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Cervicovaginal microbiome may be involved in some preterm births
NEW ORLEANS – Could the cervicovaginal microbiome be responsible for some preterm births?
"It is a hot topic because there is increasing interest in medicine with regard to the microbiome and how our health is affected by it," said Dr. William Grobman, program chair for the Society for Maternal-Fetal Medicine’s annual meeting. "Preterm birth remains poorly understood, but there is intriguing evidence that its occurrence may be related to alterations in the microbiome."
To explore the potential relationship between cervicovaginal microbiota and preterm birth, Dr. Michal Elovitz, director of the maternal and child health research program at the University of Pennsylvania, Philadelphia, led a team in a nested case-control study of 46 women. She presented her results at the meeting.
Dr. Elovitz and her colleagues tested vaginal swabs taken from pregnant women during 20-24 weeks’ gestation, and again during 24-28 weeks. After the women delivered, the cervicovaginal specimens from women who had preterm deliveries were compared with those taken from women who delivered at term.
The researchers tested the DNA from the samples and characterized the microbial communities. Vaginal samples were characterized into community state types (CSTs) based on which bacteria dominated the microbial community. The first group, CST I, is dominated by Lactobacillus crispatus, which according to the Dr. Elovitz is traditionally considered a beneficial bacteria. CST III is dominated by L. iners, and CST IV is dominated by anaerobic bacteria, typical in bacterial vaginosis.
In the 14 women who had a preterm birth, the CST proportions were significantly different than those who delivered at term. In the preterm cohort, 17% had CST I, 61% had CST III, and 22% had CST IV.
In the term cohort, 35% had CST I, 37% had CST III, and 33% had CST IV (P = .012). The percentage of women who had no CST III was higher in women delivering at term than in those who delivered prematurely: 68% vs. 39% (P =.002).
"The percent of non–CST-III was significantly lower in samples from women delivering preterm than term. Notably, the differences in these microbial communities were evident in the late second trimester of pregnancy, weeks if not months prior to the preterm birth," said Dr. Elovitz.
Seventy-eight percent of the women in the study were black; Dr. Elovitz and her colleagues conducted a subanalysis of only those women. "And what we found is that the results were even stronger."
"The implications are very broad, and hopefully very clinically impactful. The microbiome is modifiable. We can find ways to change it," said Dr. Elovitz. The challenge now, she said, is to determine whether the microbiome is just a marker, or if it’s a cause. If microbiota are implicated, "there is a whole new window of opportunity for therapeutics to reduce preterm birth."
Dr. Elovitz did not have any relevant disclosures.
NEW ORLEANS – Could the cervicovaginal microbiome be responsible for some preterm births?
"It is a hot topic because there is increasing interest in medicine with regard to the microbiome and how our health is affected by it," said Dr. William Grobman, program chair for the Society for Maternal-Fetal Medicine’s annual meeting. "Preterm birth remains poorly understood, but there is intriguing evidence that its occurrence may be related to alterations in the microbiome."
To explore the potential relationship between cervicovaginal microbiota and preterm birth, Dr. Michal Elovitz, director of the maternal and child health research program at the University of Pennsylvania, Philadelphia, led a team in a nested case-control study of 46 women. She presented her results at the meeting.
Dr. Elovitz and her colleagues tested vaginal swabs taken from pregnant women during 20-24 weeks’ gestation, and again during 24-28 weeks. After the women delivered, the cervicovaginal specimens from women who had preterm deliveries were compared with those taken from women who delivered at term.
The researchers tested the DNA from the samples and characterized the microbial communities. Vaginal samples were characterized into community state types (CSTs) based on which bacteria dominated the microbial community. The first group, CST I, is dominated by Lactobacillus crispatus, which according to the Dr. Elovitz is traditionally considered a beneficial bacteria. CST III is dominated by L. iners, and CST IV is dominated by anaerobic bacteria, typical in bacterial vaginosis.
In the 14 women who had a preterm birth, the CST proportions were significantly different than those who delivered at term. In the preterm cohort, 17% had CST I, 61% had CST III, and 22% had CST IV.
In the term cohort, 35% had CST I, 37% had CST III, and 33% had CST IV (P = .012). The percentage of women who had no CST III was higher in women delivering at term than in those who delivered prematurely: 68% vs. 39% (P =.002).
"The percent of non–CST-III was significantly lower in samples from women delivering preterm than term. Notably, the differences in these microbial communities were evident in the late second trimester of pregnancy, weeks if not months prior to the preterm birth," said Dr. Elovitz.
Seventy-eight percent of the women in the study were black; Dr. Elovitz and her colleagues conducted a subanalysis of only those women. "And what we found is that the results were even stronger."
"The implications are very broad, and hopefully very clinically impactful. The microbiome is modifiable. We can find ways to change it," said Dr. Elovitz. The challenge now, she said, is to determine whether the microbiome is just a marker, or if it’s a cause. If microbiota are implicated, "there is a whole new window of opportunity for therapeutics to reduce preterm birth."
Dr. Elovitz did not have any relevant disclosures.
NEW ORLEANS – Could the cervicovaginal microbiome be responsible for some preterm births?
"It is a hot topic because there is increasing interest in medicine with regard to the microbiome and how our health is affected by it," said Dr. William Grobman, program chair for the Society for Maternal-Fetal Medicine’s annual meeting. "Preterm birth remains poorly understood, but there is intriguing evidence that its occurrence may be related to alterations in the microbiome."
To explore the potential relationship between cervicovaginal microbiota and preterm birth, Dr. Michal Elovitz, director of the maternal and child health research program at the University of Pennsylvania, Philadelphia, led a team in a nested case-control study of 46 women. She presented her results at the meeting.
Dr. Elovitz and her colleagues tested vaginal swabs taken from pregnant women during 20-24 weeks’ gestation, and again during 24-28 weeks. After the women delivered, the cervicovaginal specimens from women who had preterm deliveries were compared with those taken from women who delivered at term.
The researchers tested the DNA from the samples and characterized the microbial communities. Vaginal samples were characterized into community state types (CSTs) based on which bacteria dominated the microbial community. The first group, CST I, is dominated by Lactobacillus crispatus, which according to the Dr. Elovitz is traditionally considered a beneficial bacteria. CST III is dominated by L. iners, and CST IV is dominated by anaerobic bacteria, typical in bacterial vaginosis.
In the 14 women who had a preterm birth, the CST proportions were significantly different than those who delivered at term. In the preterm cohort, 17% had CST I, 61% had CST III, and 22% had CST IV.
In the term cohort, 35% had CST I, 37% had CST III, and 33% had CST IV (P = .012). The percentage of women who had no CST III was higher in women delivering at term than in those who delivered prematurely: 68% vs. 39% (P =.002).
"The percent of non–CST-III was significantly lower in samples from women delivering preterm than term. Notably, the differences in these microbial communities were evident in the late second trimester of pregnancy, weeks if not months prior to the preterm birth," said Dr. Elovitz.
Seventy-eight percent of the women in the study were black; Dr. Elovitz and her colleagues conducted a subanalysis of only those women. "And what we found is that the results were even stronger."
"The implications are very broad, and hopefully very clinically impactful. The microbiome is modifiable. We can find ways to change it," said Dr. Elovitz. The challenge now, she said, is to determine whether the microbiome is just a marker, or if it’s a cause. If microbiota are implicated, "there is a whole new window of opportunity for therapeutics to reduce preterm birth."
Dr. Elovitz did not have any relevant disclosures.
AT THE PREGNANCY MEETING
Major finding: Of the 14 women in the preterm group, 17% had CST I, 61% had CST III, and 22% had CST IV. In the term cohort, 35% had CST I, 37% had CST III, and 33% had CST IV.
Data source: Nested case-controlled study of 14 women who delivered preterm and 32 who delivered at term.
Disclosures: Dr. Elovitz did not have any relevant disclosures.
