Obstetrics

TOPLINE:

Individuals with severe maternal morbidity (SMM) are at an increased risk for mental health condition–related hospitalization or emergency department (ED) visits up to 13 years after delivery.

METHODOLOGY:

• This retrospective cohort study compared mental health hospitalizations and ED visits in postpartum individuals with and without SMM over 13 years after delivery from April 2008 to March 2021.
• The study analyzed 1,579,392 individuals aged 18-55 years with a first recorded liveborn or stillborn delivery from a pregnancy lasting 20-43 weeks, of which 35,825 (2.3%) had exposure to SMM.
• The SMM exposure was analyzed for events occurring after 20 weeks’ gestation and up to 42 days after delivery hospital discharge in the first recorded birth; those without SMM were considered unexposed.
• The main outcome was a combination of mental health hospitalizations or ED visits occurring at least 43 days after the index birth hospitalization.

TAKEAWAY:

• Individuals with SMM had a 1.3-fold increased risk of mental health hospitalizations or ED visits.
• The hospital or ED visits per 10,000 person-years were 59.2 for mood and anxiety disorders, 17.1 for substance abuse and related disorders, 4.8 for suicidality or self-harm, and 4.1 for schizophrenia spectrum or other psychotic disorders.
• Following SMM, an elevated risk was observed for all mental health outcomes except one (schizophrenia spectrum and other psychotic disorders), with the highest risk seen for suicidality and self-harm (aHR, 1.54).

IN PRACTICE:

“Knowledge of the short- and long-term risks of serious mental health conditions after SMM and its subtypes could inform the need for enhanced postpartum supportive resources,” the authors wrote.

SOURCE:

This study was led by Asia Blackman, MSc, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada. It was published online in JAMA Network Open.

LIMITATIONS:

The study is limited by its observational design, missing data, and misclassification bias.

DISCLOSURES:

This study was supported by funding from the Canadian Institutes of Health Research. Three authors reported receiving personal fees or grants outside the submitted work. No other conflicts of interest were reported.

A version of this article first appeared on Medscape.com.

TOPLINE:

Individuals with severe maternal morbidity (SMM) are at an increased risk for mental health condition–related hospitalization or emergency department (ED) visits up to 13 years after delivery.

METHODOLOGY:

• This retrospective cohort study compared mental health hospitalizations and ED visits in postpartum individuals with and without SMM over 13 years after delivery from April 2008 to March 2021.
• The study analyzed 1,579,392 individuals aged 18-55 years with a first recorded liveborn or stillborn delivery from a pregnancy lasting 20-43 weeks, of which 35,825 (2.3%) had exposure to SMM.
• The SMM exposure was analyzed for events occurring after 20 weeks’ gestation and up to 42 days after delivery hospital discharge in the first recorded birth; those without SMM were considered unexposed.
• The main outcome was a combination of mental health hospitalizations or ED visits occurring at least 43 days after the index birth hospitalization.

TAKEAWAY:

• Individuals with SMM had a 1.3-fold increased risk of mental health hospitalizations or ED visits.
• The hospital or ED visits per 10,000 person-years were 59.2 for mood and anxiety disorders, 17.1 for substance abuse and related disorders, 4.8 for suicidality or self-harm, and 4.1 for schizophrenia spectrum or other psychotic disorders.
• Following SMM, an elevated risk was observed for all mental health outcomes except one (schizophrenia spectrum and other psychotic disorders), with the highest risk seen for suicidality and self-harm (aHR, 1.54).

IN PRACTICE:

“Knowledge of the short- and long-term risks of serious mental health conditions after SMM and its subtypes could inform the need for enhanced postpartum supportive resources,” the authors wrote.

SOURCE:

This study was led by Asia Blackman, MSc, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada. It was published online in JAMA Network Open.

LIMITATIONS:

The study is limited by its observational design, missing data, and misclassification bias.

DISCLOSURES:

This study was supported by funding from the Canadian Institutes of Health Research. Three authors reported receiving personal fees or grants outside the submitted work. No other conflicts of interest were reported.

A version of this article first appeared on Medscape.com.

TOPLINE:

Individuals with severe maternal morbidity (SMM) are at an increased risk for mental health condition–related hospitalization or emergency department (ED) visits up to 13 years after delivery.

METHODOLOGY:

• This retrospective cohort study compared mental health hospitalizations and ED visits in postpartum individuals with and without SMM over 13 years after delivery from April 2008 to March 2021.
• The study analyzed 1,579,392 individuals aged 18-55 years with a first recorded liveborn or stillborn delivery from a pregnancy lasting 20-43 weeks, of which 35,825 (2.3%) had exposure to SMM.
• The SMM exposure was analyzed for events occurring after 20 weeks’ gestation and up to 42 days after delivery hospital discharge in the first recorded birth; those without SMM were considered unexposed.
• The main outcome was a combination of mental health hospitalizations or ED visits occurring at least 43 days after the index birth hospitalization.

TAKEAWAY:

• Individuals with SMM had a 1.3-fold increased risk of mental health hospitalizations or ED visits.
• The hospital or ED visits per 10,000 person-years were 59.2 for mood and anxiety disorders, 17.1 for substance abuse and related disorders, 4.8 for suicidality or self-harm, and 4.1 for schizophrenia spectrum or other psychotic disorders.
• Following SMM, an elevated risk was observed for all mental health outcomes except one (schizophrenia spectrum and other psychotic disorders), with the highest risk seen for suicidality and self-harm (aHR, 1.54).

IN PRACTICE:

“Knowledge of the short- and long-term risks of serious mental health conditions after SMM and its subtypes could inform the need for enhanced postpartum supportive resources,” the authors wrote.

SOURCE:

This study was led by Asia Blackman, MSc, Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada. It was published online in JAMA Network Open.

LIMITATIONS:

The study is limited by its observational design, missing data, and misclassification bias.

DISCLOSURES:

This study was supported by funding from the Canadian Institutes of Health Research. Three authors reported receiving personal fees or grants outside the submitted work. No other conflicts of interest were reported.

A version of this article first appeared on Medscape.com.

People with HIV who wish to breastfeed their infants should have sustained viral suppression, with a viral load below 50 copies per mL, to have the least risk of transmitting HIV to their baby aside from avoiding breastfeeding altogether, according to a new clinical report from the American Academy of Pediatrics (AAP).

“The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%,” Lisa Abuogi, MD, an associate professor of pediatric infectious disease at the University of Colorado Anschutz Medical Campus, and her colleagues wrote in Pediatrics. For people living with HIV in the United States, however, the AAP recommends that “avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission.”

The authors go on to suggest that pediatricians “be prepared to offer a family-centered, nonjudgmental, harm reduction approach” to support people with HIV who do want to breastfeed and have sustained viral suppression. Parents with HIV who are not on ART or who do not have adequate viral suppression should be advised against breastfeeding, the report states. Members of the AAP Committee on Pediatric and Adolescent HIV and of the AAP Section on Breastfeeding coauthored the clinical report.

“The new guidelines emphasize the importance of patient-centered counseling as the foundation for shared decision-making, allowing patients and pediatric providers to make feeding decisions together and for the first time really giving support to people with HIV in the U.S. who want to breastfeed,” Danna Biala, MD, MS, an attending pediatrician at Children’s Hospital at Montefiore and an assistant professor at Albert Einstein College of Medicine, told MDedge News.

Dr. Biala was not involved in the development of the report, but she said the AAP’s guidance reflects the recent shift in the stance of the Centers for Disease Control and Prevention (CDC) regarding breastfeeding among people who are HIV+. Recommendations from the CDC and the U.S. Department of Health and Human Services (HHS) were updated in 2023.

“I’m glad that the AAP is putting out guidelines on infant feeding for people with HIV,” Dr. Biala said. “For so long in the U.S., pediatricians have been advising all mothers with HIV to avoid breastfeeding, believing that the risk of transmission outweighed the benefits of breastfeeding.”

The updated guidance from HHS in 2023 “was revolutionary in supporting people with HIV in low-risk situations who want to breastfeed,” Dr. Biala said, but “clear protocols for monitoring and follow-up were not in place,” which these AAP guidelines help address.
 

Prior Discordance Between Global, U.S. Guidance

An estimated 5,000 people with HIV give birth each year in the United States, and up to one third of pregnant people with HIV may be unaware of their HIV status, the AAP report notes. Pediatric healthcare professionals in the United States therefore need to be aware of recommendations related to HIV testing of pregnant people and of counseling the feeding of infants exposed to HIV. The report recommends opt-out HIV testing at the first prenatal visit and then possibly retesting in the third trimester in areas with high HIV incidence or for people at high risk for HIV or with signs or symptoms of acute HIV infection.

The report also highlights the health benefits of breastfeeding to both the infant and the breastfeeding parent, but notes the CDC’s historical recommendation against breastfeeding for people who are HIV+. The WHO, meanwhile, began recommending in 2016 that infants be breastfed through 12 to 24 months old if the parent was on ART and/or the infant was receiving antiretroviral (ARV) prophylaxis, since research showed those treatments were effective in reducing transmission risk.

Still, an estimated 30% of perinatal HIV transmission occurs via breastfeeding worldwide, primarily from people with HIV who are not on ART or are not adequately virally suppressed. Without parental ART or infant ARV prophylaxis, HIV transmission risk to infants via breastfeeding is highest, about 5%-6%, in the first 4-6 weeks of life. Risk then declines to about 0.9% a month thereafter. The AAP report goes on to describe factors that increase or decrease the likelihood of transmission during breastfeeding, but it notes that neither ART in the breastfeeding person nor ARV prophylaxis in the infant completely eliminates the risk of HIV transmission during breastfeeding. There have been rare cases where transmission occurred despite viral suppression in the person with HIV.

Among the reasons people with HIV have expressed a desire to breastfeed are wanting to bond with their infant, wanting to provide optimal nutrition and health benefits to their baby, and meeting cultural expectations, including the desire not to disclose their HIV infection status to family or friends by virtue of not breastfeeding.

“Among immigrant and refugee populations, the discordance between infant feeding guidelines in the United States and their country of birth may result in confusion, especially among parents who breastfed previous infants,” the AAP report also notes. Further, not breastfeeding could compound health disparities already more likely to be present among those living with HIV.

Discussions about infant feeding with parents with HIV should therefore “begin as early as possible and involve a multidisciplinary team that might include the pediatric primary care provider (once identified), a pediatric HIV expert, the breastfeeding parent’s HIV care and obstetric providers, and lactation consultants,” the report states. ”The parent’s motivations for breastfeeding should be explored and counseling provided on the risks and benefits of each feeding option, including breastfeeding, formula feeding, or certified, banked donor human milk.” The statement emphasizes the need for providing counseling in a “non-judgmental, respectful way, recognizing potential drivers for their decisions such as avoidance of stigma, prior experience with breastfeeding, and cultural contributors.”
 

Clear Recommendations Can Help Providers

The AAP’s statement that “replacement feeding (with formula or certified, banked donor human milk) is the only option that is 100% certain to prevent postnatal transmission of HIV” feels like it takes a “more conservative or discouraging approach” to breastfeeding than the CDC or WHO guidelines, Alissa Parker-Smith, APRN, DNP, CPNP-PC, IBCLC, a nurse practitioner and lactation consultant at PrimaryPlus, a Federally Qualified Health Clinic in Ashland, Kentucky, told MDedge. But she said they do clearly align with the CDC guidelines, and their differences from the WHO guidelines make sense in light of the different populations served by the WHO versus the U.S. agencies.

“Unclean water for formula preparation and a reduced or lack of access to formula in general can lead to many other risks of death for the infant other than the very small risk of HIV infection from breastfeeding from an HIV+ parent,” Ms. Parker-Smith said. “In the U.S. we generally have consistent access to clean water and safe formula as well as social structures to help families have access to formula, so the very small risk of HIV being passed to the infant is far greater than an infant in the U.S. dying as a result of unclean water or formula contamination.”

Ms. Parker-Smith also said the AAP recommendations seem thorough in helping pediatric practitioners counsel and support parents with HIV. “If I had a parent who is HIV+ walk in the door today wanting to breastfeed their infant, the AAP guidelines give me specific steps to make me feel confident in helping that parent breastfeed as safely as possible as well as providing education to assist that parent through the decision process,” she said.

Dr. Biala agreed, noting that the clinical report “very clearly delineates recommendations for different groups of people: those in labor or postpartum with undocumented HIV infection status, pregnant and postpartum people with HIV, those without HIV but at high risk of acquiring it, and those with suspected acute HIV infection while breastfeeding.” Dr. Biala said the report “provides concrete, detailed, and easy-to-follow guidance on comprehensive counseling, strategies to minimize risk of transmission, and infant screening timelines.”

How easily the guidelines can be implemented will depend on the existing resources at different institutions in the United States, Dr. Biala added.

“In hospitals and clinics that have, or could easily have, systems in place to ensure follow-up and regular assessment during breastfeeding, the guidelines could be implemented fairly quickly,” she said. “It might be more challenging in areas with inadequate or limited access to multidisciplinary team members, including HIV care providers and lactation consultants.”

The report did not use external funding, and the authors reported no disclosures. Dr. Abuogi and Ms. Parker-Smith have no disclosures.

People with HIV who wish to breastfeed their infants should have sustained viral suppression, with a viral load below 50 copies per mL, to have the least risk of transmitting HIV to their baby aside from avoiding breastfeeding altogether, according to a new clinical report from the American Academy of Pediatrics (AAP).

“The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%,” Lisa Abuogi, MD, an associate professor of pediatric infectious disease at the University of Colorado Anschutz Medical Campus, and her colleagues wrote in Pediatrics. For people living with HIV in the United States, however, the AAP recommends that “avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission.”

The authors go on to suggest that pediatricians “be prepared to offer a family-centered, nonjudgmental, harm reduction approach” to support people with HIV who do want to breastfeed and have sustained viral suppression. Parents with HIV who are not on ART or who do not have adequate viral suppression should be advised against breastfeeding, the report states. Members of the AAP Committee on Pediatric and Adolescent HIV and of the AAP Section on Breastfeeding coauthored the clinical report.

“The new guidelines emphasize the importance of patient-centered counseling as the foundation for shared decision-making, allowing patients and pediatric providers to make feeding decisions together and for the first time really giving support to people with HIV in the U.S. who want to breastfeed,” Danna Biala, MD, MS, an attending pediatrician at Children’s Hospital at Montefiore and an assistant professor at Albert Einstein College of Medicine, told MDedge News.

Dr. Biala was not involved in the development of the report, but she said the AAP’s guidance reflects the recent shift in the stance of the Centers for Disease Control and Prevention (CDC) regarding breastfeeding among people who are HIV+. Recommendations from the CDC and the U.S. Department of Health and Human Services (HHS) were updated in 2023.

“I’m glad that the AAP is putting out guidelines on infant feeding for people with HIV,” Dr. Biala said. “For so long in the U.S., pediatricians have been advising all mothers with HIV to avoid breastfeeding, believing that the risk of transmission outweighed the benefits of breastfeeding.”

The updated guidance from HHS in 2023 “was revolutionary in supporting people with HIV in low-risk situations who want to breastfeed,” Dr. Biala said, but “clear protocols for monitoring and follow-up were not in place,” which these AAP guidelines help address.
 

