Women's Health

NEWPORT BEACH, CALIF. – Psoriasis often clears in pregnant women, giving them a rare break from the skin disease. But there still are plenty of reasons to pay close attention to psoriasis drugs in any women who is or could become pregnant.

Bruce Jancin/Frontline Medical News

Data from 2011 found 45% of pregnancies in U.S. women aged 15-44 years were unintended (N Engl J Med. 2016 Mar 3;374[9]:843-52), cautioned Jashin J. Wu, MD, of Dermatology Research and Education Foundation, Irvine, Calif.

In a presentation at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar, Dr. Wu offered these tips about pregnancy and psoriasis:

Counsel patients before pregnancy

There’s conflicting data about the risks of psoriasis in pregnancy, Dr. Wu said. One 23-year-old study suggests a link to adverse outcomes such as preterm and low-birth-weight babies. But another more recent study found no sign of increased risk (Int J Dermatol. 1996;35:169-72; J Am Acad Dermatol. 2011;64:71-7).

Counseling can include information about risks such as hospitalization during pregnancy because of undertreatment of psoriasis, he said. Discuss lowering medication doses to the lowest effective dose, he recommended, and talk about alternatives to systemic medications.

Make adjustments to timing as needed

In patients with severe cases, it may be appropriate to recommend that they postpone pregnancy until their psoriasis is under better control. As for treatment of psoriasis, “you may want to consider timing medication to end around the first trimester to get the medication out of them during the greatest risk period for the baby,” Dr. Wu said.

Adjust steroids as necessary

There are no “good” studies about the use of steroids in pregnant women with psoriasis, Dr. Wu said. “We can probably assume they are safe overall. Weaker steroids may have less risk,” and some of the stronger steroids may raise concerns.

Dr. Wu made these recommendations: Limit mild-potency topical corticosteroids to less than 100 g/week, potent topical corticosteroids to less than 50 g/week, and superpotent topical corticosteroids to less than 30 g/week.

Some topical drugs appear to be OK

Vitamin D analogues have not been well-studied in pregnancy, he said, but “we consider topical use to be fairly safe.”

There’s no data on calcineurin inhibitors in pregnancy, he said, but topical use is considered to be safe because there’s limited systemic absorption.

Beware of certain drugs in pregnancyTazarotene is considered to be dangerous in pregnancy, Dr. Wu said, and females of childbearing age who take it should use effective contraception, and have a recent negative pregnancy test (within 2 weeks before treatment begins). “In general, I’d probably not use this,” he said. “We have so many other options.”

Data about pregnancy safety for three topical drugs – coal tar, anthralin, and salicylic acid – is limited or nonexistent, Dr. Wu said, and he recommends against their use in pregnancy.

Phototherapy is OK in pregnancy

Phototherapy is considered safe because UVB doesn’t penetrate the superficial layer of the skin, he said. But phototherapy brings a potential risk of lowered folic acid levels, and he urges folic acid supplementation in women undergoing the treatment who are considering pregnancy or who are in the first trimester.

Avoid certain systemic drugs

Dr. Wu offered these recommendations:

• Methotrexate: Do not take during pregnancy, or 3 months prior to conception.
• Acitretin (Soriatane): Avoid all use in women who may become pregnant.
• Cyclosporine: Be aware of reports of prematurity and low birth weight linked to the drug.
• Apremilast (Otezla): Animal studies have shown a risk in pregnancy. Stop the drug at least 2 days before conception.

Avoid monoclonal antibodies

These drugs “result in therapeutic levels in the fetus, which is not a good thing,” Dr. Wu said. “You obviously don’t want to have monoclonal antibodies in the baby.”

Nix the PUVA

While one study found no link between psoralen plus UVA (PUVA) and birth defects (Arch Dermatol. 1993 Mar;129[3]:320-3), there’s still a theoretical risk, Dr. Wu said. He recommended that the treatment be avoided during pregnancy.

Watch for waxing and waning

Dr. Wu pointed to a small 2005 study that suggested that psoriasis activity declines during pregnancy. The study used different measures, finding that psoriasis improved by 30% (based on at least a 3% change in body surface area) or 55% (based on patient self-reporting). But it flares after pregnancy as reported by 65% of women surveyed; a body surface area analysis found that psoriasis worsened in 41% (Arch Dermatol. 2005 May;141[5]:601-6).

