User login
Labetalol vs nifedipine associated with higher rates of postpartum readmission for hypertension
Key clinical point: The chances of postpartum readmission for hypertension were significantly higher among patients discharged with labetalol vs nifedipine after delivery, irrespective of the severity of their hypertensive disorder of pregnancy.
Major finding: Compared with nifedipine, the chances of postpartum readmission for hypertension were higher with labetalol (adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85), with the risk being persistent among patients with mild (aOR 1.57; 95% CI 1.29-1.93) and severe (aOR 1.63, 95% CI 1.43-1.85) hypertensive disorders.
Study details: This study evaluated 24,477 patients who were discharged with nifedipine (36.8%), labetalol (57.7%), or both medications (5.6%) after delivery.
Disclosures: This study did not report any source of funding. DJ Lyell declared receiving payment from various sources.
Source: Do SC et al. Postpartum readmission for hypertension after discharge on labetalol or nifedipine. Obstet Gynecol. 2022;140(4):591-598 (Sep 8). Doi: 10.1097/AOG.0000000000004918
Key clinical point: The chances of postpartum readmission for hypertension were significantly higher among patients discharged with labetalol vs nifedipine after delivery, irrespective of the severity of their hypertensive disorder of pregnancy.
Major finding: Compared with nifedipine, the chances of postpartum readmission for hypertension were higher with labetalol (adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85), with the risk being persistent among patients with mild (aOR 1.57; 95% CI 1.29-1.93) and severe (aOR 1.63, 95% CI 1.43-1.85) hypertensive disorders.
Study details: This study evaluated 24,477 patients who were discharged with nifedipine (36.8%), labetalol (57.7%), or both medications (5.6%) after delivery.
Disclosures: This study did not report any source of funding. DJ Lyell declared receiving payment from various sources.
Source: Do SC et al. Postpartum readmission for hypertension after discharge on labetalol or nifedipine. Obstet Gynecol. 2022;140(4):591-598 (Sep 8). Doi: 10.1097/AOG.0000000000004918
Key clinical point: The chances of postpartum readmission for hypertension were significantly higher among patients discharged with labetalol vs nifedipine after delivery, irrespective of the severity of their hypertensive disorder of pregnancy.
Major finding: Compared with nifedipine, the chances of postpartum readmission for hypertension were higher with labetalol (adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85), with the risk being persistent among patients with mild (aOR 1.57; 95% CI 1.29-1.93) and severe (aOR 1.63, 95% CI 1.43-1.85) hypertensive disorders.
Study details: This study evaluated 24,477 patients who were discharged with nifedipine (36.8%), labetalol (57.7%), or both medications (5.6%) after delivery.
Disclosures: This study did not report any source of funding. DJ Lyell declared receiving payment from various sources.
Source: Do SC et al. Postpartum readmission for hypertension after discharge on labetalol or nifedipine. Obstet Gynecol. 2022;140(4):591-598 (Sep 8). Doi: 10.1097/AOG.0000000000004918
Simulation training on management of shoulder dystocia reduces incidence of permanent BPBI
Key clinical point: Weekly 3-hour simulation-based training of midwives and doctors on shoulder dystocia (SD) management significantly reduced the incidence of permanent brachial plexus birth injury (BPBI).
Major finding: Despite an increase in the incidence of SD cases (0.1% vs 0.3%; P < .001) and risk factors in pre-training vs post-training period, the incidence of permanent BPBI decreased significantly (0.05% vs 0.02%; P < .001), with the risk for permanent BPBI among those with SD reducing (43.5% vs 6.0%; P < .001) and the rate of successful posterior arm delivery increasing (11.3% vs 23.4%; P = .04) significantly after the implementation of systematic simulation-based training.
Study details: Findings are from a retrospective observational study including 113,785 vertex deliveries performed by a team of doctors and midwives after receiving the weekly 3-hour simulation-based training.
Disclosures: This study was funded by Helsinki University State Research Funding. No conflicts of interest were declared.
Source: Kaijomaa M et al. Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study. BJOG. 2022 (Aug 10). Doi: 10.1111/1471-0528.17278
Key clinical point: Weekly 3-hour simulation-based training of midwives and doctors on shoulder dystocia (SD) management significantly reduced the incidence of permanent brachial plexus birth injury (BPBI).
Major finding: Despite an increase in the incidence of SD cases (0.1% vs 0.3%; P < .001) and risk factors in pre-training vs post-training period, the incidence of permanent BPBI decreased significantly (0.05% vs 0.02%; P < .001), with the risk for permanent BPBI among those with SD reducing (43.5% vs 6.0%; P < .001) and the rate of successful posterior arm delivery increasing (11.3% vs 23.4%; P = .04) significantly after the implementation of systematic simulation-based training.
Study details: Findings are from a retrospective observational study including 113,785 vertex deliveries performed by a team of doctors and midwives after receiving the weekly 3-hour simulation-based training.
Disclosures: This study was funded by Helsinki University State Research Funding. No conflicts of interest were declared.
Source: Kaijomaa M et al. Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study. BJOG. 2022 (Aug 10). Doi: 10.1111/1471-0528.17278
Key clinical point: Weekly 3-hour simulation-based training of midwives and doctors on shoulder dystocia (SD) management significantly reduced the incidence of permanent brachial plexus birth injury (BPBI).
Major finding: Despite an increase in the incidence of SD cases (0.1% vs 0.3%; P < .001) and risk factors in pre-training vs post-training period, the incidence of permanent BPBI decreased significantly (0.05% vs 0.02%; P < .001), with the risk for permanent BPBI among those with SD reducing (43.5% vs 6.0%; P < .001) and the rate of successful posterior arm delivery increasing (11.3% vs 23.4%; P = .04) significantly after the implementation of systematic simulation-based training.
Study details: Findings are from a retrospective observational study including 113,785 vertex deliveries performed by a team of doctors and midwives after receiving the weekly 3-hour simulation-based training.
Disclosures: This study was funded by Helsinki University State Research Funding. No conflicts of interest were declared.
Source: Kaijomaa M et al. Impact of simulation training on the management of shoulder dystocia and incidence of permanent brachial plexus birth injury: An observational study. BJOG. 2022 (Aug 10). Doi: 10.1111/1471-0528.17278
Postpartum sexual enjoyment: Does mode of delivery matter?
For some parents, resuming sexual intimacy after having a baby is a top priority. For others, not so much – and late-night feedings and diaper changes may not be the only hang-ups.
Dyspareunia – pain during sex – occurs in a substantial number of women after childbirth, and recent research sheds light on how psychological and biomedical factors relate to this condition.
Mode of delivery, for instance, may have less of an effect on sexual well-being than some people suspect.
Despite a perception that cesarean delivery might affect sexual function less than vaginal delivery does, how mothers delivered did not affect how often they had sex postpartum or the amount of enjoyment they got from it, according to research published in BJOG.
Eleven years after delivery, however, cesarean delivery was associated with a 74% increased likelihood of pain in the vagina during sex, compared with vaginal delivery, the researchers found (odds ratio, 1.74; 95% confidence interval, 1.46-2.08).
The results suggest that cesarean delivery “may not help protect against sexual dysfunction, as previously thought,” Flo Martin, a PhD student in epidemiology at the University of Bristol, United Kingdom, and lead author of the study, said in a news release.
For their study, Ms. Martin and her colleagues analyzed data from more than 10,300 participants in the Avon Longitudinal Study of Parents and Children, which recruited women in the United Kingdom who were pregnant in 1991 and 1992.
The researchers had data about pain during sex at 11 years. They had data about sexual enjoyment and frequency at 33 months, 5 years, 12 years, and 18 years after delivery.
If women experienced pain during sex years after cesarean delivery, uterine scarring might have been a cause, Ms. Martin and colleagues suggested. Alternatively, women with dyspareunia before delivery may be more likely to have cesarean surgery, which also could explain the association.
Other studies have likewise found that different modes of delivery generally lead to similar outcomes of sexual well-being after birth.
“Several of my own longitudinal studies have shown limited associations between mode of delivery and various aspects of sexual well-being, including sexual satisfaction, sexual function, and sexual desire,” said Natalie O. Rosen, PhD, director of the Couples and Sexual Health Laboratory at Dalhousie University, Halifax, N.S.
Nevertheless, other published studies have yielded conflicting results, so the question warrants further study, she said.
Pain catastrophizing
One study by Dr. Rosen’s group, published in Obstetrics & Gynecology, tracked sexual pain in 582 people from mid-pregnancy to 2 years postpartum.
About 21% of participants experienced moderate pain during sex, as determined by an average pain score greater than 4 on scale of 0-10 points. The rest were classified as having “minimal dyspareunia.”
Pain tended to peak at 3 months postpartum and then steadily decrease in both the moderate and minimal pain groups.
Mode of delivery did not affect the odds that a participant would have moderate dyspareunia. Neither did breastfeeding or prior chronic pain.
“But we did find one key thing to look out for: Those who reported a lot of negative thoughts and feelings about pain, something called pain catastrophizing, were more likely to experience moderate persistent pain during sex,” the researchers said in a video about their findings.
Pain catastrophizing 3 months after delivery was associated with significantly increased odds of following a moderate pain trajectory (odds ratio, 1.09; 95% confidence interval, 1.04-1.15).
Let’s talk about #postbabyhankypanky
Caring for a newborn while maintaining a romantic relationship can be challenging, and “there is a lack of evidence-based research aimed at helping couples prevent and navigate changes to their sexual well-being postpartum,” Dr. Rosen said.
During the 2-year study, a growing number of participants reported having sex less often over time. The percentage of women who had engaged in sexual activity in the past 4 weeks was 99% at baseline (20-24 weeks of gestation), 83.5% at 32 weeks of gestation, 73.9% at 3 months postpartum, and 69.6% at 2 years postpartum.
“One crucial way that couples sustain their connection is through their sexuality,” Dr. Rosen said. “Unfortunately, most new parents experience significant disruptions to their sexual function,” such as lower sexual desire or more pain during intercourse.
Dr. Rosen’s group has created a series of videos related to this topic dubbed #postbabyhankypanky to facilitate communication about sex postpartum. She encourages women with dyspareunia to talk with a health care provider because treatments such as cognitive-behavioral therapy, pelvic floor physical therapy, and topical medications can help manage pain.
‘Reassuring’ data
Veronica Gillispie-Bell, MD, MAS, director of quality for women’s services at the Ochsner Health System, New Orleans, said that she sees patients with postpartum sexual pain frequently.
Patients typically are instructed to have pelvic rest from delivery until 6 weeks after.
At the 6-week appointment, she tells patients to make sure that they are using lots of lubrication, because vaginal dryness related to hormonal changes during pregnancy and breastfeeding can make sex more painful, regardless of mode of delivery.
For many patients, she also recommends pelvic floor physical therapy.
As the medical director for the Louisiana Perinatal Quality Collaborative – a network of care providers, public health officials, and advocates that aims to improve outcomes for birthing persons, families, and newborns – Dr. Gillispie-Bell also is focused on reducing the rate of cesarean deliveries in the state. The BJOG study showing an increased risk for dyspareunia after a cesarean surgery serves as a reminder that there may be “long-term effects of having a C-section that may not be as obvious,” she said.
“C-sections are life-saving procedures, but they are not without risk,” Dr. Gillispie-Bell said.
Leila Frodsham, MBChB, a spokesperson for the Royal College of Obstetricians and Gynaecologists, told Medscape UK that it was “reassuring” to see “no difference in sexual enjoyment or sexual frequency at any time point postpartum between women who gave birth via cesarean section and those who delivered vaginally.”
“Women should be supported to make informed decisions about how they plan to give birth, and it is vital that health care professionals respect their preferences,” Dr. Frodsham added.
Clinicians should also remain aware that sexual pain is also common during periods of subfertility, perimenopause, and initiation of sexual activity.
Combinations of biological, psychological, and social factors can influence pain during sex, and there is an interpersonal element to keep in mind as well, Dr. Rosen noted.
“Pain during sex is typically elicited in the context of a partnered relationship,” Dr. Rosen said. “This means that this is an inherently interpersonal issue – let’s not forget about the partner who is both impacted by and can impact the pain through their own responses.”
A version of this article first appeared on Medscape.com.
For some parents, resuming sexual intimacy after having a baby is a top priority. For others, not so much – and late-night feedings and diaper changes may not be the only hang-ups.
Dyspareunia – pain during sex – occurs in a substantial number of women after childbirth, and recent research sheds light on how psychological and biomedical factors relate to this condition.
Mode of delivery, for instance, may have less of an effect on sexual well-being than some people suspect.
Despite a perception that cesarean delivery might affect sexual function less than vaginal delivery does, how mothers delivered did not affect how often they had sex postpartum or the amount of enjoyment they got from it, according to research published in BJOG.
Eleven years after delivery, however, cesarean delivery was associated with a 74% increased likelihood of pain in the vagina during sex, compared with vaginal delivery, the researchers found (odds ratio, 1.74; 95% confidence interval, 1.46-2.08).
The results suggest that cesarean delivery “may not help protect against sexual dysfunction, as previously thought,” Flo Martin, a PhD student in epidemiology at the University of Bristol, United Kingdom, and lead author of the study, said in a news release.
For their study, Ms. Martin and her colleagues analyzed data from more than 10,300 participants in the Avon Longitudinal Study of Parents and Children, which recruited women in the United Kingdom who were pregnant in 1991 and 1992.
The researchers had data about pain during sex at 11 years. They had data about sexual enjoyment and frequency at 33 months, 5 years, 12 years, and 18 years after delivery.
If women experienced pain during sex years after cesarean delivery, uterine scarring might have been a cause, Ms. Martin and colleagues suggested. Alternatively, women with dyspareunia before delivery may be more likely to have cesarean surgery, which also could explain the association.
Other studies have likewise found that different modes of delivery generally lead to similar outcomes of sexual well-being after birth.
“Several of my own longitudinal studies have shown limited associations between mode of delivery and various aspects of sexual well-being, including sexual satisfaction, sexual function, and sexual desire,” said Natalie O. Rosen, PhD, director of the Couples and Sexual Health Laboratory at Dalhousie University, Halifax, N.S.
Nevertheless, other published studies have yielded conflicting results, so the question warrants further study, she said.
Pain catastrophizing
One study by Dr. Rosen’s group, published in Obstetrics & Gynecology, tracked sexual pain in 582 people from mid-pregnancy to 2 years postpartum.
About 21% of participants experienced moderate pain during sex, as determined by an average pain score greater than 4 on scale of 0-10 points. The rest were classified as having “minimal dyspareunia.”
Pain tended to peak at 3 months postpartum and then steadily decrease in both the moderate and minimal pain groups.
Mode of delivery did not affect the odds that a participant would have moderate dyspareunia. Neither did breastfeeding or prior chronic pain.
“But we did find one key thing to look out for: Those who reported a lot of negative thoughts and feelings about pain, something called pain catastrophizing, were more likely to experience moderate persistent pain during sex,” the researchers said in a video about their findings.
Pain catastrophizing 3 months after delivery was associated with significantly increased odds of following a moderate pain trajectory (odds ratio, 1.09; 95% confidence interval, 1.04-1.15).
Let’s talk about #postbabyhankypanky
Caring for a newborn while maintaining a romantic relationship can be challenging, and “there is a lack of evidence-based research aimed at helping couples prevent and navigate changes to their sexual well-being postpartum,” Dr. Rosen said.
During the 2-year study, a growing number of participants reported having sex less often over time. The percentage of women who had engaged in sexual activity in the past 4 weeks was 99% at baseline (20-24 weeks of gestation), 83.5% at 32 weeks of gestation, 73.9% at 3 months postpartum, and 69.6% at 2 years postpartum.
“One crucial way that couples sustain their connection is through their sexuality,” Dr. Rosen said. “Unfortunately, most new parents experience significant disruptions to their sexual function,” such as lower sexual desire or more pain during intercourse.
Dr. Rosen’s group has created a series of videos related to this topic dubbed #postbabyhankypanky to facilitate communication about sex postpartum. She encourages women with dyspareunia to talk with a health care provider because treatments such as cognitive-behavioral therapy, pelvic floor physical therapy, and topical medications can help manage pain.
‘Reassuring’ data
Veronica Gillispie-Bell, MD, MAS, director of quality for women’s services at the Ochsner Health System, New Orleans, said that she sees patients with postpartum sexual pain frequently.
Patients typically are instructed to have pelvic rest from delivery until 6 weeks after.
At the 6-week appointment, she tells patients to make sure that they are using lots of lubrication, because vaginal dryness related to hormonal changes during pregnancy and breastfeeding can make sex more painful, regardless of mode of delivery.
For many patients, she also recommends pelvic floor physical therapy.
As the medical director for the Louisiana Perinatal Quality Collaborative – a network of care providers, public health officials, and advocates that aims to improve outcomes for birthing persons, families, and newborns – Dr. Gillispie-Bell also is focused on reducing the rate of cesarean deliveries in the state. The BJOG study showing an increased risk for dyspareunia after a cesarean surgery serves as a reminder that there may be “long-term effects of having a C-section that may not be as obvious,” she said.
“C-sections are life-saving procedures, but they are not without risk,” Dr. Gillispie-Bell said.
Leila Frodsham, MBChB, a spokesperson for the Royal College of Obstetricians and Gynaecologists, told Medscape UK that it was “reassuring” to see “no difference in sexual enjoyment or sexual frequency at any time point postpartum between women who gave birth via cesarean section and those who delivered vaginally.”
“Women should be supported to make informed decisions about how they plan to give birth, and it is vital that health care professionals respect their preferences,” Dr. Frodsham added.
Clinicians should also remain aware that sexual pain is also common during periods of subfertility, perimenopause, and initiation of sexual activity.