Prior Discordance Between Global, U.S. Guidance

An estimated 5,000 people with HIV give birth each year in the United States, and up to one third of pregnant people with HIV may be unaware of their HIV status, the AAP report notes. Pediatric healthcare professionals in the United States therefore need to be aware of recommendations related to HIV testing of pregnant people and of counseling the feeding of infants exposed to HIV. The report recommends opt-out HIV testing at the first prenatal visit and then possibly retesting in the third trimester in areas with high HIV incidence or for people at high risk for HIV or with signs or symptoms of acute HIV infection.

The report also highlights the health benefits of breastfeeding to both the infant and the breastfeeding parent, but notes the CDC’s historical recommendation against breastfeeding for people who are HIV+. The WHO, meanwhile, began recommending in 2016 that infants be breastfed through 12 to 24 months old if the parent was on ART and/or the infant was receiving antiretroviral (ARV) prophylaxis, since research showed those treatments were effective in reducing transmission risk.

Still, an estimated 30% of perinatal HIV transmission occurs via breastfeeding worldwide, primarily from people with HIV who are not on ART or are not adequately virally suppressed. Without parental ART or infant ARV prophylaxis, HIV transmission risk to infants via breastfeeding is highest, about 5%-6%, in the first 4-6 weeks of life. Risk then declines to about 0.9% a month thereafter. The AAP report goes on to describe factors that increase or decrease the likelihood of transmission during breastfeeding, but it notes that neither ART in the breastfeeding person nor ARV prophylaxis in the infant completely eliminates the risk of HIV transmission during breastfeeding. There have been rare cases where transmission occurred despite viral suppression in the person with HIV.

Among the reasons people with HIV have expressed a desire to breastfeed are wanting to bond with their infant, wanting to provide optimal nutrition and health benefits to their baby, and meeting cultural expectations, including the desire not to disclose their HIV infection status to family or friends by virtue of not breastfeeding.

“Among immigrant and refugee populations, the discordance between infant feeding guidelines in the United States and their country of birth may result in confusion, especially among parents who breastfed previous infants,” the AAP report also notes. Further, not breastfeeding could compound health disparities already more likely to be present among those living with HIV.

Discussions about infant feeding with parents with HIV should therefore “begin as early as possible and involve a multidisciplinary team that might include the pediatric primary care provider (once identified), a pediatric HIV expert, the breastfeeding parent’s HIV care and obstetric providers, and lactation consultants,” the report states. ”The parent’s motivations for breastfeeding should be explored and counseling provided on the risks and benefits of each feeding option, including breastfeeding, formula feeding, or certified, banked donor human milk.” The statement emphasizes the need for providing counseling in a “non-judgmental, respectful way, recognizing potential drivers for their decisions such as avoidance of stigma, prior experience with breastfeeding, and cultural contributors.”
 

Clear Recommendations Can Help Providers

The AAP’s statement that “replacement feeding (with formula or certified, banked donor human milk) is the only option that is 100% certain to prevent postnatal transmission of HIV” feels like it takes a “more conservative or discouraging approach” to breastfeeding than the CDC or WHO guidelines, Alissa Parker-Smith, APRN, DNP, CPNP-PC, IBCLC, a nurse practitioner and lactation consultant at PrimaryPlus, a Federally Qualified Health Clinic in Ashland, Kentucky, told MDedge. But she said they do clearly align with the CDC guidelines, and their differences from the WHO guidelines make sense in light of the different populations served by the WHO versus the U.S. agencies.

“Unclean water for formula preparation and a reduced or lack of access to formula in general can lead to many other risks of death for the infant other than the very small risk of HIV infection from breastfeeding from an HIV+ parent,” Ms. Parker-Smith said. “In the U.S. we generally have consistent access to clean water and safe formula as well as social structures to help families have access to formula, so the very small risk of HIV being passed to the infant is far greater than an infant in the U.S. dying as a result of unclean water or formula contamination.”

Ms. Parker-Smith also said the AAP recommendations seem thorough in helping pediatric practitioners counsel and support parents with HIV. “If I had a parent who is HIV+ walk in the door today wanting to breastfeed their infant, the AAP guidelines give me specific steps to make me feel confident in helping that parent breastfeed as safely as possible as well as providing education to assist that parent through the decision process,” she said.

Dr. Biala agreed, noting that the clinical report “very clearly delineates recommendations for different groups of people: those in labor or postpartum with undocumented HIV infection status, pregnant and postpartum people with HIV, those without HIV but at high risk of acquiring it, and those with suspected acute HIV infection while breastfeeding.” Dr. Biala said the report “provides concrete, detailed, and easy-to-follow guidance on comprehensive counseling, strategies to minimize risk of transmission, and infant screening timelines.”

How easily the guidelines can be implemented will depend on the existing resources at different institutions in the United States, Dr. Biala added.

“In hospitals and clinics that have, or could easily have, systems in place to ensure follow-up and regular assessment during breastfeeding, the guidelines could be implemented fairly quickly,” she said. “It might be more challenging in areas with inadequate or limited access to multidisciplinary team members, including HIV care providers and lactation consultants.”

The report did not use external funding, and the authors reported no disclosures. Dr. Abuogi and Ms. Parker-Smith have no disclosures.

People with HIV who wish to breastfeed their infants should have sustained viral suppression, with a viral load below 50 copies per mL, to have the least risk of transmitting HIV to their baby aside from avoiding breastfeeding altogether, according to a new clinical report from the American Academy of Pediatrics (AAP).

“The risk of HIV transmission via breastfeeding from a parent with HIV who is receiving antiretroviral treatment (ART) and is virally suppressed is estimated to be less than 1%,” Lisa Abuogi, MD, an associate professor of pediatric infectious disease at the University of Colorado Anschutz Medical Campus, and her colleagues wrote in Pediatrics. For people living with HIV in the United States, however, the AAP recommends that “avoidance of breastfeeding is the only infant feeding option with 0% risk of HIV transmission.”

The authors go on to suggest that pediatricians “be prepared to offer a family-centered, nonjudgmental, harm reduction approach” to support people with HIV who do want to breastfeed and have sustained viral suppression. Parents with HIV who are not on ART or who do not have adequate viral suppression should be advised against breastfeeding, the report states. Members of the AAP Committee on Pediatric and Adolescent HIV and of the AAP Section on Breastfeeding coauthored the clinical report.

“The new guidelines emphasize the importance of patient-centered counseling as the foundation for shared decision-making, allowing patients and pediatric providers to make feeding decisions together and for the first time really giving support to people with HIV in the U.S. who want to breastfeed,” Danna Biala, MD, MS, an attending pediatrician at Children’s Hospital at Montefiore and an assistant professor at Albert Einstein College of Medicine, told MDedge News.

Dr. Biala was not involved in the development of the report, but she said the AAP’s guidance reflects the recent shift in the stance of the Centers for Disease Control and Prevention (CDC) regarding breastfeeding among people who are HIV+. Recommendations from the CDC and the U.S. Department of Health and Human Services (HHS) were updated in 2023.

“I’m glad that the AAP is putting out guidelines on infant feeding for people with HIV,” Dr. Biala said. “For so long in the U.S., pediatricians have been advising all mothers with HIV to avoid breastfeeding, believing that the risk of transmission outweighed the benefits of breastfeeding.”

The updated guidance from HHS in 2023 “was revolutionary in supporting people with HIV in low-risk situations who want to breastfeed,” Dr. Biala said, but “clear protocols for monitoring and follow-up were not in place,” which these AAP guidelines help address.
 

Prior Discordance Between Global, U.S. Guidance

An estimated 5,000 people with HIV give birth each year in the United States, and up to one third of pregnant people with HIV may be unaware of their HIV status, the AAP report notes. Pediatric healthcare professionals in the United States therefore need to be aware of recommendations related to HIV testing of pregnant people and of counseling the feeding of infants exposed to HIV. The report recommends opt-out HIV testing at the first prenatal visit and then possibly retesting in the third trimester in areas with high HIV incidence or for people at high risk for HIV or with signs or symptoms of acute HIV infection.

The report also highlights the health benefits of breastfeeding to both the infant and the breastfeeding parent, but notes the CDC’s historical recommendation against breastfeeding for people who are HIV+. The WHO, meanwhile, began recommending in 2016 that infants be breastfed through 12 to 24 months old if the parent was on ART and/or the infant was receiving antiretroviral (ARV) prophylaxis, since research showed those treatments were effective in reducing transmission risk.

Still, an estimated 30% of perinatal HIV transmission occurs via breastfeeding worldwide, primarily from people with HIV who are not on ART or are not adequately virally suppressed. Without parental ART or infant ARV prophylaxis, HIV transmission risk to infants via breastfeeding is highest, about 5%-6%, in the first 4-6 weeks of life. Risk then declines to about 0.9% a month thereafter. The AAP report goes on to describe factors that increase or decrease the likelihood of transmission during breastfeeding, but it notes that neither ART in the breastfeeding person nor ARV prophylaxis in the infant completely eliminates the risk of HIV transmission during breastfeeding. There have been rare cases where transmission occurred despite viral suppression in the person with HIV.

Among the reasons people with HIV have expressed a desire to breastfeed are wanting to bond with their infant, wanting to provide optimal nutrition and health benefits to their baby, and meeting cultural expectations, including the desire not to disclose their HIV infection status to family or friends by virtue of not breastfeeding.

“Among immigrant and refugee populations, the discordance between infant feeding guidelines in the United States and their country of birth may result in confusion, especially among parents who breastfed previous infants,” the AAP report also notes. Further, not breastfeeding could compound health disparities already more likely to be present among those living with HIV.

Discussions about infant feeding with parents with HIV should therefore “begin as early as possible and involve a multidisciplinary team that might include the pediatric primary care provider (once identified), a pediatric HIV expert, the breastfeeding parent’s HIV care and obstetric providers, and lactation consultants,” the report states. ”The parent’s motivations for breastfeeding should be explored and counseling provided on the risks and benefits of each feeding option, including breastfeeding, formula feeding, or certified, banked donor human milk.” The statement emphasizes the need for providing counseling in a “non-judgmental, respectful way, recognizing potential drivers for their decisions such as avoidance of stigma, prior experience with breastfeeding, and cultural contributors.”
 

Clear Recommendations Can Help Providers

The AAP’s statement that “replacement feeding (with formula or certified, banked donor human milk) is the only option that is 100% certain to prevent postnatal transmission of HIV” feels like it takes a “more conservative or discouraging approach” to breastfeeding than the CDC or WHO guidelines, Alissa Parker-Smith, APRN, DNP, CPNP-PC, IBCLC, a nurse practitioner and lactation consultant at PrimaryPlus, a Federally Qualified Health Clinic in Ashland, Kentucky, told MDedge. But she said they do clearly align with the CDC guidelines, and their differences from the WHO guidelines make sense in light of the different populations served by the WHO versus the U.S. agencies.

“Unclean water for formula preparation and a reduced or lack of access to formula in general can lead to many other risks of death for the infant other than the very small risk of HIV infection from breastfeeding from an HIV+ parent,” Ms. Parker-Smith said. “In the U.S. we generally have consistent access to clean water and safe formula as well as social structures to help families have access to formula, so the very small risk of HIV being passed to the infant is far greater than an infant in the U.S. dying as a result of unclean water or formula contamination.”

Ms. Parker-Smith also said the AAP recommendations seem thorough in helping pediatric practitioners counsel and support parents with HIV. “If I had a parent who is HIV+ walk in the door today wanting to breastfeed their infant, the AAP guidelines give me specific steps to make me feel confident in helping that parent breastfeed as safely as possible as well as providing education to assist that parent through the decision process,” she said.

Dr. Biala agreed, noting that the clinical report “very clearly delineates recommendations for different groups of people: those in labor or postpartum with undocumented HIV infection status, pregnant and postpartum people with HIV, those without HIV but at high risk of acquiring it, and those with suspected acute HIV infection while breastfeeding.” Dr. Biala said the report “provides concrete, detailed, and easy-to-follow guidance on comprehensive counseling, strategies to minimize risk of transmission, and infant screening timelines.”

How easily the guidelines can be implemented will depend on the existing resources at different institutions in the United States, Dr. Biala added.

“In hospitals and clinics that have, or could easily have, systems in place to ensure follow-up and regular assessment during breastfeeding, the guidelines could be implemented fairly quickly,” she said. “It might be more challenging in areas with inadequate or limited access to multidisciplinary team members, including HIV care providers and lactation consultants.”

The report did not use external funding, and the authors reported no disclosures. Dr. Abuogi and Ms. Parker-Smith have no disclosures.

New expert guidance to help clinicians manage the treatment of patients with epilepsy during pregnancy has been released.

Issued by the American Academy of Neurology, the American Epilepsy Society, and the Society for Maternal-Fetal Medicine, the new practice guideline covers the use of antiseizure medications (ASMs) and folic acid supplementation before conception and during pregnancy.

“Most children born to people with epilepsy are healthy, but there is a small risk of pregnancy-related problems, partly due to seizures and partly due to the effects of antiseizure medications,” the guidelines’ lead author Alison M. Pack, MD, MPH, professor of neurology and chief of the Epilepsy and Sleep Division, Columbia University, New York City, said in a news release.

“This guideline provides recommendations regarding the effects of antiseizure medications and folic acid supplementation on malformations at birth and the development of children during pregnancy, so that doctors and people with epilepsy can determine which treatments may be best for them,” she added. 

The guideline was published online in Neurology.
 

Why Now? 

The new guideline updates the 2009 guidance on epilepsy management during pregnancy. Since then, Dr. Pack told this news organization, there has been a wealth of new data on differential effects of different ASMs — notably, lamotrigine and levetiracetam — the most commonly prescribed medications in this population.

“In this guideline, we were able to assess differential effects of different ASMs on outcomes of interest, including major congenital malformations [MCMs], perinatal outcomes, and neurodevelopmental outcomes. In addition, we looked at the effect of folic acid supplementation on each of these outcomes,” she said.

The overarching goals of care for patients are to “optimize health outcomes both for individuals and their future offspring,” the authors wrote. Shared decision-making, they add, leads to better decision-making by providing a better understanding of the available treatment options and their potential risks, resulting in enhanced decision-making that aligns with personal values.

Clinicians should recommend ASMs that optimize seizure control and fetal outcomes, in the event of a pregnancy, at the earliest possible preconception time, the guideline authors note.

“Overall, treating clinicians need to balance treating the person with epilepsy to control convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent and the possible risks of certain ASMs on the fetus if pregnancy occurs,” they wrote.

If a patient is already pregnant, the experts recommend that clinicians “exercise caution” in removing or replacing an ASM that controls convulsive seizures, even if it’s “not an optimal choice” for the fetus. 

In addition, they advise that ASM levels should be monitored throughout the pregnancy, guided by individual ASM pharmacokinetics and an individual patient’s clinical presentation. ASM dose, they note, should be adjusted during pregnancy in response to decreasing serum ASM levels or worsening seizure control.

The authors point out that there are limited data on “pregnancy-related outcomes with respect to acetazolamide, eslicarbazepine, ethosuximide, lacosamide, nitrazepam, perampanel, piracetam, pregabalin, rufinamide, stiripentol, tiagabine, and vigabatrin.”

Patients should be informed that the birth prevalence of any major congenital malformation in the general population ranges between 2.4% and 2.9%.
 

If Feasible, Avoid Valproic Acid 

“One of the most important take-home messages is that valproic acid has the highest unadjusted birth prevalence of all major congenital malformations — 9.7% — and the highest unadjusted birth prevalence of neural tube defects at 1.4%,” Dr. Pack said. As a result, the guideline authors advise against using valproic acid, if clinically feasible.

