Does Maternal Depression or Stress Affect Fetal Growth?
BACKGROUND AND PURPOSE:
Intrauterine fetal growth restriction (FGR or IUGR), defined as weight below the 10th percentile, has been associated with excessive maternal stress
Most studies are based on birth weight, and therefore cannot fully assess timing of various exposures in addition to confounders
Grobman et al. (Journal of Ultrasound in Medicine, 2017) sought to determine whether women reporting greater perceived stress or depression symptoms at start of or during pregnancy would demonstrate altered longitudinal fetal growth
METHODS:
NICHD Fetal Growth Study multicenter prospective (2009 – 2013)
Women screened at 8 weeks and 13 weeks 6 days gestation for stress/depression status and underwent serial sonographic examinations
Definition of high risk
Cohen Perceived Stress Scale (PSS): Score ≥ 15
Edinburgh Postpartum Depression Survey (EPDS): Score of ≥ 10 (13 used for sensitivity analysis)
Fetal weight growth curves and individual biometric parameters were created using serial sonographic data
Interaction between race/ethnicity and stress/depression scores were assessed
RESULTS:
Multicenter longitudinal study of 2334 women
89% and 90% of women completed PSS and EPDS, respectively, at least once in all trimesters
Despite participant’s reported PSS or EPDS score, longitudinal growth curves and fetal weight were similar
Race/ethnicity did not modify biometric parameters
CONCLUSION:
Quantified depressive symptoms and greater perceived stress are not associated with alterations in fetal growth throughout all three trimesters
Authors recommend further research to determine whether combination of stress and/or depression with environmental factors may alter fetal growth
This paper complements the Wing et al. study that likewise did not find an association between perceived maternal stress and neonatal growth measurements (summarized in ‘Related ObG Topics’ below)
Gestational Thrombocytopenia – a Diagnosis of Exclusion
Thrombocytopenia is a common finding which occurs in 7-12% of pregnant women. The cause of isolated thrombocytopenia may be differentiated by history, physical examination, laboratory investigation, and medical imaging.
CLINICAL ACTIONS:
When evaluating a patient for gestational thrombocytopenia (GT), consider the following
≥Use platelet count <150 x 109/L to define thrombocytopenia in pregnancy
Normal platelet range in nonpregnant women is 165-415 x 109/L
Expect lower platelet counts in pregnant women, especially 3rd trimester
Order the following tests to assist with diagnosis/underlying cause
Based on clinical context, may require medical imaging to evaluate splenic size
Diagnose GT in the absence of historical, clinical, hematological and biochemical findings that would suggest another underlying condition
Transfuse platelets to achieve minimum platelet counts if
<10 x 109/L even without surgery and/or procedures
<50 x 109/L if active bleeding present unless undergoing cesarean in which case prophylactic platelet transfusion is recommended (or other major surgery as per AABB guidance)
Epidural and spinal “are considered acceptable” if ≥70 x 109/L prior to epidural and
Platelet level stable | No coagulopathy | Platelet function normal | No antiplatelet or anticoagulant therapy
Limited evidence regarding low-dose aspirin combined with thrombocytopenia and neuraxial blockade
SYNOPSIS:
GT is the most common cause of thrombocytopenia in pregnancy and accounts for 80% of such cases. GT may be a result of hemodilution and enhanced platelet clearance. The low platelet counts associated with GT are seen during the second and third trimesters with the nadir rarely lower than 70 x 109/L. The diagnosis of GT is made by the presence of a decreased platelet count during pregnancy and should be considered a diagnosis of exclusion. GT usually resolves within days to two months postpartum.