Suppressing interpregnancy HIV prevents infant transmission
NEW ORLEANS – There were no cases of HIV transmission to infants born of a second pregnancy to mothers who maintained viral suppression between their two pregnancies, a study showed.
In a retrospective cohort of 103 women, the mother-to-child transmission rate was 9% among women whose interpregnancy viral load was more than 1,000 copies/mL. But among those with a load of less than 1,000 copies/mL, the transmission rate was 0, Dr. Robert Stewart said at the annual Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.
The data support the concept of treating HIV to help protect babies as well as mothers, said Dr. Stewart of the University of Texas Southwestern Medical Center, Dallas.
"Right now there are no recommendations for HIV treatment between pregnancies, or treatment for the benefit of the fetus," he said. The only treatment guidelines suggest that pregnant women be treated as nonpregnant women are, for their own health.
Dr. Stewart examined the issue in a cohort of 103 women who had a suppressed HIV load (less than 1,000 copies/mL) at their index pregnancy, and were seen at the same institution for their next pregnancy.
At baseline, the women were about 24 years old. Most (71%) were black. Gestational age at the first prenatal visit was 14 weeks; at the next pregnancy, the women came in earlier – a mean of 12 weeks. They also had more prenatal visits with their second pregnancy (mean of 10 compared with 9).
At presentation for the index pregnancy, the mean viral load for all women was 1,860 copies/mL, but the range was wide (0-21,700 copies/mL). The mean CD4 cell count was 456/mcL. Just over a third (35%) were already on antiretroviral therapy.
At presentation for the subsequent pregnancy, the overall mean viral load was 1,120 copies/mL (0-145,000 copies/mL). The mean CD4 count was 479 cells/mcL. These differences were not statistically significant. However, at the subsequent pregnancy, significantly more women were on antiretroviral therapy (56%).
The second pregnancy occurred a mean of 2.6 years later in both groups. At presentation for the second pregnancy, 57 had maintained that level of suppression and 46 had not. At that time, the mean viral load was 0 in those who had maintained suppression and 10,160 copies/mL among those who had not – a significant difference. CD4 cell count also was significantly different (596 vs. 342 cells/mcL). Significantly more of those who had maintained suppression were on antiretroviral therapy at the second pregnancy (75% vs. 59%).
By the time of delivery, however, HIV indices had improved in the group that had not maintained suppression. At that time, their mean viral load was also 0. Their CD4 count had increased to 427 cells/mcL, and 93% were on antiretroviral therapy.
There were no significant differences in the clinical parameters of the second pregnancy between those who had maintained suppression and those who had not. These included gestational age at delivery (38 weeks); birth weight (about 3,000 g); the use of intrapartum zidovudine (more than 90% of each group); cesarean delivery (32% vs. 52%; P = .18); length of labor; length of ruptured membranes; and incidence of clinical chorioamnionitis.
Vertical transmission was significantly higher among women who had not maintained an interpregnancy suppression (9% vs. 0 infants).
Dr. Stewart said he had no relevant financial disclosures.
On Twitter @alz_gal
NEW ORLEANS – There were no cases of HIV transmission to infants born of a second pregnancy to mothers who maintained viral suppression between their two pregnancies, a study showed.
In a retrospective cohort of 103 women, the mother-to-child transmission rate was 9% among women whose interpregnancy viral load was more than 1,000 copies/mL. But among those with a load of less than 1,000 copies/mL, the transmission rate was 0, Dr. Robert Stewart said at the annual Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.
The data support the concept of treating HIV to help protect babies as well as mothers, said Dr. Stewart of the University of Texas Southwestern Medical Center, Dallas.
"Right now there are no recommendations for HIV treatment between pregnancies, or treatment for the benefit of the fetus," he said. The only treatment guidelines suggest that pregnant women be treated as nonpregnant women are, for their own health.
Dr. Stewart examined the issue in a cohort of 103 women who had a suppressed HIV load (less than 1,000 copies/mL) at their index pregnancy, and were seen at the same institution for their next pregnancy.
At baseline, the women were about 24 years old. Most (71%) were black. Gestational age at the first prenatal visit was 14 weeks; at the next pregnancy, the women came in earlier – a mean of 12 weeks. They also had more prenatal visits with their second pregnancy (mean of 10 compared with 9).
At presentation for the index pregnancy, the mean viral load for all women was 1,860 copies/mL, but the range was wide (0-21,700 copies/mL). The mean CD4 cell count was 456/mcL. Just over a third (35%) were already on antiretroviral therapy.
At presentation for the subsequent pregnancy, the overall mean viral load was 1,120 copies/mL (0-145,000 copies/mL). The mean CD4 count was 479 cells/mcL. These differences were not statistically significant. However, at the subsequent pregnancy, significantly more women were on antiretroviral therapy (56%).
The second pregnancy occurred a mean of 2.6 years later in both groups. At presentation for the second pregnancy, 57 had maintained that level of suppression and 46 had not. At that time, the mean viral load was 0 in those who had maintained suppression and 10,160 copies/mL among those who had not – a significant difference. CD4 cell count also was significantly different (596 vs. 342 cells/mcL). Significantly more of those who had maintained suppression were on antiretroviral therapy at the second pregnancy (75% vs. 59%).
By the time of delivery, however, HIV indices had improved in the group that had not maintained suppression. At that time, their mean viral load was also 0. Their CD4 count had increased to 427 cells/mcL, and 93% were on antiretroviral therapy.
There were no significant differences in the clinical parameters of the second pregnancy between those who had maintained suppression and those who had not. These included gestational age at delivery (38 weeks); birth weight (about 3,000 g); the use of intrapartum zidovudine (more than 90% of each group); cesarean delivery (32% vs. 52%; P = .18); length of labor; length of ruptured membranes; and incidence of clinical chorioamnionitis.
Vertical transmission was significantly higher among women who had not maintained an interpregnancy suppression (9% vs. 0 infants).
Dr. Stewart said he had no relevant financial disclosures.
On Twitter @alz_gal
NEW ORLEANS – There were no cases of HIV transmission to infants born of a second pregnancy to mothers who maintained viral suppression between their two pregnancies, a study showed.
In a retrospective cohort of 103 women, the mother-to-child transmission rate was 9% among women whose interpregnancy viral load was more than 1,000 copies/mL. But among those with a load of less than 1,000 copies/mL, the transmission rate was 0, Dr. Robert Stewart said at the annual Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.
The data support the concept of treating HIV to help protect babies as well as mothers, said Dr. Stewart of the University of Texas Southwestern Medical Center, Dallas.
"Right now there are no recommendations for HIV treatment between pregnancies, or treatment for the benefit of the fetus," he said. The only treatment guidelines suggest that pregnant women be treated as nonpregnant women are, for their own health.
Dr. Stewart examined the issue in a cohort of 103 women who had a suppressed HIV load (less than 1,000 copies/mL) at their index pregnancy, and were seen at the same institution for their next pregnancy.
At baseline, the women were about 24 years old. Most (71%) were black. Gestational age at the first prenatal visit was 14 weeks; at the next pregnancy, the women came in earlier – a mean of 12 weeks. They also had more prenatal visits with their second pregnancy (mean of 10 compared with 9).
At presentation for the index pregnancy, the mean viral load for all women was 1,860 copies/mL, but the range was wide (0-21,700 copies/mL). The mean CD4 cell count was 456/mcL. Just over a third (35%) were already on antiretroviral therapy.
At presentation for the subsequent pregnancy, the overall mean viral load was 1,120 copies/mL (0-145,000 copies/mL). The mean CD4 count was 479 cells/mcL. These differences were not statistically significant. However, at the subsequent pregnancy, significantly more women were on antiretroviral therapy (56%).