Valproic acid also has the highest prevalence of negative neurodevelopmental outcomes, including a reduction in global IQ and an increased prevalence of autism spectrum disorder (ASD). Patients should be counseled accordingly and advised of the increased risk for ASD and decreased IQ resulting from valproic acid.

Clinicians should consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate. Serum concentrations of most ASMs have a “defined therapeutic window” for effective seizure control and that concentration may decrease during pregnancy, particularly with lamotrigine and levetiracetam, the authors note.

Phenobarbital, topiramate, and valproic acid should because of the increased risk for cardiac malformations, oral clefts, and urogenital and renal malformations.

Fetal screening for major congenital malformations is recommended to enable early detection and timely intervention in patients treated with any ASM during pregnancy Patients receiving phenobarbital during pregnancy should also undergo fetal cardiac screenings.

Valproic acid and topiramate are also associated with children who are small for their gestational age. To enable early identification of fetal growth restriction, patients taking valproic acid or topiramate should be monitored. In addition, children exposed to these medications in utero should be monitored during childhood to ensure they are meeting age-appropriate developmental milestones. 

Folic acid taken during pregnancy can reduce the prevalence of negative neurodevelopment outcomes, but not major congenital malformations, Dr. Pack noted. 

“Due to limited available data, we were unable to define an optimal dose of folic acid supplementation beyond at least 0.4 mg/d,” Dr. Pack said. “Future studies, preferably randomized clinical trials, are needed to better define the optimal dose.”

She emphasized that epilepsy is one of the most common neurologic disorders, and 1 in 5 of those affected are people of childbearing potential. Understanding the effects of ASMs on pregnancy outcomes is critical for physicians who manage these patients.
 

Uncertainty Remains 

Commenting for this news organization, Kimford Meador, MD, a professor in the Department of Neurology and Neurological Sciences at Stanford University School of Medicine , Stanford Neuroscience Health Center, Palo Alto, California, noted that the new guidelines reflect the gains in knowledge since 2009 and that the recommendations are “reasonable, based on available data.”

However, “one very important point is how much remains unknown,” said Dr. Meador, who was not involved in writing the current guideline. “Many ASMs have no data, and several have estimates based on small samples or a single observational study.” Thus, “the risks for the majority of ASMs are uncertain.”

Given that randomized trials “are not possible in this population, and that all observational studies are subject to residual confounding, a reliable signal across multiple studies in humans is required to be certain of findings,” he stated.

This practice guideline was developed with financial support from the American Academy of Neurology. Dr. Pack serves on the editorial board for the journal Epilepsy Currents, receives royalties from UpToDate, receives funding from the National Institutes of Health for serving as coinvestigator and site principal investigator for the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, and receives funding from Bayer for serving as a co-investigator on a study on women with epilepsy initiating a progestin intrauterine device. One of Dr. Pack’s immediate family members has received personal compensation for serving as an employee of REGENEXBIO. The other authors’ disclosures are listed on the original paper. Dr. Meador has received research support from the National Institutes of Health, Veterans Administration, Eisai, Inc, and Suno Medtronic Navigation, Inc, and the Epilepsy Study Consortium pays Dr. Meador’s university for his research on the Human Epilepsy Project and consultant time related to Eisai, UCB Pharma, and Xenon.

A version of this article first appeared on Medscape.com.

New expert guidance to help clinicians manage the treatment of patients with epilepsy during pregnancy has been released.

Issued by the American Academy of Neurology, the American Epilepsy Society, and the Society for Maternal-Fetal Medicine, the new practice guideline covers the use of antiseizure medications (ASMs) and folic acid supplementation before conception and during pregnancy.

“Most children born to people with epilepsy are healthy, but there is a small risk of pregnancy-related problems, partly due to seizures and partly due to the effects of antiseizure medications,” the guidelines’ lead author Alison M. Pack, MD, MPH, professor of neurology and chief of the Epilepsy and Sleep Division, Columbia University, New York City, said in a news release.

“This guideline provides recommendations regarding the effects of antiseizure medications and folic acid supplementation on malformations at birth and the development of children during pregnancy, so that doctors and people with epilepsy can determine which treatments may be best for them,” she added. 

The guideline was published online in Neurology.
 

Why Now? 

The new guideline updates the 2009 guidance on epilepsy management during pregnancy. Since then, Dr. Pack told this news organization, there has been a wealth of new data on differential effects of different ASMs — notably, lamotrigine and levetiracetam — the most commonly prescribed medications in this population.

“In this guideline, we were able to assess differential effects of different ASMs on outcomes of interest, including major congenital malformations [MCMs], perinatal outcomes, and neurodevelopmental outcomes. In addition, we looked at the effect of folic acid supplementation on each of these outcomes,” she said.

The overarching goals of care for patients are to “optimize health outcomes both for individuals and their future offspring,” the authors wrote. Shared decision-making, they add, leads to better decision-making by providing a better understanding of the available treatment options and their potential risks, resulting in enhanced decision-making that aligns with personal values.

Clinicians should recommend ASMs that optimize seizure control and fetal outcomes, in the event of a pregnancy, at the earliest possible preconception time, the guideline authors note.

“Overall, treating clinicians need to balance treating the person with epilepsy to control convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent and the possible risks of certain ASMs on the fetus if pregnancy occurs,” they wrote.

If a patient is already pregnant, the experts recommend that clinicians “exercise caution” in removing or replacing an ASM that controls convulsive seizures, even if it’s “not an optimal choice” for the fetus. 

In addition, they advise that ASM levels should be monitored throughout the pregnancy, guided by individual ASM pharmacokinetics and an individual patient’s clinical presentation. ASM dose, they note, should be adjusted during pregnancy in response to decreasing serum ASM levels or worsening seizure control.

The authors point out that there are limited data on “pregnancy-related outcomes with respect to acetazolamide, eslicarbazepine, ethosuximide, lacosamide, nitrazepam, perampanel, piracetam, pregabalin, rufinamide, stiripentol, tiagabine, and vigabatrin.”

Patients should be informed that the birth prevalence of any major congenital malformation in the general population ranges between 2.4% and 2.9%.
 

If Feasible, Avoid Valproic Acid 

“One of the most important take-home messages is that valproic acid has the highest unadjusted birth prevalence of all major congenital malformations — 9.7% — and the highest unadjusted birth prevalence of neural tube defects at 1.4%,” Dr. Pack said. As a result, the guideline authors advise against using valproic acid, if clinically feasible.

Valproic acid also has the highest prevalence of negative neurodevelopmental outcomes, including a reduction in global IQ and an increased prevalence of autism spectrum disorder (ASD). Patients should be counseled accordingly and advised of the increased risk for ASD and decreased IQ resulting from valproic acid.

Clinicians should consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate. Serum concentrations of most ASMs have a “defined therapeutic window” for effective seizure control and that concentration may decrease during pregnancy, particularly with lamotrigine and levetiracetam, the authors note.

Phenobarbital, topiramate, and valproic acid should because of the increased risk for cardiac malformations, oral clefts, and urogenital and renal malformations.

Fetal screening for major congenital malformations is recommended to enable early detection and timely intervention in patients treated with any ASM during pregnancy Patients receiving phenobarbital during pregnancy should also undergo fetal cardiac screenings.

Valproic acid and topiramate are also associated with children who are small for their gestational age. To enable early identification of fetal growth restriction, patients taking valproic acid or topiramate should be monitored. In addition, children exposed to these medications in utero should be monitored during childhood to ensure they are meeting age-appropriate developmental milestones. 

Folic acid taken during pregnancy can reduce the prevalence of negative neurodevelopment outcomes, but not major congenital malformations, Dr. Pack noted. 

“Due to limited available data, we were unable to define an optimal dose of folic acid supplementation beyond at least 0.4 mg/d,” Dr. Pack said. “Future studies, preferably randomized clinical trials, are needed to better define the optimal dose.”

She emphasized that epilepsy is one of the most common neurologic disorders, and 1 in 5 of those affected are people of childbearing potential. Understanding the effects of ASMs on pregnancy outcomes is critical for physicians who manage these patients.
 

Uncertainty Remains 

Commenting for this news organization, Kimford Meador, MD, a professor in the Department of Neurology and Neurological Sciences at Stanford University School of Medicine , Stanford Neuroscience Health Center, Palo Alto, California, noted that the new guidelines reflect the gains in knowledge since 2009 and that the recommendations are “reasonable, based on available data.”

However, “one very important point is how much remains unknown,” said Dr. Meador, who was not involved in writing the current guideline. “Many ASMs have no data, and several have estimates based on small samples or a single observational study.” Thus, “the risks for the majority of ASMs are uncertain.”

Given that randomized trials “are not possible in this population, and that all observational studies are subject to residual confounding, a reliable signal across multiple studies in humans is required to be certain of findings,” he stated.

This practice guideline was developed with financial support from the American Academy of Neurology. Dr. Pack serves on the editorial board for the journal Epilepsy Currents, receives royalties from UpToDate, receives funding from the National Institutes of Health for serving as coinvestigator and site principal investigator for the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, and receives funding from Bayer for serving as a co-investigator on a study on women with epilepsy initiating a progestin intrauterine device. One of Dr. Pack’s immediate family members has received personal compensation for serving as an employee of REGENEXBIO. The other authors’ disclosures are listed on the original paper. Dr. Meador has received research support from the National Institutes of Health, Veterans Administration, Eisai, Inc, and Suno Medtronic Navigation, Inc, and the Epilepsy Study Consortium pays Dr. Meador’s university for his research on the Human Epilepsy Project and consultant time related to Eisai, UCB Pharma, and Xenon.

A version of this article first appeared on Medscape.com.

New expert guidance to help clinicians manage the treatment of patients with epilepsy during pregnancy has been released.

Issued by the American Academy of Neurology, the American Epilepsy Society, and the Society for Maternal-Fetal Medicine, the new practice guideline covers the use of antiseizure medications (ASMs) and folic acid supplementation before conception and during pregnancy.

“Most children born to people with epilepsy are healthy, but there is a small risk of pregnancy-related problems, partly due to seizures and partly due to the effects of antiseizure medications,” the guidelines’ lead author Alison M. Pack, MD, MPH, professor of neurology and chief of the Epilepsy and Sleep Division, Columbia University, New York City, said in a news release.

“This guideline provides recommendations regarding the effects of antiseizure medications and folic acid supplementation on malformations at birth and the development of children during pregnancy, so that doctors and people with epilepsy can determine which treatments may be best for them,” she added. 

The guideline was published online in Neurology.
 

Why Now? 

The new guideline updates the 2009 guidance on epilepsy management during pregnancy. Since then, Dr. Pack told this news organization, there has been a wealth of new data on differential effects of different ASMs — notably, lamotrigine and levetiracetam — the most commonly prescribed medications in this population.

“In this guideline, we were able to assess differential effects of different ASMs on outcomes of interest, including major congenital malformations [MCMs], perinatal outcomes, and neurodevelopmental outcomes. In addition, we looked at the effect of folic acid supplementation on each of these outcomes,” she said.

The overarching goals of care for patients are to “optimize health outcomes both for individuals and their future offspring,” the authors wrote. Shared decision-making, they add, leads to better decision-making by providing a better understanding of the available treatment options and their potential risks, resulting in enhanced decision-making that aligns with personal values.

Clinicians should recommend ASMs that optimize seizure control and fetal outcomes, in the event of a pregnancy, at the earliest possible preconception time, the guideline authors note.

“Overall, treating clinicians need to balance treating the person with epilepsy to control convulsive seizures (generalized tonic-clonic seizures and focal-to-bilateral tonic-clonic seizures) to minimize potential risks to the birth parent and the possible risks of certain ASMs on the fetus if pregnancy occurs,” they wrote.

If a patient is already pregnant, the experts recommend that clinicians “exercise caution” in removing or replacing an ASM that controls convulsive seizures, even if it’s “not an optimal choice” for the fetus. 

In addition, they advise that ASM levels should be monitored throughout the pregnancy, guided by individual ASM pharmacokinetics and an individual patient’s clinical presentation. ASM dose, they note, should be adjusted during pregnancy in response to decreasing serum ASM levels or worsening seizure control.

The authors point out that there are limited data on “pregnancy-related outcomes with respect to acetazolamide, eslicarbazepine, ethosuximide, lacosamide, nitrazepam, perampanel, piracetam, pregabalin, rufinamide, stiripentol, tiagabine, and vigabatrin.”

Patients should be informed that the birth prevalence of any major congenital malformation in the general population ranges between 2.4% and 2.9%.
 

If Feasible, Avoid Valproic Acid 

“One of the most important take-home messages is that valproic acid has the highest unadjusted birth prevalence of all major congenital malformations — 9.7% — and the highest unadjusted birth prevalence of neural tube defects at 1.4%,” Dr. Pack said. As a result, the guideline authors advise against using valproic acid, if clinically feasible.

Valproic acid also has the highest prevalence of negative neurodevelopmental outcomes, including a reduction in global IQ and an increased prevalence of autism spectrum disorder (ASD). Patients should be counseled accordingly and advised of the increased risk for ASD and decreased IQ resulting from valproic acid.

Clinicians should consider using lamotrigine, levetiracetam, or oxcarbazepine when appropriate. Serum concentrations of most ASMs have a “defined therapeutic window” for effective seizure control and that concentration may decrease during pregnancy, particularly with lamotrigine and levetiracetam, the authors note.

Phenobarbital, topiramate, and valproic acid should because of the increased risk for cardiac malformations, oral clefts, and urogenital and renal malformations.

Fetal screening for major congenital malformations is recommended to enable early detection and timely intervention in patients treated with any ASM during pregnancy Patients receiving phenobarbital during pregnancy should also undergo fetal cardiac screenings.

Valproic acid and topiramate are also associated with children who are small for their gestational age. To enable early identification of fetal growth restriction, patients taking valproic acid or topiramate should be monitored. In addition, children exposed to these medications in utero should be monitored during childhood to ensure they are meeting age-appropriate developmental milestones. 

Folic acid taken during pregnancy can reduce the prevalence of negative neurodevelopment outcomes, but not major congenital malformations, Dr. Pack noted. 

“Due to limited available data, we were unable to define an optimal dose of folic acid supplementation beyond at least 0.4 mg/d,” Dr. Pack said. “Future studies, preferably randomized clinical trials, are needed to better define the optimal dose.”

She emphasized that epilepsy is one of the most common neurologic disorders, and 1 in 5 of those affected are people of childbearing potential. Understanding the effects of ASMs on pregnancy outcomes is critical for physicians who manage these patients.
 

Uncertainty Remains 

Commenting for this news organization, Kimford Meador, MD, a professor in the Department of Neurology and Neurological Sciences at Stanford University School of Medicine , Stanford Neuroscience Health Center, Palo Alto, California, noted that the new guidelines reflect the gains in knowledge since 2009 and that the recommendations are “reasonable, based on available data.”

However, “one very important point is how much remains unknown,” said Dr. Meador, who was not involved in writing the current guideline. “Many ASMs have no data, and several have estimates based on small samples or a single observational study.” Thus, “the risks for the majority of ASMs are uncertain.”

Given that randomized trials “are not possible in this population, and that all observational studies are subject to residual confounding, a reliable signal across multiple studies in humans is required to be certain of findings,” he stated.