Combinations of biological, psychological, and social factors can influence pain during sex, and there is an interpersonal element to keep in mind as well, Dr. Rosen noted.
“Pain during sex is typically elicited in the context of a partnered relationship,” Dr. Rosen said. “This means that this is an inherently interpersonal issue – let’s not forget about the partner who is both impacted by and can impact the pain through their own responses.”
A version of this article first appeared on Medscape.com.
For some parents, resuming sexual intimacy after having a baby is a top priority. For others, not so much – and late-night feedings and diaper changes may not be the only hang-ups.
Dyspareunia – pain during sex – occurs in a substantial number of women after childbirth, and recent research sheds light on how psychological and biomedical factors relate to this condition.
Mode of delivery, for instance, may have less of an effect on sexual well-being than some people suspect.
Despite a perception that cesarean delivery might affect sexual function less than vaginal delivery does, how mothers delivered did not affect how often they had sex postpartum or the amount of enjoyment they got from it, according to research published in BJOG.
Eleven years after delivery, however, cesarean delivery was associated with a 74% increased likelihood of pain in the vagina during sex, compared with vaginal delivery, the researchers found (odds ratio, 1.74; 95% confidence interval, 1.46-2.08).
The results suggest that cesarean delivery “may not help protect against sexual dysfunction, as previously thought,” Flo Martin, a PhD student in epidemiology at the University of Bristol, United Kingdom, and lead author of the study, said in a news release.
For their study, Ms. Martin and her colleagues analyzed data from more than 10,300 participants in the Avon Longitudinal Study of Parents and Children, which recruited women in the United Kingdom who were pregnant in 1991 and 1992.
The researchers had data about pain during sex at 11 years. They had data about sexual enjoyment and frequency at 33 months, 5 years, 12 years, and 18 years after delivery.
If women experienced pain during sex years after cesarean delivery, uterine scarring might have been a cause, Ms. Martin and colleagues suggested. Alternatively, women with dyspareunia before delivery may be more likely to have cesarean surgery, which also could explain the association.
Other studies have likewise found that different modes of delivery generally lead to similar outcomes of sexual well-being after birth.
“Several of my own longitudinal studies have shown limited associations between mode of delivery and various aspects of sexual well-being, including sexual satisfaction, sexual function, and sexual desire,” said Natalie O. Rosen, PhD, director of the Couples and Sexual Health Laboratory at Dalhousie University, Halifax, N.S.
Nevertheless, other published studies have yielded conflicting results, so the question warrants further study, she said.
Pain catastrophizing
One study by Dr. Rosen’s group, published in Obstetrics & Gynecology, tracked sexual pain in 582 people from mid-pregnancy to 2 years postpartum.
About 21% of participants experienced moderate pain during sex, as determined by an average pain score greater than 4 on scale of 0-10 points. The rest were classified as having “minimal dyspareunia.”
Pain tended to peak at 3 months postpartum and then steadily decrease in both the moderate and minimal pain groups.
Mode of delivery did not affect the odds that a participant would have moderate dyspareunia. Neither did breastfeeding or prior chronic pain.
“But we did find one key thing to look out for: Those who reported a lot of negative thoughts and feelings about pain, something called pain catastrophizing, were more likely to experience moderate persistent pain during sex,” the researchers said in a video about their findings.
Pain catastrophizing 3 months after delivery was associated with significantly increased odds of following a moderate pain trajectory (odds ratio, 1.09; 95% confidence interval, 1.04-1.15).
Let’s talk about #postbabyhankypanky
Caring for a newborn while maintaining a romantic relationship can be challenging, and “there is a lack of evidence-based research aimed at helping couples prevent and navigate changes to their sexual well-being postpartum,” Dr. Rosen said.
During the 2-year study, a growing number of participants reported having sex less often over time. The percentage of women who had engaged in sexual activity in the past 4 weeks was 99% at baseline (20-24 weeks of gestation), 83.5% at 32 weeks of gestation, 73.9% at 3 months postpartum, and 69.6% at 2 years postpartum.
“One crucial way that couples sustain their connection is through their sexuality,” Dr. Rosen said. “Unfortunately, most new parents experience significant disruptions to their sexual function,” such as lower sexual desire or more pain during intercourse.
Dr. Rosen’s group has created a series of videos related to this topic dubbed #postbabyhankypanky to facilitate communication about sex postpartum. She encourages women with dyspareunia to talk with a health care provider because treatments such as cognitive-behavioral therapy, pelvic floor physical therapy, and topical medications can help manage pain.
‘Reassuring’ data
Veronica Gillispie-Bell, MD, MAS, director of quality for women’s services at the Ochsner Health System, New Orleans, said that she sees patients with postpartum sexual pain frequently.
Patients typically are instructed to have pelvic rest from delivery until 6 weeks after.
At the 6-week appointment, she tells patients to make sure that they are using lots of lubrication, because vaginal dryness related to hormonal changes during pregnancy and breastfeeding can make sex more painful, regardless of mode of delivery.
For many patients, she also recommends pelvic floor physical therapy.
As the medical director for the Louisiana Perinatal Quality Collaborative – a network of care providers, public health officials, and advocates that aims to improve outcomes for birthing persons, families, and newborns – Dr. Gillispie-Bell also is focused on reducing the rate of cesarean deliveries in the state. The BJOG study showing an increased risk for dyspareunia after a cesarean surgery serves as a reminder that there may be “long-term effects of having a C-section that may not be as obvious,” she said.
“C-sections are life-saving procedures, but they are not without risk,” Dr. Gillispie-Bell said.
Leila Frodsham, MBChB, a spokesperson for the Royal College of Obstetricians and Gynaecologists, told Medscape UK that it was “reassuring” to see “no difference in sexual enjoyment or sexual frequency at any time point postpartum between women who gave birth via cesarean section and those who delivered vaginally.”
“Women should be supported to make informed decisions about how they plan to give birth, and it is vital that health care professionals respect their preferences,” Dr. Frodsham added.
Clinicians should also remain aware that sexual pain is also common during periods of subfertility, perimenopause, and initiation of sexual activity.
Combinations of biological, psychological, and social factors can influence pain during sex, and there is an interpersonal element to keep in mind as well, Dr. Rosen noted.
“Pain during sex is typically elicited in the context of a partnered relationship,” Dr. Rosen said. “This means that this is an inherently interpersonal issue – let’s not forget about the partner who is both impacted by and can impact the pain through their own responses.”
A version of this article first appeared on Medscape.com.
Community-level actions could mitigate maternal mortality
Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.
Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.
In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.
Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.
Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.
The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.
Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.
In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.
Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.
Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.
Strategies to reduce disparity
Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.
Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”
For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.
Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.
Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.
Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.
Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.
In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.
Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.
Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.
The presenters had no relevant financial conflicts to disclose.
Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.
Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.
In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.
Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.
Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.
The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.
Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.
In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.
Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.
Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.
Strategies to reduce disparity
Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.
Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”
For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.
Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.
Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.
Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.
Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.
In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.
Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.
Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.
The presenters had no relevant financial conflicts to disclose.
Maternal mortality in the United States has been rising for several decades, but actions taken at the community level, as well as larger public health initiatives, have the potential to slow this trend, according to experts at a webinar sponsored by the National Institute for Health Care Management.
Maternal mortality in the United States increased by 14% from 2018 to 2020, according to data from the Centers for Disease Control and Prevention’s National Center for Health Statistics.
However, more than 80% of pregnancy-related deaths are preventable, according to 2017-2019 data from the Maternal Mortality Review Committees published online by the CDC. MMRCs include representatives of diverse clinical and nonclinical backgrounds who review the circumstances of pregnancy-related deaths.
In a webinar presented on Sept. 20, the NIHCM enlisted a panel of experts to discuss maternal mortality, the effect of changes to reproductive rights, and potential strategies to improve maternal health outcomes.
Maternal mortality is defined as “death while pregnant or within 42 days of the end of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to pregnancy or its management,” according to the CDC.
Importantly, mortality rates in the United States are approximately three times higher in Black women compared with White women, said Ndidiamaka Amutah-Onukagha, PhD, MPH, of the Tufts University Center for Black Maternal Health & Reproductive Justice. Dr. Amutah-Onukagha addressed some of the potential issues that appear to drive the disparity in care.
The lack of diversity in the health care workforce has a significant effect on patient outcomes, Dr. Amutah-Onukagha said. Overall, Black newborns are more than twice as likely as White newborns to die during their first year of life, but this number is cut in half when Black infants are cared for by Black physicians, she emphasized.
Other factors that may affect disparities in maternal health care include limited access to prenatal care, discriminatory hospital protocols, and mistreatment by health care professionals, said Dr. Amutah-Onukagha. She cited data showing that maternal mortality rates were higher in rural compared with urban areas. “According to the American Hospital Association, half of rural hospitals have no obstetric care, leaving mothers in maternity care deserts; this exacerbates existing disparities,” she said.
In the webinar, Sindhu Srinivas, MD, a maternal-fetal medicine specialist at the University of Pennsylvania, explained how patient, community, and system factors play a role in the disparities in maternal care.
Overall, Black women have to travel further to receive care, which has implications for high-risk pregnancies, and patients on Medicaid have to wait longer for care, and are less likely to be referred, she added. Black women also have higher rates of preexisting conditions compared with other populations that put them in the high-risk category, such as high blood pressure, diabetes, obesity, or being HIV positive, she said.
Other factors contributing to persistent disparities in maternal care include sociodemographics, patient beliefs and knowledge, and psychological issues including stress, said Dr. Srinivas. Community factors, such as social networks, safety, and poverty, also play a role, as do clinician factors of implicit bias and communication skills, she said.
Strategies to reduce disparity
Dr. Srinivas presented several strategies to reduce disparities at various levels. At the policy level, interventions such as establishing a Maternal Mortality Review Committee, establishing a perinatal quality collaborative, and extending Medicaid for a full year postpartum could help improve outcomes, she said. Dr. Srinivas also encouraged clinicians to report maternal mortality data stratified by race and ethnicity, and to participate in the Alliance for Innovation on Maternal Health program (AIM), an initiative in partnership with the American College of Obstetrics and Gynecology.
Dr. Srinivas also proposed maternal health policies to develop payment models “to sustain and scale innovative solutions, and “preserve access to contraception and abortion care.”
For clinicians looking to have an immediate impact, the panelists agreed that working with community health centers can make a significant difference by improving access to maternal care. Consider opportunities for partnership between hospitals and health care delivery centers in the community, said Dr. Srinivas.
Also, don’t underestimate the value of doulas in the birthing process, Dr. Amutah-Onukagha said. She urged clinicians to advocate for doula reimbursement and to take advantage of opportunities for doulas to work with pregnant individuals at the community levels. Data suggest that doulas are associated with increased maternal care visits and with breastfeeding, she noted.
Adam Myers, MD, of the Blue Cross Blue Shield Association, also contributed to the webinar discussion with a key point: Having financial means and commercial coverage is not a buffer against adverse maternal outcomes for racial minorities.
Dr. Myers cited the latest Health of America Report, which included data up to April 2021 with surveys of Medicaid members and their experiences. According to the report, rates of severe maternal mortality (SMM) increased by 9% for commercially and Medicaid-insured women between 2018 and 2020.
Among commercially insured women, SMM was 53% higher among Black women than White women; among Medicaid-insured women, Black women had a 73% higher rate of SMM, compared with White women.
In addition, the report showed that significantly more mothers of color were not able to complete the recommended series of prenatal visits, mainly for reasons of scheduling and transportation, which were greater barriers than COVID-19, Dr. Myers said.
Based on the data, one specific risk profile rose to the top: “We believe women of color aged 35 or higher with comorbid conditions should be treated as very high risk for SMM,” Dr. Myers emphasized. He stressed the need to focus on transportation and scheduling barriers and expressed support for partnerships and health care delivery centers in the community to mitigate these issues.
Finally, Dr. Srinivas encouraged clinicians to have confidence in their expertise and make themselves heard to help their patients and improve maternal health for all. “Use your voice,” said Dr. Srinivas, “As physicians we don’t think of that as an important aspect of our work, or that we can’t articulate, but remember that we are experts, and sharing stories of patients who are impacted is incredibly powerful,” she said.
The presenters had no relevant financial conflicts to disclose.
‘Cracking’ technology shows promise for reducing environmental inhaled nitrous oxide impacts during labor
New evidence indicates that the use of “cracking” technology can significantly reduce the ambient levels of inhaled nitrous oxide (N2O) during labor, especially when women are coached on how best to use it.
The findings, from a quality improvement study conducted by anesthetists and midwives in the United Kingdom, appear to have implications for minimizing staff exposures and for lowering N2O’s environmental effect overall. The potent greenhouse gas has a carbon footprint that is 265 times larger than carbon dioxide.
“Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure,” reported Annie Pinder, MBChB, a fellow in sustainable anesthesia at North West School of Anaesthesia, Manchester, England, and colleagues in Anaesthesia.
Proportionally, the United Kingdom is one of the largest users of inhaled N2O during labor, often for first-line pain control. A 2017 survey by the Care Quality Commission estimated that 77% of women in labor used inhaled N2O for pain, and that it didn’t preclude them from using other types of analgesia, including opioids, epidurals, and nonpharmacologic approaches.
Previous research has established the effectiveness of cracking, which uses a catalyst to convert N2O into nitrogen and oxygen. However, little is known about the effectiveness of scavenging devices that minimize waste N2O in a real-world setting, the authors said.
For the study, median ambient N2O levels were recorded for 36 women during the final 30 minutes of uncomplicated labor. Ambient N2O levels were initially recorded in 12 patients without use of three N2O scavenging devices, and then in three groups of eight patients using either a mouthpiece, a facemask with an air-filled cushion, or a low-profile facemask. Women were also coached on how to use the devices, and given feedback.
“Given that a similar magnitude of reduction in nitrous oxide levels was seen with mouthpieces and low-profile face masks, we suggest that pregnant women should be offered the option of either device when cracking is used,” the study authors wrote.
Staff feedback was generally positive, but some found use of the technology cumbersome. Sufficient staff engagement is the key to successful implementation, the researchers pointed out.
The results showed that when women consistently exhaled into the mouthpiece, median ambient N2O levels were 71% lower compared with levels recorded prior to use of the scavenging device. When women exhaled into a lightweight face mask with a flexible seal, median ambient N2O levels were 81% lower compared with baseline.
These data are consistent with the United Kingdom’s goal of achieving a net zero carbon footprint for the National Health Service by 2040, the researchers said. The study findings are also in keeping with predictions that cracking technology could reduce greenhouse gas emissions associated with N2O by an estimated 75%.
“Although cracking may make nitrous oxide ‘greener,’ it does not make it ‘green,’ ” noted Dr. Pinder and coauthor Cliff Shelton, MBChB, in an interview. Dr. Shelton is a senior clinical lecturer in anesthesia at Lancaster (England) University and a consultant anesthetist at Wythenshawe Hospital, Manchester.
Even with the use of cracking technology, the occupational effect of inhaled N2O is likely to remain higher than for other, more effective forms of anesthesia, such as epidurals and remifentanil (Ultiva), Dr. Pinder and Dr. Shelton said. Furthermore, ambient N2O levels are not a direct measure of the proportion of nitrous oxide cracked, “so there is scope for further work to more precisely understand the ‘carbon footprint’ impacts,” they pointed out.
Inhaled N20 is widely used for labor pain in the Scandinavian countries, as well as in Canada, Australia, and New Zealand. It’s also making a comeback in the United States, facilitated by the Food and Drug Administration’s (FDA) approval of a portable N2O delivery system in 2012.
The system, which delivers a mixture of 50% nitrous oxide and 50% oxygen, has offered a new option for laboring mothers, said Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s Hospital, Boston, and coauthors in a 2014 report.
“Nitrous oxide works really well as an adjunct to other analgesia,” said Laura Goetzl, MD, MPH, professor of obstetrics, gynecology, and reproductive sciences at University of Texas at Houston Health Science Center. Women in labor really like having the option of inhaled N2O to manage pain, she said in an interview. “The more options that we have to offer, the better for women.”
“Not only does nitrous oxide help with perception of pain, it’s also highly effective for reducing patient anxiety,” Dr. Goetzl explained. “If a patient is waiting for an epidural, the use of nitrous oxide can be particularly helpful.”
Dr. Shelton reported that he is executive editor of Anaesthesia Reports. Dr. Pinder and the remaining coauthors disclosed having no conflicts of interest. Dr. Goetzl reported that she is on the medical advisory board of Mirvie.
This story was updated on Sept. 27, 2022.
New evidence indicates that the use of “cracking” technology can significantly reduce the ambient levels of inhaled nitrous oxide (N2O) during labor, especially when women are coached on how best to use it.
The findings, from a quality improvement study conducted by anesthetists and midwives in the United Kingdom, appear to have implications for minimizing staff exposures and for lowering N2O’s environmental effect overall. The potent greenhouse gas has a carbon footprint that is 265 times larger than carbon dioxide.
“Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure,” reported Annie Pinder, MBChB, a fellow in sustainable anesthesia at North West School of Anaesthesia, Manchester, England, and colleagues in Anaesthesia.
Proportionally, the United Kingdom is one of the largest users of inhaled N2O during labor, often for first-line pain control. A 2017 survey by the Care Quality Commission estimated that 77% of women in labor used inhaled N2O for pain, and that it didn’t preclude them from using other types of analgesia, including opioids, epidurals, and nonpharmacologic approaches.
Previous research has established the effectiveness of cracking, which uses a catalyst to convert N2O into nitrogen and oxygen. However, little is known about the effectiveness of scavenging devices that minimize waste N2O in a real-world setting, the authors said.