The second pregnancy occurred a mean of 2.6 years later in both groups. At presentation for the second pregnancy, 57 had maintained that level of suppression and 46 had not. At that time, the mean viral load was 0 in those who had maintained suppression and 10,160 copies/mL among those who had not – a significant difference. CD4 cell count also was significantly different (596 vs. 342 cells/mcL). Significantly more of those who had maintained suppression were on antiretroviral therapy at the second pregnancy (75% vs. 59%).
By the time of delivery, however, HIV indices had improved in the group that had not maintained suppression. At that time, their mean viral load was also 0. Their CD4 count had increased to 427 cells/mcL, and 93% were on antiretroviral therapy.
There were no significant differences in the clinical parameters of the second pregnancy between those who had maintained suppression and those who had not. These included gestational age at delivery (38 weeks); birth weight (about 3,000 g); the use of intrapartum zidovudine (more than 90% of each group); cesarean delivery (32% vs. 52%; P = .18); length of labor; length of ruptured membranes; and incidence of clinical chorioamnionitis.
Vertical transmission was significantly higher among women who had not maintained an interpregnancy suppression (9% vs. 0 infants).
Dr. Stewart said he had no relevant financial disclosures.
On Twitter @alz_gal
AT THE PREGNANCY MEETING
Major finding: There were no cases of HIV transmission to infants among women who maintained a well-suppressed viral load between pregnancies, compared with 9% in those women whose interpregnancy viral load was more than 1,000 copies/mL.
Data source: A retrospective study that included 103 women who had an HIV viral load of less than 1,000 copies/mL at their index pregnancy.
Disclosures: Dr. Stewart said he had no financial disclosures.
VIDEO: Longer period of postpartum thromboembolic risk raises therapeutic questions
Findings from a large study of women following their first pregnancy extend the postpartum period of heightened risk for thromboembolic events from the previously known 6 weeks to 12 weeks, leaving physicians with new questions that need to be answered in further studies about the need for longer periods of anticoagulation therapy in some women. In a video interview, Dr. Bruce Ovbiagele of the Medical University of South Carolina, Charleston, comments on the findings at the International Stroke Conference. The study also was published Feb. 13 in the New England Journal of Medicine in conjunction with the report at the conference (2014 Feb. 13 [doi:10.1056/NEJMoa1311485).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Findings from a large study of women following their first pregnancy extend the postpartum period of heightened risk for thromboembolic events from the previously known 6 weeks to 12 weeks, leaving physicians with new questions that need to be answered in further studies about the need for longer periods of anticoagulation therapy in some women. In a video interview, Dr. Bruce Ovbiagele of the Medical University of South Carolina, Charleston, comments on the findings at the International Stroke Conference. The study also was published Feb. 13 in the New England Journal of Medicine in conjunction with the report at the conference (2014 Feb. 13 [doi:10.1056/NEJMoa1311485).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Findings from a large study of women following their first pregnancy extend the postpartum period of heightened risk for thromboembolic events from the previously known 6 weeks to 12 weeks, leaving physicians with new questions that need to be answered in further studies about the need for longer periods of anticoagulation therapy in some women. In a video interview, Dr. Bruce Ovbiagele of the Medical University of South Carolina, Charleston, comments on the findings at the International Stroke Conference. The study also was published Feb. 13 in the New England Journal of Medicine in conjunction with the report at the conference (2014 Feb. 13 [doi:10.1056/NEJMoa1311485).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
ADA backs second gestational diabetes screening option
SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.
Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.
What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.
In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.
A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.
One-step vs. two-step approach
"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.
The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.
On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.
"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."
During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.
Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.
"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."
In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.
"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "
In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.
The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.
Individualized diabetes care
"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.
To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.
Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.
"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.
Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.
Other revisions include:
• Clarification that the hemoglobin A1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;
• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;
• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and
• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.
"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.
The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.
ADA dodges dietary dogma
Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:
• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.
• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.
• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.
• Early referral to registered dietitians and nutritionists for nutrition therapy.
• First-ever call to avoid sugar-sweetened beverages.
• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.
• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.
Dr. Grant disclosed no conflicts of interest.
SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.
Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.
What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.
In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.
A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.
One-step vs. two-step approach
"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.
The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.
On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.
"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."
During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.
Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.
"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."
In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.
"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "
In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.
The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.
Individualized diabetes care
"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.
To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.
Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.
"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.
Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.
Other revisions include:
• Clarification that the hemoglobin A1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;
• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;
• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and
• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.
"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.
The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.
ADA dodges dietary dogma
Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:
• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.
• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.
• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.
• Early referral to registered dietitians and nutritionists for nutrition therapy.
• First-ever call to avoid sugar-sweetened beverages.
• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.
• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.
Dr. Grant disclosed no conflicts of interest.
SAN FRANCISCO – Updated guidelines from the American Diabetes Association open the door to using a two-step approach to gestational diabetes screening.
Screening is still recommended for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, and for gestational diabetes mellitus (GDM) between weeks 24 and 28 of gestation.
What’s changed in the 2014 Standards of Medical Care in Diabetes (Diabetes Care 2014;37(suppl 1):S14-80) is how that screening is accomplished, Dr. Richard W. Grant, chair of the ADA professional practice committee, said at the annual advanced postgraduate course held by the American Diabetes Association.
In prior years, the ADA adopted the International Association of Diabetes and Pregnancy Study Groups (IADPSG) 2009 recommendation that a 2-hour, 75-gram oral glucose tolerance test (OGTT) be performed the morning after a fast of at least an 8 hours.
A two-step approach was added this year to reflect the 2013 National Institutes of Health Consensus Guidelines recommendation for a 1-hour, 50-gram glucose tolerance screening test followed by a fasting OGTT on another day, if the test is abnormal.
One-step vs. two-step approach
"The issues for these two approaches are the sensitivity with which you can diagnose GDM and the difficulty in implementing these two approaches," said Dr. Grant, a research scientist with Kaiser Permanente Northern California, Oakland.
The one-step approach tends to be more sensitive and diagnoses a broader range of GDM, but it may be a barrier to screening because it requires the patient to fast for 8 hours, he said. Though the one-step approach allows for a diagnosis of GDM within the context of a single office visit, critics also argue its tight diagnostic glucose cut points could dramatically increase the prevalence of GDM from about 5%-6% to 15%-20%, and bring added health care costs and interventions without clear evidence of improved outcomes.
On the other hand, the two-step approach may be more palatable to women because it avoids the up-front fasting requirement, but it could miss GDM in women with an abnormal screen who fail to return for a second visit.
"The bottom line is we need to make sure we do gestational diabetes screening, whichever method we use," Dr. Grant said. "What’s more important is that all women in early pregnancy get screened."
During a discussion following the presentation, a Canadian attendee said similar recommendations released last fall in Canada allowing two screening methods, albeit with different diagnostic thresholds, have resulted in confusion, particularly among referring obstetricians and endocrinologists.
Dr. Grant said there shouldn’t be confusion surrounding the new option as long as recommendations are consistent within an institution.
"I don’t think it’s actually going to make people change what they’re doing currently," he said in an interview. "There’s not a good reason to jump from one to another if you’ve already chosen an approach."
In a separate interview, Dr. R. Harsha Rao, with the Center for Diabetes and Endocrinology at the University of Pittsburgh, said he can see the rationale for the one-step method, but that the two-step approach is almost implanted in the DNA of American obstetricians and that this behavior pattern will be difficult to change for practical reasons alone.
"Patients don’t like 75 grams of Glucola; it’s an awful-tasting substance," he said. "I’ve had patients tell me they felt like [vomiting] when they got the 75-gram Glucola load, and as it is, ‘I’m pregnant and already feeling nauseated.’ "
In addition, there’s the added stress of waiting for a second appointment and a definitive diagnosis for women who screen positive.
The ADA’s bimodal approach to gestational screening reflects an overarching theme of individualized care for diabetes in the 2014 standards. The guidelines are updated annually and this year they contain 232 recommendations, of which 52% are based on high level A or B evidence.