This practice guideline was developed with financial support from the American Academy of Neurology. Dr. Pack serves on the editorial board for the journal Epilepsy Currents, receives royalties from UpToDate, receives funding from the National Institutes of Health for serving as coinvestigator and site principal investigator for the Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs (MONEAD) study, and receives funding from Bayer for serving as a co-investigator on a study on women with epilepsy initiating a progestin intrauterine device. One of Dr. Pack’s immediate family members has received personal compensation for serving as an employee of REGENEXBIO. The other authors’ disclosures are listed on the original paper. Dr. Meador has received research support from the National Institutes of Health, Veterans Administration, Eisai, Inc, and Suno Medtronic Navigation, Inc, and the Epilepsy Study Consortium pays Dr. Meador’s university for his research on the Human Epilepsy Project and consultant time related to Eisai, UCB Pharma, and Xenon.

A version of this article first appeared on Medscape.com.

SAN FRANCISCO — Discussion of gestational weight gain occurred in only half of first-time obstetric visits, most often brought up by the provider, according to data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Weight can be a challenging and sensitive topic at a healthcare visit,” Malini Harinath, an undergraduate research assistant at Magee-Women’s Research Institute at University of Pittsburgh Medical Center, told attendees. “Providers discussed weight gain recommendations in less than half of conversations.”

The researchers analyzed an existing dataset of audio-recorded first obstetric visits to find out how often gestational weight gain was brought up, who initiated the discussion, whether ACOG guidelines were discussed, and what the provider’s comments were.

Among 150 visits, half (50%) involved discussion of weight, with patients bringing it up 24% of the time and providers bringing it up 72% of the time. In the other 3% of visits, it was brought up by a third party, such as a partner or other family member with the patient.

Only two of those visits mentioned body mass index (BMI) specifically, and ACOG guidelines on gestational weight gain were brought up in only six visits (8% of the visits where weight was mentioned). However, mention of recommendations on gestational weight gain was more frequent, coming up in nearly half (46.7%) of the visits where weight was mentioned, though that was still just 23% of all visits.

Concern about weight was brought up in 25.3% of visits where weight was discussed, and the provider’s reassurance to the patient occurred in about a third (32%) of those visits. General comments about the patient’s body occurred in 16% of visits, such as a clinician saying, “Usually we start trying [to find the heartbeat] at about 15 weeks, but you are so skinny we might be able to find it now.”

Ms. Harinath intends to look in future research at whether patient race or BMI are associated with the frequency and content of gestational weight gain conversations and to explore how patients react to different ways that discussion of weight is brought up.

Katherine Kaak, MD, a second-year resident at the University of Tennessee Graduate School of Medicine in Knoxville, was surprised that weight was brought up in only half of the visits. “The clinical takeaway is just how important counseling in the prenatal time is and how a lot of this discussion is preventive medicine,” Dr. Kaak said. “Even though we think of those visits as being quick, it’s good to keep in mind that we need to really take our time and make sure we counsel the patient as best we can.”

There’s a fair amount of research suggesting that existing recommendations on gestational weight gain are not very good because they’re very generic, Jill Maples, PhD, associate professor of ob.gyn. research at the University of Tennessee Graduate School of Medicine, said in an interview. For example, the guidelines are generally the same for everyone with a BMI over 30, but a person with a BMI of 30 is very different from someone with a BMI of 50, she said.

“There’s not even a lot of clarity on what is appropriate weight gain for that group because some people have seen good outcomes on the lower end of gestational weight gain,” Dr. Maples said. She said it’s important that clinicians not forget about the importance of these discussions, however, because lifestyle habits and gestational weight gain are related to maternal and neonatal outcomes.

The authors, Dr. Kaak, and Dr. Maples had no disclosures. The research was funded by the National Institute on Drug Abuse.

SAN FRANCISCO — Discussion of gestational weight gain occurred in only half of first-time obstetric visits, most often brought up by the provider, according to data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Weight can be a challenging and sensitive topic at a healthcare visit,” Malini Harinath, an undergraduate research assistant at Magee-Women’s Research Institute at University of Pittsburgh Medical Center, told attendees. “Providers discussed weight gain recommendations in less than half of conversations.”

The researchers analyzed an existing dataset of audio-recorded first obstetric visits to find out how often gestational weight gain was brought up, who initiated the discussion, whether ACOG guidelines were discussed, and what the provider’s comments were.

Among 150 visits, half (50%) involved discussion of weight, with patients bringing it up 24% of the time and providers bringing it up 72% of the time. In the other 3% of visits, it was brought up by a third party, such as a partner or other family member with the patient.

Only two of those visits mentioned body mass index (BMI) specifically, and ACOG guidelines on gestational weight gain were brought up in only six visits (8% of the visits where weight was mentioned). However, mention of recommendations on gestational weight gain was more frequent, coming up in nearly half (46.7%) of the visits where weight was mentioned, though that was still just 23% of all visits.

Concern about weight was brought up in 25.3% of visits where weight was discussed, and the provider’s reassurance to the patient occurred in about a third (32%) of those visits. General comments about the patient’s body occurred in 16% of visits, such as a clinician saying, “Usually we start trying [to find the heartbeat] at about 15 weeks, but you are so skinny we might be able to find it now.”

Ms. Harinath intends to look in future research at whether patient race or BMI are associated with the frequency and content of gestational weight gain conversations and to explore how patients react to different ways that discussion of weight is brought up.

Katherine Kaak, MD, a second-year resident at the University of Tennessee Graduate School of Medicine in Knoxville, was surprised that weight was brought up in only half of the visits. “The clinical takeaway is just how important counseling in the prenatal time is and how a lot of this discussion is preventive medicine,” Dr. Kaak said. “Even though we think of those visits as being quick, it’s good to keep in mind that we need to really take our time and make sure we counsel the patient as best we can.”

There’s a fair amount of research suggesting that existing recommendations on gestational weight gain are not very good because they’re very generic, Jill Maples, PhD, associate professor of ob.gyn. research at the University of Tennessee Graduate School of Medicine, said in an interview. For example, the guidelines are generally the same for everyone with a BMI over 30, but a person with a BMI of 30 is very different from someone with a BMI of 50, she said.

“There’s not even a lot of clarity on what is appropriate weight gain for that group because some people have seen good outcomes on the lower end of gestational weight gain,” Dr. Maples said. She said it’s important that clinicians not forget about the importance of these discussions, however, because lifestyle habits and gestational weight gain are related to maternal and neonatal outcomes.

The authors, Dr. Kaak, and Dr. Maples had no disclosures. The research was funded by the National Institute on Drug Abuse.

SAN FRANCISCO — Discussion of gestational weight gain occurred in only half of first-time obstetric visits, most often brought up by the provider, according to data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

“Weight can be a challenging and sensitive topic at a healthcare visit,” Malini Harinath, an undergraduate research assistant at Magee-Women’s Research Institute at University of Pittsburgh Medical Center, told attendees. “Providers discussed weight gain recommendations in less than half of conversations.”

The researchers analyzed an existing dataset of audio-recorded first obstetric visits to find out how often gestational weight gain was brought up, who initiated the discussion, whether ACOG guidelines were discussed, and what the provider’s comments were.

Among 150 visits, half (50%) involved discussion of weight, with patients bringing it up 24% of the time and providers bringing it up 72% of the time. In the other 3% of visits, it was brought up by a third party, such as a partner or other family member with the patient.

Only two of those visits mentioned body mass index (BMI) specifically, and ACOG guidelines on gestational weight gain were brought up in only six visits (8% of the visits where weight was mentioned). However, mention of recommendations on gestational weight gain was more frequent, coming up in nearly half (46.7%) of the visits where weight was mentioned, though that was still just 23% of all visits.

Concern about weight was brought up in 25.3% of visits where weight was discussed, and the provider’s reassurance to the patient occurred in about a third (32%) of those visits. General comments about the patient’s body occurred in 16% of visits, such as a clinician saying, “Usually we start trying [to find the heartbeat] at about 15 weeks, but you are so skinny we might be able to find it now.”

Ms. Harinath intends to look in future research at whether patient race or BMI are associated with the frequency and content of gestational weight gain conversations and to explore how patients react to different ways that discussion of weight is brought up.

Katherine Kaak, MD, a second-year resident at the University of Tennessee Graduate School of Medicine in Knoxville, was surprised that weight was brought up in only half of the visits. “The clinical takeaway is just how important counseling in the prenatal time is and how a lot of this discussion is preventive medicine,” Dr. Kaak said. “Even though we think of those visits as being quick, it’s good to keep in mind that we need to really take our time and make sure we counsel the patient as best we can.”

There’s a fair amount of research suggesting that existing recommendations on gestational weight gain are not very good because they’re very generic, Jill Maples, PhD, associate professor of ob.gyn. research at the University of Tennessee Graduate School of Medicine, said in an interview. For example, the guidelines are generally the same for everyone with a BMI over 30, but a person with a BMI of 30 is very different from someone with a BMI of 50, she said.

“There’s not even a lot of clarity on what is appropriate weight gain for that group because some people have seen good outcomes on the lower end of gestational weight gain,” Dr. Maples said. She said it’s important that clinicians not forget about the importance of these discussions, however, because lifestyle habits and gestational weight gain are related to maternal and neonatal outcomes.

The authors, Dr. Kaak, and Dr. Maples had no disclosures. The research was funded by the National Institute on Drug Abuse.

SAN FRANCISCO — Women who used marijuana during pregnancy were significantly less likely to view it as risky even in a state where it was not legalized, according to prospectively collected data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. But most of those women had not received any counseling about stopping its use, and more than half wanted more information about its effects on pregnancy complications.

“The biggest thing we recognized was that our counseling in prenatal visits was lower than what it really should have been,” Abigail M. Ramseyer, DO, of University of Michigan Health– Sparrow in Lansing, said in an interview. She said doctors really need to be asking their patients about marijuana use and having a conversation about the risks of its use during pregnancy.

An estimated 3%-30% of pregnant women use marijuana, depending on the population, but prevalence has been rising as more states legalize its use. Yet research has shown an association between marijuana use during pregnancy and multiple neonatal complications, including fetal growth restriction and low birth weight.

Pregnant women at a single center in Arkansas were invited during their prenatal visits to complete a 35-question, anonymous survey electronically or on paper. Of the 460 approached, 88.7% completed the survey and 11.8% of those women reported use of marijuana during pregnancy. Among those who used it while pregnant, 50% reported using it 2-3 times a week, 27% reported using it once weekly, and 18.8% reported using it daily.

The women who used it while pregnant were less likely to have a college degree and half (50%) were aged 18-24, with use declining with increasing age. A third of those who use it were White (33.3%), 52.1% were Black, and 6.3% were Hispanic.

More than half of the women (52.7%) who used marijuana during pregnancy reported that there had not been any discussion about substance use during pregnancy at the prenatal visit, and 82.4% said they had not received any counseling about stopping its use during pregnancy. Yet 54% of them wanted more information about pregnancy complications linked to cannabis use.

The other questions asked respondents on a 5-point Likert scale how much they agreed or disagreed with various statements related to perceptions of marijuana, its use during pregnancy, and its risks.

Most respondents strongly agreed that “marijuana isn’t as bad as other drugs like heroin, cocaine or meth,” but average agreement was higher among those who used marijuana (4.88) than who didn’t (4.02, P < .001).

Respondents largely neither agreed nor disagreed with its being okay to use marijuana during pregnancy with a prescription, but agreement was still higher among those who used it (3.68) than didn’t use it (2.82, P < .001). Those who used marijuana were more likely to agree that it’s “a natural substance and not a drug” (4.67 vs. 3.38, P < .001); to believe “marijuana has minimal health risks during and outside of pregnancy” (4.15 vs. 2.96, P < .001); and to believe “marijuana has less risk for treating symptoms in pregnancy than prescription medication from my provider” (4.19 vs. 3.01, P < .001).

It was not surprising that patients using marijuana would have more favorable opinions toward legalizing it, Dr. Ramseyer said, but it was interesting that the respondents’ attitude overall, regardless of use, was positive in a fairly conservative state where it was still illegal. She said her research group has data they are starting to analyze about the perceptions of patients’ partners and family members regarding marijuana use during pregnancy.

Animesh Upadhyay, MD, a resident at Yale–New Haven Medical Center in Connecticut, was also surprised by how positive the attitudes toward marijuana use and legalization were in a state where it’s illegal.

“The thing that disturbs me is that nobody has spoken about the risks of marijuana in pregnancy” to many of the respondents, said Dr. Upadhyay, who was not involved in the study. Based on the findings, Dr. Upadhyay said he would definitely begin asking patients more about their use of marijuana and their beliefs about it.

In a separate poster, Sarah Dzubay, BS, of Oregon Health & Science University, Portland, presented data examining potential associations between cannabis use and fertility. Previous research has suggested an association, but the cross-sectional analysis by Ms. Dzubay identified only a nonsignificant trend toward an association.

The researchers analyzed data from the 2013-2018 National Health and Nutrition Examination Study (NHANES) for woman aged 20-49 based on self-reported use of cannabis. Among 3166 women, 51% reported never using cannabis, 29% reported irregular use, and 20% reported regular use at least monthly.

“Women reporting regular use were younger, of lower income and educational attainment, and more likely to be single,” Ms. Dzubay reported. Those reporting irregular use, meanwhile, were more likely to be college graduates.

More of the women who used cannabis regularly (15.4%) reported an inability to conceive within one year than women who used cannabis irregularly (10.8%) or never (12.6%). The higher odds ratio of infertility among those using cannabis regularly (OR 1.47) compared to never using it was not statistically significant, however, nor was the reduced odds ratio among those using it irregularly (OR 0.83).

Because the results were not significant, the possibility of a link to infertility is “something to keep in mind,” Ms. Dzubay said, but “a lot more data has to be collected about this question before we can definitively say there’s a risk.”

The authors and Dr. Upadhyay had no disclosures. Neither study noted any external funding.

SAN FRANCISCO — Women who used marijuana during pregnancy were significantly less likely to view it as risky even in a state where it was not legalized, according to prospectively collected data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. But most of those women had not received any counseling about stopping its use, and more than half wanted more information about its effects on pregnancy complications.

“The biggest thing we recognized was that our counseling in prenatal visits was lower than what it really should have been,” Abigail M. Ramseyer, DO, of University of Michigan Health– Sparrow in Lansing, said in an interview. She said doctors really need to be asking their patients about marijuana use and having a conversation about the risks of its use during pregnancy.

An estimated 3%-30% of pregnant women use marijuana, depending on the population, but prevalence has been rising as more states legalize its use. Yet research has shown an association between marijuana use during pregnancy and multiple neonatal complications, including fetal growth restriction and low birth weight.

Pregnant women at a single center in Arkansas were invited during their prenatal visits to complete a 35-question, anonymous survey electronically or on paper. Of the 460 approached, 88.7% completed the survey and 11.8% of those women reported use of marijuana during pregnancy. Among those who used it while pregnant, 50% reported using it 2-3 times a week, 27% reported using it once weekly, and 18.8% reported using it daily.

The women who used it while pregnant were less likely to have a college degree and half (50%) were aged 18-24, with use declining with increasing age. A third of those who use it were White (33.3%), 52.1% were Black, and 6.3% were Hispanic.

More than half of the women (52.7%) who used marijuana during pregnancy reported that there had not been any discussion about substance use during pregnancy at the prenatal visit, and 82.4% said they had not received any counseling about stopping its use during pregnancy. Yet 54% of them wanted more information about pregnancy complications linked to cannabis use.

The other questions asked respondents on a 5-point Likert scale how much they agreed or disagreed with various statements related to perceptions of marijuana, its use during pregnancy, and its risks.

