COVID-19 severity
  • For women with COVID-19 (particularly severe and critical) there is an increased risk for cesarean and preterm birth

Learn More – Primary Sources:

Characteristics and Outcomes of 241 Births to Women With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection at Five New York City Medical Centers

CDC Guidelines on the Prevention and Control of Influenza in Pregnancy

SUMMARY:  

The CDC has released guidance for managing pregnant women who have suspected or confirmed flu. Of note, pregnant women are considered to be in the high-risk category.

Pre-Delivery 

Suspected or laboratory-confirmed influenza  

  • Place in a private room on Droplet Precautions 
    • If patient is hospitalized, continue Droplet Precautions for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer 
    • Discharge patient from medical care when clinically appropriate, not based on the period of potential virus shedding or recommended duration of Droplet Precautions 
  • Instruct patient to follow respiratory hygiene and cough etiquette, including wearing a facemask, if being transported outside of her room 
  • Health care personnel entering rooms of pregnant women with suspected or confirmed influenza should adhere to Standard and Droplet Precautions, which include  
    • Donning a facemask upon entry into the room 
    • Performing hand hygiene 
    • Wearing gloves for any contact with potentially infectious materials 
    • Wearing gowns for any patient-care activity where contact with body fluids may occur 
  • Patient and visitor education  
    • Inform regarding the risks of influenza virus transmission  
    • Instruct about adherence to respiratory hygiene and cough etiquette, hand hygiene, and use of personal protective equipment (PPE) according to current facility policy 

During Delivery 

Suspected or confirmed influenza, on labor & delivery floor  

  • Patient should remain on Droplet Precautions 
  • Health care personnel on labor & delivery should adhere to Standard and Droplet Precautions, including practicing hand hygiene before and after handling the newborn 

After Delivery 

To reduce the risk of influenza virus transmission to the newborn 

  • Consider temporarily separating the mother who is ill with suspected or confirmed influenza from her baby following delivery during the hospital stay 
  • Discuss the risks and benefits of temporary separation with the mother  
    • Ideal setting for care of a healthy term newborn while in the hospital is within the mother’s room 
    • Newborns infected with influenza virus are at increased risk for severe complications 
  • Decisions about temporary separation should be made in accordance with the mother’s wishes 
  • Throughout the course of temporary separation 
    • Feedings should be provided by a healthy caregiver if possible 
    • Mothers should be encouraged to express their milk to establish and maintain milk supply 
    • Expressed breastmilk should be fed to the newborn 
  • Because the ideal length of temporary separation in the hospital is not yet established, assess on a case-by-case basis and consider the following in the decision process  
    • Risk/benefit factors  
    • If the mother has been afebrile without antipyretics for >24 hours 
    • Whether the mother can control her cough and respiratory secretions 
  • If co-location (“rooming in”) of the newborn with his/her ill mother in the same hospital room, limit influenza-virus exposure of the newborn using the following strategies  
    • Use engineering controls like physical barriers (e.g., a curtain between the mother and newborn) 
    • Keep the newborn ≥6 feet away from the ill mother 
    • Ensure a healthy adult is present to care for the newborn 
    • If no other healthy adult is present in the room to care for the newborn 
      • Instruct the mother to put on a facemask and practice hand hygiene before each feeding or other close contact with her newborn 
      • Retain use of facemask during contact with the newborn  
      • Continue these practices while on Droplet Precautions in the hospital 
  • Once contact between mother and newborn is resumed 
    • Droplet Precautions for influenza should continue to be observed in the hospital until at least 7 days after maternal illness onset 

Nursery 

If a newborn of a mother with suspected or confirmed influenza is in the nursery  

  • Newborn care can be provided by a non-ill person using Standard Precautions and the newborn should be closely observed for signs of infection 
  • Symptomatic mothers, care givers, and family members should not enter the nursery 
  • If a newborn develops signs of the flu, place on Droplet Precautions and have the newborn examined by a physician 
    • Test for influenza  
    • Consider oseltamivir treatment 

KEY POINTS:  