For the study, median ambient N2O levels were recorded for 36 women during the final 30 minutes of uncomplicated labor. Ambient N2O levels were initially recorded in 12 patients without use of three N2O scavenging devices, and then in three groups of eight patients using either a mouthpiece, a facemask with an air-filled cushion, or a low-profile facemask. Women were also coached on how to use the devices, and given feedback.
“Given that a similar magnitude of reduction in nitrous oxide levels was seen with mouthpieces and low-profile face masks, we suggest that pregnant women should be offered the option of either device when cracking is used,” the study authors wrote.
Staff feedback was generally positive, but some found use of the technology cumbersome. Sufficient staff engagement is the key to successful implementation, the researchers pointed out.
The results showed that when women consistently exhaled into the mouthpiece, median ambient N2O levels were 71% lower compared with levels recorded prior to use of the scavenging device. When women exhaled into a lightweight face mask with a flexible seal, median ambient N2O levels were 81% lower compared with baseline.
These data are consistent with the United Kingdom’s goal of achieving a net zero carbon footprint for the National Health Service by 2040, the researchers said. The study findings are also in keeping with predictions that cracking technology could reduce greenhouse gas emissions associated with N2O by an estimated 75%.
“Although cracking may make nitrous oxide ‘greener,’ it does not make it ‘green,’ ” noted Dr. Pinder and coauthor Cliff Shelton, MBChB, in an interview. Dr. Shelton is a senior clinical lecturer in anesthesia at Lancaster (England) University and a consultant anesthetist at Wythenshawe Hospital, Manchester.
Even with the use of cracking technology, the occupational effect of inhaled N2O is likely to remain higher than for other, more effective forms of anesthesia, such as epidurals and remifentanil (Ultiva), Dr. Pinder and Dr. Shelton said. Furthermore, ambient N2O levels are not a direct measure of the proportion of nitrous oxide cracked, “so there is scope for further work to more precisely understand the ‘carbon footprint’ impacts,” they pointed out.
Inhaled N20 is widely used for labor pain in the Scandinavian countries, as well as in Canada, Australia, and New Zealand. It’s also making a comeback in the United States, facilitated by the Food and Drug Administration’s (FDA) approval of a portable N2O delivery system in 2012.
The system, which delivers a mixture of 50% nitrous oxide and 50% oxygen, has offered a new option for laboring mothers, said Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s Hospital, Boston, and coauthors in a 2014 report.
“Nitrous oxide works really well as an adjunct to other analgesia,” said Laura Goetzl, MD, MPH, professor of obstetrics, gynecology, and reproductive sciences at University of Texas at Houston Health Science Center. Women in labor really like having the option of inhaled N2O to manage pain, she said in an interview. “The more options that we have to offer, the better for women.”
“Not only does nitrous oxide help with perception of pain, it’s also highly effective for reducing patient anxiety,” Dr. Goetzl explained. “If a patient is waiting for an epidural, the use of nitrous oxide can be particularly helpful.”
Dr. Shelton reported that he is executive editor of Anaesthesia Reports. Dr. Pinder and the remaining coauthors disclosed having no conflicts of interest. Dr. Goetzl reported that she is on the medical advisory board of Mirvie.
This story was updated on Sept. 27, 2022.
New evidence indicates that the use of “cracking” technology can significantly reduce the ambient levels of inhaled nitrous oxide (N2O) during labor, especially when women are coached on how best to use it.
The findings, from a quality improvement study conducted by anesthetists and midwives in the United Kingdom, appear to have implications for minimizing staff exposures and for lowering N2O’s environmental effect overall. The potent greenhouse gas has a carbon footprint that is 265 times larger than carbon dioxide.
“Our results indicate that cracking technology can reduce ambient nitrous oxide levels in the obstetric setting, with potential for reductions in environmental impacts and occupational exposure,” reported Annie Pinder, MBChB, a fellow in sustainable anesthesia at North West School of Anaesthesia, Manchester, England, and colleagues in Anaesthesia.
Proportionally, the United Kingdom is one of the largest users of inhaled N2O during labor, often for first-line pain control. A 2017 survey by the Care Quality Commission estimated that 77% of women in labor used inhaled N2O for pain, and that it didn’t preclude them from using other types of analgesia, including opioids, epidurals, and nonpharmacologic approaches.
Previous research has established the effectiveness of cracking, which uses a catalyst to convert N2O into nitrogen and oxygen. However, little is known about the effectiveness of scavenging devices that minimize waste N2O in a real-world setting, the authors said.
For the study, median ambient N2O levels were recorded for 36 women during the final 30 minutes of uncomplicated labor. Ambient N2O levels were initially recorded in 12 patients without use of three N2O scavenging devices, and then in three groups of eight patients using either a mouthpiece, a facemask with an air-filled cushion, or a low-profile facemask. Women were also coached on how to use the devices, and given feedback.
“Given that a similar magnitude of reduction in nitrous oxide levels was seen with mouthpieces and low-profile face masks, we suggest that pregnant women should be offered the option of either device when cracking is used,” the study authors wrote.
Staff feedback was generally positive, but some found use of the technology cumbersome. Sufficient staff engagement is the key to successful implementation, the researchers pointed out.
The results showed that when women consistently exhaled into the mouthpiece, median ambient N2O levels were 71% lower compared with levels recorded prior to use of the scavenging device. When women exhaled into a lightweight face mask with a flexible seal, median ambient N2O levels were 81% lower compared with baseline.
These data are consistent with the United Kingdom’s goal of achieving a net zero carbon footprint for the National Health Service by 2040, the researchers said. The study findings are also in keeping with predictions that cracking technology could reduce greenhouse gas emissions associated with N2O by an estimated 75%.
“Although cracking may make nitrous oxide ‘greener,’ it does not make it ‘green,’ ” noted Dr. Pinder and coauthor Cliff Shelton, MBChB, in an interview. Dr. Shelton is a senior clinical lecturer in anesthesia at Lancaster (England) University and a consultant anesthetist at Wythenshawe Hospital, Manchester.
Even with the use of cracking technology, the occupational effect of inhaled N2O is likely to remain higher than for other, more effective forms of anesthesia, such as epidurals and remifentanil (Ultiva), Dr. Pinder and Dr. Shelton said. Furthermore, ambient N2O levels are not a direct measure of the proportion of nitrous oxide cracked, “so there is scope for further work to more precisely understand the ‘carbon footprint’ impacts,” they pointed out.
Inhaled N20 is widely used for labor pain in the Scandinavian countries, as well as in Canada, Australia, and New Zealand. It’s also making a comeback in the United States, facilitated by the Food and Drug Administration’s (FDA) approval of a portable N2O delivery system in 2012.
The system, which delivers a mixture of 50% nitrous oxide and 50% oxygen, has offered a new option for laboring mothers, said Robert L. Barbieri, MD, chair of obstetrics and gynecology at Brigham and Women’s Hospital, Boston, and coauthors in a 2014 report.
“Nitrous oxide works really well as an adjunct to other analgesia,” said Laura Goetzl, MD, MPH, professor of obstetrics, gynecology, and reproductive sciences at University of Texas at Houston Health Science Center. Women in labor really like having the option of inhaled N2O to manage pain, she said in an interview. “The more options that we have to offer, the better for women.”
“Not only does nitrous oxide help with perception of pain, it’s also highly effective for reducing patient anxiety,” Dr. Goetzl explained. “If a patient is waiting for an epidural, the use of nitrous oxide can be particularly helpful.”
Dr. Shelton reported that he is executive editor of Anaesthesia Reports. Dr. Pinder and the remaining coauthors disclosed having no conflicts of interest. Dr. Goetzl reported that she is on the medical advisory board of Mirvie.
This story was updated on Sept. 27, 2022.
FROM ANAESTHESIA
Eighty percent of U.S. maternal deaths are preventable: Study
More than 80% of U.S. maternal deaths across a 2-year period were due to preventable causes, according to a new CDC report.
Black mothers made up about a third of deaths, and more than 90% of deaths among Indigenous mothers were preventable.
“It’s significant. It’s staggering. It’s heartbreaking,” Allison Bryant, MD, a high-risk pregnancy specialist and senior medical director for health equity at Massachusetts General Hospital, told USA Today.
“It just means that we have so much work to do,” she said.
In the report, CDC researchers looked at pregnancy-related deaths between 2017 to 2019 based on numbers from maternal mortality review committees, which are multidisciplinary groups in 36 states that investigate the circumstances around maternal deaths.
Of the 1,018 deaths during the 2-year period, 839 occurred up to a year after delivery. About 22% of deaths happened during pregnancy, and 25% happened on the day of delivery or within a week after delivery. But 53% occurred more than 7 days after delivery.
Mental health conditions, such as overdoses and deaths by suicide, were the top underlying cause, followed by hemorrhage, or extreme bleeding. About a quarter of deaths were due to mental health conditions, followed by 14% due to hemorrhage and 13% due to heart problems. The rest were related to infection, embolism, cardiomyopathy, and high blood pressure-related disorders.
The analysis included a section on maternal deaths for American Indian and Alaska Native mothers, who are more than twice as likely as White mothers to die but are often undercounted in health data due to misclassification. More than 90% of their deaths were preventable between 2017 to 2019, with most due to mental health conditions and hemorrhage.
“It’s incredibly distressful,” Brian Thompson, MD, of the Oneida Nation and assistant professor of obstetrics and gynecology at Upstate Medical University, New York, told USA Today.
Dr. Thompson is working with the National Indian Health Board to create the first national tribal review committee for maternal deaths.
“It really needs to be looked at and examined why that is the case if essentially all of them are preventable,” he said.
Black mothers were also three times as likely as White mothers to die and more likely to die from heart problems. Hispanic mothers, who made up 14% of deaths, were more likely to die from mental health conditions.
Some of the deaths, such as hemorrhage, should be highly preventable. Existing toolkits for clinicians provide evidence-based guidelines to prevent and treat excessive bleeding.
“No pregnant person should be passing away from a hemorrhage,” Andrea Jackson, MD, division chief of obstetrics and gynecology at the University of California, San Francisco, told USA Today.
“We have the tools in the United States, and we know how to deal with it,” she said. “That was really disheartening to see.”
What’s more, the new CDC report highlights the need for more mental health resources during pregnancy and the postpartum period – up to a year or more after delivery – including improvements in access to care, diagnosis, and treatment.
“These are things that need to happen systemically,” LeThenia Baker, MD, an obstetrician and gynecologist at Wellstar Health, Georgia, told USA Today.
“It can’t just be a few practices here or there who are adopting best practices,” she said. “It has to be a systemic change.”
A version of this article first appeared on WebMD.com.
More than 80% of U.S. maternal deaths across a 2-year period were due to preventable causes, according to a new CDC report.
Black mothers made up about a third of deaths, and more than 90% of deaths among Indigenous mothers were preventable.
“It’s significant. It’s staggering. It’s heartbreaking,” Allison Bryant, MD, a high-risk pregnancy specialist and senior medical director for health equity at Massachusetts General Hospital, told USA Today.
“It just means that we have so much work to do,” she said.
In the report, CDC researchers looked at pregnancy-related deaths between 2017 to 2019 based on numbers from maternal mortality review committees, which are multidisciplinary groups in 36 states that investigate the circumstances around maternal deaths.
Of the 1,018 deaths during the 2-year period, 839 occurred up to a year after delivery. About 22% of deaths happened during pregnancy, and 25% happened on the day of delivery or within a week after delivery. But 53% occurred more than 7 days after delivery.
Mental health conditions, such as overdoses and deaths by suicide, were the top underlying cause, followed by hemorrhage, or extreme bleeding. About a quarter of deaths were due to mental health conditions, followed by 14% due to hemorrhage and 13% due to heart problems. The rest were related to infection, embolism, cardiomyopathy, and high blood pressure-related disorders.
The analysis included a section on maternal deaths for American Indian and Alaska Native mothers, who are more than twice as likely as White mothers to die but are often undercounted in health data due to misclassification. More than 90% of their deaths were preventable between 2017 to 2019, with most due to mental health conditions and hemorrhage.
“It’s incredibly distressful,” Brian Thompson, MD, of the Oneida Nation and assistant professor of obstetrics and gynecology at Upstate Medical University, New York, told USA Today.
Dr. Thompson is working with the National Indian Health Board to create the first national tribal review committee for maternal deaths.
“It really needs to be looked at and examined why that is the case if essentially all of them are preventable,” he said.
Black mothers were also three times as likely as White mothers to die and more likely to die from heart problems. Hispanic mothers, who made up 14% of deaths, were more likely to die from mental health conditions.
Some of the deaths, such as hemorrhage, should be highly preventable. Existing toolkits for clinicians provide evidence-based guidelines to prevent and treat excessive bleeding.
“No pregnant person should be passing away from a hemorrhage,” Andrea Jackson, MD, division chief of obstetrics and gynecology at the University of California, San Francisco, told USA Today.
“We have the tools in the United States, and we know how to deal with it,” she said. “That was really disheartening to see.”
What’s more, the new CDC report highlights the need for more mental health resources during pregnancy and the postpartum period – up to a year or more after delivery – including improvements in access to care, diagnosis, and treatment.
“These are things that need to happen systemically,” LeThenia Baker, MD, an obstetrician and gynecologist at Wellstar Health, Georgia, told USA Today.
“It can’t just be a few practices here or there who are adopting best practices,” she said. “It has to be a systemic change.”
A version of this article first appeared on WebMD.com.
More than 80% of U.S. maternal deaths across a 2-year period were due to preventable causes, according to a new CDC report.
Black mothers made up about a third of deaths, and more than 90% of deaths among Indigenous mothers were preventable.
“It’s significant. It’s staggering. It’s heartbreaking,” Allison Bryant, MD, a high-risk pregnancy specialist and senior medical director for health equity at Massachusetts General Hospital, told USA Today.
“It just means that we have so much work to do,” she said.
In the report, CDC researchers looked at pregnancy-related deaths between 2017 to 2019 based on numbers from maternal mortality review committees, which are multidisciplinary groups in 36 states that investigate the circumstances around maternal deaths.
Of the 1,018 deaths during the 2-year period, 839 occurred up to a year after delivery. About 22% of deaths happened during pregnancy, and 25% happened on the day of delivery or within a week after delivery. But 53% occurred more than 7 days after delivery.
Mental health conditions, such as overdoses and deaths by suicide, were the top underlying cause, followed by hemorrhage, or extreme bleeding. About a quarter of deaths were due to mental health conditions, followed by 14% due to hemorrhage and 13% due to heart problems. The rest were related to infection, embolism, cardiomyopathy, and high blood pressure-related disorders.
The analysis included a section on maternal deaths for American Indian and Alaska Native mothers, who are more than twice as likely as White mothers to die but are often undercounted in health data due to misclassification. More than 90% of their deaths were preventable between 2017 to 2019, with most due to mental health conditions and hemorrhage.
“It’s incredibly distressful,” Brian Thompson, MD, of the Oneida Nation and assistant professor of obstetrics and gynecology at Upstate Medical University, New York, told USA Today.
Dr. Thompson is working with the National Indian Health Board to create the first national tribal review committee for maternal deaths.
“It really needs to be looked at and examined why that is the case if essentially all of them are preventable,” he said.
Black mothers were also three times as likely as White mothers to die and more likely to die from heart problems. Hispanic mothers, who made up 14% of deaths, were more likely to die from mental health conditions.
Some of the deaths, such as hemorrhage, should be highly preventable. Existing toolkits for clinicians provide evidence-based guidelines to prevent and treat excessive bleeding.
“No pregnant person should be passing away from a hemorrhage,” Andrea Jackson, MD, division chief of obstetrics and gynecology at the University of California, San Francisco, told USA Today.
“We have the tools in the United States, and we know how to deal with it,” she said. “That was really disheartening to see.”
What’s more, the new CDC report highlights the need for more mental health resources during pregnancy and the postpartum period – up to a year or more after delivery – including improvements in access to care, diagnosis, and treatment.
“These are things that need to happen systemically,” LeThenia Baker, MD, an obstetrician and gynecologist at Wellstar Health, Georgia, told USA Today.
“It can’t just be a few practices here or there who are adopting best practices,” she said. “It has to be a systemic change.”
A version of this article first appeared on WebMD.com.
What is the best management strategy for complicated appendicitis in pregnancy?
Ashbrook M, et al. Management of complicated appendicitis during pregnancy in the US. JAMA Network Open. 2022;5:e227555. doi:10.1001/jamanetworkopen.2022.7555.
Expert Commentary
Over the last decade, the management of acute appendicitis in the nonpregnant adult has evolved such that some authorities favor first-line nonoperative therapy in the appropriate candidate, including some individuals with complicated appendicitis. While the conventional teaching regarding appendicitis in pregnancy has always been immediate surgery, favorable outcomes from nonoperative management in the nonpregnant population have led to an increasing application of conservative therapy in pregnancy, particularly among patients with uncomplicated appendicitis. However, optimal management of complicated appendicitis in pregnancy is unclear, as the risks of both operative and nonoperative management can be significant.
Details about the study
This retrospective cohort study using data from the National Inpatient Sample (NIS) focuses on outcomes of various management options among pregnant women with complicated appendicitis from January 2003 to September 2015. Complicated appendicitis refers to individuals with appendiceal perforation with peritonitis (a free perforation) or phlegmon/abscess (a walled-off perforation). Women included in the study were identified using ICD-9 codes for both pregnancy and complicated appendicitis; they were categorized into 3 groups: immediate operative management, successful nonoperative management, and failed nonoperative management (defined as surgical intervention >1 day after admission). The clinical and other outcomes of interest included maternal death, preterm labor/delivery or pregnancy loss, amniotic infection, sepsis, pneumonia, antenatal hemorrhage, and premature rupture of membranes. Outcomes included are those that occurred during the hospitalization for appendicitis; outcomes that may have occurred between discharge from the appendicitis hospitalization to the delivery hospitalization are not included in this study.