Most respondents strongly agreed that “marijuana isn’t as bad as other drugs like heroin, cocaine or meth,” but average agreement was higher among those who used marijuana (4.88) than who didn’t (4.02, P < .001).

Respondents largely neither agreed nor disagreed with its being okay to use marijuana during pregnancy with a prescription, but agreement was still higher among those who used it (3.68) than didn’t use it (2.82, P < .001). Those who used marijuana were more likely to agree that it’s “a natural substance and not a drug” (4.67 vs. 3.38, P < .001); to believe “marijuana has minimal health risks during and outside of pregnancy” (4.15 vs. 2.96, P < .001); and to believe “marijuana has less risk for treating symptoms in pregnancy than prescription medication from my provider” (4.19 vs. 3.01, P < .001).

It was not surprising that patients using marijuana would have more favorable opinions toward legalizing it, Dr. Ramseyer said, but it was interesting that the respondents’ attitude overall, regardless of use, was positive in a fairly conservative state where it was still illegal. She said her research group has data they are starting to analyze about the perceptions of patients’ partners and family members regarding marijuana use during pregnancy.

Animesh Upadhyay, MD, a resident at Yale–New Haven Medical Center in Connecticut, was also surprised by how positive the attitudes toward marijuana use and legalization were in a state where it’s illegal.

“The thing that disturbs me is that nobody has spoken about the risks of marijuana in pregnancy” to many of the respondents, said Dr. Upadhyay, who was not involved in the study. Based on the findings, Dr. Upadhyay said he would definitely begin asking patients more about their use of marijuana and their beliefs about it.

In a separate poster, Sarah Dzubay, BS, of Oregon Health & Science University, Portland, presented data examining potential associations between cannabis use and fertility. Previous research has suggested an association, but the cross-sectional analysis by Ms. Dzubay identified only a nonsignificant trend toward an association.

The researchers analyzed data from the 2013-2018 National Health and Nutrition Examination Study (NHANES) for woman aged 20-49 based on self-reported use of cannabis. Among 3166 women, 51% reported never using cannabis, 29% reported irregular use, and 20% reported regular use at least monthly.

“Women reporting regular use were younger, of lower income and educational attainment, and more likely to be single,” Ms. Dzubay reported. Those reporting irregular use, meanwhile, were more likely to be college graduates.

More of the women who used cannabis regularly (15.4%) reported an inability to conceive within one year than women who used cannabis irregularly (10.8%) or never (12.6%). The higher odds ratio of infertility among those using cannabis regularly (OR 1.47) compared to never using it was not statistically significant, however, nor was the reduced odds ratio among those using it irregularly (OR 0.83).

Because the results were not significant, the possibility of a link to infertility is “something to keep in mind,” Ms. Dzubay said, but “a lot more data has to be collected about this question before we can definitively say there’s a risk.”

The authors and Dr. Upadhyay had no disclosures. Neither study noted any external funding.

SAN FRANCISCO — Women who used marijuana during pregnancy were significantly less likely to view it as risky even in a state where it was not legalized, according to prospectively collected data presented at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists. But most of those women had not received any counseling about stopping its use, and more than half wanted more information about its effects on pregnancy complications.

“The biggest thing we recognized was that our counseling in prenatal visits was lower than what it really should have been,” Abigail M. Ramseyer, DO, of University of Michigan Health– Sparrow in Lansing, said in an interview. She said doctors really need to be asking their patients about marijuana use and having a conversation about the risks of its use during pregnancy.

An estimated 3%-30% of pregnant women use marijuana, depending on the population, but prevalence has been rising as more states legalize its use. Yet research has shown an association between marijuana use during pregnancy and multiple neonatal complications, including fetal growth restriction and low birth weight.

Pregnant women at a single center in Arkansas were invited during their prenatal visits to complete a 35-question, anonymous survey electronically or on paper. Of the 460 approached, 88.7% completed the survey and 11.8% of those women reported use of marijuana during pregnancy. Among those who used it while pregnant, 50% reported using it 2-3 times a week, 27% reported using it once weekly, and 18.8% reported using it daily.

The women who used it while pregnant were less likely to have a college degree and half (50%) were aged 18-24, with use declining with increasing age. A third of those who use it were White (33.3%), 52.1% were Black, and 6.3% were Hispanic.

More than half of the women (52.7%) who used marijuana during pregnancy reported that there had not been any discussion about substance use during pregnancy at the prenatal visit, and 82.4% said they had not received any counseling about stopping its use during pregnancy. Yet 54% of them wanted more information about pregnancy complications linked to cannabis use.

The other questions asked respondents on a 5-point Likert scale how much they agreed or disagreed with various statements related to perceptions of marijuana, its use during pregnancy, and its risks.

Most respondents strongly agreed that “marijuana isn’t as bad as other drugs like heroin, cocaine or meth,” but average agreement was higher among those who used marijuana (4.88) than who didn’t (4.02, P < .001).

Respondents largely neither agreed nor disagreed with its being okay to use marijuana during pregnancy with a prescription, but agreement was still higher among those who used it (3.68) than didn’t use it (2.82, P < .001). Those who used marijuana were more likely to agree that it’s “a natural substance and not a drug” (4.67 vs. 3.38, P < .001); to believe “marijuana has minimal health risks during and outside of pregnancy” (4.15 vs. 2.96, P < .001); and to believe “marijuana has less risk for treating symptoms in pregnancy than prescription medication from my provider” (4.19 vs. 3.01, P < .001).

It was not surprising that patients using marijuana would have more favorable opinions toward legalizing it, Dr. Ramseyer said, but it was interesting that the respondents’ attitude overall, regardless of use, was positive in a fairly conservative state where it was still illegal. She said her research group has data they are starting to analyze about the perceptions of patients’ partners and family members regarding marijuana use during pregnancy.

Animesh Upadhyay, MD, a resident at Yale–New Haven Medical Center in Connecticut, was also surprised by how positive the attitudes toward marijuana use and legalization were in a state where it’s illegal.

“The thing that disturbs me is that nobody has spoken about the risks of marijuana in pregnancy” to many of the respondents, said Dr. Upadhyay, who was not involved in the study. Based on the findings, Dr. Upadhyay said he would definitely begin asking patients more about their use of marijuana and their beliefs about it.

In a separate poster, Sarah Dzubay, BS, of Oregon Health & Science University, Portland, presented data examining potential associations between cannabis use and fertility. Previous research has suggested an association, but the cross-sectional analysis by Ms. Dzubay identified only a nonsignificant trend toward an association.

The researchers analyzed data from the 2013-2018 National Health and Nutrition Examination Study (NHANES) for woman aged 20-49 based on self-reported use of cannabis. Among 3166 women, 51% reported never using cannabis, 29% reported irregular use, and 20% reported regular use at least monthly.

“Women reporting regular use were younger, of lower income and educational attainment, and more likely to be single,” Ms. Dzubay reported. Those reporting irregular use, meanwhile, were more likely to be college graduates.

More of the women who used cannabis regularly (15.4%) reported an inability to conceive within one year than women who used cannabis irregularly (10.8%) or never (12.6%). The higher odds ratio of infertility among those using cannabis regularly (OR 1.47) compared to never using it was not statistically significant, however, nor was the reduced odds ratio among those using it irregularly (OR 0.83).

Because the results were not significant, the possibility of a link to infertility is “something to keep in mind,” Ms. Dzubay said, but “a lot more data has to be collected about this question before we can definitively say there’s a risk.”

The authors and Dr. Upadhyay had no disclosures. Neither study noted any external funding.

NEW YORK — Systemic autoimmune disease is well-recognized as a major risk factor for cardiovascular disease (CVD), but less recognized as a cardiovascular risk factor is a history of pregnancy complications, including preeclampsia, and cardiologists and rheumatologists need to include an obstetric history when managing patients with autoimmune diseases, a specialist in reproductive health in rheumatology told attendees at the 4th Annual Cardiometabolic Risk in Inflammatory Conditions conference.

“Autoimmune diseases, lupus in particular, increase the risk for both cardiovascular disease and maternal placental syndromes,” Lisa R. Sammaritano, MD, a professor at Hospital for Special Surgery in New York City and a specialist in reproductive health issues in rheumatology patients, told attendees. “For those patients who have complications during pregnancy, it further increases their already increased risk for later cardiovascular disease.”
 

CVD Risk Double Whammy

A history of systemic lupus erythematosus (SLE) and problematic pregnancy can be a double whammy for CVD risk. Dr. Sammaritano cited a 2022 meta-analysis that showed patients with SLE had a 2.5 times greater risk for stroke and almost three times greater risk for myocardial infarction than people without SLE.

Maternal placental syndromes include pregnancy loss, restricted fetal growth, preeclampsia, premature membrane rupture, placental abruption, and intrauterine fetal demise, Dr. Sammaritano said. Hypertensive disorders of pregnancy, formerly called adverse pregnancy outcomes, she noted, include gestational hypertension, preeclampsia, and eclampsia.

Pregnancy complications can have an adverse effect on the mother’s postpartum cardiovascular health, Dr. Sammaritano noted, a fact borne out by the cardiovascular health after maternal placental syndromes population-based retrospective cohort study and a 2007 meta-analysis that found a history of preeclampsia doubles the risk for venous thromboembolism, stroke, and ischemic heart disease up to 15 years after pregnancy.

“It is always important to obtain a reproductive health history from patients with autoimmune diseases,” Dr. Sammaritano told this news organization in an interview. “This is an integral part of any medical history. In the usual setting, this includes not only pregnancy history but also use of contraception in reproductive-aged women. Unplanned pregnancy can lead to adverse outcomes in the setting of active or severe autoimmune disease or when teratogenic medications are used.”

Pregnancy history can be a factor in a woman’s cardiovascular health more than 15 years postpartum, even if a woman is no longer planning a pregnancy or is menopausal. “As such, this history is important in assessing every woman’s risk profile for CVD in addition to usual traditional risk factors,” Dr. Sammaritano said.

“It is even more important for women with autoimmune disorders, who have been shown to have an already increased risk for CVD independent of their pregnancy history, likely related to a chronic inflammatory state and other autoimmune-related factors such as presence of antiphospholipid antibodies [aPL] or use of corticosteroids.”

Timing of disease onset is also an issue, she said. “In patients with SLE, for example, onset of CVD is much earlier than in the general population,” Dr. Sammaritano said. “As a result, these patients should likely be assessed for risk — both traditional and other risk factors — earlier than the general population, especially if an adverse obstetric history is present.”

At the younger end of the age continuum, women with autoimmune disease, including SLE and antiphospholipid syndrome, who are pregnant should be put on guideline-directed low-dose aspirin preeclampsia prophylaxis, Dr. Sammaritano said. “Whether every patient with SLE needs this is still uncertain, but certainly, those with a history of renal disease, hypertension, or aPL antibody clearly do,” she added.

The evidence supporting hydroxychloroquine (HCQ) in these patients is controversial, but Dr. Sammaritano noted two meta-analyses, one in 2022 and the other in 2023, that showed that HCQ lowered the risk for preeclampsia in women.

“The clear benefit of HCQ in preventing maternal disease complications, including flare, means we recommend it regardless for all patients with SLE at baseline and during pregnancy [if tolerated],” Dr. Sammaritano said. “The benefit or optimal use of these medications in other autoimmune diseases is less studied and less certain.”

Dr. Sammaritano added in her presentation, “We really need better therapies and, hopefully, those will be on the way, but I think the takeaway message, particularly for practicing rheumatologists and cardiologists, is to ask the question about obstetric history. Many of us don’t. It doesn’t seem relevant in the moment, but it really is in terms of the patient’s long-term risk for cardiovascular disease.”
 

The Case for Treatment During Pregnancy

Prophylaxis against pregnancy complications in patients with autoimmune disease may be achievable, Taryn Youngstein, MBBS, consultant rheumatologist and codirector of the Centre of Excellence in Vasculitis Research, Imperial College London, London, England, told this news organization after Dr. Sammaritano’s presentation. At the 2023 American College of Rheumatology Annual Meeting, her group reported the safety and effectiveness of continuing tocilizumab in pregnant women with Takayasu arteritis, a large-vessel vasculitis predominantly affecting women of reproductive age.

“What traditionally happens is you would stop the biologic particularly before the third trimester because of safety and concerns that the monoclonal antibody is actively transported across the placenta, which means the baby gets much more concentration of the drug than the mum,” Dr. Youngstein said.

It’s a situation physicians must monitor closely, she said. “The mum is donating their immune system to the baby, but they’re also donating drug.”

“In high-risk patients, we would share decision-making with the patient,” Dr. Youngstein continued. “We have decided it’s too high of a risk for us to stop the drug, so we have been continuing the interleukin-6 [IL-6] inhibitor throughout the entire pregnancy.”

The data from Dr. Youngstein’s group showed that pregnant women with Takayasu arteritis who continued IL-6 inhibition therapy all carried to term with healthy births.

“We’ve shown that it’s relatively safe to do that, but you have to be very careful in monitoring the baby,” she said. This includes not giving the infant any live vaccines at birth because it will have the high levels of IL-6 inhibition, she said.

Dr. Sammaritano and Dr. Youngstein had no relevant financial relationships to disclose.

A version of this article appeared on Medscape.com.

NEW YORK — Systemic autoimmune disease is well-recognized as a major risk factor for cardiovascular disease (CVD), but less recognized as a cardiovascular risk factor is a history of pregnancy complications, including preeclampsia, and cardiologists and rheumatologists need to include an obstetric history when managing patients with autoimmune diseases, a specialist in reproductive health in rheumatology told attendees at the 4th Annual Cardiometabolic Risk in Inflammatory Conditions conference.

“Autoimmune diseases, lupus in particular, increase the risk for both cardiovascular disease and maternal placental syndromes,” Lisa R. Sammaritano, MD, a professor at Hospital for Special Surgery in New York City and a specialist in reproductive health issues in rheumatology patients, told attendees. “For those patients who have complications during pregnancy, it further increases their already increased risk for later cardiovascular disease.”
 

CVD Risk Double Whammy

A history of systemic lupus erythematosus (SLE) and problematic pregnancy can be a double whammy for CVD risk. Dr. Sammaritano cited a 2022 meta-analysis that showed patients with SLE had a 2.5 times greater risk for stroke and almost three times greater risk for myocardial infarction than people without SLE.

Maternal placental syndromes include pregnancy loss, restricted fetal growth, preeclampsia, premature membrane rupture, placental abruption, and intrauterine fetal demise, Dr. Sammaritano said. Hypertensive disorders of pregnancy, formerly called adverse pregnancy outcomes, she noted, include gestational hypertension, preeclampsia, and eclampsia.

Pregnancy complications can have an adverse effect on the mother’s postpartum cardiovascular health, Dr. Sammaritano noted, a fact borne out by the cardiovascular health after maternal placental syndromes population-based retrospective cohort study and a 2007 meta-analysis that found a history of preeclampsia doubles the risk for venous thromboembolism, stroke, and ischemic heart disease up to 15 years after pregnancy.

“It is always important to obtain a reproductive health history from patients with autoimmune diseases,” Dr. Sammaritano told this news organization in an interview. “This is an integral part of any medical history. In the usual setting, this includes not only pregnancy history but also use of contraception in reproductive-aged women. Unplanned pregnancy can lead to adverse outcomes in the setting of active or severe autoimmune disease or when teratogenic medications are used.”

Pregnancy history can be a factor in a woman’s cardiovascular health more than 15 years postpartum, even if a woman is no longer planning a pregnancy or is menopausal. “As such, this history is important in assessing every woman’s risk profile for CVD in addition to usual traditional risk factors,” Dr. Sammaritano said.