Dr. Wu reports various relationships (research, consultation and speaking) with 15 pharmaceutical companies. SDEF and this news organization are owned by the same parent company.

NEWPORT BEACH, CALIF. – Psoriasis often clears in pregnant women, giving them a rare break from the skin disease. But there still are plenty of reasons to pay close attention to psoriasis drugs in any women who is or could become pregnant.

Bruce Jancin/Frontline Medical News

Data from 2011 found 45% of pregnancies in U.S. women aged 15-44 years were unintended (N Engl J Med. 2016 Mar 3;374[9]:843-52), cautioned Jashin J. Wu, MD, of Dermatology Research and Education Foundation, Irvine, Calif.

In a presentation at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar, Dr. Wu offered these tips about pregnancy and psoriasis:

Counsel patients before pregnancy

There’s conflicting data about the risks of psoriasis in pregnancy, Dr. Wu said. One 23-year-old study suggests a link to adverse outcomes such as preterm and low-birth-weight babies. But another more recent study found no sign of increased risk (Int J Dermatol. 1996;35:169-72; J Am Acad Dermatol. 2011;64:71-7).

Counseling can include information about risks such as hospitalization during pregnancy because of undertreatment of psoriasis, he said. Discuss lowering medication doses to the lowest effective dose, he recommended, and talk about alternatives to systemic medications.

Make adjustments to timing as needed

In patients with severe cases, it may be appropriate to recommend that they postpone pregnancy until their psoriasis is under better control. As for treatment of psoriasis, “you may want to consider timing medication to end around the first trimester to get the medication out of them during the greatest risk period for the baby,” Dr. Wu said.

Adjust steroids as necessary

There are no “good” studies about the use of steroids in pregnant women with psoriasis, Dr. Wu said. “We can probably assume they are safe overall. Weaker steroids may have less risk,” and some of the stronger steroids may raise concerns.

Dr. Wu made these recommendations: Limit mild-potency topical corticosteroids to less than 100 g/week, potent topical corticosteroids to less than 50 g/week, and superpotent topical corticosteroids to less than 30 g/week.

Some topical drugs appear to be OK

Vitamin D analogues have not been well-studied in pregnancy, he said, but “we consider topical use to be fairly safe.”

There’s no data on calcineurin inhibitors in pregnancy, he said, but topical use is considered to be safe because there’s limited systemic absorption.

Beware of certain drugs in pregnancyTazarotene is considered to be dangerous in pregnancy, Dr. Wu said, and females of childbearing age who take it should use effective contraception, and have a recent negative pregnancy test (within 2 weeks before treatment begins). “In general, I’d probably not use this,” he said. “We have so many other options.”

Data about pregnancy safety for three topical drugs – coal tar, anthralin, and salicylic acid – is limited or nonexistent, Dr. Wu said, and he recommends against their use in pregnancy.

Phototherapy is OK in pregnancy

Phototherapy is considered safe because UVB doesn’t penetrate the superficial layer of the skin, he said. But phototherapy brings a potential risk of lowered folic acid levels, and he urges folic acid supplementation in women undergoing the treatment who are considering pregnancy or who are in the first trimester.

Avoid certain systemic drugs

Dr. Wu offered these recommendations:

• Methotrexate: Do not take during pregnancy, or 3 months prior to conception.
• Acitretin (Soriatane): Avoid all use in women who may become pregnant.
• Cyclosporine: Be aware of reports of prematurity and low birth weight linked to the drug.
• Apremilast (Otezla): Animal studies have shown a risk in pregnancy. Stop the drug at least 2 days before conception.

Avoid monoclonal antibodies

These drugs “result in therapeutic levels in the fetus, which is not a good thing,” Dr. Wu said. “You obviously don’t want to have monoclonal antibodies in the baby.”

Nix the PUVA

While one study found no link between psoralen plus UVA (PUVA) and birth defects (Arch Dermatol. 1993 Mar;129[3]:320-3), there’s still a theoretical risk, Dr. Wu said. He recommended that the treatment be avoided during pregnancy.