A total of 8,087 pregnant women with complicated appendicitis were included in this study, of whom 954 (11.8%) had successful nonoperative management, 2,646 (32.7%) had failed nonoperative management, and 4,487 (55.5%) had immediate operative management. First, when comparing successful nonoperative management to immediate operative management, there were no differences in preterm labor/delivery or pregnancy loss, or antenatal hemorrhage; however, successful nonoperative management was also associated with higher risks of maternal infectious complications, including risks of amniotic infection, pneumonia, and sepsis. When comparing failed nonoperative management (women who required surgical intervention during the index hospitalization) to immediate operative management, failed conservative management was associated with higher risks of preterm labor/delivery or pregnancy loss, antenatal hemorrhage, amniotic infection, pneumonia, and sepsis. For every 1 day that surgery was delayed in the group of women who failed nonoperative management, the odds of preterm labor/delivery or pregnancy loss, antenatal hemorrhage, sepsis, amniotic infection, and pneumonia increased.
Study strengths and weaknesses
Database studies have inherent limitations that are overcome with strength in numbers. In this study, our understanding of outcomes associated with management of complicated appendicitis assumes that women were correctly identified as both being pregnant and having complicated appendicitis (as opposed to uncomplicated appendicitis but miscoded). Clinical data that may have led to selection of one management strategy over another, or specific clinical management decisions, are not possible to extract from the NIS. For instance, did nonoperative management systematically include percutaneous guided drainage if an abscess was noted, and appropriately targeted antibiotic therapy? If delayed operative intervention with IV antibiotics to allow for “cooling off” of the abdomen prior to surgery was planned, this strategy would have been included in the failed nonoperative management group, when in fact nonoperative management was never the plan. Whether gestational age (which is not known in this study), or any other clinical data contributed to the initially chosen management strategy is not known.
The treating clinicians, obstetricians and surgeons alike, would like to know the pregnancy outcome when considering the various management strategies for complicated appendicitis. However, this study only provides insight into the outcomes for the hospitalization for appendicitis. Whether or not women categorized as successful nonoperative management go on to require surgery or have preterm labor in the future, or whether women with successful immediate surgical management might be readmitted with complications, is not known. This is a significant limitation of the database, which does not allow for linking of individual hospitalizations, and rather can provide only a snapshot in time.
This study includes a fairly long timespan–2003 to 2015–during which the management of complicated appendicitis was actively evolving. Early in this time frame, nonoperative management outside of pregnancy was uncommon, and nonoperative management may have been even rarer and perhaps reserved for the most ill of pregnant women on presentation (for whom surgery may have been considered too risky without a short time with IV antibiotics to “cool off” the abdomen). As time progressed over the study span, nonoperative management was likely offered with greater frequency and among women with lesser degrees of illness. However, the year of presentation was not controlled for in this study.
Finally, given the differences noted in management strategy by race/ethnicity and type of hospital, it is not clear how this bias influences the findings from this study. ●
Immediate operative intervention for complicated appendicitis in pregnancy remains a mainstay of management. Perinatal risks associated with surgical intervention are low and are comparable in many respects to successful nonoperative intervention. However, characteristics that predict successful nonoperative intervention are not known, and nonoperative therapy still carries higher risks of maternal infectious complications. When nonoperative intervention is the chosen approach in pregnant women with complicated appendicitis, clinicians must maintain a low threshold for conversion to operative management to avoid maternal morbidity. In addition, clinicians must closely monitor women discharged after successful appendicitis treatment for subsequent complications, as the long-term risks of conservative management or delayed operative intervention are not clear.
Ashbrook M, et al. Management of complicated appendicitis during pregnancy in the US. JAMA Network Open. 2022;5:e227555. doi:10.1001/jamanetworkopen.2022.7555.
Expert Commentary
Over the last decade, the management of acute appendicitis in the nonpregnant adult has evolved such that some authorities favor first-line nonoperative therapy in the appropriate candidate, including some individuals with complicated appendicitis. While the conventional teaching regarding appendicitis in pregnancy has always been immediate surgery, favorable outcomes from nonoperative management in the nonpregnant population have led to an increasing application of conservative therapy in pregnancy, particularly among patients with uncomplicated appendicitis. However, optimal management of complicated appendicitis in pregnancy is unclear, as the risks of both operative and nonoperative management can be significant.
Details about the study
This retrospective cohort study using data from the National Inpatient Sample (NIS) focuses on outcomes of various management options among pregnant women with complicated appendicitis from January 2003 to September 2015. Complicated appendicitis refers to individuals with appendiceal perforation with peritonitis (a free perforation) or phlegmon/abscess (a walled-off perforation). Women included in the study were identified using ICD-9 codes for both pregnancy and complicated appendicitis; they were categorized into 3 groups: immediate operative management, successful nonoperative management, and failed nonoperative management (defined as surgical intervention >1 day after admission). The clinical and other outcomes of interest included maternal death, preterm labor/delivery or pregnancy loss, amniotic infection, sepsis, pneumonia, antenatal hemorrhage, and premature rupture of membranes. Outcomes included are those that occurred during the hospitalization for appendicitis; outcomes that may have occurred between discharge from the appendicitis hospitalization to the delivery hospitalization are not included in this study.
A total of 8,087 pregnant women with complicated appendicitis were included in this study, of whom 954 (11.8%) had successful nonoperative management, 2,646 (32.7%) had failed nonoperative management, and 4,487 (55.5%) had immediate operative management. First, when comparing successful nonoperative management to immediate operative management, there were no differences in preterm labor/delivery or pregnancy loss, or antenatal hemorrhage; however, successful nonoperative management was also associated with higher risks of maternal infectious complications, including risks of amniotic infection, pneumonia, and sepsis. When comparing failed nonoperative management (women who required surgical intervention during the index hospitalization) to immediate operative management, failed conservative management was associated with higher risks of preterm labor/delivery or pregnancy loss, antenatal hemorrhage, amniotic infection, pneumonia, and sepsis. For every 1 day that surgery was delayed in the group of women who failed nonoperative management, the odds of preterm labor/delivery or pregnancy loss, antenatal hemorrhage, sepsis, amniotic infection, and pneumonia increased.
Study strengths and weaknesses
Database studies have inherent limitations that are overcome with strength in numbers. In this study, our understanding of outcomes associated with management of complicated appendicitis assumes that women were correctly identified as both being pregnant and having complicated appendicitis (as opposed to uncomplicated appendicitis but miscoded). Clinical data that may have led to selection of one management strategy over another, or specific clinical management decisions, are not possible to extract from the NIS. For instance, did nonoperative management systematically include percutaneous guided drainage if an abscess was noted, and appropriately targeted antibiotic therapy? If delayed operative intervention with IV antibiotics to allow for “cooling off” of the abdomen prior to surgery was planned, this strategy would have been included in the failed nonoperative management group, when in fact nonoperative management was never the plan. Whether gestational age (which is not known in this study), or any other clinical data contributed to the initially chosen management strategy is not known.
The treating clinicians, obstetricians and surgeons alike, would like to know the pregnancy outcome when considering the various management strategies for complicated appendicitis. However, this study only provides insight into the outcomes for the hospitalization for appendicitis. Whether or not women categorized as successful nonoperative management go on to require surgery or have preterm labor in the future, or whether women with successful immediate surgical management might be readmitted with complications, is not known. This is a significant limitation of the database, which does not allow for linking of individual hospitalizations, and rather can provide only a snapshot in time.
This study includes a fairly long timespan–2003 to 2015–during which the management of complicated appendicitis was actively evolving. Early in this time frame, nonoperative management outside of pregnancy was uncommon, and nonoperative management may have been even rarer and perhaps reserved for the most ill of pregnant women on presentation (for whom surgery may have been considered too risky without a short time with IV antibiotics to “cool off” the abdomen). As time progressed over the study span, nonoperative management was likely offered with greater frequency and among women with lesser degrees of illness. However, the year of presentation was not controlled for in this study.
Finally, given the differences noted in management strategy by race/ethnicity and type of hospital, it is not clear how this bias influences the findings from this study. ●
Immediate operative intervention for complicated appendicitis in pregnancy remains a mainstay of management. Perinatal risks associated with surgical intervention are low and are comparable in many respects to successful nonoperative intervention. However, characteristics that predict successful nonoperative intervention are not known, and nonoperative therapy still carries higher risks of maternal infectious complications. When nonoperative intervention is the chosen approach in pregnant women with complicated appendicitis, clinicians must maintain a low threshold for conversion to operative management to avoid maternal morbidity. In addition, clinicians must closely monitor women discharged after successful appendicitis treatment for subsequent complications, as the long-term risks of conservative management or delayed operative intervention are not clear.
Ashbrook M, et al. Management of complicated appendicitis during pregnancy in the US. JAMA Network Open. 2022;5:e227555. doi:10.1001/jamanetworkopen.2022.7555.
Expert Commentary
Over the last decade, the management of acute appendicitis in the nonpregnant adult has evolved such that some authorities favor first-line nonoperative therapy in the appropriate candidate, including some individuals with complicated appendicitis. While the conventional teaching regarding appendicitis in pregnancy has always been immediate surgery, favorable outcomes from nonoperative management in the nonpregnant population have led to an increasing application of conservative therapy in pregnancy, particularly among patients with uncomplicated appendicitis. However, optimal management of complicated appendicitis in pregnancy is unclear, as the risks of both operative and nonoperative management can be significant.
Details about the study
This retrospective cohort study using data from the National Inpatient Sample (NIS) focuses on outcomes of various management options among pregnant women with complicated appendicitis from January 2003 to September 2015. Complicated appendicitis refers to individuals with appendiceal perforation with peritonitis (a free perforation) or phlegmon/abscess (a walled-off perforation). Women included in the study were identified using ICD-9 codes for both pregnancy and complicated appendicitis; they were categorized into 3 groups: immediate operative management, successful nonoperative management, and failed nonoperative management (defined as surgical intervention >1 day after admission). The clinical and other outcomes of interest included maternal death, preterm labor/delivery or pregnancy loss, amniotic infection, sepsis, pneumonia, antenatal hemorrhage, and premature rupture of membranes. Outcomes included are those that occurred during the hospitalization for appendicitis; outcomes that may have occurred between discharge from the appendicitis hospitalization to the delivery hospitalization are not included in this study.
A total of 8,087 pregnant women with complicated appendicitis were included in this study, of whom 954 (11.8%) had successful nonoperative management, 2,646 (32.7%) had failed nonoperative management, and 4,487 (55.5%) had immediate operative management. First, when comparing successful nonoperative management to immediate operative management, there were no differences in preterm labor/delivery or pregnancy loss, or antenatal hemorrhage; however, successful nonoperative management was also associated with higher risks of maternal infectious complications, including risks of amniotic infection, pneumonia, and sepsis. When comparing failed nonoperative management (women who required surgical intervention during the index hospitalization) to immediate operative management, failed conservative management was associated with higher risks of preterm labor/delivery or pregnancy loss, antenatal hemorrhage, amniotic infection, pneumonia, and sepsis. For every 1 day that surgery was delayed in the group of women who failed nonoperative management, the odds of preterm labor/delivery or pregnancy loss, antenatal hemorrhage, sepsis, amniotic infection, and pneumonia increased.
Study strengths and weaknesses
Database studies have inherent limitations that are overcome with strength in numbers. In this study, our understanding of outcomes associated with management of complicated appendicitis assumes that women were correctly identified as both being pregnant and having complicated appendicitis (as opposed to uncomplicated appendicitis but miscoded). Clinical data that may have led to selection of one management strategy over another, or specific clinical management decisions, are not possible to extract from the NIS. For instance, did nonoperative management systematically include percutaneous guided drainage if an abscess was noted, and appropriately targeted antibiotic therapy? If delayed operative intervention with IV antibiotics to allow for “cooling off” of the abdomen prior to surgery was planned, this strategy would have been included in the failed nonoperative management group, when in fact nonoperative management was never the plan. Whether gestational age (which is not known in this study), or any other clinical data contributed to the initially chosen management strategy is not known.
The treating clinicians, obstetricians and surgeons alike, would like to know the pregnancy outcome when considering the various management strategies for complicated appendicitis. However, this study only provides insight into the outcomes for the hospitalization for appendicitis. Whether or not women categorized as successful nonoperative management go on to require surgery or have preterm labor in the future, or whether women with successful immediate surgical management might be readmitted with complications, is not known. This is a significant limitation of the database, which does not allow for linking of individual hospitalizations, and rather can provide only a snapshot in time.
This study includes a fairly long timespan–2003 to 2015–during which the management of complicated appendicitis was actively evolving. Early in this time frame, nonoperative management outside of pregnancy was uncommon, and nonoperative management may have been even rarer and perhaps reserved for the most ill of pregnant women on presentation (for whom surgery may have been considered too risky without a short time with IV antibiotics to “cool off” the abdomen). As time progressed over the study span, nonoperative management was likely offered with greater frequency and among women with lesser degrees of illness. However, the year of presentation was not controlled for in this study.
Finally, given the differences noted in management strategy by race/ethnicity and type of hospital, it is not clear how this bias influences the findings from this study. ●
Immediate operative intervention for complicated appendicitis in pregnancy remains a mainstay of management. Perinatal risks associated with surgical intervention are low and are comparable in many respects to successful nonoperative intervention. However, characteristics that predict successful nonoperative intervention are not known, and nonoperative therapy still carries higher risks of maternal infectious complications. When nonoperative intervention is the chosen approach in pregnant women with complicated appendicitis, clinicians must maintain a low threshold for conversion to operative management to avoid maternal morbidity. In addition, clinicians must closely monitor women discharged after successful appendicitis treatment for subsequent complications, as the long-term risks of conservative management or delayed operative intervention are not clear.
An epidemic of hypertensive disorders of pregnancy
Hypertension in pregnancy is a major challenge in current obstetric practice. Based on an analysis of the National Inpatient Sample, the Centers for Disease Control and Prevention (CDC) recently reported that from 2017 to 2019 the prevalence of hypertensive disorders in pregnancy increased from 13.3% to 15.9% of hospital deliveries.1 During that same time period, the prevalence of pregnancy-associated hypertension, which includes preeclampsia, eclampsia, and gestational hypertension, increased from 10.8% to 13.0%.1 The prevalence of chronic hypertension increased from 2.0% to 2.3%.1 In 2017 and 2019, unspecified maternal hypertension was diagnosed in 0.5% and 0.6% of the sample, respectively.1
Bruno and colleagues reported a 3-fold increase in the prevalence of HDPs from 1989 to 2020, with an acceleration in the rate of increase from 2010 to 2020.2 The increase in prevalence of HDPs may be caused by an increase in the prevalence of advanced maternal age, obesity, and diabetes. Black patients are disproportionately impacted by both pregnancy-associated hypertension and chronic hypertension.1 In 2019, the prevalence of pregnancy-associated hypertension was greater among Black patients (15.6%), than White (12.1%), Hispanic (10.6%), or Asian or Pacific Islander patients (7.7%).1 Similarly, the prevalence of chronic hypertension was greater among Black patients (4.3%) than among White (2.0%), Hispanic (1.5%), or Asian or Pacific Islander patients (1.2%).1 Racial/ethnic differences in HDPs may be influenced by poverty; structural racism; or lack of access to care, diet, and obesity.3,4
HDPs are major contributors to maternal morbidity and mortality. The CDC reported that among maternal deaths occurring during the delivery hospitalization, 32% of the decedents had documented hypertension.1 HDPs are associated with an approximately 2.5-fold increased risk of a severe morbidity, a composite measure that includes blood transfusion, acute kidney injury, disseminated intravascular coagulation, sepsis, shock, and pulmonary edema.5 A history of HDPs is associated with an approximately 67% increase in the lifetime risk of cardiovascular disease, including coronary artery disease, stroke, peripheral vascular disease, and heart failure.6,7
What are the best antihypertensive medications for pregnancy?
All clinicians know that the use of angiotensin-converting-enzyme inhibitors (ACE-Is) and angiotensin-receptor-blockers (ARBs) are contraindicated in pregnancy because they cause major congenital anomalies, with an odds ratio of 1.8 (95% confidence interval [CI], 1.42-2.34), compared with no exposure.8 In addition, ACE-Is and ARBs increase the risk of stillbirth, with an odds ratio of 1.75 (95% CI, 1.21-2.53).8 No increase in congenital anomalies were detected for patients exposed to other antihypertensive medications.8 Prior to attempting conception, patients with chronic hypertension should discontinue ACE-Is and ARBs and initiate an alternative medication.
The most commonly used antihypertensive medications in pregnancy are labetalol, nifedipine, and methyldopa.9 Labetalol blocks the beta-1, beta-2, and alpha-1 adrenergic receptors.10 Nifedipine blocks calcium entry into cells through the L-type calcium channel.11 Methyldopa is a central nervous system alpha-2 adrenergic agonist.12 The dose range for these commonly used medications are labetalol 400 mg to 2,400 mg daily in divided doses every 8 to 12 hours, nifedipine extended-release 30 mg to 120 mg daily, and methyldopa 500 mg to 2 g daily in 2 to 4 divided doses. Some clinicians recommend prescribing divided doses of nifedipine extended release at doses ≥ 60 mg for patients who have bothersome adverse effects, hypotension following a single daily dose, or hypertension between single daily doses. The nifedipine extended release tablets should not be divided. If monotherapy with the maximal daily dose of labetalol does not achieve the blood pressure (BP) target, adding nifedipine as a second agent is an option.9 Similarly, if monotherapy with the maximal daily dose of nifedipine extended release does not achieve the BP target, adding labetalol as a second agent is an option.9
In a network meta-analysis of antihypertensive medications used in pregnancy, that included 61 trials and 6,923 participants, all the medications studied reduced the risk of developing severe hypertension by 30% to 70%.13 Sufficient data was available to also report that labetalol used to treat hypertension in pregnancy reduced the risk of developing proteinuria.13 Given similar efficacy among antihypertensive medications, patient comorbidities may influence the medication choice. For example, labetalol may not be the optimal medication for a patient with poorly controlled asthma due to its ability to cause bronchospasm.14,15 Methyldopa may not be the optimal medication for a patient with depression.16 Based on the available data, labetalol, nifedipine, and methyldopa are the best antihypertensive medications for pregnant patients.