Individualized diabetes care
"One of the themes that comes out in looking at the data very carefully is that you can’t have a one-size-fits-all approach," Dr. Grant observed.
To that end, the guidelines maintain an earlier recommendation raising the systolic blood pressure target goal for hypertension to 140 mm Hg, but also allow a target goal of less than 130 mm Hg in certain populations, such as younger patients.
Dr. Grant observed that the ADA’s position was confirmed by the U.S. Preventive Services Task Force’s recent endorsement of GDM screening using the two-step approach.
"The USPSTF said that the two-step method is an accurate approach, which is what the ADA also says," he remarked.
Based on the recently revised 2013 ADA nutrition position paper (described in the next section below), the guidelines also encourage individualized dietary approaches rather recommending one particular diet over another, Dr. Grant said.
Other revisions include:
• Clarification that the hemoglobin A1c test is just one of three methods to diagnose diabetes in asymptomatic patients, along with the fasting plasma glucose or 75-gram, 2-hour OGTT;
• An expanded chapter on neuropathy screening and treatment, including B level evidentiary support to test for distal symmetric polyneuropathy;
• Added emphasis on the need to ask patients about symptomatic and asymptomatic hypoglycemia and perform ongoing assessments of cognitive function; and
• Added emphasis on a patient-centered communication style that assesses literacy, but also the often overlooked issue of numeracy.
"It’s really quite impressive how many patients don’t get numbers, but we as physicians speak in numbers," Dr. Grant said.
The recent controversial 2013 American College of Cardiology/American Heart Association cholesterol guideline could not be reviewed in time to for this year’s guidelines, but it will be something to keep an eye out for next year.
ADA dodges dietary dogma
Highlights of the American Diabetes Association’s nutrition recommendations, updated in late 2013, and also presented at the meeting by Patti Urbanski, M.Ed., a member of the ADA Nutrition Recommendations Writing Group Committee, include:
• Select an "eating pattern" based on an individual’s personal and cultural preferences; literacy and numeracy; readiness; and ability to change, because no one dietary plan – be it the Mediterranean, low-carb, or DASH (Dietary Approaches to Stop Hypertension) diet – is best.
• In the absence of evidence supporting an ideal percentage of calories from carbohydrates, protein, or fat for all patients with diabetes, macronutrient distribution should be based on individualized assessment of current eating patterns, preferences, and goals.
• Reduce energy intake/carbohydrate portions and number of servings per meal, as indicated by individual assessment.
• Early referral to registered dietitians and nutritionists for nutrition therapy.
• First-ever call to avoid sugar-sweetened beverages.
• Continued support to limit sodium intake to 2,300 mg/day, as recommended for the general population, with lower sodium targets an option for those with comorbid hypertension.
• Routine supplementation with oxidants, such as vitamin E and C and carotene, is not advised, nor is routine use of micronutrients such as chromium, magnesium, and vitamin D to improve glycemic control.
Dr. Grant disclosed no conflicts of interest.
EXPERT ANALYSIS FROM THE ADA ADVANCED POSTGRADUATE COURSE
Postpartum thrombosis risk high for 12 weeks
SAN DIEGO – The risk of thrombosis after giving birth remains significantly elevated for 12 weeks after delivery, twice as long as previously thought, an analysis of data on 1.7 million women found.
Dr. Hooman Kamel and his associates analyzed data on 1,687,930 million women admitted to nonfederal acute-care hospitals or emergency departments in California for first-time labor and delivery during 2005-2010, 1,015 of whom had a thrombotic event within 24 weeks after delivery (0.06%). These included strokes (248), MIs (47), and venous thromboemboli (720 cases).
The chance of a clotting event was 11-fold higher than normal in the first 6 weeks after delivery and was doubled when compared with normal in postpartum weeks 7-12, he reported in a press briefing at the International Stroke Conference.
An extra 22 cases/100,000 deliveries occurred in the first 6 weeks postpartum and an extra 3 cases per 100,000 deliveries occurred in weeks 7-12 postpartum.
By 13-18 weeks after delivery, a 40% higher odds of blood clot was not significantly different than with a year later, said Dr. Kamel, a neurologist at Cornell University, N.Y.
The blood clot risk returned to normal levels seen in women who’ve never delivered a baby by 19-24 weeks after delivery.
The New England Journal of Medicine published the findings online (2014 Feb. 13 [doi: 10.1056/NEJMoa1311485]).
The study confirms that thrombosis after delivery is rare and suggests that clinicians may want to take seriously any possible symptoms of stroke beyond the period that’s generally thought of as postpartum: 6 weeks after delivery. Especially in women who have other risk factors for thrombosis, awareness of continued elevated risk in weeks 7-12 could lead to quicker treatment if a blood clot forms, he said in an interview at the meeting, sponsored by the American Heart Association.
Current guidelines call for postpartum blood-thinning therapy in high-risk women who had an elevated stroke risk prior to pregnancy or other risk factors, and it’s unclear whether this should be extended beyond 6 weeks postpartum, Dr. Kamel said. The new findings may prompt research in this direction.
Meanwhile, physicians and women should take seriously any symptoms of possible thrombosis out to 12 weeks after delivery, such as chest pain or pressure, he said.
The study was supported by a grant from the National Institute of Neurological Disorders and Stroke. Dr. Kamel and his colleagues reported having no financial disclosures.
On Twitter @sherryboschert
Correction, 3/4/2014: An earlier version of this article misstated the amount of time passed between delivery and blood clot formation.
SAN DIEGO – The risk of thrombosis after giving birth remains significantly elevated for 12 weeks after delivery, twice as long as previously thought, an analysis of data on 1.7 million women found.
Dr. Hooman Kamel and his associates analyzed data on 1,687,930 million women admitted to nonfederal acute-care hospitals or emergency departments in California for first-time labor and delivery during 2005-2010, 1,015 of whom had a thrombotic event within 24 weeks after delivery (0.06%). These included strokes (248), MIs (47), and venous thromboemboli (720 cases).
The chance of a clotting event was 11-fold higher than normal in the first 6 weeks after delivery and was doubled when compared with normal in postpartum weeks 7-12, he reported in a press briefing at the International Stroke Conference.
An extra 22 cases/100,000 deliveries occurred in the first 6 weeks postpartum and an extra 3 cases per 100,000 deliveries occurred in weeks 7-12 postpartum.
By 13-18 weeks after delivery, a 40% higher odds of blood clot was not significantly different than with a year later, said Dr. Kamel, a neurologist at Cornell University, N.Y.
The blood clot risk returned to normal levels seen in women who’ve never delivered a baby by 19-24 weeks after delivery.
The New England Journal of Medicine published the findings online (2014 Feb. 13 [doi: 10.1056/NEJMoa1311485]).
The study confirms that thrombosis after delivery is rare and suggests that clinicians may want to take seriously any possible symptoms of stroke beyond the period that’s generally thought of as postpartum: 6 weeks after delivery. Especially in women who have other risk factors for thrombosis, awareness of continued elevated risk in weeks 7-12 could lead to quicker treatment if a blood clot forms, he said in an interview at the meeting, sponsored by the American Heart Association.
Current guidelines call for postpartum blood-thinning therapy in high-risk women who had an elevated stroke risk prior to pregnancy or other risk factors, and it’s unclear whether this should be extended beyond 6 weeks postpartum, Dr. Kamel said. The new findings may prompt research in this direction.
Meanwhile, physicians and women should take seriously any symptoms of possible thrombosis out to 12 weeks after delivery, such as chest pain or pressure, he said.
The study was supported by a grant from the National Institute of Neurological Disorders and Stroke. Dr. Kamel and his colleagues reported having no financial disclosures.
On Twitter @sherryboschert
Correction, 3/4/2014: An earlier version of this article misstated the amount of time passed between delivery and blood clot formation.
SAN DIEGO – The risk of thrombosis after giving birth remains significantly elevated for 12 weeks after delivery, twice as long as previously thought, an analysis of data on 1.7 million women found.
