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
CDC Guidelines on the Prevention and Control of Influenza in Pregnancy
SUMMARY:
The CDC provides guidance for managing pregnant women who have suspected or confirmed flu. Of note, pregnant women are considered to be in the high-risk category. ACOG has a committee statement that provides recommendations aligned with the CDC.
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 confirmed or suspected influenza of any severity due to complication risks associated with pregnancy
To reduce treatment delay
Inform patients regarding need for early treatment and signs and symptoms of influenza
Other: Vomiting | Diarrhea | Conjunctivitis | Fever may be absent
Ensure rapid access to telephone consultation and clinical evaluation during pregnancy and postpartum
Consider empiric antiviral treatment based on telephone contact if hospitalization is not indicated and if this will substantially reduce delay before treatment is initiated
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
Preferred
Oseltamivir 75 mg orally twice daily for 5 days
Alternative medications
Zanamivir: Two 5-mg inhalations (10 mg total) twice daily for
5 days
Peramivir: 600-mg dose IV over 15 to 30 minutes
Not recommended: Baloxavir
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
Person to Person
Flu viruses spread mainly by droplets made when people with flu cough, sneeze, or talk
Most common
Droplets can land in the mouths or noses of people who are nearby (usually within about 6 feet away) or possibly be inhaled into the lungs
Less often
Touching a surface or object that has flu virus on it and then touching their own mouth, nose, or possibly their eyes
When Are People with Flu Contagious?
Flu viruses can usually be detected one day before symptoms develop and up to 5 to 7 days after becoming sick
People with flu are most contagious in the first 3 to 4 days after illness begins
In theory, possible for an infected person to spread flu viruses to close contacts while still asymptomatic
Symptoms typically begin approximately at 2 days (range from 1 to 4 days) following infection of the respiratory tract
Asymptomatic individuals can spread virus to close contacts
Note: Those with weakened immune systems may be contagious for >7 days
Postexposure Antiviral Chemoprophylaxis
Due to high risk for complications, postexposure antiviral chemoprophylaxis should be considered for pregnant and postpartum individuals who have been in close contact with infectious individuals
Oseltamivir 75 mg daily for 7 days
Influenza and COVID-19
Influenza and COVID-19 have overlapping signs and symptoms
Do not wait for test results before initiating empiric antiviral treatment for influenza if suspected
If a patient tests positive for SARS-CoV-2 infection, Paxlovid can be taken together with oseltamivir
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
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
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
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
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
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
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)
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’
CONCEPTT Study: Time for Continuous Glucose Monitoring for All Pregnant Women with Type 1 Diabetes?
BACKGROUND AND PURPOSE:
Continuous glucose monitoring (CGM) provides contemporaneous glucose readings, thus allowing patients to adjust insulin in real-time
Data in non-pregnant women show benefit but conflicting data in pregnancy
Feig et al. (Lancet, 2017) determined the effectiveness of continuous glucose monitoring (CGM) on maternal glucose control compared to capillary glucose monitoring alone
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
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