KEY POINTS:
Primary immune thrombocytopenia (ITP) may be difficult to distinguish from GT
ITP induces development of platelet autoantibodies that may cross the placenta
Features that may help distinguish GT from ITP
GT usually mid-late 2nd & 3rd trimester / ITP all trimesters
GT only in pregnancy / ITP may occur outside pregnancy
GT will resolve postpartum / ITP may not resolve
GT does not affect fetus or neonate / ITP may cause neonatal thrombocytopenia
If the diagnosis thrombocytopenia is unclear at the time of delivery, assume ITP and manage accordingly due to fetal/newborn risk for thrombocytopenia
Mode of delivery in ITP should be based on obstetric indications alone
ITP treatment options comparable to non-pregnant management – corticosteroids and intravenous immune globulin (IVIG)
In pregnancy, may start at lower end of prednisone dose (10-20 mg daily) and titrate up
Both GT and ITP may recur
Other disorders resulting in non-isolated thrombocytopenia that will present with other related findings include
ACOG Response to FDA Communication on Anesthesia in Pregnancy
SUMMARY:
In 2016, the FDA released a warning stating that repeated or lengthy use of general anesthetic or sedation drugs in children less than 3 years of age or in pregnant women in their 3rd trimester may be harmful to children’s brain development. The FDA issued an update (2017) requiring warnings to be added to labels of these medications. The FDA does point out in the update that the concern relates to procedures >3 hours and that most surgeries in the 3rd trimester are generally well within that time frame. Therefore, the FDA safety communication states
We are advising that in these situations, pregnant women should not delay or avoid surgeries or procedures during pregnancy, as doing so can negatively affect themselves and their infants
In response to the initial warning, ACOG released a practice advisory (2016) making the following important points
The data used to derive this warning were obtained from a pediatric study only – no pregnant women were included
There are potential negative clinical implications if healthcare professionals hesitate in providing appropriate care and management
The FDA did not seek input from ACOG and obsetetrician-gynecologists were not involved in the development of this warning
As a result of the above and based on current evidence
ACOG continues to recommend that women in any trimester of pregnancy should be counseled regarding evidence-based benefits and risks of any proposed interventions which may involve the use of general anesthetic or sedative agents, and no woman should be denied a medically indicated surgery or procedure which may involve the use of these agents
ACOG and the American Society for Anesthesiologists (2019) confirmed the above in their committee opinion and state that presently there is “no evidence that in utero human exposure to anesthetic or sedative drugs has any effect on the developing fetal brain.”
Exposure to Ionizing Radiation During Pregnancy – What Now?
CLINICAL ACTIONS:
When considering the effects of ionizing radiation during pregnancy:
Do not recommend termination solely on the basis of exposure to ionizing radiation
Patients should be counseled and prenatal imaging performed for structural anomalies and growth restriction for exposure >50mGy
Radiation exposure through radiography, CT scan or nuclear imaging is usually at a dose that is lower than the threshold exposure associated with risk to the fetus and should not be withheld if necessary
Ultrasound and MRI are not associated with fetal risk and are first line imaging modalities
Use ‘prudently’ and when the results will provide medical benefit
Consult radiation physicist to calculate total dose, if multiple imaging studies were performed
The Health Physics Society (HPS) maintains an open access website with information for professionals and patients (see ‘Learn More – Primary Sources’ below)
A 10-20 mGy fetal exposure may increase the background risk of leukemia by a factor of 1.5-2.0
There is no risk to lactation from external sources of ionizing radiation
Interim ACOG Update (October 2017) Regarding Exposure to MRI and Gadolinium in Pregnancy
Limit the use of gadolinium contrast with MRI
Only use gadolinium contrast if it ‘significantly improves diagnostic performance’ and will improve maternal and/or fetal outcomes
Breastfeeding should not be interrupted after use of gadolinium, consistent with ACR guidance
A recent retrospective cohort study by Ray et al. (JAMA, 2016) comparing gadolinium MRI (n = 397) at any time during pregnancy with no MRI (n = 1,418,451), demonstrated
The risk of any rheumatological, inflammatory, or infiltrative skin condition in offspring was increased (adjusted hazard ratio (HR) 1.36; 95% CI, 1.09 to 1.69)
Stillbirths and neonatal deaths (within 28 days of birth) were increased (adjusted relative risk 3.70; 95% CI, 1.55 to 8.85) for an adjusted risk difference of 47.5 per 1000 pregnancies (95% CI, 9.7 to 138.2)
SYNOPSIS:
X-ray procedures may be indicated during pregnancy or may occur inadvertently before the pregnancy is diagnosed. The risk to a fetus from ionizing radiation is dependent on the gestational age at the time of the exposure and the dose of radiation. Growth restriction, microcephaly and intellectual disability are the most common adverse effects from highdose radiation exposure. They have not been reported with radiation exposure less than 50 mGy. Actual fetal doses are dependent on gestational age, maternal body habitus and acquisition parameters.
KEY POINTS:
Fetal Dose for common radiologic exams
Chest X-ray, two views generally: 0.0005-0.01 mGy
Abdominal radiography: 0.1-3 mGy
IVP: 5-10 mGy
Double contrast barium enema: 1.0-20 mGy
Head or neck CT: 1.0-10 mGy
Chest CT or CT pulmonary angiography: 0.01-0.66 mGy
Abdominal CT: 1.3-35 mGy
‘All or None’ Effect
Before implantation (0 to 2 weeks after fertilization)
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Disclosure of Unlabeled Use
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Disclaimer
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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