“It is even more important for women with autoimmune disorders, who have been shown to have an already increased risk for CVD independent of their pregnancy history, likely related to a chronic inflammatory state and other autoimmune-related factors such as presence of antiphospholipid antibodies [aPL] or use of corticosteroids.”

Timing of disease onset is also an issue, she said. “In patients with SLE, for example, onset of CVD is much earlier than in the general population,” Dr. Sammaritano said. “As a result, these patients should likely be assessed for risk — both traditional and other risk factors — earlier than the general population, especially if an adverse obstetric history is present.”

At the younger end of the age continuum, women with autoimmune disease, including SLE and antiphospholipid syndrome, who are pregnant should be put on guideline-directed low-dose aspirin preeclampsia prophylaxis, Dr. Sammaritano said. “Whether every patient with SLE needs this is still uncertain, but certainly, those with a history of renal disease, hypertension, or aPL antibody clearly do,” she added.

The evidence supporting hydroxychloroquine (HCQ) in these patients is controversial, but Dr. Sammaritano noted two meta-analyses, one in 2022 and the other in 2023, that showed that HCQ lowered the risk for preeclampsia in women.

“The clear benefit of HCQ in preventing maternal disease complications, including flare, means we recommend it regardless for all patients with SLE at baseline and during pregnancy [if tolerated],” Dr. Sammaritano said. “The benefit or optimal use of these medications in other autoimmune diseases is less studied and less certain.”

Dr. Sammaritano added in her presentation, “We really need better therapies and, hopefully, those will be on the way, but I think the takeaway message, particularly for practicing rheumatologists and cardiologists, is to ask the question about obstetric history. Many of us don’t. It doesn’t seem relevant in the moment, but it really is in terms of the patient’s long-term risk for cardiovascular disease.”
 

The Case for Treatment During Pregnancy

Prophylaxis against pregnancy complications in patients with autoimmune disease may be achievable, Taryn Youngstein, MBBS, consultant rheumatologist and codirector of the Centre of Excellence in Vasculitis Research, Imperial College London, London, England, told this news organization after Dr. Sammaritano’s presentation. At the 2023 American College of Rheumatology Annual Meeting, her group reported the safety and effectiveness of continuing tocilizumab in pregnant women with Takayasu arteritis, a large-vessel vasculitis predominantly affecting women of reproductive age.

“What traditionally happens is you would stop the biologic particularly before the third trimester because of safety and concerns that the monoclonal antibody is actively transported across the placenta, which means the baby gets much more concentration of the drug than the mum,” Dr. Youngstein said.

It’s a situation physicians must monitor closely, she said. “The mum is donating their immune system to the baby, but they’re also donating drug.”

“In high-risk patients, we would share decision-making with the patient,” Dr. Youngstein continued. “We have decided it’s too high of a risk for us to stop the drug, so we have been continuing the interleukin-6 [IL-6] inhibitor throughout the entire pregnancy.”

The data from Dr. Youngstein’s group showed that pregnant women with Takayasu arteritis who continued IL-6 inhibition therapy all carried to term with healthy births.

“We’ve shown that it’s relatively safe to do that, but you have to be very careful in monitoring the baby,” she said. This includes not giving the infant any live vaccines at birth because it will have the high levels of IL-6 inhibition, she said.

Dr. Sammaritano and Dr. Youngstein had no relevant financial relationships to disclose.

A version of this article appeared on Medscape.com.

NEW YORK — Systemic autoimmune disease is well-recognized as a major risk factor for cardiovascular disease (CVD), but less recognized as a cardiovascular risk factor is a history of pregnancy complications, including preeclampsia, and cardiologists and rheumatologists need to include an obstetric history when managing patients with autoimmune diseases, a specialist in reproductive health in rheumatology told attendees at the 4th Annual Cardiometabolic Risk in Inflammatory Conditions conference.

“Autoimmune diseases, lupus in particular, increase the risk for both cardiovascular disease and maternal placental syndromes,” Lisa R. Sammaritano, MD, a professor at Hospital for Special Surgery in New York City and a specialist in reproductive health issues in rheumatology patients, told attendees. “For those patients who have complications during pregnancy, it further increases their already increased risk for later cardiovascular disease.”
 

CVD Risk Double Whammy

A history of systemic lupus erythematosus (SLE) and problematic pregnancy can be a double whammy for CVD risk. Dr. Sammaritano cited a 2022 meta-analysis that showed patients with SLE had a 2.5 times greater risk for stroke and almost three times greater risk for myocardial infarction than people without SLE.

Maternal placental syndromes include pregnancy loss, restricted fetal growth, preeclampsia, premature membrane rupture, placental abruption, and intrauterine fetal demise, Dr. Sammaritano said. Hypertensive disorders of pregnancy, formerly called adverse pregnancy outcomes, she noted, include gestational hypertension, preeclampsia, and eclampsia.

Pregnancy complications can have an adverse effect on the mother’s postpartum cardiovascular health, Dr. Sammaritano noted, a fact borne out by the cardiovascular health after maternal placental syndromes population-based retrospective cohort study and a 2007 meta-analysis that found a history of preeclampsia doubles the risk for venous thromboembolism, stroke, and ischemic heart disease up to 15 years after pregnancy.

“It is always important to obtain a reproductive health history from patients with autoimmune diseases,” Dr. Sammaritano told this news organization in an interview. “This is an integral part of any medical history. In the usual setting, this includes not only pregnancy history but also use of contraception in reproductive-aged women. Unplanned pregnancy can lead to adverse outcomes in the setting of active or severe autoimmune disease or when teratogenic medications are used.”

Pregnancy history can be a factor in a woman’s cardiovascular health more than 15 years postpartum, even if a woman is no longer planning a pregnancy or is menopausal. “As such, this history is important in assessing every woman’s risk profile for CVD in addition to usual traditional risk factors,” Dr. Sammaritano said.

“It is even more important for women with autoimmune disorders, who have been shown to have an already increased risk for CVD independent of their pregnancy history, likely related to a chronic inflammatory state and other autoimmune-related factors such as presence of antiphospholipid antibodies [aPL] or use of corticosteroids.”

Timing of disease onset is also an issue, she said. “In patients with SLE, for example, onset of CVD is much earlier than in the general population,” Dr. Sammaritano said. “As a result, these patients should likely be assessed for risk — both traditional and other risk factors — earlier than the general population, especially if an adverse obstetric history is present.”

At the younger end of the age continuum, women with autoimmune disease, including SLE and antiphospholipid syndrome, who are pregnant should be put on guideline-directed low-dose aspirin preeclampsia prophylaxis, Dr. Sammaritano said. “Whether every patient with SLE needs this is still uncertain, but certainly, those with a history of renal disease, hypertension, or aPL antibody clearly do,” she added.

The evidence supporting hydroxychloroquine (HCQ) in these patients is controversial, but Dr. Sammaritano noted two meta-analyses, one in 2022 and the other in 2023, that showed that HCQ lowered the risk for preeclampsia in women.

“The clear benefit of HCQ in preventing maternal disease complications, including flare, means we recommend it regardless for all patients with SLE at baseline and during pregnancy [if tolerated],” Dr. Sammaritano said. “The benefit or optimal use of these medications in other autoimmune diseases is less studied and less certain.”

Dr. Sammaritano added in her presentation, “We really need better therapies and, hopefully, those will be on the way, but I think the takeaway message, particularly for practicing rheumatologists and cardiologists, is to ask the question about obstetric history. Many of us don’t. It doesn’t seem relevant in the moment, but it really is in terms of the patient’s long-term risk for cardiovascular disease.”
 

The Case for Treatment During Pregnancy

Prophylaxis against pregnancy complications in patients with autoimmune disease may be achievable, Taryn Youngstein, MBBS, consultant rheumatologist and codirector of the Centre of Excellence in Vasculitis Research, Imperial College London, London, England, told this news organization after Dr. Sammaritano’s presentation. At the 2023 American College of Rheumatology Annual Meeting, her group reported the safety and effectiveness of continuing tocilizumab in pregnant women with Takayasu arteritis, a large-vessel vasculitis predominantly affecting women of reproductive age.

“What traditionally happens is you would stop the biologic particularly before the third trimester because of safety and concerns that the monoclonal antibody is actively transported across the placenta, which means the baby gets much more concentration of the drug than the mum,” Dr. Youngstein said.

It’s a situation physicians must monitor closely, she said. “The mum is donating their immune system to the baby, but they’re also donating drug.”

“In high-risk patients, we would share decision-making with the patient,” Dr. Youngstein continued. “We have decided it’s too high of a risk for us to stop the drug, so we have been continuing the interleukin-6 [IL-6] inhibitor throughout the entire pregnancy.”

The data from Dr. Youngstein’s group showed that pregnant women with Takayasu arteritis who continued IL-6 inhibition therapy all carried to term with healthy births.

“We’ve shown that it’s relatively safe to do that, but you have to be very careful in monitoring the baby,” she said. This includes not giving the infant any live vaccines at birth because it will have the high levels of IL-6 inhibition, she said.

Dr. Sammaritano and Dr. Youngstein had no relevant financial relationships to disclose.

A version of this article appeared on Medscape.com.

In the first randomized controlled trial of prednisone for postvasectomy reversals, fertility researchers found that a high dose of the steroid reduced the rate of subsequent pregnancy.

“This is the first time it’s been shown that high doses [of prednisone] can make someone infertile,” said Landon Trost, MD, director of the Male Fertility and Peyronie’s Clinic in Orem, Utah, and a faculty member at Mayo Clinic, in Rochester, Minnesota, who presented the study (Abstract MP42-19) on May 4 at the 2024 annual meeting of the American Urological Association (AUA) in San Antonio, Texas. 

Dr. Trost called the findings “a real shock. I almost didn’t believe the data when I saw it. It opens up a whole new set of areas for research and exploration.”

Dr. Trost’s clinic performs 1200 reversals per year out of the estimated 20,000 performed annually in the United States, he said. He said his practice has stopped using high-dose prednisone as a result of the study, which he performed at his own expense to examine the varying protocols for vasectomy reversal.

William Berg, MD, director of the Stony Brook Urology Men’s Health Program, in Stony Brook, New York, said that the expected patency rate for modern postvasectomy reversals, if performed properly, can be as high as 98%. However, in some men, patency occurs initially, but the accumulation of scar tissue at the site of reversal causes sperm counts in ejaculate to drop to zero.

Since the 1970s, urologists — with limited research to back — the practice  prescribed prednisone to patients with the goal of preventing scarring and blockages associated with vasectomy reversals. Dr. Berg called this practice “unsubstantiated” and noted that Dr. Trost’s study is the first prospective randomized controlled trial of this approach.

The study enrolled 75 men, with a mean age of roughly 38 years. The mean time since vasectomy was 6.6 years.

The low-dose arm (25 patients) received 5 mg of prednisone per week alternating with no treatment per week over 6 months. The high-dose arm (n = 14) received 20 mg of prednisone, tapered to 10 mg, 5 mg, and then off over 1 month, followed by every other month for 6 months. A prednisone-as-needed group (n = 11) received a tapered course of prednisone on the basis of whether they had decreasing or zero sperm counts. They received 20 mg for 5 days, 10 mg for 5 days, and 5 mg for 20 days.

A control arm (n = 25) received no prednisone.

Urologists typically use patency rates to measure success of vasectomy reversals. The patency rates at 12 months in Dr. Trost’s study were 100% in the control participants, prednisone-as-needed, and low-dose groups and 92% (13/14) in the high-dose group. 

Dr. Trost said that the story was told in the pregnancy rates. At the 1-year mark, pregnancy rates were 67% in the low-risk group and 65% in the control group but 38% and 17% in the prednisone-as-needed and high-dose group, respectively (P = .02).

The mean maximum sperm concentration was 40 million per mL, ranging from 29.7 million per mL for men in the control group to 54.3 million per mL in the low-dose group.

Dr. Trost said that he immediately stopped using high doses of prednisone in his practice and predicted that other clinics would follow suit. 

Dr. Berg said the drop in pregnancies with higher doses of prednisone is a first-time finding and suggests that a high dose may “be detrimental to sperm function in some way. I don’t think this ever has been described before.”

Dr. Trost financed the study himself. Dr. Berg reported no conflicts.

A version of this article first appeared on Medscape.com.

In the first randomized controlled trial of prednisone for postvasectomy reversals, fertility researchers found that a high dose of the steroid reduced the rate of subsequent pregnancy.

“This is the first time it’s been shown that high doses [of prednisone] can make someone infertile,” said Landon Trost, MD, director of the Male Fertility and Peyronie’s Clinic in Orem, Utah, and a faculty member at Mayo Clinic, in Rochester, Minnesota, who presented the study (Abstract MP42-19) on May 4 at the 2024 annual meeting of the American Urological Association (AUA) in San Antonio, Texas. 

Dr. Trost called the findings “a real shock. I almost didn’t believe the data when I saw it. It opens up a whole new set of areas for research and exploration.”

Dr. Trost’s clinic performs 1200 reversals per year out of the estimated 20,000 performed annually in the United States, he said. He said his practice has stopped using high-dose prednisone as a result of the study, which he performed at his own expense to examine the varying protocols for vasectomy reversal.

William Berg, MD, director of the Stony Brook Urology Men’s Health Program, in Stony Brook, New York, said that the expected patency rate for modern postvasectomy reversals, if performed properly, can be as high as 98%. However, in some men, patency occurs initially, but the accumulation of scar tissue at the site of reversal causes sperm counts in ejaculate to drop to zero.

Since the 1970s, urologists — with limited research to back — the practice  prescribed prednisone to patients with the goal of preventing scarring and blockages associated with vasectomy reversals. Dr. Berg called this practice “unsubstantiated” and noted that Dr. Trost’s study is the first prospective randomized controlled trial of this approach.

The study enrolled 75 men, with a mean age of roughly 38 years. The mean time since vasectomy was 6.6 years.

The low-dose arm (25 patients) received 5 mg of prednisone per week alternating with no treatment per week over 6 months. The high-dose arm (n = 14) received 20 mg of prednisone, tapered to 10 mg, 5 mg, and then off over 1 month, followed by every other month for 6 months. A prednisone-as-needed group (n = 11) received a tapered course of prednisone on the basis of whether they had decreasing or zero sperm counts. They received 20 mg for 5 days, 10 mg for 5 days, and 5 mg for 20 days.

A control arm (n = 25) received no prednisone.

Urologists typically use patency rates to measure success of vasectomy reversals. The patency rates at 12 months in Dr. Trost’s study were 100% in the control participants, prednisone-as-needed, and low-dose groups and 92% (13/14) in the high-dose group. 

Dr. Trost said that the story was told in the pregnancy rates. At the 1-year mark, pregnancy rates were 67% in the low-risk group and 65% in the control group but 38% and 17% in the prednisone-as-needed and high-dose group, respectively (P = .02).

The mean maximum sperm concentration was 40 million per mL, ranging from 29.7 million per mL for men in the control group to 54.3 million per mL in the low-dose group.

Dr. Trost said that he immediately stopped using high doses of prednisone in his practice and predicted that other clinics would follow suit. 

Dr. Berg said the drop in pregnancies with higher doses of prednisone is a first-time finding and suggests that a high dose may “be detrimental to sperm function in some way. I don’t think this ever has been described before.”

Dr. Trost financed the study himself. Dr. Berg reported no conflicts.