Dr. Hooman Kamel and his associates analyzed data on 1,687,930 million women admitted to nonfederal acute-care hospitals or emergency departments in California for first-time labor and delivery during 2005-2010, 1,015 of whom had a thrombotic event within 24 weeks after delivery (0.06%). These included strokes (248), MIs (47), and venous thromboemboli (720 cases).
The chance of a clotting event was 11-fold higher than normal in the first 6 weeks after delivery and was doubled when compared with normal in postpartum weeks 7-12, he reported in a press briefing at the International Stroke Conference.
An extra 22 cases/100,000 deliveries occurred in the first 6 weeks postpartum and an extra 3 cases per 100,000 deliveries occurred in weeks 7-12 postpartum.
By 13-18 weeks after delivery, a 40% higher odds of blood clot was not significantly different than with a year later, said Dr. Kamel, a neurologist at Cornell University, N.Y.
The blood clot risk returned to normal levels seen in women who’ve never delivered a baby by 19-24 weeks after delivery.
The New England Journal of Medicine published the findings online (2014 Feb. 13 [doi: 10.1056/NEJMoa1311485]).
The study confirms that thrombosis after delivery is rare and suggests that clinicians may want to take seriously any possible symptoms of stroke beyond the period that’s generally thought of as postpartum: 6 weeks after delivery. Especially in women who have other risk factors for thrombosis, awareness of continued elevated risk in weeks 7-12 could lead to quicker treatment if a blood clot forms, he said in an interview at the meeting, sponsored by the American Heart Association.
Current guidelines call for postpartum blood-thinning therapy in high-risk women who had an elevated stroke risk prior to pregnancy or other risk factors, and it’s unclear whether this should be extended beyond 6 weeks postpartum, Dr. Kamel said. The new findings may prompt research in this direction.
Meanwhile, physicians and women should take seriously any symptoms of possible thrombosis out to 12 weeks after delivery, such as chest pain or pressure, he said.
The study was supported by a grant from the National Institute of Neurological Disorders and Stroke. Dr. Kamel and his colleagues reported having no financial disclosures.
On Twitter @sherryboschert
Correction, 3/4/2014: An earlier version of this article misstated the amount of time passed between delivery and blood clot formation.
AT THE INTERNATIONAL STROKE CONFERENCE
Major finding: The odds of developing a thrombosis remained significantly elevated for 12 weeks postpartum: 11-fold higher during weeks 0-6 and two times higher in weeks 7-12, compared with 1 year after pregnancy.
Data source: A retrospective analysis of data on 1.7 million pregnant women at California hospitals, 1,015 of whom developed blood clots within 24 weeks* of delivery.
Disclosures: The study was supported by a grant from the National Institute of Neurological Disorders and Stroke. Dr. Kamel and his colleagues reported having no financial disclosures.
VIDEO: Postpartum elevated thrombosis risk lasts 12 weeks
The risk of thrombosis in women giving birth for the first time was 10- to 11-fold higher in the first 6 weeks postpartum, but in a report presented at the International Stroke Conference, Dr. Hooman Kamel of Cornell University, N.Y., and his colleagues found that the risk of thrombosis (stroke, MI, and venous thromboembolism) is still doubled during 7-12 weeks postpartum. The study was published Feb. 13 in the New England Journal of Medicine in conjunction with the report at the conference (2014 Feb. 13 [doi:10.1056/NEJMoa1311485]).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The risk of thrombosis in women giving birth for the first time was 10- to 11-fold higher in the first 6 weeks postpartum, but in a report presented at the International Stroke Conference, Dr. Hooman Kamel of Cornell University, N.Y., and his colleagues found that the risk of thrombosis (stroke, MI, and venous thromboembolism) is still doubled during 7-12 weeks postpartum. The study was published Feb. 13 in the New England Journal of Medicine in conjunction with the report at the conference (2014 Feb. 13 [doi:10.1056/NEJMoa1311485]).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
The risk of thrombosis in women giving birth for the first time was 10- to 11-fold higher in the first 6 weeks postpartum, but in a report presented at the International Stroke Conference, Dr. Hooman Kamel of Cornell University, N.Y., and his colleagues found that the risk of thrombosis (stroke, MI, and venous thromboembolism) is still doubled during 7-12 weeks postpartum. The study was published Feb. 13 in the New England Journal of Medicine in conjunction with the report at the conference (2014 Feb. 13 [doi:10.1056/NEJMoa1311485]).
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
Treat subclinical hypothyroidism in pregnancy, expert says
SAN FRANCISCO – Pregnancy is one of the few relatively clear reasons to screen and treat for subclinical hypothyroidism, according to Dr. Elizabeth J. Murphy.
There are reasons to consider treating subclinical hypothyroidism in women other than pregnancy, but there’s no clear right or wrong answer in most cases, she said at a conference on women’s health sponsored by the University of California, San Francisco.
The Endocrine Society in 2012 recommended against universal thyroid screening of healthy women before pregnancy and said to screen those who are at high risk of thyroid disease, but they rated the evidence for those recommendations as poor (J. Clin. Endocrinol. Metab. 2012;97:2543-65).
For newly pregnant women, the guidelines offered a choice of two options, Dr. Murphy said: Screen all pregnant women by week 9 or at the first prenatal visit (with fair evidence to support this strategy), or screen only high-risk women unless that’s too burdensome, in which case, screen all pregnant women (with poor evidence behind this).
The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice issued Opinion No. 381 in 2007 (and reaffirmed it in 2012) saying that routine screening for subclinical hypothyroidism is not currently recommended because there’s no evidence that routinely identifying and treating pregnant women with subclinical hypothyroidism improves outcomes (Obstet. Gynecol. 2007;110:959-60).
"I don’t agree with any of those, and I’m not the only one who doesn’t agree," said Dr. Murphy, chief of the division of endocrinology at San Francisco General Hospital.
A study of serum samples from 25,216 pregnant women and follow-up on their children at ages 7-9 years found lower IQ scores in the offspring of women with undiagnosed hypothyroidism during pregnancy, compared with women whose hypothyroidism was treated prior to pregnancy or euthyroid women in a control group (N. Engl. J. Med. 1999;341:549-55).
A more recent multinational, randomized trial of 21,846 women who were screened at a median of 12 weeks and 3 days of gestation reported that identifying and treating hypothyroidism did not improve the cognitive function of offspring at age 3, compared with a control group whose serum was analyzed after delivery (N. Engl. J. Med. 2012;366:493-501). That study was flawed, however, and "doesn’t provide useful data for prepregnancy screening. It only provides data for screening at 12 weeks," Dr. Murphy said.
The fetal thyroid develops at week 12, and the mother’s thyroid function needs to be in good shape before then, she explained. In addition, the median thyroid-stimulating hormone (TSH) level in the study was low, and half of the women in the study were enrolled not because they had a high TSH level but because they had a low level of free T4, an assay that is "notoriously unreliable in pregnancy," she said. "Many people recommend getting a total T4." It’s unclear whether many of the women who were considered to be hypothyroid truly were. Lastly, 3 years of age might be too young to assess cognitive function in the offspring, she said.
A huge study on the same subject is underway in China with plans to screen 21,500 pregnant women and treat 4,800 for hypothyroidism before pregnancy, she said.
A separate study suggested that both universal thyroid screening in pregnancy and risk-based screening are cost effective, compared with no screening (J. Clin. Endocrinol. Metabol. 2012;97:1536-46).
Guidelines from the American Thyroid Association in 2011 recommended treating pregnant women if the TSH level is greater than 10 mIU/L or if the patient is positive for thyroid peroxidase antibody (Thyroid 2011;21:1081-125). Most clinicians, however, probably would want to treat a woman in early pregnancy whose TSH level is 9 mIU/L, "especially with the IQ data that we have out there," Dr. Murphy said. "Congenital hypothyroidism, remember, is cretinism. It’s really good to have thyroid when your brain’s developing. I would definitely treat a woman with subclinical hypothyroidism who is pregnant."