Treatment  

CDC considers women who are pregnant or postpartum (within 2 weeks after delivery) to be at high-risk  

  • CDC recommends starting oseltamivir treatment as soon as possible for 
    • Hospitalized patients with suspected or confirmed influenza 
    • High-risk outpatients with suspected or confirmed influenza 
  • Administer antiviral treatment as early as possible   
    • Ideally, within 48 hours of symptom onset  
    • Do not delay treatment even for a few hours while awaiting test results 
    • Treatment initiation even after 48 hours can still be beneficial   
  • Adult dose for oseltamivir is 75 mg twice daily for 5 days

Visitors

  • Visitors should be limited to persons who are necessary for patient’s care/wellbeing   
  • Visitors who have been in contact with an infected patient before and during her hospitalization are a possible source of influenza for other patients, visitors, and staff 
  • Screen all visitors for acute respiratory illness  
    • Only allow asymptomatic individuals to visit 
    • Instruct visitors to limit their movement within the facility 
  • Facilities should provide instruction, before visitors enter patients’ rooms, on proper hygiene and procedures 

Before Hospital Discharge 

  • Strongly encourage and, if possible, provide the flu vaccination to 
    • Any unvaccinated family members aged 6 months and older  
    • Caregivers in contact with the newborn 
  • Advise caregivers that they should 
    • Contact their health care provider promptly if the newborn develops signs that suggest a flu infection 
    • Isolate any individuals in the home who become ill to protect the newborn 
    • Ensure that the ill postpartum woman follows hand hygiene and respiratory hygiene and cough etiquette when having contact with her newborn 
  • Caregivers, if possible, should be limited to vaccinated non-ill adults until the mother’s flu resolves 

How Flu Spreads

The CDC provides the following information on contagiousness of the flu

Person to Person
People with flu can spread it to others up to about 6 feet away. Most experts think that flu viruses spread mainly by droplets made when people with flu cough, sneeze or talk. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. Less often, a person might get flu by touching a surface or object that has flu virus on it and then touching their own mouth, nose, or possibly their eyes.

When Flu Spreads
People with flu are most contagious in the first three to four days after their illness begins.  Most healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick. Children and some people with weakened immune systems may  pass the virus for longer than 7 days.

Symptoms can begin about 2 days (but can range from 1 to 4 days)  after the virus enters the body. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as while you are sick. Some people can be infected with the flu virus but have no symptoms. During this time, those people may still spread the virus to others.

Period of Contagiousness
You may be able to pass on flu to someone else before you know you are sick, as well as while you are sick.

People with flu are most contagious in the first 3-4 days after their illness begins.
Some otherwise healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 to 7 days after becoming sick.
Some people, especially young children and people with weakened immune systems, might be able to infect others with flu viruses for an even longer time.

Learn More – Primary Sources:  

CDC Guidance for the Prevention and Control of Influenza in the Peri- and Postpartum Settings

CDC: Recommendations for Obstetric Health Care Providers Related to Use of Antiviral Medications in the Treatment and Prevention of Influenza

CDC: Influenza Antiviral Medications: Summary for Clinicians

CDC: How Flu Spreads

ACOG Committee Opinion 753: Assessment and Treatment of Pregnant Women with Suspected or Confirmed Influenza 

Which Thrombophilias in Pregnancy Warrant Thromboprophylaxis? 

BACKGROUND AND PURPOSE:

  • Thrombophilias are a known risk factor for venous thromboembolism (VTE) in pregnancy
  • Pregnancy increases the risk of VTE in pregnancy approximately five to sixfold
  • Data is limited on absolute risk of pregnancy-associated VTE in women with thrombophilias and there are no meta-analyses
  • Croles et al. (BMJ, 2017) sought to establish evidence that could be used to update guidelines for prevention of VTEs in pregnant women with heritable thrombophilias

METHODS:

  • Systematic Review and meta-analysis
  • Included studies with information on specific inherited thrombophilias
    • Antithrombin deficiency
    • Protein C deficiency
    • Protein S deficiency
    • Factor V Leiden mutation (heterozygous or homozygous)
    • Prothrombin G20210A mutation (heterozygous or homozygous)
    • Compound heterozygous factor V Leiden and prothrombin G20210A mutation
  • VTE was considered established if it was confirmed by objective means, or when the patient had received a full course of a full dose anticoagulant treatment without objective testing
  • Studies were classified as family and non-family studies due to increased risk based on family history
    • Non-family cohort studies rarely included data on women with high risk thrombophilias

RESULTS:

  • 36 studies were included in the systematic review (12 case-control; 24 cohort studies)
    • 41,297 pregnancies included
  • All thrombophilias increased the risk for pregnancy-associated VTE (probabilities ≥91%)
  • Thrombophilias with high absolute risks included the following (absolute risk, using 95% credible interval range)
    • Antithrombin deficiency
      • Antepartum: 7.3% (1.8% to 15.6%)
      • Postpartum: 11.1 (3.7% to 21.0%)
    • Protein C deficiency
      • Antepartum: 3.2% (0.6% to 8.2%)
      • Postpartum: 5.4% (0.9% to 13.8%)
    • Protein S deficiency
      • Antepartum: 0.9% (0.0% to 3.7%)
      • Postpartum: 4.2% (0.7% to 9.4%)
    • Homozygous factor V Leiden
      • Antepartum: 2.8% (0.0% to 8.6%)
      • Post partum: 2.8% (0.0% to 8.8%)
    • Absolute combined antepartum and postpartum risks for women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutations, or compound heterozygous factor V Leiden and prothrombin G20210A mutations were all below 3% (cut-off for thromboprophylaxis used in some guidelines)

CONCLUSION:

  • Based on 3% risk cut-offs, authors draw the following conclusions for antepartum prophylaxis and prophylaxis up to six weeks postpartum for women with no previous VTE
    • Suggest prophylaxis for women with antithrombin and protein C deficiency if they have a positive family history.
    • Consider prophylaxis for women with homozygous factor V Leiden mutations for women with a family history and additional risk factors for VTE
    • Suggest prophylaxis for women with protein S deficiency and a positive family only in postpartum
    • Cannot give recommendations for homozygous prothrombin G20210A mutation due to lack of cohort data
  • In contrast, women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutation, or compound heterozygous factor V Leiden and prothrombin G20210A mutation should generally not receive thrombosis prophylaxis on the basis of thrombophilia and family history alone

Learn More – Primary Sources:

Pregnancy, thrombophilia, and the risk of a first venous thrombosis: systematic review and bayesian meta-analysis

Results of the BUMPES Trial: Sitting Up or Lying Down to Promote Vaginal Delivery with an Epidural in the 2nd Stage of Labor?

BACKGROUND AND PURPOSE:

  • Recent Cochrane Review did not demonstrate a difference between upright or recumbent when assessing the chance of a spontaneous vaginal birth in women with epidural anesthesia
  • Brockehurst et al. (BMJ, 2017) sought to determine whether the  upright position  during the second stage of labor increases the chance of spontaneous vaginal birth in women with a low-dose epidural

METHODS:

  • Birth in the Upright Maternal Position with Epidural in Second stage (BUMPES) Trial
  • Multicenter randomized controlled trial (RCT)
  • Inclusion Criteria
    • ≥ 16 years, ≥ 37 weeks gestation, nulliparous, singleton cephalic presentation, and intended to have a spontaneous vaginal birth
    • 2nd stage with low dose epidual in situ
  • Subjects were assigned to the following groups:
    • Upright position
      • Maintain pelvis in as vertical a plane as possible
      • Walking, kneeling, sitting etc. all acceptable
    • Lying down position
      • Up to 30 degrees inclination
    • Groups were stratified by center
      • Blinding of participants or clinicians not possible
    • Primary outcome was spontaneous vaginal birth
    • Secondary outcomes were
      • mode of birth, perineal trauma, infant Apgar score <4 at 5 minutes, admission to a neonatal unit
      • longer term outcomes included maternal physical and psychological health, incontinence, and infant gross developmental delay

RESULTS:

  • 1,556 participants were in the upright group and 1,537 in the lying down group
  • Primary Outcome
    • There were significantly fewer spontaneous vaginal births in the upright group (35.2%) vs the lying down group (41.1%) with adjusted risk ratio (RR) 0.86 (95% CI 0.78 to 0.94)
  • Secondary Outcomes
    • No evidence of difference for most of the secondary maternal, neonatal, or longer term outcomes including
      • Vaginal delivery, obstetric anal sphincter injury, infant Apgar score <4 at five minutes and maternal fecal incontinence at one year

CONCLUSION:

  • There is a 5.9% absolute increase in the chance of spontaneous vaginal birth in the lying down group
  • Authors recognize limitations of the study
    • Inability to mask
    • Unless there is an indication to do otherwise, guidance and practice promote women using any position they find more comfortable and may have resulted in superior adherence in the upright group
  • No obvious mechanism to explain findings
  • When adding this current cohort of approximately 3,000 well randomized women to previous data, sum of evidence strengthens findings in this paper
    • Combining present results with previous data, odds ratio of upright vs lying down is 0.80 (95% CI 0.70 to 0.92)

Learn More – Primary Sources:

Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomized controlled trial

Does Intrapartum Fever Really Predict Neonatal Sepsis?

BACKGROUND AND PURPOSE:

  • There is guidance from the CDC, ACOG and AAP that well-appearing newborns should undergo limited evaluation for possible sepsis if mothers have suspected chorioamnionitis
  • In some hospitals, newborn sepsis work-up may require NICU admission
  • Towers et al. (AJOG, 2017) sought to evaluate the rate of fever during labor and whether there is an association with early-onset neonatal sepsis

METHODS:

  • Prospective cohort study (2011 – 2014)
  • Patients with fever (≥38°C) at ≥36 weeks’ gestation were evaluated for
    • gestational age, parity, spontaneous or induced labor, group B streptococcus status, regional anesthesia, mode of delivery, treatment with intrapartum antibiotics, and whether a clinical diagnosis of chorioamnionitis was made by the managing physician
  • Cases started labor afebrile but then developed fever prior to delivery with no other infectious cause identified
  • Neonates were assessed for blood culture results, neonatal intensive care unit admission, length of stay, and any major newborn complications

RESULTS:

  • 412 patients developed a fever in 6,057 deliveries (6.8%; 95% CI 6.2–7.5%)
  • No cases of maternal sepsis
  • There was no difference in rate of newborn sepsis in fever vs. control group (p=0.3)
    • Febrile group: 1 newborn out of 417 developed sepsis from Escherichia coli (0.24%; 95% CI 0.01–1.3%)
    • Non-febrile group: 4 cases of early-onset neonatal sepsis, 2 with GBS and 2 with Escherichia coli (0.07%; 95% CI 0.02–0.18%)

CONCLUSION:

  • The incidence of intrapartum fever is common at 6.8% and consistent with retrospective studies, although is double the rate in the CDC guideline of 3.3%
  • Neonatal sepsis incidence rate in the population of women with fever ≥36 weeks’ gestation is rare at 0.82/1000 live births
  • Need to treat (NTT): 1/417 neonates
  • Authors suggest that the practice of follow-up cultures and universal antibiotic treatment in well-appearing newborns in the setting of intrapartum fever may not be ‘clinically sound’

Learn More – Primary Sources:

Incidence of fever in labor and risk of neonatal sepsis

CONCEPTT Study: Time for Continuous Glucose Monitoring for All Pregnant Women with Type 1 Diabetes?