A version of this article first appeared on Medscape.com.

In the first randomized controlled trial of prednisone for postvasectomy reversals, fertility researchers found that a high dose of the steroid reduced the rate of subsequent pregnancy.

“This is the first time it’s been shown that high doses [of prednisone] can make someone infertile,” said Landon Trost, MD, director of the Male Fertility and Peyronie’s Clinic in Orem, Utah, and a faculty member at Mayo Clinic, in Rochester, Minnesota, who presented the study (Abstract MP42-19) on May 4 at the 2024 annual meeting of the American Urological Association (AUA) in San Antonio, Texas. 

Dr. Trost called the findings “a real shock. I almost didn’t believe the data when I saw it. It opens up a whole new set of areas for research and exploration.”

Dr. Trost’s clinic performs 1200 reversals per year out of the estimated 20,000 performed annually in the United States, he said. He said his practice has stopped using high-dose prednisone as a result of the study, which he performed at his own expense to examine the varying protocols for vasectomy reversal.

William Berg, MD, director of the Stony Brook Urology Men’s Health Program, in Stony Brook, New York, said that the expected patency rate for modern postvasectomy reversals, if performed properly, can be as high as 98%. However, in some men, patency occurs initially, but the accumulation of scar tissue at the site of reversal causes sperm counts in ejaculate to drop to zero.

Since the 1970s, urologists — with limited research to back — the practice  prescribed prednisone to patients with the goal of preventing scarring and blockages associated with vasectomy reversals. Dr. Berg called this practice “unsubstantiated” and noted that Dr. Trost’s study is the first prospective randomized controlled trial of this approach.

The study enrolled 75 men, with a mean age of roughly 38 years. The mean time since vasectomy was 6.6 years.

The low-dose arm (25 patients) received 5 mg of prednisone per week alternating with no treatment per week over 6 months. The high-dose arm (n = 14) received 20 mg of prednisone, tapered to 10 mg, 5 mg, and then off over 1 month, followed by every other month for 6 months. A prednisone-as-needed group (n = 11) received a tapered course of prednisone on the basis of whether they had decreasing or zero sperm counts. They received 20 mg for 5 days, 10 mg for 5 days, and 5 mg for 20 days.

A control arm (n = 25) received no prednisone.

Urologists typically use patency rates to measure success of vasectomy reversals. The patency rates at 12 months in Dr. Trost’s study were 100% in the control participants, prednisone-as-needed, and low-dose groups and 92% (13/14) in the high-dose group. 

Dr. Trost said that the story was told in the pregnancy rates. At the 1-year mark, pregnancy rates were 67% in the low-risk group and 65% in the control group but 38% and 17% in the prednisone-as-needed and high-dose group, respectively (P = .02).

The mean maximum sperm concentration was 40 million per mL, ranging from 29.7 million per mL for men in the control group to 54.3 million per mL in the low-dose group.

Dr. Trost said that he immediately stopped using high doses of prednisone in his practice and predicted that other clinics would follow suit. 

Dr. Berg said the drop in pregnancies with higher doses of prednisone is a first-time finding and suggests that a high dose may “be detrimental to sperm function in some way. I don’t think this ever has been described before.”

Dr. Trost financed the study himself. Dr. Berg reported no conflicts.

A version of this article first appeared on Medscape.com.

An evolving legal landscape surrounding medication abortion has left physicians with as many questions as patients. A panel of clinicians at the annual meeting of the American College of Physicians offered guidance on how to help patients who choose medication abortion, which is available to women until 10 weeks of gestation.

Approved in 2000, abortion pills have become the most common method for terminating pregnancy in the United States, accounting for 63% of all abortions in 2023. The US Supreme Court is reviewing access to medication abortions, with a decision expected within months.

According to the Guttmacher Institute, 29 states as of February restrict access to medication abortion, either by limiting or banning the use of the drugs or by curtailing who can prescribe them and under what circumstances.
 

First, Determine Gestational Age

Cynthia Chuang, MD, MSc, an internist and professor of medicine at Penn State College of Medicine in Hershey, Pennsylvania, said in most cases, a woman can pinpoint the date of the first day of her last menstrual period, and the physician can confirm gestational age is 70 days or less. An ultrasound should be performed if the date of the last period is uncertain, she said, or if ectopic pregnancy is suspected, periods are irregular, or ultrasound is legally required in the state.

Women are not eligible for abortion pills if they have a bleeding or clotting disorder, have an intrauterine device, have adrenal insufficiency or chronic steroid use, or have porphyria or hemoglobin levels < 9 g/dL, she said.

“If the person has a known hemoglobin of less than 9, we would suggest that person have a procedural abortion,” Dr. Chuang said.
 

Components of Medication

Patients first receive 200 mg of oral mifepristone, which separates the pregnancy from the uterine wall. “Typically, people don’t experience side effects from the mifepristone alone,” Dr. Chaung said.

In the next 48 hours, the patient takes 800 mcg of misoprostol, either vaginally or buccally. “Patients can expect heavy cramping and bleeding 1-2 days after taking misoprostol,” she said. The bleeding should gradually subside over the following week or 2, she said. If the gestational age is 9 weeks or more, a second dose of misoprostol can be administered 3-6 hours after the first dose to improve efficacy.

If mifepristone is not available, misoprostol can be used alone in three doses spaced 3 hours apart, Dr. Chuang said.

The failure rate for mifepristone plus misoprostol has been calculated at 2% if the gestational age is less than 7 weeks. For misoprostol alone, the failure rate varies by the study, depending on gestational age and population analyzed, Dr. Chuang said. A 2023 meta-analysis in Contraception put the failure rate at 11%.
 

When to Call the Clinician

Dr. Chuang said clinicians should instruct women who have taken abortion pills to call the clinic if they are soaking through two sanitary pads an hour for more than 1 hour, if there is little to no bleeding, or if they think the medication isn’t working after taking the full regimen.

Mindy Sobota, MD, MS, an internist and associate professor of medicine at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, recommended a continuing medical education site for evidence-based guidance on how best to talk with women about medication abortions.

She also recommended physicians and patients consult the Plan C website for guidance on telehealth services and price information on receiving abortion pills by mail in every state. “It’s a very reliable and safe clearing house,” Dr. Sobota said.

Internists should let patients know that whatever their choices are around pregnancy, they are open to discussing those choices and helping them through the process, Dr. Sobota said, adding that she makes those statements in annual visits.

Alexandra Bachorik, MD, EdM, director of education in the Women’s Health Unit and assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, said patients in restrictive states who need financial help related to obtaining abortion services in a less restricted state can visit the National Network of Abortion Funds, which can help people with travel or housing expenses.

Facilitating access to a clinic in a less restrictive state may be helpful to people approaching a gestational age limit, she said.

Adelaide McClintock, MD, an internist and assistant professor of general internal medicine at the University of Washington School of Medicine in Seattle, Washington, noted that even clinicians who cannot legally prescribe abortion pills can support their patients by providing resources and counseling on options before, during, and after pregnancy. Those who live in restrictive states also can provide support to women who have traveled to less restrictive states for an abortion if they have postabortion complications, she said.

She recommended the Reproductive Health Access Project website for a comprehensive guide for evidence-based care and counseling patients about all choices in reproductive healthcare.

Panelists urged clinicians to get familiar with abortion-access resources and keep them at their fingertips in practice. Patient requests for the services are common, she noted, as “one in four women will have an abortion by the age of 45.”

Dr. Chuang, Dr. McClintock, Dr. Sobota, and Dr. Bachorik reported no relevant financial conflicts of interest.

A version of this article appeared on Medscape.com.

An evolving legal landscape surrounding medication abortion has left physicians with as many questions as patients. A panel of clinicians at the annual meeting of the American College of Physicians offered guidance on how to help patients who choose medication abortion, which is available to women until 10 weeks of gestation.

Approved in 2000, abortion pills have become the most common method for terminating pregnancy in the United States, accounting for 63% of all abortions in 2023. The US Supreme Court is reviewing access to medication abortions, with a decision expected within months.

According to the Guttmacher Institute, 29 states as of February restrict access to medication abortion, either by limiting or banning the use of the drugs or by curtailing who can prescribe them and under what circumstances.
 

First, Determine Gestational Age

Cynthia Chuang, MD, MSc, an internist and professor of medicine at Penn State College of Medicine in Hershey, Pennsylvania, said in most cases, a woman can pinpoint the date of the first day of her last menstrual period, and the physician can confirm gestational age is 70 days or less. An ultrasound should be performed if the date of the last period is uncertain, she said, or if ectopic pregnancy is suspected, periods are irregular, or ultrasound is legally required in the state.

Women are not eligible for abortion pills if they have a bleeding or clotting disorder, have an intrauterine device, have adrenal insufficiency or chronic steroid use, or have porphyria or hemoglobin levels < 9 g/dL, she said.

“If the person has a known hemoglobin of less than 9, we would suggest that person have a procedural abortion,” Dr. Chuang said.
 

Components of Medication

Patients first receive 200 mg of oral mifepristone, which separates the pregnancy from the uterine wall. “Typically, people don’t experience side effects from the mifepristone alone,” Dr. Chaung said.

In the next 48 hours, the patient takes 800 mcg of misoprostol, either vaginally or buccally. “Patients can expect heavy cramping and bleeding 1-2 days after taking misoprostol,” she said. The bleeding should gradually subside over the following week or 2, she said. If the gestational age is 9 weeks or more, a second dose of misoprostol can be administered 3-6 hours after the first dose to improve efficacy.

If mifepristone is not available, misoprostol can be used alone in three doses spaced 3 hours apart, Dr. Chuang said.

The failure rate for mifepristone plus misoprostol has been calculated at 2% if the gestational age is less than 7 weeks. For misoprostol alone, the failure rate varies by the study, depending on gestational age and population analyzed, Dr. Chuang said. A 2023 meta-analysis in Contraception put the failure rate at 11%.
 

When to Call the Clinician

Dr. Chuang said clinicians should instruct women who have taken abortion pills to call the clinic if they are soaking through two sanitary pads an hour for more than 1 hour, if there is little to no bleeding, or if they think the medication isn’t working after taking the full regimen.

Mindy Sobota, MD, MS, an internist and associate professor of medicine at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, recommended a continuing medical education site for evidence-based guidance on how best to talk with women about medication abortions.

She also recommended physicians and patients consult the Plan C website for guidance on telehealth services and price information on receiving abortion pills by mail in every state. “It’s a very reliable and safe clearing house,” Dr. Sobota said.

Internists should let patients know that whatever their choices are around pregnancy, they are open to discussing those choices and helping them through the process, Dr. Sobota said, adding that she makes those statements in annual visits.

Alexandra Bachorik, MD, EdM, director of education in the Women’s Health Unit and assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, said patients in restrictive states who need financial help related to obtaining abortion services in a less restricted state can visit the National Network of Abortion Funds, which can help people with travel or housing expenses.

Facilitating access to a clinic in a less restrictive state may be helpful to people approaching a gestational age limit, she said.

Adelaide McClintock, MD, an internist and assistant professor of general internal medicine at the University of Washington School of Medicine in Seattle, Washington, noted that even clinicians who cannot legally prescribe abortion pills can support their patients by providing resources and counseling on options before, during, and after pregnancy. Those who live in restrictive states also can provide support to women who have traveled to less restrictive states for an abortion if they have postabortion complications, she said.

She recommended the Reproductive Health Access Project website for a comprehensive guide for evidence-based care and counseling patients about all choices in reproductive healthcare.

Panelists urged clinicians to get familiar with abortion-access resources and keep them at their fingertips in practice. Patient requests for the services are common, she noted, as “one in four women will have an abortion by the age of 45.”

Dr. Chuang, Dr. McClintock, Dr. Sobota, and Dr. Bachorik reported no relevant financial conflicts of interest.

A version of this article appeared on Medscape.com.

An evolving legal landscape surrounding medication abortion has left physicians with as many questions as patients. A panel of clinicians at the annual meeting of the American College of Physicians offered guidance on how to help patients who choose medication abortion, which is available to women until 10 weeks of gestation.

Approved in 2000, abortion pills have become the most common method for terminating pregnancy in the United States, accounting for 63% of all abortions in 2023. The US Supreme Court is reviewing access to medication abortions, with a decision expected within months.

According to the Guttmacher Institute, 29 states as of February restrict access to medication abortion, either by limiting or banning the use of the drugs or by curtailing who can prescribe them and under what circumstances.
 

First, Determine Gestational Age

Cynthia Chuang, MD, MSc, an internist and professor of medicine at Penn State College of Medicine in Hershey, Pennsylvania, said in most cases, a woman can pinpoint the date of the first day of her last menstrual period, and the physician can confirm gestational age is 70 days or less. An ultrasound should be performed if the date of the last period is uncertain, she said, or if ectopic pregnancy is suspected, periods are irregular, or ultrasound is legally required in the state.

Women are not eligible for abortion pills if they have a bleeding or clotting disorder, have an intrauterine device, have adrenal insufficiency or chronic steroid use, or have porphyria or hemoglobin levels < 9 g/dL, she said.

“If the person has a known hemoglobin of less than 9, we would suggest that person have a procedural abortion,” Dr. Chuang said.
 

Components of Medication

Patients first receive 200 mg of oral mifepristone, which separates the pregnancy from the uterine wall. “Typically, people don’t experience side effects from the mifepristone alone,” Dr. Chaung said.

In the next 48 hours, the patient takes 800 mcg of misoprostol, either vaginally or buccally. “Patients can expect heavy cramping and bleeding 1-2 days after taking misoprostol,” she said. The bleeding should gradually subside over the following week or 2, she said. If the gestational age is 9 weeks or more, a second dose of misoprostol can be administered 3-6 hours after the first dose to improve efficacy.

If mifepristone is not available, misoprostol can be used alone in three doses spaced 3 hours apart, Dr. Chuang said.

The failure rate for mifepristone plus misoprostol has been calculated at 2% if the gestational age is less than 7 weeks. For misoprostol alone, the failure rate varies by the study, depending on gestational age and population analyzed, Dr. Chuang said. A 2023 meta-analysis in Contraception put the failure rate at 11%.
 

When to Call the Clinician

Dr. Chuang said clinicians should instruct women who have taken abortion pills to call the clinic if they are soaking through two sanitary pads an hour for more than 1 hour, if there is little to no bleeding, or if they think the medication isn’t working after taking the full regimen.

Mindy Sobota, MD, MS, an internist and associate professor of medicine at the Warren Alpert Medical School of Brown University in Providence, Rhode Island, recommended a continuing medical education site for evidence-based guidance on how best to talk with women about medication abortions.

She also recommended physicians and patients consult the Plan C website for guidance on telehealth services and price information on receiving abortion pills by mail in every state. “It’s a very reliable and safe clearing house,” Dr. Sobota said.

Internists should let patients know that whatever their choices are around pregnancy, they are open to discussing those choices and helping them through the process, Dr. Sobota said, adding that she makes those statements in annual visits.

Alexandra Bachorik, MD, EdM, director of education in the Women’s Health Unit and assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, said patients in restrictive states who need financial help related to obtaining abortion services in a less restricted state can visit the National Network of Abortion Funds, which can help people with travel or housing expenses.

Facilitating access to a clinic in a less restrictive state may be helpful to people approaching a gestational age limit, she said.

Adelaide McClintock, MD, an internist and assistant professor of general internal medicine at the University of Washington School of Medicine in Seattle, Washington, noted that even clinicians who cannot legally prescribe abortion pills can support their patients by providing resources and counseling on options before, during, and after pregnancy. Those who live in restrictive states also can provide support to women who have traveled to less restrictive states for an abortion if they have postabortion complications, she said.