Dr. Murphy reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Pregnancy is one of the few relatively clear reasons to screen and treat for subclinical hypothyroidism, according to Dr. Elizabeth J. Murphy.
There are reasons to consider treating subclinical hypothyroidism in women other than pregnancy, but there’s no clear right or wrong answer in most cases, she said at a conference on women’s health sponsored by the University of California, San Francisco.
The Endocrine Society in 2012 recommended against universal thyroid screening of healthy women before pregnancy and said to screen those who are at high risk of thyroid disease, but they rated the evidence for those recommendations as poor (J. Clin. Endocrinol. Metab. 2012;97:2543-65).
For newly pregnant women, the guidelines offered a choice of two options, Dr. Murphy said: Screen all pregnant women by week 9 or at the first prenatal visit (with fair evidence to support this strategy), or screen only high-risk women unless that’s too burdensome, in which case, screen all pregnant women (with poor evidence behind this).
The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice issued Opinion No. 381 in 2007 (and reaffirmed it in 2012) saying that routine screening for subclinical hypothyroidism is not currently recommended because there’s no evidence that routinely identifying and treating pregnant women with subclinical hypothyroidism improves outcomes (Obstet. Gynecol. 2007;110:959-60).
"I don’t agree with any of those, and I’m not the only one who doesn’t agree," said Dr. Murphy, chief of the division of endocrinology at San Francisco General Hospital.
A study of serum samples from 25,216 pregnant women and follow-up on their children at ages 7-9 years found lower IQ scores in the offspring of women with undiagnosed hypothyroidism during pregnancy, compared with women whose hypothyroidism was treated prior to pregnancy or euthyroid women in a control group (N. Engl. J. Med. 1999;341:549-55).
A more recent multinational, randomized trial of 21,846 women who were screened at a median of 12 weeks and 3 days of gestation reported that identifying and treating hypothyroidism did not improve the cognitive function of offspring at age 3, compared with a control group whose serum was analyzed after delivery (N. Engl. J. Med. 2012;366:493-501). That study was flawed, however, and "doesn’t provide useful data for prepregnancy screening. It only provides data for screening at 12 weeks," Dr. Murphy said.
The fetal thyroid develops at week 12, and the mother’s thyroid function needs to be in good shape before then, she explained. In addition, the median thyroid-stimulating hormone (TSH) level in the study was low, and half of the women in the study were enrolled not because they had a high TSH level but because they had a low level of free T4, an assay that is "notoriously unreliable in pregnancy," she said. "Many people recommend getting a total T4." It’s unclear whether many of the women who were considered to be hypothyroid truly were. Lastly, 3 years of age might be too young to assess cognitive function in the offspring, she said.
A huge study on the same subject is underway in China with plans to screen 21,500 pregnant women and treat 4,800 for hypothyroidism before pregnancy, she said.
A separate study suggested that both universal thyroid screening in pregnancy and risk-based screening are cost effective, compared with no screening (J. Clin. Endocrinol. Metabol. 2012;97:1536-46).
Guidelines from the American Thyroid Association in 2011 recommended treating pregnant women if the TSH level is greater than 10 mIU/L or if the patient is positive for thyroid peroxidase antibody (Thyroid 2011;21:1081-125). Most clinicians, however, probably would want to treat a woman in early pregnancy whose TSH level is 9 mIU/L, "especially with the IQ data that we have out there," Dr. Murphy said. "Congenital hypothyroidism, remember, is cretinism. It’s really good to have thyroid when your brain’s developing. I would definitely treat a woman with subclinical hypothyroidism who is pregnant."
Dr. Murphy reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – Pregnancy is one of the few relatively clear reasons to screen and treat for subclinical hypothyroidism, according to Dr. Elizabeth J. Murphy.
There are reasons to consider treating subclinical hypothyroidism in women other than pregnancy, but there’s no clear right or wrong answer in most cases, she said at a conference on women’s health sponsored by the University of California, San Francisco.
The Endocrine Society in 2012 recommended against universal thyroid screening of healthy women before pregnancy and said to screen those who are at high risk of thyroid disease, but they rated the evidence for those recommendations as poor (J. Clin. Endocrinol. Metab. 2012;97:2543-65).
For newly pregnant women, the guidelines offered a choice of two options, Dr. Murphy said: Screen all pregnant women by week 9 or at the first prenatal visit (with fair evidence to support this strategy), or screen only high-risk women unless that’s too burdensome, in which case, screen all pregnant women (with poor evidence behind this).
The American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice issued Opinion No. 381 in 2007 (and reaffirmed it in 2012) saying that routine screening for subclinical hypothyroidism is not currently recommended because there’s no evidence that routinely identifying and treating pregnant women with subclinical hypothyroidism improves outcomes (Obstet. Gynecol. 2007;110:959-60).
"I don’t agree with any of those, and I’m not the only one who doesn’t agree," said Dr. Murphy, chief of the division of endocrinology at San Francisco General Hospital.
A study of serum samples from 25,216 pregnant women and follow-up on their children at ages 7-9 years found lower IQ scores in the offspring of women with undiagnosed hypothyroidism during pregnancy, compared with women whose hypothyroidism was treated prior to pregnancy or euthyroid women in a control group (N. Engl. J. Med. 1999;341:549-55).
A more recent multinational, randomized trial of 21,846 women who were screened at a median of 12 weeks and 3 days of gestation reported that identifying and treating hypothyroidism did not improve the cognitive function of offspring at age 3, compared with a control group whose serum was analyzed after delivery (N. Engl. J. Med. 2012;366:493-501). That study was flawed, however, and "doesn’t provide useful data for prepregnancy screening. It only provides data for screening at 12 weeks," Dr. Murphy said.
The fetal thyroid develops at week 12, and the mother’s thyroid function needs to be in good shape before then, she explained. In addition, the median thyroid-stimulating hormone (TSH) level in the study was low, and half of the women in the study were enrolled not because they had a high TSH level but because they had a low level of free T4, an assay that is "notoriously unreliable in pregnancy," she said. "Many people recommend getting a total T4." It’s unclear whether many of the women who were considered to be hypothyroid truly were. Lastly, 3 years of age might be too young to assess cognitive function in the offspring, she said.
A huge study on the same subject is underway in China with plans to screen 21,500 pregnant women and treat 4,800 for hypothyroidism before pregnancy, she said.
A separate study suggested that both universal thyroid screening in pregnancy and risk-based screening are cost effective, compared with no screening (J. Clin. Endocrinol. Metabol. 2012;97:1536-46).
Guidelines from the American Thyroid Association in 2011 recommended treating pregnant women if the TSH level is greater than 10 mIU/L or if the patient is positive for thyroid peroxidase antibody (Thyroid 2011;21:1081-125). Most clinicians, however, probably would want to treat a woman in early pregnancy whose TSH level is 9 mIU/L, "especially with the IQ data that we have out there," Dr. Murphy said. "Congenital hypothyroidism, remember, is cretinism. It’s really good to have thyroid when your brain’s developing. I would definitely treat a woman with subclinical hypothyroidism who is pregnant."
Dr. Murphy reported having no financial disclosures.
On Twitter @sherryboschert
EXPERT ANALYSIS FROM A CONFERENCE ON WOMEN’S HEALTH
Sepsis less common, less deadly in pregnancy
SAN FRANCISCO – The incidence of severe sepsis was nearly five times lower and the risk of death from severe sepsis was 43% lower during pregnancy, compared with nonpregnant women, in a large retrospective study of data on more than 47 million pregnancy-related discharges.
The decreased mortality rate in pregnancy remained after investigators controlled for the effects of age, comorbidities, and severity of illness, Dr. Gagan Kumar reported.