Continue to: What is an optimal BP target when treating chronic hypertension in pregnancy?...
What is an optimal BP target when treating chronic hypertension in pregnancy?
When treating chronic hypertension in pregnant patients, a concern is that reducing maternal BP may decrease uteroplacental perfusion and result in fetal growth restriction. However, a recent trial reported that a BP treatment target < 140/90 mm Hg is associated with better outcomes for both mother and newborn than withholding antihypertension medications. In the trial, 2,408 women with chronic hypertension diagnosed before 20 weeks of gestation were randomly assigned to an active treatment group with prescription of antihypertension medicines to achieve a BP target of < 140/90 mm Hg; or to a control group where no antihypertension or no additional antihypertension treatment was prescribed unless BP was ≥ 160 mm Hg systolic or ≥ 105 mm Hg diastolic.9 The hypertension medications prescribed to the patients in the active treatment group were labetalol (63.2%), nifedipine (33.4%), amlodipine (1.7%), methyldopa (0.5%), hydrochlorothiazide (0.3%), metoprolol (0.2%), and missing/unknown/other (0.7%).9
If a patient in the control group developed severe hypertension, they were started on an antihypertension medicine and the BP treatment target was < 140/90 mm Hg. Compared with the control regimen, active treatment resulted in a significant decrease in the development of preeclampsia (24.4% vs 31.1%; risk ratio [RR], 0.79; 95% CI, 0.69-0.89), severe hypertension (36.1% vs 44.3%; RR, 0.82; 95% CI, 0.74-0.90), preterm birth < 37 weeks’ gestation (27.5% vs 31.4%; RR, 0.87; 95% CI, 0.77-0.99), preterm birth < 35 weeks’ gestation (12.2% vs 16.7%; odds ratio [OR], 0.69; 95% CI, 0.55-0.88), and low birth-weight (< 2,500 g) newborns (19.2% vs 23.1%; RR, 0.83; 95% CI, 0.71-0.97).9 The percentage of small for gestational age birth weight below the 10th percentile was similar in the treatment and control groups, 11.2% and 10.4%, respectively (adjusted RR, 1.04; 95% CI, 0.82-1.31).9 The number of patients who would need to be treated to prevent one primary-outcome event was 15.9 The investigators concluded that for pregnant patients with chronic hypertension, the optimal BP target is < 140/90 mm Hg.9
When does BP reach a postpartum peak?
In pregnant patients with hypertension, BP may decrease immediately after birth. Following birth, BP tends to increase, reaching a peak 3 to 6 days postpartum.17,18 This pattern was observed in patients with and without preeclampsia in the index pregnancy. Among 136 patients without antepartum preeclampsia, the prevalence of a diastolic BP > 89 mm Hg was 5% and 15% on postpartum days 1 and 3, respectively.17 The postpartum rise in BP may be due to mobilization of water from the extravascular to the intravascular space and excretion of total body sodium that accumulated during pregnancy.19 In one study of 998 consecutive singleton cesarean births, 7.7% of the patients with no recorded elevated BP before delivery developed de novo hypertension postpartum.20 Compared with patients without antepartum or new onset postpartum hypertension, the patients who developed postpartum hypertension had a higher body mass index, were more likely to be Black and to have a history of type 2 diabetes. Compared with patients without antepartum or postpartum hypertension, the patients who developed de novo postpartum hypertension, had significantly elevated soluble fms-like tyrosine kinase-1 and significantly decreased placental growth factor, a pattern seen with preeclampsia.20 These results suggest that de novo postpartum hypertension may have molecular causes similar to preeclampsia.20
Postpartum hypertension should be treated with a medication that is thought to be safe for breastfeeding patients, including labetalol, nifedipine, or enalapril.21-23 The relative infant dose of labetalol, nifedipine, and enalapril is approximately 3.6%, ≤ 3.2%, and 1.1%, respectively.24 If the relative infant dose of a medication is < 10% it is generally considered to be compatible with breastfeeding.25
Many obstetricians have seldom prescribed enalapril, an ACE-I. The initial dose of enalapril is 5 mg or 10 mg daily. After initiation of treatment, the dose can be adjusted based on BP measurement. The maximal daily dose is 40 mg daily in one dose or two divided doses. Similar to other hypertension medicines, enalapril therapy may cause hypotension and dizziness. Enalapril should not be used by pregnant patients because it is associated with an increased risk of congenital anomalies and fetal demise.
Does a HDP increase the risk of developing chronic hypertension?
All obstetricians know that a patient with a history of a HDP is at an increased risk for developing chronic hypertension treated with a medication, but the magnitude of the risk is less well known. In a nationwide study in Denmark, the prevalence of chronic hypertension treated with medication 10 years after delivery among patients with a history of a HDP in their first pregnancy, was 14%, 21%, and 32%, if the first pregnancy occurred in the patient’s 20s, 30s, or 40s, respectively.26 The corresponding prevalence of chronic hypertension in patients without a history of a HDP was 4%, 6%, and 11%, if the first pregnancy occurred in the 20s, 30s, or 40s, respectively.26 Maternal age is an important predictor of who will develop chronic hypertension within 10 years following a pregnancy with a HDP.
In modern obstetric practice, the hypertensive disorders of pregnancy are prevalent and associated with increased maternal and newborn morbidity. Appropriate treatment of hypertension with labetalol, nifedipine, or methyldopa improves maternal and newborn health. Available evidence suggests that maintaining BP < 140/90 mm Hg during pregnancy for most patients is a practical goal with significant benefit. A significant public-health concern is that an increase in the prevalence of HDPs will eventually translate into an increase in chronic hypertension and the attendant complications of heart attack, heart failure, stroke, and renal insufficiency. Recognizing the increased prevalence of HDPs, ObGyns will need to alert patients to their long-term health risks and coordinate appropriate follow-up and treatment to optimize the future health of their patients. ●
- Ford ND, Cox S, Ko JY, et al. Hypertensive disorders in pregnancy and mortality at delivery hospitalization-United States, 2017-2019. Morb Mortal Week Report. 2022;71:585-591.
- Bruno AM, Allshouse AA, Metz TD, et al. Trends in hypertensive disorders of pregnancy in the United States from 1989 to 2020. Obstet Gynecol. 2022;140:83-86.
- Doleszar CM, McGrath JJ, Herzig AJM, et al. Perceived racial discrimination and hypertension: a comprehensive systematic review. Health Psychol. 2014;33:20-34.
- Centers for Disease Control and Prevention. A Closer Look at African American Men and High Blood Pressure Control; A Review of Psychosocial Factors and Systems-Level Interventions. Atlanta: U.S. Department of Health and Human Services; 2010.
- Boulet SL, Platner M, Joseph NT, et al. Hypertensive disorders of pregnancy, cesarean delivery and severe maternal morbidity in an urban safety-net population. Am J Epidemiol. 2020;189:1502-1511.
- Parikh NI, Gonzalez JM, Andreson CAM, et al. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021;143:e902-e916.
- Okoth K, Chandan JS, Marshall T, et al. Association between the reproductive health of young women and cardiovascular disease later in life: umbrella review. BMJ. 2020;371:m3502.
- Fu J, Tomlinson G, Feig DS. Increased risk of major congenital malformations in early pregnancy uses of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers: a meta-analysis. Diabetes Metab Res Rev. 2021;37:e3453.
- Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386:1781-1792.
- Baum T, Sybertz EJ. Pharmacology of labetalol in experimental animals. Am J Med. 1983;75:15-23.
- Khan KM, Patel JB, Schaefer TJ. StatPearls (Internet). StatPearls Publishing; 2022.
- Gupta M, Khalili. Methyldopa StatPearls (Internet). StatPearls Publishing; 2022.
- Bone JN, Sandhu A, Diablos ED, et al. Oral antihypertensives for non-severe pregnancy hypertension: systematic review, network meta-analysis and trial sequential analysis. Hypertension. 2022;79:614-628.
- Morales DR, Jackson C, Lipworth BJ, et al. Adverse respiratory effects of acute beta-blocker exposure in asthma: a systematic review and meta-analysis of randomized controlled trials. Chest. 2014;145:779-786.
- Huang KY, Tseng PT, Wu YC, et al. Do beta-adrenergic blocking agents increase asthma exacerbation? A network meta-analysis of randomized controlled trials. Sci Rep. 2021;11:452.
- Nayak AS, Nachane HB. Risk analysis of suicidal ideation and postpartum depression with antenatal alpha methyldopa use. Asian J Psychiatry. 2018;38:42-44.
- Walters BNJ, Thompson ME, Lee A, et al. Blood pressure in the puerperium. Clin Sci. 1986;71:589-594.
- Walters BNJ, Walters T. Hypertension in the puerperium. Lancet. 1987;2(8554):330.
- Magee L, von Dadelszen. Prevention and treatment of postpartum hypertension. Cochrane Database Syst Rev. 2013;CD004351.
- Goel A, Maski MR, Bajracharya S, et al. Epidemiology and mechanisms of de novo and persistent hypertension in the postpartum period. Circulation. 2015;132:1726-1733.
- Powles K, Gandhi S. Postpartum hypertension. CMAJ. 2017;189:E913.
- Tosounidou S, Gordon C. Medications in pregnancy and breastfeeding. Best Prac Res Clin Obstet Gynaecol. 2020;64:68-76.
- Anderson PO. Treating hypertension during breastfeeding. Breastfeed Med. 2018;13:95-96.
- Lexicomp web site. https://www.wolterskluwer.com/en/solutions/lexicomp.
- Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343:118-126.
- Behrens I, Basit S, Melbye M, et al. Risk of postpartum hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study. BMJ. 2017;358:j3078.
Hypertension in pregnancy is a major challenge in current obstetric practice. Based on an analysis of the National Inpatient Sample, the Centers for Disease Control and Prevention (CDC) recently reported that from 2017 to 2019 the prevalence of hypertensive disorders in pregnancy increased from 13.3% to 15.9% of hospital deliveries.1 During that same time period, the prevalence of pregnancy-associated hypertension, which includes preeclampsia, eclampsia, and gestational hypertension, increased from 10.8% to 13.0%.1 The prevalence of chronic hypertension increased from 2.0% to 2.3%.1 In 2017 and 2019, unspecified maternal hypertension was diagnosed in 0.5% and 0.6% of the sample, respectively.1
Bruno and colleagues reported a 3-fold increase in the prevalence of HDPs from 1989 to 2020, with an acceleration in the rate of increase from 2010 to 2020.2 The increase in prevalence of HDPs may be caused by an increase in the prevalence of advanced maternal age, obesity, and diabetes. Black patients are disproportionately impacted by both pregnancy-associated hypertension and chronic hypertension.1 In 2019, the prevalence of pregnancy-associated hypertension was greater among Black patients (15.6%), than White (12.1%), Hispanic (10.6%), or Asian or Pacific Islander patients (7.7%).1 Similarly, the prevalence of chronic hypertension was greater among Black patients (4.3%) than among White (2.0%), Hispanic (1.5%), or Asian or Pacific Islander patients (1.2%).1 Racial/ethnic differences in HDPs may be influenced by poverty; structural racism; or lack of access to care, diet, and obesity.3,4
HDPs are major contributors to maternal morbidity and mortality. The CDC reported that among maternal deaths occurring during the delivery hospitalization, 32% of the decedents had documented hypertension.1 HDPs are associated with an approximately 2.5-fold increased risk of a severe morbidity, a composite measure that includes blood transfusion, acute kidney injury, disseminated intravascular coagulation, sepsis, shock, and pulmonary edema.5 A history of HDPs is associated with an approximately 67% increase in the lifetime risk of cardiovascular disease, including coronary artery disease, stroke, peripheral vascular disease, and heart failure.6,7
What are the best antihypertensive medications for pregnancy?
All clinicians know that the use of angiotensin-converting-enzyme inhibitors (ACE-Is) and angiotensin-receptor-blockers (ARBs) are contraindicated in pregnancy because they cause major congenital anomalies, with an odds ratio of 1.8 (95% confidence interval [CI], 1.42-2.34), compared with no exposure.8 In addition, ACE-Is and ARBs increase the risk of stillbirth, with an odds ratio of 1.75 (95% CI, 1.21-2.53).8 No increase in congenital anomalies were detected for patients exposed to other antihypertensive medications.8 Prior to attempting conception, patients with chronic hypertension should discontinue ACE-Is and ARBs and initiate an alternative medication.
The most commonly used antihypertensive medications in pregnancy are labetalol, nifedipine, and methyldopa.9 Labetalol blocks the beta-1, beta-2, and alpha-1 adrenergic receptors.10 Nifedipine blocks calcium entry into cells through the L-type calcium channel.11 Methyldopa is a central nervous system alpha-2 adrenergic agonist.12 The dose range for these commonly used medications are labetalol 400 mg to 2,400 mg daily in divided doses every 8 to 12 hours, nifedipine extended-release 30 mg to 120 mg daily, and methyldopa 500 mg to 2 g daily in 2 to 4 divided doses. Some clinicians recommend prescribing divided doses of nifedipine extended release at doses ≥ 60 mg for patients who have bothersome adverse effects, hypotension following a single daily dose, or hypertension between single daily doses. The nifedipine extended release tablets should not be divided. If monotherapy with the maximal daily dose of labetalol does not achieve the blood pressure (BP) target, adding nifedipine as a second agent is an option.9 Similarly, if monotherapy with the maximal daily dose of nifedipine extended release does not achieve the BP target, adding labetalol as a second agent is an option.9
In a network meta-analysis of antihypertensive medications used in pregnancy, that included 61 trials and 6,923 participants, all the medications studied reduced the risk of developing severe hypertension by 30% to 70%.13 Sufficient data was available to also report that labetalol used to treat hypertension in pregnancy reduced the risk of developing proteinuria.13 Given similar efficacy among antihypertensive medications, patient comorbidities may influence the medication choice. For example, labetalol may not be the optimal medication for a patient with poorly controlled asthma due to its ability to cause bronchospasm.14,15 Methyldopa may not be the optimal medication for a patient with depression.16 Based on the available data, labetalol, nifedipine, and methyldopa are the best antihypertensive medications for pregnant patients.
Continue to: What is an optimal BP target when treating chronic hypertension in pregnancy?...
What is an optimal BP target when treating chronic hypertension in pregnancy?
When treating chronic hypertension in pregnant patients, a concern is that reducing maternal BP may decrease uteroplacental perfusion and result in fetal growth restriction. However, a recent trial reported that a BP treatment target < 140/90 mm Hg is associated with better outcomes for both mother and newborn than withholding antihypertension medications. In the trial, 2,408 women with chronic hypertension diagnosed before 20 weeks of gestation were randomly assigned to an active treatment group with prescription of antihypertension medicines to achieve a BP target of < 140/90 mm Hg; or to a control group where no antihypertension or no additional antihypertension treatment was prescribed unless BP was ≥ 160 mm Hg systolic or ≥ 105 mm Hg diastolic.9 The hypertension medications prescribed to the patients in the active treatment group were labetalol (63.2%), nifedipine (33.4%), amlodipine (1.7%), methyldopa (0.5%), hydrochlorothiazide (0.3%), metoprolol (0.2%), and missing/unknown/other (0.7%).9
If a patient in the control group developed severe hypertension, they were started on an antihypertension medicine and the BP treatment target was < 140/90 mm Hg. Compared with the control regimen, active treatment resulted in a significant decrease in the development of preeclampsia (24.4% vs 31.1%; risk ratio [RR], 0.79; 95% CI, 0.69-0.89), severe hypertension (36.1% vs 44.3%; RR, 0.82; 95% CI, 0.74-0.90), preterm birth < 37 weeks’ gestation (27.5% vs 31.4%; RR, 0.87; 95% CI, 0.77-0.99), preterm birth < 35 weeks’ gestation (12.2% vs 16.7%; odds ratio [OR], 0.69; 95% CI, 0.55-0.88), and low birth-weight (< 2,500 g) newborns (19.2% vs 23.1%; RR, 0.83; 95% CI, 0.71-0.97).9 The percentage of small for gestational age birth weight below the 10th percentile was similar in the treatment and control groups, 11.2% and 10.4%, respectively (adjusted RR, 1.04; 95% CI, 0.82-1.31).9 The number of patients who would need to be treated to prevent one primary-outcome event was 15.9 The investigators concluded that for pregnant patients with chronic hypertension, the optimal BP target is < 140/90 mm Hg.9
When does BP reach a postpartum peak?