She recommended the Reproductive Health Access Project website for a comprehensive guide for evidence-based care and counseling patients about all choices in reproductive healthcare.

Panelists urged clinicians to get familiar with abortion-access resources and keep them at their fingertips in practice. Patient requests for the services are common, she noted, as “one in four women will have an abortion by the age of 45.”

Dr. Chuang, Dr. McClintock, Dr. Sobota, and Dr. Bachorik reported no relevant financial conflicts of interest.

A version of this article appeared on Medscape.com.

How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.

Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians. 

In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.

Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.

Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
 

Interpregnancy Interval and SGA Risk

The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.

According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.

According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.

Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.

“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
 

Previous and Subsequent Adverse Events

The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.

Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.” 

“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.

There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.

The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.

The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.

“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.

Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians. 

In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.

Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.

Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
 

Interpregnancy Interval and SGA Risk

The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.

According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.

According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.

Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.

“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
 

Previous and Subsequent Adverse Events

The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.

Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.” 

“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.

There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.

The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.

The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.

“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

How long should a woman wait before becoming pregnant again? According to the World Health Organization (WHO), it is advisable to wait at least 24 months between childbirth and a new pregnancy. But a study published in February of this year in The Lancet Regional Health — Americas, using data from more than 4.7 million live births in Brazil, suggests that this recommendation should be individualized, considering factors such as maternal obstetric history.

Researchers from the Federal University of Grande Dourados (UFGD), Oswaldo Cruz Foundation, São José do Rio Preto Medical School, Federal University of Bahia, and the London School of Hygiene and Tropical Medicine in the United Kingdom, used a birth cohort from the Center for Data Integration and Knowledge for Health, which combines data from the Ministry of Health’s Information System on Live Births (SINASC) and from a cohort of 100 million Brazilians. 

In total, the analysis included information on 3,804,152 women and 4,788,279 births. All participants had at least two consecutive live births.

Most interpregnancy intervals, ie, the difference between the previous childbirth and the subsequent conception, ranged from 23 to 58 months (39.1%). Extreme intervals of < 6 months and > 120 months occurred in 5.6% and 1.6% of cases, respectively.

Regarding adverse outcomes, the research indicated that, in the general population, small-for-gestational-age (SGA) babies were observed in 8.4% of subsequent births, while low birth weight (LBW) occurred in 5.9% and preterm birth in 7.5%.
 

Interpregnancy Interval and SGA Risk

The authors noted that the risk for subsequent adverse outcomes increased with extreme interpregnancy intervals, with SGA being the only exception. In this case, women who had an interval between the previous childbirth and the subsequent conception > 120 months had a lower risk for SGA.

According to João Guilherme Tedde, a medical student at UFGD and the first author of the study, similar patterns (extremely long interpregnancy intervals associated with a lower risk for subsequent SGA) have been described in the literature. In an interview with this news organization, he explained some hypotheses that could explain this phenomenon.

According to the researcher, the finding may reflect the distinct risk profile of mothers who wait a very long time to conceive again. “This group, composed of older women, likely has a higher prevalence of health problems, such as diabetes and obesity, which are known risk factors for having large-for-gestational-age (LGA) babies,” he said. He also highlighted the fact that the study showed that the risk for LGA also increased as the interval between pregnancies grew.

Another hypothesis suggested by the author is the possible occurrence of events between pregnancies, such as miscarriages or stillbirths. According to him, women who have experienced these events between two consecutive pregnancies may have falsely increased interpregnancy intervals, since miscarriages and stillbirths (which are considered conceptions) are not counted in SINASC.

“Thus, the lower occurrence of SGA in the group with very long intervals may reflect a competition of events between stillbirths or miscarriages and live SGAs,” he said.
 

Previous and Subsequent Adverse Events

The research also showed that the risks for subsequent SGA, LBW, and preterm birth were higher among women with a history of adverse events in previous pregnancies.

Furthermore, the authors noted that the previous occurrence of adverse outcomes seems to “have a more significant impact on the outcome of the current pregnancy than the interpregnancy interval.” 

“We found that, for women with the same interpregnancy interval (say < 6 months), but with different obstetric history (zero previous events vs one event), the absolute risk for subsequent adverse outcomes increased much more than when we change only the duration of the interval in a group with the same number of previous adverse events,” said Dr. Tedde.

There is still no convincing explanation for this fact, he said, since the cause-and-effect relationship between interpregnancy intervals and perinatal events is not clear. But the obstetrics literature generally shows that among the main risk factors for an adverse event is the previous occurrence of the same event. This effect could be related to living conditions and maternal habits, genetics, epigenetics, among others.

The researcher observed that this study is one of the largest in terms of sampling to investigate how maternal obstetric history can modulate the effect of interpregnancy interval on the risk for adverse outcomes in subsequent pregnancies.

The findings of the research published this year reinforce the importance of individualizing recommendations regarding interpregnancy intervals, considering factors such as maternal obstetric history. However, the author warns that it is still too early to point out the “best” interval for each situation.

“We need more studies that reproduce our findings and that expand the analyzed outcomes to also include those of interest to the mother, such as maternal mortality,” he concluded.

This story was translated from the Medscape Portuguese edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Safety concerns persist for out-of-hospital births in the United States with multiple potential risk factors and few safety requirements, according to a paper published in the American Journal of Obstetrics and Gynecology.

In 2022, the Centers for Disease Control and Prevention (CDC) reported the highest number of planned home births in 30 years. The numbers rose 12% from 2020 to 2021, the latest period for which complete data are available. Home births rose from 45,646 (1.26% of births) in 2020 to 51,642 (1.41% of births).

Amos Grünebaum, MD, and Frank A. Chervenak, MD, with Northwell Health, and the Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine in New Hyde Park, New York, reviewed the latest safety data surrounding community births in the United States along with well-known perinatal risks and safety requirements for safe out-of-hospital births.

“Most planned home births continue to have one or more risk factors that are associated with an increase in adverse pregnancy outcomes,” they wrote.
 

Birth Certificate Data Analyzed

The researchers used the CDC birth certificate database and analyzed deliveries between 2016 and 2022 regarding the incidence of perinatal risks in community births. The risks included were prior cesarean, first baby, mother older than 35 years, twins, breech presentation, gestational age of less than 37 weeks or more than 41 weeks, newborn weight over 4,000 grams, adequacy of prenatal care, grand multiparity (5 or more prior pregnancies), and a prepregnancy body mass index of at least 35.

The incidence of perinatal risks for out-of-hospital births ranged individually from 0.2% to 28.54% among birthing center births and 0.32% to 24.4% for planned home births.

“The ACOG committee opinion on home births states that for every 1000 home births, 3.9 babies will die,” the authors noted, or about twice the risk of hospital births. The deaths are “potentially avoidable with easy access to an operating room,” they wrote.

Among the safety concerns for perinatal morbidity and mortality in community births, the authors cited the lack of:

• Appropriate patient selection for out-of-hospital births through standardized guidelines.
• Availability of a Certified Nurse Midwife, a Certified Midwife, or midwife whose education and licensure meet International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education.
• Providers practicing obstetrics within an integrated and regulated health system with ready access and availability of board-certified obstetricians to provide consultation for qualified midwives.
• Standardized guidelines on when transport to a hospital is necessary.

“While prerequisites for a safe out-of-hospital delivery may be in place in other high-income countries, these prerequisites have not been actualized in the United States,” the authors wrote.

Incorporating Patient Preferences Into Delivery Models

Yalda Afshar, MD, PhD, maternal-fetal medicine subspecialist and a physician-scientist at UCLA Health in California, said obstetricians are responsible for offering the most evidence-based care to pregnant people.

“What this birth certificate data demonstrates,” she said, “is a tendency among birthing people to opt for out-of-hospital births, despite documented risks to both the pregnant person and the neonate. This underscores the need to persist in educating on risk stratification, risk reduction, and safe birthing practices, while also fostering innovation. Innovation should stem from our commitment to incorporate the preferences of pregnant people into our healthcare delivery model.”

Dr. Afshar, who was not part of the study, said clinicians should develop innovative ways to effectively meet the needs of pregnant patients while ensuring their safety and well-being.

“Ideally, we would establish safe environments within hospital systems and centers that emulate home-like birthing experiences, thereby mitigating risks for these families,” she said.

Though not explicitly stated in the data, she added, it is crucial to emphasize the need for continuous risk assessment throughout pregnancy and childbirth, “with a paramount focus on the safety of the pregnant individual.”

The authors and Dr. Afshar have no relevant financial disclosures.

Safety concerns persist for out-of-hospital births in the United States with multiple potential risk factors and few safety requirements, according to a paper published in the American Journal of Obstetrics and Gynecology.

In 2022, the Centers for Disease Control and Prevention (CDC) reported the highest number of planned home births in 30 years. The numbers rose 12% from 2020 to 2021, the latest period for which complete data are available. Home births rose from 45,646 (1.26% of births) in 2020 to 51,642 (1.41% of births).

Amos Grünebaum, MD, and Frank A. Chervenak, MD, with Northwell Health, and the Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine in New Hyde Park, New York, reviewed the latest safety data surrounding community births in the United States along with well-known perinatal risks and safety requirements for safe out-of-hospital births.

“Most planned home births continue to have one or more risk factors that are associated with an increase in adverse pregnancy outcomes,” they wrote.
 

Birth Certificate Data Analyzed

The researchers used the CDC birth certificate database and analyzed deliveries between 2016 and 2022 regarding the incidence of perinatal risks in community births. The risks included were prior cesarean, first baby, mother older than 35 years, twins, breech presentation, gestational age of less than 37 weeks or more than 41 weeks, newborn weight over 4,000 grams, adequacy of prenatal care, grand multiparity (5 or more prior pregnancies), and a prepregnancy body mass index of at least 35.

The incidence of perinatal risks for out-of-hospital births ranged individually from 0.2% to 28.54% among birthing center births and 0.32% to 24.4% for planned home births.

“The ACOG committee opinion on home births states that for every 1000 home births, 3.9 babies will die,” the authors noted, or about twice the risk of hospital births. The deaths are “potentially avoidable with easy access to an operating room,” they wrote.

Among the safety concerns for perinatal morbidity and mortality in community births, the authors cited the lack of:

• Appropriate patient selection for out-of-hospital births through standardized guidelines.
• Availability of a Certified Nurse Midwife, a Certified Midwife, or midwife whose education and licensure meet International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education.
• Providers practicing obstetrics within an integrated and regulated health system with ready access and availability of board-certified obstetricians to provide consultation for qualified midwives.
• Standardized guidelines on when transport to a hospital is necessary.

“While prerequisites for a safe out-of-hospital delivery may be in place in other high-income countries, these prerequisites have not been actualized in the United States,” the authors wrote.

Incorporating Patient Preferences Into Delivery Models

Yalda Afshar, MD, PhD, maternal-fetal medicine subspecialist and a physician-scientist at UCLA Health in California, said obstetricians are responsible for offering the most evidence-based care to pregnant people.

“What this birth certificate data demonstrates,” she said, “is a tendency among birthing people to opt for out-of-hospital births, despite documented risks to both the pregnant person and the neonate. This underscores the need to persist in educating on risk stratification, risk reduction, and safe birthing practices, while also fostering innovation. Innovation should stem from our commitment to incorporate the preferences of pregnant people into our healthcare delivery model.”

Dr. Afshar, who was not part of the study, said clinicians should develop innovative ways to effectively meet the needs of pregnant patients while ensuring their safety and well-being.

“Ideally, we would establish safe environments within hospital systems and centers that emulate home-like birthing experiences, thereby mitigating risks for these families,” she said.

Though not explicitly stated in the data, she added, it is crucial to emphasize the need for continuous risk assessment throughout pregnancy and childbirth, “with a paramount focus on the safety of the pregnant individual.”

The authors and Dr. Afshar have no relevant financial disclosures.

Safety concerns persist for out-of-hospital births in the United States with multiple potential risk factors and few safety requirements, according to a paper published in the American Journal of Obstetrics and Gynecology.

In 2022, the Centers for Disease Control and Prevention (CDC) reported the highest number of planned home births in 30 years. The numbers rose 12% from 2020 to 2021, the latest period for which complete data are available. Home births rose from 45,646 (1.26% of births) in 2020 to 51,642 (1.41% of births).

Amos Grünebaum, MD, and Frank A. Chervenak, MD, with Northwell Health, and the Department of Obstetrics and Gynecology, Lenox Hill Hospital, Zucker School of Medicine in New Hyde Park, New York, reviewed the latest safety data surrounding community births in the United States along with well-known perinatal risks and safety requirements for safe out-of-hospital births.

“Most planned home births continue to have one or more risk factors that are associated with an increase in adverse pregnancy outcomes,” they wrote.
 

Birth Certificate Data Analyzed

The researchers used the CDC birth certificate database and analyzed deliveries between 2016 and 2022 regarding the incidence of perinatal risks in community births. The risks included were prior cesarean, first baby, mother older than 35 years, twins, breech presentation, gestational age of less than 37 weeks or more than 41 weeks, newborn weight over 4,000 grams, adequacy of prenatal care, grand multiparity (5 or more prior pregnancies), and a prepregnancy body mass index of at least 35.

The incidence of perinatal risks for out-of-hospital births ranged individually from 0.2% to 28.54% among birthing center births and 0.32% to 24.4% for planned home births.

“The ACOG committee opinion on home births states that for every 1000 home births, 3.9 babies will die,” the authors noted, or about twice the risk of hospital births. The deaths are “potentially avoidable with easy access to an operating room,” they wrote.

Among the safety concerns for perinatal morbidity and mortality in community births, the authors cited the lack of:

• Appropriate patient selection for out-of-hospital births through standardized guidelines.
• Availability of a Certified Nurse Midwife, a Certified Midwife, or midwife whose education and licensure meet International Confederation of Midwives’ (ICM) Global Standards for Midwifery Education.
• Providers practicing obstetrics within an integrated and regulated health system with ready access and availability of board-certified obstetricians to provide consultation for qualified midwives.
• Standardized guidelines on when transport to a hospital is necessary.

“While prerequisites for a safe out-of-hospital delivery may be in place in other high-income countries, these prerequisites have not been actualized in the United States,” the authors wrote.

Incorporating Patient Preferences Into Delivery Models

Yalda Afshar, MD, PhD, maternal-fetal medicine subspecialist and a physician-scientist at UCLA Health in California, said obstetricians are responsible for offering the most evidence-based care to pregnant people.

“What this birth certificate data demonstrates,” she said, “is a tendency among birthing people to opt for out-of-hospital births, despite documented risks to both the pregnant person and the neonate. This underscores the need to persist in educating on risk stratification, risk reduction, and safe birthing practices, while also fostering innovation. Innovation should stem from our commitment to incorporate the preferences of pregnant people into our healthcare delivery model.”

Dr. Afshar, who was not part of the study, said clinicians should develop innovative ways to effectively meet the needs of pregnant patients while ensuring their safety and well-being.

“Ideally, we would establish safe environments within hospital systems and centers that emulate home-like birthing experiences, thereby mitigating risks for these families,” she said.

Though not explicitly stated in the data, she added, it is crucial to emphasize the need for continuous risk assessment throughout pregnancy and childbirth, “with a paramount focus on the safety of the pregnant individual.”

The authors and Dr. Afshar have no relevant financial disclosures.