The incidence of sepsis in pregnancy increased fourfold from 2000 to 2009 – from 0.01% to 0.04% – and tripled in nonpregnant women – from 0.06% to 0.18% – while the U.S. pregnancy rate and the rate of hospitalizations during pregnancy remained relatively stable during that period, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
In-hospital mortality from severe sepsis decreased gradually for nonpregnant patients from about 30% in 2000 to approximately 18% in 2009, but remained relatively stable in pregnant patients, increasing from approximately 3% in 2000 to 10% in 2009, he said.
The investigators studied claims data from 2000 to 2009 from the Nationwide Inpatient Sample for 47,027,806 pregnancy-related discharges of women aged 15-44 years. Of these, 0.03% had a diagnosis of severe sepsis. Among all cases of severe sepsis in the cohort, 2.4% were during pregnancy (643,417 cases).
Eight percent of pregnant women with severe sepsis died, compared with 22% of nonpregnant women with severe sepsis, a significant difference. The median time to death was significantly longer in pregnancy (10 days) than without pregnancy (8.5 days). The median length of stay was significantly shorter in pregnant women who survived severe sepsis (8 days), compared with nonpregnant survivors (11 days). Pregnant survivors were more likely to be discharged home and less likely to go to a skilled nursing facility or have home care compared with nonpregnant survivors, reported Dr. Kumar of the Medical College of Wisconsin, Milwaukee.
Compared with nonpregnant women, pregnant women were significantly less likely to have three or more organs fail (16% vs. 22%) or to have cardiac, renal, hepatic, hematologic, metabolic, or neurologic failure. Pregnant women were significantly more likely to have respiratory failure than were nonpregnant women.
The likelihood of dying of severe sepsis was 62% lower in pregnant women, compared with nonpregnant women, in an unadjusted analysis and 41%-43% lower than in nonpregnant women under three separate analyses that adjusted for various risk factors or incorporated matched data, Dr. Kumar said.
Although the rate of in-hospital mortality decreased in nonpregnant women from approximately 30% in 2000 to approximately 18% in 2009, the rate increased in pregnant women from approximately 4% in 2000 to 10% in 2009.
Published data are limited and suggested that sepsis in pregnancy is rare, affecting approximately 0.1% of pregnancies, with septic shock in approximately 0.01%-0.001%. These studies relied predominantly on single centers, and used varying definitions of severe sepsis; most were conducted before the year 2000. Since then, the average age of mothers in pregnancy has risen, invasive tests are more common, the rate of cesarean deliveries increased by 7% per year between 1996 and 2011, and the rates of comorbidities such as obesity and diabetes during pregnancy have increased, he said.
Pregnant patients with severe sepsis were 7 years younger on average (27 years of age), compared with nonpregnant women with severe sepsis (age 34 years). Severe sepsis in pregnancy was significantly more common in Hispanics (17%) and Asians (4%), compared with nonpregnant patients (9% and 2%, respectively). Pregnant patients with severe sepsis also had less comorbidity, obesity, and atrial fibrillation, compared with nonpregnant patients with severe sepsis.
Previously Dr. Kumar and his associates reported that the rate of hospitalizations for severe sepsis increased from 143/100,000 persons in 2000 to 343/100,000 in 2007, while mortality rates from severe sepsis decreased from 39% to 27% (Chest 2011;40:1223-31).
The findings of the current study raise questions worth pursuing in future studies, he said, such as the reasons for rising rates of severe sepsis in pregnancy despite no increase in pregnancies or hospitalizations during pregnancy. Pregnancy is considered an immunocompromised state, so why are incidence and mortality rates for severe sepsis lower in pregnancy? he asked. And why has mortality from severe sepsis in pregnancy not improved over the past 10 years?
Dr. Kumar reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – The incidence of severe sepsis was nearly five times lower and the risk of death from severe sepsis was 43% lower during pregnancy, compared with nonpregnant women, in a large retrospective study of data on more than 47 million pregnancy-related discharges.
The decreased mortality rate in pregnancy remained after investigators controlled for the effects of age, comorbidities, and severity of illness, Dr. Gagan Kumar reported.
The incidence of sepsis in pregnancy increased fourfold from 2000 to 2009 – from 0.01% to 0.04% – and tripled in nonpregnant women – from 0.06% to 0.18% – while the U.S. pregnancy rate and the rate of hospitalizations during pregnancy remained relatively stable during that period, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
In-hospital mortality from severe sepsis decreased gradually for nonpregnant patients from about 30% in 2000 to approximately 18% in 2009, but remained relatively stable in pregnant patients, increasing from approximately 3% in 2000 to 10% in 2009, he said.
The investigators studied claims data from 2000 to 2009 from the Nationwide Inpatient Sample for 47,027,806 pregnancy-related discharges of women aged 15-44 years. Of these, 0.03% had a diagnosis of severe sepsis. Among all cases of severe sepsis in the cohort, 2.4% were during pregnancy (643,417 cases).
Eight percent of pregnant women with severe sepsis died, compared with 22% of nonpregnant women with severe sepsis, a significant difference. The median time to death was significantly longer in pregnancy (10 days) than without pregnancy (8.5 days). The median length of stay was significantly shorter in pregnant women who survived severe sepsis (8 days), compared with nonpregnant survivors (11 days). Pregnant survivors were more likely to be discharged home and less likely to go to a skilled nursing facility or have home care compared with nonpregnant survivors, reported Dr. Kumar of the Medical College of Wisconsin, Milwaukee.
Compared with nonpregnant women, pregnant women were significantly less likely to have three or more organs fail (16% vs. 22%) or to have cardiac, renal, hepatic, hematologic, metabolic, or neurologic failure. Pregnant women were significantly more likely to have respiratory failure than were nonpregnant women.
The likelihood of dying of severe sepsis was 62% lower in pregnant women, compared with nonpregnant women, in an unadjusted analysis and 41%-43% lower than in nonpregnant women under three separate analyses that adjusted for various risk factors or incorporated matched data, Dr. Kumar said.
Although the rate of in-hospital mortality decreased in nonpregnant women from approximately 30% in 2000 to approximately 18% in 2009, the rate increased in pregnant women from approximately 4% in 2000 to 10% in 2009.
Published data are limited and suggested that sepsis in pregnancy is rare, affecting approximately 0.1% of pregnancies, with septic shock in approximately 0.01%-0.001%. These studies relied predominantly on single centers, and used varying definitions of severe sepsis; most were conducted before the year 2000. Since then, the average age of mothers in pregnancy has risen, invasive tests are more common, the rate of cesarean deliveries increased by 7% per year between 1996 and 2011, and the rates of comorbidities such as obesity and diabetes during pregnancy have increased, he said.
Pregnant patients with severe sepsis were 7 years younger on average (27 years of age), compared with nonpregnant women with severe sepsis (age 34 years). Severe sepsis in pregnancy was significantly more common in Hispanics (17%) and Asians (4%), compared with nonpregnant patients (9% and 2%, respectively). Pregnant patients with severe sepsis also had less comorbidity, obesity, and atrial fibrillation, compared with nonpregnant patients with severe sepsis.
Previously Dr. Kumar and his associates reported that the rate of hospitalizations for severe sepsis increased from 143/100,000 persons in 2000 to 343/100,000 in 2007, while mortality rates from severe sepsis decreased from 39% to 27% (Chest 2011;40:1223-31).
The findings of the current study raise questions worth pursuing in future studies, he said, such as the reasons for rising rates of severe sepsis in pregnancy despite no increase in pregnancies or hospitalizations during pregnancy. Pregnancy is considered an immunocompromised state, so why are incidence and mortality rates for severe sepsis lower in pregnancy? he asked. And why has mortality from severe sepsis in pregnancy not improved over the past 10 years?
Dr. Kumar reported having no financial disclosures.