In pregnant patients with hypertension, BP may decrease immediately after birth. Following birth, BP tends to increase, reaching a peak 3 to 6 days postpartum.17,18 This pattern was observed in patients with and without preeclampsia in the index pregnancy. Among 136 patients without antepartum preeclampsia, the prevalence of a diastolic BP > 89 mm Hg was 5% and 15% on postpartum days 1 and 3, respectively.17 The postpartum rise in BP may be due to mobilization of water from the extravascular to the intravascular space and excretion of total body sodium that accumulated during pregnancy.19 In one study of 998 consecutive singleton cesarean births, 7.7% of the patients with no recorded elevated BP before delivery developed de novo hypertension postpartum.20 Compared with patients without antepartum or new onset postpartum hypertension, the patients who developed postpartum hypertension had a higher body mass index, were more likely to be Black and to have a history of type 2 diabetes. Compared with patients without antepartum or postpartum hypertension, the patients who developed de novo postpartum hypertension, had significantly elevated soluble fms-like tyrosine kinase-1 and significantly decreased placental growth factor, a pattern seen with preeclampsia.20 These results suggest that de novo postpartum hypertension may have molecular causes similar to preeclampsia.20
Postpartum hypertension should be treated with a medication that is thought to be safe for breastfeeding patients, including labetalol, nifedipine, or enalapril.21-23 The relative infant dose of labetalol, nifedipine, and enalapril is approximately 3.6%, ≤ 3.2%, and 1.1%, respectively.24 If the relative infant dose of a medication is < 10% it is generally considered to be compatible with breastfeeding.25
Many obstetricians have seldom prescribed enalapril, an ACE-I. The initial dose of enalapril is 5 mg or 10 mg daily. After initiation of treatment, the dose can be adjusted based on BP measurement. The maximal daily dose is 40 mg daily in one dose or two divided doses. Similar to other hypertension medicines, enalapril therapy may cause hypotension and dizziness. Enalapril should not be used by pregnant patients because it is associated with an increased risk of congenital anomalies and fetal demise.
Does a HDP increase the risk of developing chronic hypertension?
All obstetricians know that a patient with a history of a HDP is at an increased risk for developing chronic hypertension treated with a medication, but the magnitude of the risk is less well known. In a nationwide study in Denmark, the prevalence of chronic hypertension treated with medication 10 years after delivery among patients with a history of a HDP in their first pregnancy, was 14%, 21%, and 32%, if the first pregnancy occurred in the patient’s 20s, 30s, or 40s, respectively.26 The corresponding prevalence of chronic hypertension in patients without a history of a HDP was 4%, 6%, and 11%, if the first pregnancy occurred in the 20s, 30s, or 40s, respectively.26 Maternal age is an important predictor of who will develop chronic hypertension within 10 years following a pregnancy with a HDP.
In modern obstetric practice, the hypertensive disorders of pregnancy are prevalent and associated with increased maternal and newborn morbidity. Appropriate treatment of hypertension with labetalol, nifedipine, or methyldopa improves maternal and newborn health. Available evidence suggests that maintaining BP < 140/90 mm Hg during pregnancy for most patients is a practical goal with significant benefit. A significant public-health concern is that an increase in the prevalence of HDPs will eventually translate into an increase in chronic hypertension and the attendant complications of heart attack, heart failure, stroke, and renal insufficiency. Recognizing the increased prevalence of HDPs, ObGyns will need to alert patients to their long-term health risks and coordinate appropriate follow-up and treatment to optimize the future health of their patients. ●
Hypertension in pregnancy is a major challenge in current obstetric practice. Based on an analysis of the National Inpatient Sample, the Centers for Disease Control and Prevention (CDC) recently reported that from 2017 to 2019 the prevalence of hypertensive disorders in pregnancy increased from 13.3% to 15.9% of hospital deliveries.1 During that same time period, the prevalence of pregnancy-associated hypertension, which includes preeclampsia, eclampsia, and gestational hypertension, increased from 10.8% to 13.0%.1 The prevalence of chronic hypertension increased from 2.0% to 2.3%.1 In 2017 and 2019, unspecified maternal hypertension was diagnosed in 0.5% and 0.6% of the sample, respectively.1
Bruno and colleagues reported a 3-fold increase in the prevalence of HDPs from 1989 to 2020, with an acceleration in the rate of increase from 2010 to 2020.2 The increase in prevalence of HDPs may be caused by an increase in the prevalence of advanced maternal age, obesity, and diabetes. Black patients are disproportionately impacted by both pregnancy-associated hypertension and chronic hypertension.1 In 2019, the prevalence of pregnancy-associated hypertension was greater among Black patients (15.6%), than White (12.1%), Hispanic (10.6%), or Asian or Pacific Islander patients (7.7%).1 Similarly, the prevalence of chronic hypertension was greater among Black patients (4.3%) than among White (2.0%), Hispanic (1.5%), or Asian or Pacific Islander patients (1.2%).1 Racial/ethnic differences in HDPs may be influenced by poverty; structural racism; or lack of access to care, diet, and obesity.3,4
HDPs are major contributors to maternal morbidity and mortality. The CDC reported that among maternal deaths occurring during the delivery hospitalization, 32% of the decedents had documented hypertension.1 HDPs are associated with an approximately 2.5-fold increased risk of a severe morbidity, a composite measure that includes blood transfusion, acute kidney injury, disseminated intravascular coagulation, sepsis, shock, and pulmonary edema.5 A history of HDPs is associated with an approximately 67% increase in the lifetime risk of cardiovascular disease, including coronary artery disease, stroke, peripheral vascular disease, and heart failure.6,7
What are the best antihypertensive medications for pregnancy?
All clinicians know that the use of angiotensin-converting-enzyme inhibitors (ACE-Is) and angiotensin-receptor-blockers (ARBs) are contraindicated in pregnancy because they cause major congenital anomalies, with an odds ratio of 1.8 (95% confidence interval [CI], 1.42-2.34), compared with no exposure.8 In addition, ACE-Is and ARBs increase the risk of stillbirth, with an odds ratio of 1.75 (95% CI, 1.21-2.53).8 No increase in congenital anomalies were detected for patients exposed to other antihypertensive medications.8 Prior to attempting conception, patients with chronic hypertension should discontinue ACE-Is and ARBs and initiate an alternative medication.
The most commonly used antihypertensive medications in pregnancy are labetalol, nifedipine, and methyldopa.9 Labetalol blocks the beta-1, beta-2, and alpha-1 adrenergic receptors.10 Nifedipine blocks calcium entry into cells through the L-type calcium channel.11 Methyldopa is a central nervous system alpha-2 adrenergic agonist.12 The dose range for these commonly used medications are labetalol 400 mg to 2,400 mg daily in divided doses every 8 to 12 hours, nifedipine extended-release 30 mg to 120 mg daily, and methyldopa 500 mg to 2 g daily in 2 to 4 divided doses. Some clinicians recommend prescribing divided doses of nifedipine extended release at doses ≥ 60 mg for patients who have bothersome adverse effects, hypotension following a single daily dose, or hypertension between single daily doses. The nifedipine extended release tablets should not be divided. If monotherapy with the maximal daily dose of labetalol does not achieve the blood pressure (BP) target, adding nifedipine as a second agent is an option.9 Similarly, if monotherapy with the maximal daily dose of nifedipine extended release does not achieve the BP target, adding labetalol as a second agent is an option.9
In a network meta-analysis of antihypertensive medications used in pregnancy, that included 61 trials and 6,923 participants, all the medications studied reduced the risk of developing severe hypertension by 30% to 70%.13 Sufficient data was available to also report that labetalol used to treat hypertension in pregnancy reduced the risk of developing proteinuria.13 Given similar efficacy among antihypertensive medications, patient comorbidities may influence the medication choice. For example, labetalol may not be the optimal medication for a patient with poorly controlled asthma due to its ability to cause bronchospasm.14,15 Methyldopa may not be the optimal medication for a patient with depression.16 Based on the available data, labetalol, nifedipine, and methyldopa are the best antihypertensive medications for pregnant patients.
Continue to: What is an optimal BP target when treating chronic hypertension in pregnancy?...
What is an optimal BP target when treating chronic hypertension in pregnancy?
When treating chronic hypertension in pregnant patients, a concern is that reducing maternal BP may decrease uteroplacental perfusion and result in fetal growth restriction. However, a recent trial reported that a BP treatment target < 140/90 mm Hg is associated with better outcomes for both mother and newborn than withholding antihypertension medications. In the trial, 2,408 women with chronic hypertension diagnosed before 20 weeks of gestation were randomly assigned to an active treatment group with prescription of antihypertension medicines to achieve a BP target of < 140/90 mm Hg; or to a control group where no antihypertension or no additional antihypertension treatment was prescribed unless BP was ≥ 160 mm Hg systolic or ≥ 105 mm Hg diastolic.9 The hypertension medications prescribed to the patients in the active treatment group were labetalol (63.2%), nifedipine (33.4%), amlodipine (1.7%), methyldopa (0.5%), hydrochlorothiazide (0.3%), metoprolol (0.2%), and missing/unknown/other (0.7%).9
If a patient in the control group developed severe hypertension, they were started on an antihypertension medicine and the BP treatment target was < 140/90 mm Hg. Compared with the control regimen, active treatment resulted in a significant decrease in the development of preeclampsia (24.4% vs 31.1%; risk ratio [RR], 0.79; 95% CI, 0.69-0.89), severe hypertension (36.1% vs 44.3%; RR, 0.82; 95% CI, 0.74-0.90), preterm birth < 37 weeks’ gestation (27.5% vs 31.4%; RR, 0.87; 95% CI, 0.77-0.99), preterm birth < 35 weeks’ gestation (12.2% vs 16.7%; odds ratio [OR], 0.69; 95% CI, 0.55-0.88), and low birth-weight (< 2,500 g) newborns (19.2% vs 23.1%; RR, 0.83; 95% CI, 0.71-0.97).9 The percentage of small for gestational age birth weight below the 10th percentile was similar in the treatment and control groups, 11.2% and 10.4%, respectively (adjusted RR, 1.04; 95% CI, 0.82-1.31).9 The number of patients who would need to be treated to prevent one primary-outcome event was 15.9 The investigators concluded that for pregnant patients with chronic hypertension, the optimal BP target is < 140/90 mm Hg.9
When does BP reach a postpartum peak?
In pregnant patients with hypertension, BP may decrease immediately after birth. Following birth, BP tends to increase, reaching a peak 3 to 6 days postpartum.17,18 This pattern was observed in patients with and without preeclampsia in the index pregnancy. Among 136 patients without antepartum preeclampsia, the prevalence of a diastolic BP > 89 mm Hg was 5% and 15% on postpartum days 1 and 3, respectively.17 The postpartum rise in BP may be due to mobilization of water from the extravascular to the intravascular space and excretion of total body sodium that accumulated during pregnancy.19 In one study of 998 consecutive singleton cesarean births, 7.7% of the patients with no recorded elevated BP before delivery developed de novo hypertension postpartum.20 Compared with patients without antepartum or new onset postpartum hypertension, the patients who developed postpartum hypertension had a higher body mass index, were more likely to be Black and to have a history of type 2 diabetes. Compared with patients without antepartum or postpartum hypertension, the patients who developed de novo postpartum hypertension, had significantly elevated soluble fms-like tyrosine kinase-1 and significantly decreased placental growth factor, a pattern seen with preeclampsia.20 These results suggest that de novo postpartum hypertension may have molecular causes similar to preeclampsia.20
Postpartum hypertension should be treated with a medication that is thought to be safe for breastfeeding patients, including labetalol, nifedipine, or enalapril.21-23 The relative infant dose of labetalol, nifedipine, and enalapril is approximately 3.6%, ≤ 3.2%, and 1.1%, respectively.24 If the relative infant dose of a medication is < 10% it is generally considered to be compatible with breastfeeding.25
Many obstetricians have seldom prescribed enalapril, an ACE-I. The initial dose of enalapril is 5 mg or 10 mg daily. After initiation of treatment, the dose can be adjusted based on BP measurement. The maximal daily dose is 40 mg daily in one dose or two divided doses. Similar to other hypertension medicines, enalapril therapy may cause hypotension and dizziness. Enalapril should not be used by pregnant patients because it is associated with an increased risk of congenital anomalies and fetal demise.
Does a HDP increase the risk of developing chronic hypertension?
All obstetricians know that a patient with a history of a HDP is at an increased risk for developing chronic hypertension treated with a medication, but the magnitude of the risk is less well known. In a nationwide study in Denmark, the prevalence of chronic hypertension treated with medication 10 years after delivery among patients with a history of a HDP in their first pregnancy, was 14%, 21%, and 32%, if the first pregnancy occurred in the patient’s 20s, 30s, or 40s, respectively.26 The corresponding prevalence of chronic hypertension in patients without a history of a HDP was 4%, 6%, and 11%, if the first pregnancy occurred in the 20s, 30s, or 40s, respectively.26 Maternal age is an important predictor of who will develop chronic hypertension within 10 years following a pregnancy with a HDP.
In modern obstetric practice, the hypertensive disorders of pregnancy are prevalent and associated with increased maternal and newborn morbidity. Appropriate treatment of hypertension with labetalol, nifedipine, or methyldopa improves maternal and newborn health. Available evidence suggests that maintaining BP < 140/90 mm Hg during pregnancy for most patients is a practical goal with significant benefit. A significant public-health concern is that an increase in the prevalence of HDPs will eventually translate into an increase in chronic hypertension and the attendant complications of heart attack, heart failure, stroke, and renal insufficiency. Recognizing the increased prevalence of HDPs, ObGyns will need to alert patients to their long-term health risks and coordinate appropriate follow-up and treatment to optimize the future health of their patients. ●
- Ford ND, Cox S, Ko JY, et al. Hypertensive disorders in pregnancy and mortality at delivery hospitalization-United States, 2017-2019. Morb Mortal Week Report. 2022;71:585-591.
- Bruno AM, Allshouse AA, Metz TD, et al. Trends in hypertensive disorders of pregnancy in the United States from 1989 to 2020. Obstet Gynecol. 2022;140:83-86.
- Doleszar CM, McGrath JJ, Herzig AJM, et al. Perceived racial discrimination and hypertension: a comprehensive systematic review. Health Psychol. 2014;33:20-34.
- Centers for Disease Control and Prevention. A Closer Look at African American Men and High Blood Pressure Control; A Review of Psychosocial Factors and Systems-Level Interventions. Atlanta: U.S. Department of Health and Human Services; 2010.
- Boulet SL, Platner M, Joseph NT, et al. Hypertensive disorders of pregnancy, cesarean delivery and severe maternal morbidity in an urban safety-net population. Am J Epidemiol. 2020;189:1502-1511.
- Parikh NI, Gonzalez JM, Andreson CAM, et al. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021;143:e902-e916.
- Okoth K, Chandan JS, Marshall T, et al. Association between the reproductive health of young women and cardiovascular disease later in life: umbrella review. BMJ. 2020;371:m3502.
- Fu J, Tomlinson G, Feig DS. Increased risk of major congenital malformations in early pregnancy uses of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers: a meta-analysis. Diabetes Metab Res Rev. 2021;37:e3453.
- Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386:1781-1792.
- Baum T, Sybertz EJ. Pharmacology of labetalol in experimental animals. Am J Med. 1983;75:15-23.
- Khan KM, Patel JB, Schaefer TJ. StatPearls (Internet). StatPearls Publishing; 2022.
- Gupta M, Khalili. Methyldopa StatPearls (Internet). StatPearls Publishing; 2022.
- Bone JN, Sandhu A, Diablos ED, et al. Oral antihypertensives for non-severe pregnancy hypertension: systematic review, network meta-analysis and trial sequential analysis. Hypertension. 2022;79:614-628.
- Morales DR, Jackson C, Lipworth BJ, et al. Adverse respiratory effects of acute beta-blocker exposure in asthma: a systematic review and meta-analysis of randomized controlled trials. Chest. 2014;145:779-786.
- Huang KY, Tseng PT, Wu YC, et al. Do beta-adrenergic blocking agents increase asthma exacerbation? A network meta-analysis of randomized controlled trials. Sci Rep. 2021;11:452.
- Nayak AS, Nachane HB. Risk analysis of suicidal ideation and postpartum depression with antenatal alpha methyldopa use. Asian J Psychiatry. 2018;38:42-44.
- Walters BNJ, Thompson ME, Lee A, et al. Blood pressure in the puerperium. Clin Sci. 1986;71:589-594.
- Walters BNJ, Walters T. Hypertension in the puerperium. Lancet. 1987;2(8554):330.
- Magee L, von Dadelszen. Prevention and treatment of postpartum hypertension. Cochrane Database Syst Rev. 2013;CD004351.
- Goel A, Maski MR, Bajracharya S, et al. Epidemiology and mechanisms of de novo and persistent hypertension in the postpartum period. Circulation. 2015;132:1726-1733.
- Powles K, Gandhi S. Postpartum hypertension. CMAJ. 2017;189:E913.
- Tosounidou S, Gordon C. Medications in pregnancy and breastfeeding. Best Prac Res Clin Obstet Gynaecol. 2020;64:68-76.
- Anderson PO. Treating hypertension during breastfeeding. Breastfeed Med. 2018;13:95-96.
- Lexicomp web site. https://www.wolterskluwer.com/en/solutions/lexicomp.
- Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343:118-126.
- Behrens I, Basit S, Melbye M, et al. Risk of postpartum hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study. BMJ. 2017;358:j3078.
- Ford ND, Cox S, Ko JY, et al. Hypertensive disorders in pregnancy and mortality at delivery hospitalization-United States, 2017-2019. Morb Mortal Week Report. 2022;71:585-591.
- Bruno AM, Allshouse AA, Metz TD, et al. Trends in hypertensive disorders of pregnancy in the United States from 1989 to 2020. Obstet Gynecol. 2022;140:83-86.
- Doleszar CM, McGrath JJ, Herzig AJM, et al. Perceived racial discrimination and hypertension: a comprehensive systematic review. Health Psychol. 2014;33:20-34.
- Centers for Disease Control and Prevention. A Closer Look at African American Men and High Blood Pressure Control; A Review of Psychosocial Factors and Systems-Level Interventions. Atlanta: U.S. Department of Health and Human Services; 2010.
- Boulet SL, Platner M, Joseph NT, et al. Hypertensive disorders of pregnancy, cesarean delivery and severe maternal morbidity in an urban safety-net population. Am J Epidemiol. 2020;189:1502-1511.