BACKGROUND AND PURPOSE:

  1. Continuous glucose monitoring (CGM) provides contemporaneous glucose readings, thus allowing patients to adjust insulin in real-time
  2. Data in non-pregnant women show benefit but conflicting data in pregnancy
  3. Feig et al. (Lancet, 2017) determined the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control compared to capillary glucose monitoring alone

METHODS:

  • Multicenter, open-label, randomized controlled trial (2013-2016)
  • 31 hospital centers in Canada, England, Scotland, Spain, Italy, Ireland, and the USA
  • Women aged 18 to 40 years, with type 1 diabetes for a minimum of 1 year, receiving intensive insulin therapy, and pregnant or planning pregnancy
    • Live singleton fetus confirmed by ultrasound
    • ≤13 weeks and 6 days’ gestation
    • Pregnant: HbA1c between 6.5–10.0% (48–86 mmol/mol)
    • Planning for pregnancy: 7.0–10.0% (53–86 mmol/mol)
  • Ran 2 trials in parallel for (1) pregnant and (2) planning pregnancy
  • In both trials, participants were assigned to the following cohorts
    • Receive CGM in addition to capillary glucose monitoring
    • Receive capillary glucose monitoring
  • Randomization was stratified by insulin delivery and baseline HbA1c
  • Primary outcome was change in HbA1c
    • at 34 weeks’ gestation in pregnant participants
    • at 24 weeks for planning pregnancy participants
  • Secondary outcomes included obstetric and neonatal health outcomes

RESULTS:

  • 325 women were randomized
  • When comparing pregnant CGM users to capillary monitored group, CGM users
    • had a slightly greater change in HbA1c (mean difference -0.19%; 95% CI -0.34 to -0.03; p=0.0207)
    • Spent more time in target range (68% vs 61%; 0.0034)
    • Spent less time hyperglycemic range (27% vs 32%; p= 0.0279)
    • Had comparable hypoglycemic episodes
    • Spent comparable amount of time in hypoglycemic range (3% vs 4%, respectively)
  • Neonatal outcomes in CGM users were significantly improved
    • Lower incidence of large for gestational age (odds ratio [OR] 0.51, 95% CI 0.28 – 0.90; p=0.0210)
    • Fewer NICU admissions lasting more than 24 h (OR 0.48; 95% CI 0.26 – 0.86; p=0.0157)
    • Fewer incidences of neonatal hypoglycemia (OR 0.45; 95% CI 0.22 to 0.89; p=0.0250)
    • 1-day shorter length of hospital stay (p=0.0091)
  • There was no apparent benefit of CGM for women planning pregnancy
  • CGM users had significantly more adverse skin reactions during trials (48% CGM vs 8% control during pregnancy; 44% CGM vs 9% control planning pregnancy)
  • Data was generalizable across centers

CONCLUSION:

  • CGM during pregnancy in patients with type 1 diabetes is linked to improved neonatal outcomes, likely because of better maternal glycemic control and reduced maternal hyperglycemia
  • Number needed to treat (NNT) with CGM
    • 6 pregnant women NNT to prevent one NICU admission
    • 6 pregnant women NNT to prevent one large for gestational age
    • 8 pregnant women NNT to prevent one case of neonatal hypoglycemia
  • The authors conclude that guidelines in type 1 diabetes in pregnancy should be revised to recommend offering CGM to pregnant women with type 1 diabetes using intensive insulin therapy in the first trimester

Learn More – Primary Sources:

Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial.

Prenatal Sonographic Features and Parental Origin of Triploidy

BACKGROUND AND PURPOSE:

  • Triploidy results from an extra haploid chromosome set of paternal (diandric) or maternal (digynic) origin
  • Occurs in 1–2% of all conceptions, with majority resulting in early embryonic/fetal loss
  • McFadden and Kalousek prenatal sonographic assessment
    • Diandric phenotype: Relatively normal-sized fetus with microcephaly or normal head circumference, but abnormally large, cystic placenta
    • Digynic phenotype: Asymmetric fetal growth and non-cystic placenta
  • Massalska et al. (Prenatal Diagnosis, 2017) sought to determine
    • The pattern of sonographic abnormalities in triploid pregnancies
    • The efficacy of McFadden and Kalousek prenatal sonographic assessment

METHODS:

Retrospective case analysis in a single unit between 1997 and 2015

RESULTS:

  • Data analysis of 67 triploidy cases (64 singletons and 3 twins) between 11 and 30 weeks gestation
  • All invasive testing was the result of fetal growth restriction and/or fetal anomalies
    • NT was increased in 25% of fetuses with diandric or undefined phenotype and no fetus with digynic phenotype, consistent with previous research
  • Abnormal ultrasound findings included
    • Fetal growth restriction: 81.5%
    • Oligohydramnios: 50.7%
    • Structural defects: 61.2%
    • Multiple structural anomalies: 35.8%
      • Central nervous system, heart and urinary tract were most common
  • ‘Diandric Phenotype’ was seen in 11.9% of fetuses that presented with cystic placentas
  • ‘Digynic phenotype’ was identified in 70.2% asymmetrically growth-restricted fetuses with non-cystic placentas
  • 17.9% of cases featured both diandric and digynic phenotype
  • There were no live births in this cohort in cases with follow-up due to termination, IUFD or spontaneous miscarriage

CONCLUSION:

  • Almost 40% of triploid fetuses do not appear to have structural abnormalities
  • Diandric triploidy based on previous literature (small ‘n’) carries high risk for maternal complications
    • Preeclampsia and HELLP reported to be between 4 and 35%
    • Molar placenta changes not required
  • In approximately 20% of triploid pregnancies, parental origin cannot be detected using McFadden and Kalousek assessment

Learn More – Primary Sources:

Triploidy – variability of sonographic phenotypes

Is Air Travel Safe in Pregnancy?

CLINICAL ACTIONS:

Occasional air travel during pregnancy is generally safe but is not recommended for women who have medical or obstetric conditions that may be exacerbated by flight or that could require emergency care. If a pregnant patient does opt to fly, consider the following discussion points:

  • Use a seat belt continuously while seated to avoid turbulence-induced trauma
    • Ensure that the belt sits low on the hip bones between the protuberant abdomen and the pelvis
  • Avoid gas-producing food or drink before flying to decrease general discomfort as entrapped gasses will expand at higher altitudes
  • Consider preventive antiemetic medication especially for those women experiencing nausea
  • Noise and vibration are a negligible risk
  • Cosmic radiation is a negligible risk
    • National Council on Radiation Protection and Measurements and the International Commission on Radiological Protection recommend a maximum annual radiation exposure limit of 1 millisievert (mSv) (100 rem) for general public and 1 mSv over the course of a 40-week pregnancy
    • The longest intercontinental flight will not exceed 15% of this limit
  • Check with the individual carrier for specific airline requirements as policies may vary
  • Pregnant civilian and military air crew members should check with their specific agencies for regulations and/or restrictions on their flying duties

Note: ACOG has updated guidance regarding aircrew and frequent flyers and provides the following statement

The Federal Aviation Administration and the International Commission on Radiological Protection consider aircrew to be occupationally exposed to ionizing radiation and recommend that they be informed about radiation exposure and health risks

  • The Federal Aviation Administration (FAA) has a document (see ‘Learn More – Primary Sources’ below) that provides tables and links to websites to aid in the calculation of effective dose of galactic cosmic radiation by a crewmember while inflight
    • The document also includes tables that provide risks for severe genetics defects
  • The CDC also has a site with a section for aircrew (see ‘Primary Sources – Learn More’ below)

SYNOPSIS:

Most commercial airlines allow pregnant women to fly up to 36 weeks of gestation. However, some airlines restrict pregnant women from international flights earlier in gestation and some require documentation of gestational age.  Changes in vital signs (increased maternal heart rate, increased blood pressure, decreased aerobic capacity) may result due to cabin pressure and humidity levels alterations.

KEY POINTS:

  • The following preventative measures can be used to minimize the risk of lower extremity edema and venous thromboembolic events
    • Support stockings
    • Periodic movement of the lower extremities
    • Occasional ambulation during flight
    • Avoiding restrictive clothing
    • Ensuring adequate hydration

Learn More – Primary Sources:

ACOG Committee opinion 746: Air Travel During Pregnancy

FAA: What Aircrews Should Know About Their Occupational Exposure to Ionizing Radiation

US Department of Transportation Advisory Circular: In-Flight Radiation Exposure

CDC: Cosmic Ionizing Radiation