On Twitter @sherryboschert
SAN FRANCISCO – The incidence of severe sepsis was nearly five times lower and the risk of death from severe sepsis was 43% lower during pregnancy, compared with nonpregnant women, in a large retrospective study of data on more than 47 million pregnancy-related discharges.
The decreased mortality rate in pregnancy remained after investigators controlled for the effects of age, comorbidities, and severity of illness, Dr. Gagan Kumar reported.
The incidence of sepsis in pregnancy increased fourfold from 2000 to 2009 – from 0.01% to 0.04% – and tripled in nonpregnant women – from 0.06% to 0.18% – while the U.S. pregnancy rate and the rate of hospitalizations during pregnancy remained relatively stable during that period, he said at the Critical Care Congress, sponsored by the Society for Critical Care Medicine.
In-hospital mortality from severe sepsis decreased gradually for nonpregnant patients from about 30% in 2000 to approximately 18% in 2009, but remained relatively stable in pregnant patients, increasing from approximately 3% in 2000 to 10% in 2009, he said.
The investigators studied claims data from 2000 to 2009 from the Nationwide Inpatient Sample for 47,027,806 pregnancy-related discharges of women aged 15-44 years. Of these, 0.03% had a diagnosis of severe sepsis. Among all cases of severe sepsis in the cohort, 2.4% were during pregnancy (643,417 cases).
Eight percent of pregnant women with severe sepsis died, compared with 22% of nonpregnant women with severe sepsis, a significant difference. The median time to death was significantly longer in pregnancy (10 days) than without pregnancy (8.5 days). The median length of stay was significantly shorter in pregnant women who survived severe sepsis (8 days), compared with nonpregnant survivors (11 days). Pregnant survivors were more likely to be discharged home and less likely to go to a skilled nursing facility or have home care compared with nonpregnant survivors, reported Dr. Kumar of the Medical College of Wisconsin, Milwaukee.
Compared with nonpregnant women, pregnant women were significantly less likely to have three or more organs fail (16% vs. 22%) or to have cardiac, renal, hepatic, hematologic, metabolic, or neurologic failure. Pregnant women were significantly more likely to have respiratory failure than were nonpregnant women.
The likelihood of dying of severe sepsis was 62% lower in pregnant women, compared with nonpregnant women, in an unadjusted analysis and 41%-43% lower than in nonpregnant women under three separate analyses that adjusted for various risk factors or incorporated matched data, Dr. Kumar said.
Although the rate of in-hospital mortality decreased in nonpregnant women from approximately 30% in 2000 to approximately 18% in 2009, the rate increased in pregnant women from approximately 4% in 2000 to 10% in 2009.
Published data are limited and suggested that sepsis in pregnancy is rare, affecting approximately 0.1% of pregnancies, with septic shock in approximately 0.01%-0.001%. These studies relied predominantly on single centers, and used varying definitions of severe sepsis; most were conducted before the year 2000. Since then, the average age of mothers in pregnancy has risen, invasive tests are more common, the rate of cesarean deliveries increased by 7% per year between 1996 and 2011, and the rates of comorbidities such as obesity and diabetes during pregnancy have increased, he said.
Pregnant patients with severe sepsis were 7 years younger on average (27 years of age), compared with nonpregnant women with severe sepsis (age 34 years). Severe sepsis in pregnancy was significantly more common in Hispanics (17%) and Asians (4%), compared with nonpregnant patients (9% and 2%, respectively). Pregnant patients with severe sepsis also had less comorbidity, obesity, and atrial fibrillation, compared with nonpregnant patients with severe sepsis.
Previously Dr. Kumar and his associates reported that the rate of hospitalizations for severe sepsis increased from 143/100,000 persons in 2000 to 343/100,000 in 2007, while mortality rates from severe sepsis decreased from 39% to 27% (Chest 2011;40:1223-31).
The findings of the current study raise questions worth pursuing in future studies, he said, such as the reasons for rising rates of severe sepsis in pregnancy despite no increase in pregnancies or hospitalizations during pregnancy. Pregnancy is considered an immunocompromised state, so why are incidence and mortality rates for severe sepsis lower in pregnancy? he asked. And why has mortality from severe sepsis in pregnancy not improved over the past 10 years?
Dr. Kumar reported having no financial disclosures.
On Twitter @sherryboschert
AT THE CRITICAL CARE CONGRESS
Major finding: The odds of death in women with severe sepsis were 43% lower during pregnancy, compared with nonpregnant women.
Data source: A retrospective analysis of nationwide data on more than 47 million pregnancy-related discharges.
Disclosures: Dr. Kumar reported having no financial disclosures.
Video: Cervicovaginal microbiome implicated in some preterm births
NEW ORLEANS – Could the cervicovaginal microbiome be responsible for some preterm births?
In a video interview, Dr. Michal Elovitz of the University of Pennsylvania, Philadelphia, discussed a study exploring the role the microbiome plays in high-risk pregnancies and preterm births, and she outlines how better understanding could reshape clinical practice.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NEW ORLEANS – Could the cervicovaginal microbiome be responsible for some preterm births?
In a video interview, Dr. Michal Elovitz of the University of Pennsylvania, Philadelphia, discussed a study exploring the role the microbiome plays in high-risk pregnancies and preterm births, and she outlines how better understanding could reshape clinical practice.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NEW ORLEANS – Could the cervicovaginal microbiome be responsible for some preterm births?
In a video interview, Dr. Michal Elovitz of the University of Pennsylvania, Philadelphia, discussed a study exploring the role the microbiome plays in high-risk pregnancies and preterm births, and she outlines how better understanding could reshape clinical practice.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE SMFM ANNUAL PREGNANCY MEETING
Video: What can be done to reverse rise in C-sections?
NEW ORLEANS – The rate of cesarean section in the United States has risen dramatically in the past 2 decades, accounting for 30% of all deliveries in 2011.
Several factors are driving the increase, according to the Society for Maternal-Fetal Medicine, which sponsored the annual Pregnancy Meeting. Women are waiting until later in life to have children, and their obesity rates are higher than ever before – both of which increase the risk of medical complications during pregnancy. Fear of malpractice also motivates some ob.gyns. to rely on C-sections.
But the most common reason for a woman to have a C-section is that she has had one before, explained Dr. George Saade, director of the division of maternal-fetal medicine at the University of Texas Medical Branch, Galveston. In a video interview, Dr. Saade discussed what’s fueling the rise, and what physicians must do to reduce C-section rates.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NEW ORLEANS – The rate of cesarean section in the United States has risen dramatically in the past 2 decades, accounting for 30% of all deliveries in 2011.
Several factors are driving the increase, according to the Society for Maternal-Fetal Medicine, which sponsored the annual Pregnancy Meeting. Women are waiting until later in life to have children, and their obesity rates are higher than ever before – both of which increase the risk of medical complications during pregnancy. Fear of malpractice also motivates some ob.gyns. to rely on C-sections.
But the most common reason for a woman to have a C-section is that she has had one before, explained Dr. George Saade, director of the division of maternal-fetal medicine at the University of Texas Medical Branch, Galveston. In a video interview, Dr. Saade discussed what’s fueling the rise, and what physicians must do to reduce C-section rates.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
NEW ORLEANS – The rate of cesarean section in the United States has risen dramatically in the past 2 decades, accounting for 30% of all deliveries in 2011.
Several factors are driving the increase, according to the Society for Maternal-Fetal Medicine, which sponsored the annual Pregnancy Meeting. Women are waiting until later in life to have children, and their obesity rates are higher than ever before – both of which increase the risk of medical complications during pregnancy. Fear of malpractice also motivates some ob.gyns. to rely on C-sections.
But the most common reason for a woman to have a C-section is that she has had one before, explained Dr. George Saade, director of the division of maternal-fetal medicine at the University of Texas Medical Branch, Galveston. In a video interview, Dr. Saade discussed what’s fueling the rise, and what physicians must do to reduce C-section rates.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
AT THE PREGNANCY MEETING