- Parikh NI, Gonzalez JM, Andreson CAM, et al. Adverse pregnancy outcomes and cardiovascular disease risk: unique opportunities for cardiovascular disease prevention in women: a scientific statement from the American Heart Association. Circulation. 2021;143:e902-e916.
- Okoth K, Chandan JS, Marshall T, et al. Association between the reproductive health of young women and cardiovascular disease later in life: umbrella review. BMJ. 2020;371:m3502.
- Fu J, Tomlinson G, Feig DS. Increased risk of major congenital malformations in early pregnancy uses of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers: a meta-analysis. Diabetes Metab Res Rev. 2021;37:e3453.
- Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic hypertension during pregnancy. N Engl J Med. 2022;386:1781-1792.
- Baum T, Sybertz EJ. Pharmacology of labetalol in experimental animals. Am J Med. 1983;75:15-23.
- Khan KM, Patel JB, Schaefer TJ. StatPearls (Internet). StatPearls Publishing; 2022.
- Gupta M, Khalili. Methyldopa StatPearls (Internet). StatPearls Publishing; 2022.
- Bone JN, Sandhu A, Diablos ED, et al. Oral antihypertensives for non-severe pregnancy hypertension: systematic review, network meta-analysis and trial sequential analysis. Hypertension. 2022;79:614-628.
- Morales DR, Jackson C, Lipworth BJ, et al. Adverse respiratory effects of acute beta-blocker exposure in asthma: a systematic review and meta-analysis of randomized controlled trials. Chest. 2014;145:779-786.
- Huang KY, Tseng PT, Wu YC, et al. Do beta-adrenergic blocking agents increase asthma exacerbation? A network meta-analysis of randomized controlled trials. Sci Rep. 2021;11:452.
- Nayak AS, Nachane HB. Risk analysis of suicidal ideation and postpartum depression with antenatal alpha methyldopa use. Asian J Psychiatry. 2018;38:42-44.
- Walters BNJ, Thompson ME, Lee A, et al. Blood pressure in the puerperium. Clin Sci. 1986;71:589-594.
- Walters BNJ, Walters T. Hypertension in the puerperium. Lancet. 1987;2(8554):330.
- Magee L, von Dadelszen. Prevention and treatment of postpartum hypertension. Cochrane Database Syst Rev. 2013;CD004351.
- Goel A, Maski MR, Bajracharya S, et al. Epidemiology and mechanisms of de novo and persistent hypertension in the postpartum period. Circulation. 2015;132:1726-1733.
- Powles K, Gandhi S. Postpartum hypertension. CMAJ. 2017;189:E913.
- Tosounidou S, Gordon C. Medications in pregnancy and breastfeeding. Best Prac Res Clin Obstet Gynaecol. 2020;64:68-76.
- Anderson PO. Treating hypertension during breastfeeding. Breastfeed Med. 2018;13:95-96.
- Lexicomp web site. https://www.wolterskluwer.com/en/solutions/lexicomp.
- Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343:118-126.
- Behrens I, Basit S, Melbye M, et al. Risk of postpartum hypertension in women with a history of hypertensive disorders of pregnancy: nationwide cohort study. BMJ. 2017;358:j3078.
Integrase inhibitors and gestational weight gain: Should women worry?
In recent years, increased use of integrase strand transferase inhibitor (INSTI) antiviral treatment (ART) has raised concerns about weight gain and adverse outcomes in patients with HIV. This is especially true regarding possible excessive gestational weight gain, which in women without HIV has been associated with maternal gestational diabetes, hypertensive and liver conditions, as well as related risks for preterm birth, fetal macrosomia, and higher weight after birth.
Unfortunately, few studies in pregnant women with HIV have moved out of the controlled environment into real-world settings, potentially limiting current knowledge about the impact of gestational weight gain – as well as strategies to both prevent it and the associated adverse outcomes.
That is what a team of infectious disease specialists at the Hospital Federal dos Servidores do Estado in Rio de Janeiro recently sought to answer among a cohort of INSTI-experienced and INSTI-naive women with BMIs less than 25 kg/m2 (underweight/normal weight) and higher than 25 kg/m2.
Surprising findings
The investigators determined that rates of excessive weight gain were significantly higher in INSTI-naive women with BMI less than 25 who experienced rates as high as 31.6%, compared with approximately 12% of women who conceived while on INSTIs, regardless of BMI values at baseline (P = .004).
However, rates of unfavorable pregnancy outcomes (for example, small for gestational age, preterm birth, stillbirth, death) appeared to be low overall and similar among all the study groups.
“We had some discussions when we were working on this and thought that the weight gain might have adverse effects,” Trevon Fuller, PhD, lead author and a postdoctoral student at the Hospital Federal dos Servidores do Estado, told this news organization.
“But it looked like the weight gain might actually be good, to the extent that we didn’t see any harm to the mom or the baby of those underweight or normal weight women who were naive to INSTIs,” he explained.
Dr. Fuller and his team enrolled 198 pregnant women living with HIV who sought care at the Hospital Federal dos Servidores do Estado – a national reference center for USAID’s Prevention of Mother to Child Transmission strategic program – between October 2014 and October 2021.
Participants were divided into two primary cohorts: BMI less than 25 at enrollment (n = 74) or BMI of 25 or higher (n = 124), then further divided by timing of INSTI-based combined ART:
- INSTI-naive: women using INSTI-based ART (raltegravir [Isentress] 400 mg twice per day or dolutegravir [Tivicay] 50 mg/day plus 2 non-nucleoside reverse transcriptase inhibitors – lamivudine plus tenofovir disoproxil fumarate or lamivudine plus zidovudine) for 4 weeks between baseline and near delivery.
- INSTI-experienced: women who became pregnant while using INSTIs for at least 6 months before conception.
Among underweight/normal weight participants, 77% (n = 57) were INSTI-naive and 23% (n = 17) INSTI-experienced, and among overweight/obese participants, 81.5% (n = 101) were INSTI-naive, and 18.5% (n = 23) were experienced.
Maternal age, which did not differ significantly by BMI or treatment experience, was a median of 28 years, and most participants were non-White. All participants were virally suppressed near delivery.
Study findings, which were published online in HIV Medicine, highlighted that median weight near delivery in participants who were overweight/obese at baseline was similar regardless of whether they were treatment-experienced (90 kg [198 lb]) or treatment-naive (82.3 kg [181 lb]), P = .026.
However, participants who were underweight/normal weight who were INSTI-naive had significantly higher rates of gestational weight gain (31.5%, 18/57), compared with those of underweight/normal weight who were INSTI-experienced (11.8%, 2/17), P = .004. Notably, this gain was significant in all categories of change (that is, low < 0.18 kg/week, normal 0.18-0.59 kg/week), and high > 0.59 kg/week).
“One of the things that we took away was that this weight gain is primarily happening with women who are starting INSTIs,” said Dr. Fuller.
“The data suggest that [it] might be temporary in the sense that there’s not going to be continuous weight gain but that it will probably approach some type of horizontal asymptote,” he added.
Although obstetric and neonatal outcomes were secondary measures, the investigators did not observe any significantly different outcomes when comparing the groups, and there were no stillbirths, neonatal deaths, or macrosomia.
Preterm delivery rates in underweight/normal weight participants who were INSTI-experienced (11.8%, 2/17) and INSTI-naive (5.3%, 3/57) were similar to overweight/obese participants who were INSTI-experienced (13%, 3/23) and INSTI-naive (6.9%, 7/101).
The same was true for low birthweight.
Still, the study appears to raise more questions than it answers, Sigal Yawetz, MD, an infectious disease specialist at Brigham and Women’s Hospital, Boston, said in an interview – a factor that she said is common also in some of the more recent randomized controlled studies, such as IMPAACT PROMISE.
Dr. Yawetz, who was not involved in the study, also noted, “The groups were small, so comparisons within the groups are difficult, and so many people were excluded that it’s hard to know if there were adverse outcomes related to this ... It’s very confounded.”
The World Health Organization estimates that there are roughly 1.3 million pregnant women with HIV, 81% of whom are on antiretroviral therapy. Although the literature continues to evolve, data suggest that in general, Black women are at greater risk for gestational weight gain.
“We have to remember that women who gain excess weight in pregnancy are still going to be with this weight following pregnancy as well,” Dr. Yawetz said. “So, it might impact their pregnancy but also their health after delivery and for subsequent pregnancies, which we don’t have data for yet.”
Dr. Fuller agrees that more data are needed and mentioned that the team plans to study this further, ideally with larger sample sizes.
Yet, despite the lingering questions, there is a silver lining, one that Dr. Yawetz was emphatic about.
“I really welcome people doing studies on this because we really need the data. By far, integrase inhibitors are the first-line regimen all over the world for pregnant women, and if you look at the gestalt or full picture, this is the best regimen to give pregnant women,” she said.
Dr. Fuller and Dr. Yawetz report no relevant financial relationships. The study was independently supported.
A version of this article first appeared on Medscape.com.
In recent years, increased use of integrase strand transferase inhibitor (INSTI) antiviral treatment (ART) has raised concerns about weight gain and adverse outcomes in patients with HIV. This is especially true regarding possible excessive gestational weight gain, which in women without HIV has been associated with maternal gestational diabetes, hypertensive and liver conditions, as well as related risks for preterm birth, fetal macrosomia, and higher weight after birth.
Unfortunately, few studies in pregnant women with HIV have moved out of the controlled environment into real-world settings, potentially limiting current knowledge about the impact of gestational weight gain – as well as strategies to both prevent it and the associated adverse outcomes.
That is what a team of infectious disease specialists at the Hospital Federal dos Servidores do Estado in Rio de Janeiro recently sought to answer among a cohort of INSTI-experienced and INSTI-naive women with BMIs less than 25 kg/m2 (underweight/normal weight) and higher than 25 kg/m2.
Surprising findings
The investigators determined that rates of excessive weight gain were significantly higher in INSTI-naive women with BMI less than 25 who experienced rates as high as 31.6%, compared with approximately 12% of women who conceived while on INSTIs, regardless of BMI values at baseline (P = .004).
However, rates of unfavorable pregnancy outcomes (for example, small for gestational age, preterm birth, stillbirth, death) appeared to be low overall and similar among all the study groups.
“We had some discussions when we were working on this and thought that the weight gain might have adverse effects,” Trevon Fuller, PhD, lead author and a postdoctoral student at the Hospital Federal dos Servidores do Estado, told this news organization.
“But it looked like the weight gain might actually be good, to the extent that we didn’t see any harm to the mom or the baby of those underweight or normal weight women who were naive to INSTIs,” he explained.
Dr. Fuller and his team enrolled 198 pregnant women living with HIV who sought care at the Hospital Federal dos Servidores do Estado – a national reference center for USAID’s Prevention of Mother to Child Transmission strategic program – between October 2014 and October 2021.
Participants were divided into two primary cohorts: BMI less than 25 at enrollment (n = 74) or BMI of 25 or higher (n = 124), then further divided by timing of INSTI-based combined ART:
- INSTI-naive: women using INSTI-based ART (raltegravir [Isentress] 400 mg twice per day or dolutegravir [Tivicay] 50 mg/day plus 2 non-nucleoside reverse transcriptase inhibitors – lamivudine plus tenofovir disoproxil fumarate or lamivudine plus zidovudine) for 4 weeks between baseline and near delivery.
- INSTI-experienced: women who became pregnant while using INSTIs for at least 6 months before conception.
Among underweight/normal weight participants, 77% (n = 57) were INSTI-naive and 23% (n = 17) INSTI-experienced, and among overweight/obese participants, 81.5% (n = 101) were INSTI-naive, and 18.5% (n = 23) were experienced.
Maternal age, which did not differ significantly by BMI or treatment experience, was a median of 28 years, and most participants were non-White. All participants were virally suppressed near delivery.
Study findings, which were published online in HIV Medicine, highlighted that median weight near delivery in participants who were overweight/obese at baseline was similar regardless of whether they were treatment-experienced (90 kg [198 lb]) or treatment-naive (82.3 kg [181 lb]), P = .026.
However, participants who were underweight/normal weight who were INSTI-naive had significantly higher rates of gestational weight gain (31.5%, 18/57), compared with those of underweight/normal weight who were INSTI-experienced (11.8%, 2/17), P = .004. Notably, this gain was significant in all categories of change (that is, low < 0.18 kg/week, normal 0.18-0.59 kg/week), and high > 0.59 kg/week).
“One of the things that we took away was that this weight gain is primarily happening with women who are starting INSTIs,” said Dr. Fuller.
“The data suggest that [it] might be temporary in the sense that there’s not going to be continuous weight gain but that it will probably approach some type of horizontal asymptote,” he added.
Although obstetric and neonatal outcomes were secondary measures, the investigators did not observe any significantly different outcomes when comparing the groups, and there were no stillbirths, neonatal deaths, or macrosomia.
Preterm delivery rates in underweight/normal weight participants who were INSTI-experienced (11.8%, 2/17) and INSTI-naive (5.3%, 3/57) were similar to overweight/obese participants who were INSTI-experienced (13%, 3/23) and INSTI-naive (6.9%, 7/101).
The same was true for low birthweight.
Still, the study appears to raise more questions than it answers, Sigal Yawetz, MD, an infectious disease specialist at Brigham and Women’s Hospital, Boston, said in an interview – a factor that she said is common also in some of the more recent randomized controlled studies, such as IMPAACT PROMISE.
Dr. Yawetz, who was not involved in the study, also noted, “The groups were small, so comparisons within the groups are difficult, and so many people were excluded that it’s hard to know if there were adverse outcomes related to this ... It’s very confounded.”
The World Health Organization estimates that there are roughly 1.3 million pregnant women with HIV, 81% of whom are on antiretroviral therapy. Although the literature continues to evolve, data suggest that in general, Black women are at greater risk for gestational weight gain.
“We have to remember that women who gain excess weight in pregnancy are still going to be with this weight following pregnancy as well,” Dr. Yawetz said. “So, it might impact their pregnancy but also their health after delivery and for subsequent pregnancies, which we don’t have data for yet.”
Dr. Fuller agrees that more data are needed and mentioned that the team plans to study this further, ideally with larger sample sizes.
Yet, despite the lingering questions, there is a silver lining, one that Dr. Yawetz was emphatic about.
“I really welcome people doing studies on this because we really need the data. By far, integrase inhibitors are the first-line regimen all over the world for pregnant women, and if you look at the gestalt or full picture, this is the best regimen to give pregnant women,” she said.
Dr. Fuller and Dr. Yawetz report no relevant financial relationships. The study was independently supported.
A version of this article first appeared on Medscape.com.
In recent years, increased use of integrase strand transferase inhibitor (INSTI) antiviral treatment (ART) has raised concerns about weight gain and adverse outcomes in patients with HIV. This is especially true regarding possible excessive gestational weight gain, which in women without HIV has been associated with maternal gestational diabetes, hypertensive and liver conditions, as well as related risks for preterm birth, fetal macrosomia, and higher weight after birth.
Unfortunately, few studies in pregnant women with HIV have moved out of the controlled environment into real-world settings, potentially limiting current knowledge about the impact of gestational weight gain – as well as strategies to both prevent it and the associated adverse outcomes.
That is what a team of infectious disease specialists at the Hospital Federal dos Servidores do Estado in Rio de Janeiro recently sought to answer among a cohort of INSTI-experienced and INSTI-naive women with BMIs less than 25 kg/m2 (underweight/normal weight) and higher than 25 kg/m2.
Surprising findings
The investigators determined that rates of excessive weight gain were significantly higher in INSTI-naive women with BMI less than 25 who experienced rates as high as 31.6%, compared with approximately 12% of women who conceived while on INSTIs, regardless of BMI values at baseline (P = .004).
However, rates of unfavorable pregnancy outcomes (for example, small for gestational age, preterm birth, stillbirth, death) appeared to be low overall and similar among all the study groups.
“We had some discussions when we were working on this and thought that the weight gain might have adverse effects,” Trevon Fuller, PhD, lead author and a postdoctoral student at the Hospital Federal dos Servidores do Estado, told this news organization.
“But it looked like the weight gain might actually be good, to the extent that we didn’t see any harm to the mom or the baby of those underweight or normal weight women who were naive to INSTIs,” he explained.
Dr. Fuller and his team enrolled 198 pregnant women living with HIV who sought care at the Hospital Federal dos Servidores do Estado – a national reference center for USAID’s Prevention of Mother to Child Transmission strategic program – between October 2014 and October 2021.
Participants were divided into two primary cohorts: BMI less than 25 at enrollment (n = 74) or BMI of 25 or higher (n = 124), then further divided by timing of INSTI-based combined ART:
- INSTI-naive: women using INSTI-based ART (raltegravir [Isentress] 400 mg twice per day or dolutegravir [Tivicay] 50 mg/day plus 2 non-nucleoside reverse transcriptase inhibitors – lamivudine plus tenofovir disoproxil fumarate or lamivudine plus zidovudine) for 4 weeks between baseline and near delivery.
- INSTI-experienced: women who became pregnant while using INSTIs for at least 6 months before conception.
Among underweight/normal weight participants, 77% (n = 57) were INSTI-naive and 23% (n = 17) INSTI-experienced, and among overweight/obese participants, 81.5% (n = 101) were INSTI-naive, and 18.5% (n = 23) were experienced.
Maternal age, which did not differ significantly by BMI or treatment experience, was a median of 28 years, and most participants were non-White. All participants were virally suppressed near delivery.
Study findings, which were published online in HIV Medicine, highlighted that median weight near delivery in participants who were overweight/obese at baseline was similar regardless of whether they were treatment-experienced (90 kg [198 lb]) or treatment-naive (82.3 kg [181 lb]), P = .026.
However, participants who were underweight/normal weight who were INSTI-naive had significantly higher rates of gestational weight gain (31.5%, 18/57), compared with those of underweight/normal weight who were INSTI-experienced (11.8%, 2/17), P = .004. Notably, this gain was significant in all categories of change (that is, low < 0.18 kg/week, normal 0.18-0.59 kg/week), and high > 0.59 kg/week).
“One of the things that we took away was that this weight gain is primarily happening with women who are starting INSTIs,” said Dr. Fuller.
“The data suggest that [it] might be temporary in the sense that there’s not going to be continuous weight gain but that it will probably approach some type of horizontal asymptote,” he added.
Although obstetric and neonatal outcomes were secondary measures, the investigators did not observe any significantly different outcomes when comparing the groups, and there were no stillbirths, neonatal deaths, or macrosomia.
Preterm delivery rates in underweight/normal weight participants who were INSTI-experienced (11.8%, 2/17) and INSTI-naive (5.3%, 3/57) were similar to overweight/obese participants who were INSTI-experienced (13%, 3/23) and INSTI-naive (6.9%, 7/101).
The same was true for low birthweight.
Still, the study appears to raise more questions than it answers, Sigal Yawetz, MD, an infectious disease specialist at Brigham and Women’s Hospital, Boston, said in an interview – a factor that she said is common also in some of the more recent randomized controlled studies, such as IMPAACT PROMISE.
Dr. Yawetz, who was not involved in the study, also noted, “The groups were small, so comparisons within the groups are difficult, and so many people were excluded that it’s hard to know if there were adverse outcomes related to this ... It’s very confounded.”
The World Health Organization estimates that there are roughly 1.3 million pregnant women with HIV, 81% of whom are on antiretroviral therapy. Although the literature continues to evolve, data suggest that in general, Black women are at greater risk for gestational weight gain.
“We have to remember that women who gain excess weight in pregnancy are still going to be with this weight following pregnancy as well,” Dr. Yawetz said. “So, it might impact their pregnancy but also their health after delivery and for subsequent pregnancies, which we don’t have data for yet.”
Dr. Fuller agrees that more data are needed and mentioned that the team plans to study this further, ideally with larger sample sizes.
Yet, despite the lingering questions, there is a silver lining, one that Dr. Yawetz was emphatic about.
“I really welcome people doing studies on this because we really need the data. By far, integrase inhibitors are the first-line regimen all over the world for pregnant women, and if you look at the gestalt or full picture, this is the best regimen to give pregnant women,” she said.
Dr. Fuller and Dr. Yawetz report no relevant financial relationships. The study was independently supported.
A version of this article first appeared on Medscape.com.
Weight gain during pregnancy may play role in child ADHD risk
Obesity in women of reproductive age has emerged as one of the main risk factors associated with neonatal complications and long-term neuropsychiatric consequences in offspring, including attention-deficit/hyperactivity disorder.
Research has also linked pregestational diabetes and gestational diabetes mellitus (GDM) to an increased risk for ADHD in offspring. Now, an observational study of 1,036 singleton births at one hospital between 1998 and 2008 suggests that in the presence of GDM, maternal obesity combined with excessive weight gain during pregnancy may be jointly associated with increased risk of offspring ADHD. The median follow-up was 17.7 years.
Maternal obesity was independently associated with ADHD (adjusted hazard ratio, 1.66; 95% confidence interval: 1.07-2.60), but excessive weight gain during pregnancy and maternal overweight were not, reported Verónica Perea, MD, PhD, of the Hospital Universitari Mútua de Terrassa, Barcelona, and colleagues in the Journal of Clinical Endocrinology & Metabolism.
However, in women with pregestation obesity who gained more weight than recommended by the National Academy of Medicine (NAM), the risk of offspring ADHD was higher, compared with women of normal weight whose pregnancy weight stayed within NAM guidelines (adjusted hazard ratio, 2.13; 95% confidence interval: 1.14-4.01).
“The results of this study suggest that the negative repercussions of excessive weight gain on children within the setting of a high-risk population with GDM and obesity were not only observed during the prenatal period but also years later with a development of ADHD,” the researchers wrote.
The study also showed that when maternal weight gain did not exceed NAM guidelines, maternal obesity was no longer independently associated with ADHD in offspring (aHR, 1.36; 95% CI: 0.78-2.36). This finding conflicts with earlier studies focusing primarily on the role of pregestational maternal weight, the researchers said. A 2018 nationwide Finnish cohort study in newborns showed an increased long-term risk of ADHD in those born to women with GDM, compared with the nondiabetic population. This long-term risk of ADHD increased in the presence of pregestational obesity (HR, 1.64).
Similarly, evidence from systematic reviews and meta-analyses has demonstrated that antenatal lifestyle interventions to prevent excessive weight gain during pregnancy were associated with a reduction in adverse pregnancy outcomes. However, evidence on offspring mental health was lacking, especially in high-risk pregnancies with gestational diabetes, the study authors said.
Although causal inferences can’t be drawn from the current observational study, “it seems that the higher risk [of ADHD] observed would be explained by the role of gestational weight gain during the antenatal period,” Dr. Perea said in an interview. Importantly, the study highlights a window of opportunity for promoting healthy weight gain during pregnancy, Dr. Perea said. ”This should be a priority in the current management of gestation.”
Fatima Cody Stanford, MD, MPH, an associate professor of medicine and pediatrics at Harvard Medical School, Boston, agreed. “I think one of the key issues is that there’s very little attention paid to how weight gain is regulated during pregnancy,” she said in an interview. On many other points, however, Dr. Stanford, who is a specialist in obesity medicine at Massachusetts General Hospital Weight Center, did not agree.
The association between ADHD and obesity has already been well established by a 2019 meta-analysis and systematic review of studies over the last 10 years, she emphasized. “These studies were able to show a much stronger association between maternal obesity and ADHD in offspring because they were powered to detect differences.”
The current study does not say “anything new or novel,” Dr. Stanford added. “Maternal obesity and the association with an increased risk of ADHD in offspring is the main issue. I don’t think there was any appreciable increase when weight gain during pregnancy was factored in. It’s mild at best.”
Eran Bornstein, MD, vice-chair of obstetrics and gynecology at Lenox Hill Hospital, New York, expressed a similar point of view. Although the study findings “add to the current literature,” they should be interpreted “cautiously,” Dr. Bornstein said in an interview.
The size of the effect on ADHD risk attributable to maternal weight gain during pregnancy “was not clear,” he said. “Cohort studies of this sort are excellent for finding associations which help us generate the hypothesis, but this doesn’t demonstrate a cause and effect or a magnitude for this effect.”
Physicians should follow cumulative data suggesting that maternal obesity is associated with a number of pregnancy complications and neonatal outcomes in women with and without diabetes, Dr. Bornstein suggested. “Optimizing maternal weight prior to pregnancy and adhering to recommendations regarding weight gain has the potential to improve some of these outcomes.”
Treating obesity prior to conception mitigates GDM risk, agreed Dr. Stanford. “The issue,” she explained, “is that all of the drugs approved for the treatment of obesity are contraindicated in pregnancy and lifestyle modification fails in 96% of cases, even when there is no pregnancy.” Drugs such as metformin are being used off-label to treat obesity and to safely manage gestational weight gain, she said. “Those of us who practice obesity medicine know that metformin can be safely used throughout pregnancy with no harm to the fetus.”
This study was partially funded by Fundació Docència i Recerca MútuaTerrassa. Dr. Perea and study coauthors reporting have no conflicts of interest. Dr. Stanford disclosed relationships with Novo Nordisk, Eli Lilly, Boehringer Ingelheim, Gelesis, Pfizer, Currax, and Rhythm. Dr. Bornstein reported having no conflicts of interest.
This story was updated on 11/7/2022.
Obesity in women of reproductive age has emerged as one of the main risk factors associated with neonatal complications and long-term neuropsychiatric consequences in offspring, including attention-deficit/hyperactivity disorder.
Research has also linked pregestational diabetes and gestational diabetes mellitus (GDM) to an increased risk for ADHD in offspring. Now, an observational study of 1,036 singleton births at one hospital between 1998 and 2008 suggests that in the presence of GDM, maternal obesity combined with excessive weight gain during pregnancy may be jointly associated with increased risk of offspring ADHD. The median follow-up was 17.7 years.
Maternal obesity was independently associated with ADHD (adjusted hazard ratio, 1.66; 95% confidence interval: 1.07-2.60), but excessive weight gain during pregnancy and maternal overweight were not, reported Verónica Perea, MD, PhD, of the Hospital Universitari Mútua de Terrassa, Barcelona, and colleagues in the Journal of Clinical Endocrinology & Metabolism.
However, in women with pregestation obesity who gained more weight than recommended by the National Academy of Medicine (NAM), the risk of offspring ADHD was higher, compared with women of normal weight whose pregnancy weight stayed within NAM guidelines (adjusted hazard ratio, 2.13; 95% confidence interval: 1.14-4.01).
“The results of this study suggest that the negative repercussions of excessive weight gain on children within the setting of a high-risk population with GDM and obesity were not only observed during the prenatal period but also years later with a development of ADHD,” the researchers wrote.
The study also showed that when maternal weight gain did not exceed NAM guidelines, maternal obesity was no longer independently associated with ADHD in offspring (aHR, 1.36; 95% CI: 0.78-2.36). This finding conflicts with earlier studies focusing primarily on the role of pregestational maternal weight, the researchers said. A 2018 nationwide Finnish cohort study in newborns showed an increased long-term risk of ADHD in those born to women with GDM, compared with the nondiabetic population. This long-term risk of ADHD increased in the presence of pregestational obesity (HR, 1.64).
Similarly, evidence from systematic reviews and meta-analyses has demonstrated that antenatal lifestyle interventions to prevent excessive weight gain during pregnancy were associated with a reduction in adverse pregnancy outcomes. However, evidence on offspring mental health was lacking, especially in high-risk pregnancies with gestational diabetes, the study authors said.
Although causal inferences can’t be drawn from the current observational study, “it seems that the higher risk [of ADHD] observed would be explained by the role of gestational weight gain during the antenatal period,” Dr. Perea said in an interview. Importantly, the study highlights a window of opportunity for promoting healthy weight gain during pregnancy, Dr. Perea said. ”This should be a priority in the current management of gestation.”
Fatima Cody Stanford, MD, MPH, an associate professor of medicine and pediatrics at Harvard Medical School, Boston, agreed. “I think one of the key issues is that there’s very little attention paid to how weight gain is regulated during pregnancy,” she said in an interview. On many other points, however, Dr. Stanford, who is a specialist in obesity medicine at Massachusetts General Hospital Weight Center, did not agree.
The association between ADHD and obesity has already been well established by a 2019 meta-analysis and systematic review of studies over the last 10 years, she emphasized. “These studies were able to show a much stronger association between maternal obesity and ADHD in offspring because they were powered to detect differences.”
The current study does not say “anything new or novel,” Dr. Stanford added. “Maternal obesity and the association with an increased risk of ADHD in offspring is the main issue. I don’t think there was any appreciable increase when weight gain during pregnancy was factored in. It’s mild at best.”
Eran Bornstein, MD, vice-chair of obstetrics and gynecology at Lenox Hill Hospital, New York, expressed a similar point of view. Although the study findings “add to the current literature,” they should be interpreted “cautiously,” Dr. Bornstein said in an interview.
The size of the effect on ADHD risk attributable to maternal weight gain during pregnancy “was not clear,” he said. “Cohort studies of this sort are excellent for finding associations which help us generate the hypothesis, but this doesn’t demonstrate a cause and effect or a magnitude for this effect.”
Physicians should follow cumulative data suggesting that maternal obesity is associated with a number of pregnancy complications and neonatal outcomes in women with and without diabetes, Dr. Bornstein suggested. “Optimizing maternal weight prior to pregnancy and adhering to recommendations regarding weight gain has the potential to improve some of these outcomes.”
Treating obesity prior to conception mitigates GDM risk, agreed Dr. Stanford. “The issue,” she explained, “is that all of the drugs approved for the treatment of obesity are contraindicated in pregnancy and lifestyle modification fails in 96% of cases, even when there is no pregnancy.” Drugs such as metformin are being used off-label to treat obesity and to safely manage gestational weight gain, she said. “Those of us who practice obesity medicine know that metformin can be safely used throughout pregnancy with no harm to the fetus.”
This study was partially funded by Fundació Docència i Recerca MútuaTerrassa. Dr. Perea and study coauthors reporting have no conflicts of interest. Dr. Stanford disclosed relationships with Novo Nordisk, Eli Lilly, Boehringer Ingelheim, Gelesis, Pfizer, Currax, and Rhythm. Dr. Bornstein reported having no conflicts of interest.
This story was updated on 11/7/2022.
Obesity in women of reproductive age has emerged as one of the main risk factors associated with neonatal complications and long-term neuropsychiatric consequences in offspring, including attention-deficit/hyperactivity disorder.
Research has also linked pregestational diabetes and gestational diabetes mellitus (GDM) to an increased risk for ADHD in offspring. Now, an observational study of 1,036 singleton births at one hospital between 1998 and 2008 suggests that in the presence of GDM, maternal obesity combined with excessive weight gain during pregnancy may be jointly associated with increased risk of offspring ADHD. The median follow-up was 17.7 years.
Maternal obesity was independently associated with ADHD (adjusted hazard ratio, 1.66; 95% confidence interval: 1.07-2.60), but excessive weight gain during pregnancy and maternal overweight were not, reported Verónica Perea, MD, PhD, of the Hospital Universitari Mútua de Terrassa, Barcelona, and colleagues in the Journal of Clinical Endocrinology & Metabolism.
However, in women with pregestation obesity who gained more weight than recommended by the National Academy of Medicine (NAM), the risk of offspring ADHD was higher, compared with women of normal weight whose pregnancy weight stayed within NAM guidelines (adjusted hazard ratio, 2.13; 95% confidence interval: 1.14-4.01).
“The results of this study suggest that the negative repercussions of excessive weight gain on children within the setting of a high-risk population with GDM and obesity were not only observed during the prenatal period but also years later with a development of ADHD,” the researchers wrote.
The study also showed that when maternal weight gain did not exceed NAM guidelines, maternal obesity was no longer independently associated with ADHD in offspring (aHR, 1.36; 95% CI: 0.78-2.36). This finding conflicts with earlier studies focusing primarily on the role of pregestational maternal weight, the researchers said. A 2018 nationwide Finnish cohort study in newborns showed an increased long-term risk of ADHD in those born to women with GDM, compared with the nondiabetic population. This long-term risk of ADHD increased in the presence of pregestational obesity (HR, 1.64).
Similarly, evidence from systematic reviews and meta-analyses has demonstrated that antenatal lifestyle interventions to prevent excessive weight gain during pregnancy were associated with a reduction in adverse pregnancy outcomes. However, evidence on offspring mental health was lacking, especially in high-risk pregnancies with gestational diabetes, the study authors said.
Although causal inferences can’t be drawn from the current observational study, “it seems that the higher risk [of ADHD] observed would be explained by the role of gestational weight gain during the antenatal period,” Dr. Perea said in an interview. Importantly, the study highlights a window of opportunity for promoting healthy weight gain during pregnancy, Dr. Perea said. ”This should be a priority in the current management of gestation.”
Fatima Cody Stanford, MD, MPH, an associate professor of medicine and pediatrics at Harvard Medical School, Boston, agreed. “I think one of the key issues is that there’s very little attention paid to how weight gain is regulated during pregnancy,” she said in an interview. On many other points, however, Dr. Stanford, who is a specialist in obesity medicine at Massachusetts General Hospital Weight Center, did not agree.
The association between ADHD and obesity has already been well established by a 2019 meta-analysis and systematic review of studies over the last 10 years, she emphasized. “These studies were able to show a much stronger association between maternal obesity and ADHD in offspring because they were powered to detect differences.”
The current study does not say “anything new or novel,” Dr. Stanford added. “Maternal obesity and the association with an increased risk of ADHD in offspring is the main issue. I don’t think there was any appreciable increase when weight gain during pregnancy was factored in. It’s mild at best.”
Eran Bornstein, MD, vice-chair of obstetrics and gynecology at Lenox Hill Hospital, New York, expressed a similar point of view. Although the study findings “add to the current literature,” they should be interpreted “cautiously,” Dr. Bornstein said in an interview.
The size of the effect on ADHD risk attributable to maternal weight gain during pregnancy “was not clear,” he said. “Cohort studies of this sort are excellent for finding associations which help us generate the hypothesis, but this doesn’t demonstrate a cause and effect or a magnitude for this effect.”
Physicians should follow cumulative data suggesting that maternal obesity is associated with a number of pregnancy complications and neonatal outcomes in women with and without diabetes, Dr. Bornstein suggested. “Optimizing maternal weight prior to pregnancy and adhering to recommendations regarding weight gain has the potential to improve some of these outcomes.”
Treating obesity prior to conception mitigates GDM risk, agreed Dr. Stanford. “The issue,” she explained, “is that all of the drugs approved for the treatment of obesity are contraindicated in pregnancy and lifestyle modification fails in 96% of cases, even when there is no pregnancy.” Drugs such as metformin are being used off-label to treat obesity and to safely manage gestational weight gain, she said. “Those of us who practice obesity medicine know that metformin can be safely used throughout pregnancy with no harm to the fetus.”
This study was partially funded by Fundació Docència i Recerca MútuaTerrassa. Dr. Perea and study coauthors reporting have no conflicts of interest. Dr. Stanford disclosed relationships with Novo Nordisk, Eli Lilly, Boehringer Ingelheim, Gelesis, Pfizer, Currax, and Rhythm. Dr. Bornstein reported having no conflicts of interest.
This story was updated on 11/7/2022.
The Journal of Clinical Endocrinology & Metabolism