Watch for waxing and waning

Dr. Wu pointed to a small 2005 study that suggested that psoriasis activity declines during pregnancy. The study used different measures, finding that psoriasis improved by 30% (based on at least a 3% change in body surface area) or 55% (based on patient self-reporting). But it flares after pregnancy as reported by 65% of women surveyed; a body surface area analysis found that psoriasis worsened in 41% (Arch Dermatol. 2005 May;141[5]:601-6).

Dr. Wu reports various relationships (research, consultation and speaking) with 15 pharmaceutical companies. SDEF and this news organization are owned by the same parent company.

NEWPORT BEACH, CALIF. – Psoriasis often clears in pregnant women, giving them a rare break from the skin disease. But there still are plenty of reasons to pay close attention to psoriasis drugs in any women who is or could become pregnant.

Bruce Jancin/Frontline Medical News

Data from 2011 found 45% of pregnancies in U.S. women aged 15-44 years were unintended (N Engl J Med. 2016 Mar 3;374[9]:843-52), cautioned Jashin J. Wu, MD, of Dermatology Research and Education Foundation, Irvine, Calif.

In a presentation at the Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar, Dr. Wu offered these tips about pregnancy and psoriasis:

Counsel patients before pregnancy

There’s conflicting data about the risks of psoriasis in pregnancy, Dr. Wu said. One 23-year-old study suggests a link to adverse outcomes such as preterm and low-birth-weight babies. But another more recent study found no sign of increased risk (Int J Dermatol. 1996;35:169-72; J Am Acad Dermatol. 2011;64:71-7).

Counseling can include information about risks such as hospitalization during pregnancy because of undertreatment of psoriasis, he said. Discuss lowering medication doses to the lowest effective dose, he recommended, and talk about alternatives to systemic medications.

Make adjustments to timing as needed

In patients with severe cases, it may be appropriate to recommend that they postpone pregnancy until their psoriasis is under better control. As for treatment of psoriasis, “you may want to consider timing medication to end around the first trimester to get the medication out of them during the greatest risk period for the baby,” Dr. Wu said.

Adjust steroids as necessary

There are no “good” studies about the use of steroids in pregnant women with psoriasis, Dr. Wu said. “We can probably assume they are safe overall. Weaker steroids may have less risk,” and some of the stronger steroids may raise concerns.

Dr. Wu made these recommendations: Limit mild-potency topical corticosteroids to less than 100 g/week, potent topical corticosteroids to less than 50 g/week, and superpotent topical corticosteroids to less than 30 g/week.

Some topical drugs appear to be OK

Vitamin D analogues have not been well-studied in pregnancy, he said, but “we consider topical use to be fairly safe.”

There’s no data on calcineurin inhibitors in pregnancy, he said, but topical use is considered to be safe because there’s limited systemic absorption.

Beware of certain drugs in pregnancyTazarotene is considered to be dangerous in pregnancy, Dr. Wu said, and females of childbearing age who take it should use effective contraception, and have a recent negative pregnancy test (within 2 weeks before treatment begins). “In general, I’d probably not use this,” he said. “We have so many other options.”

Data about pregnancy safety for three topical drugs – coal tar, anthralin, and salicylic acid – is limited or nonexistent, Dr. Wu said, and he recommends against their use in pregnancy.

Phototherapy is OK in pregnancy

Phototherapy is considered safe because UVB doesn’t penetrate the superficial layer of the skin, he said. But phototherapy brings a potential risk of lowered folic acid levels, and he urges folic acid supplementation in women undergoing the treatment who are considering pregnancy or who are in the first trimester.

Avoid certain systemic drugs

Dr. Wu offered these recommendations:

• Methotrexate: Do not take during pregnancy, or 3 months prior to conception.
• Acitretin (Soriatane): Avoid all use in women who may become pregnant.
• Cyclosporine: Be aware of reports of prematurity and low birth weight linked to the drug.
• Apremilast (Otezla): Animal studies have shown a risk in pregnancy. Stop the drug at least 2 days before conception.

Avoid monoclonal antibodies

These drugs “result in therapeutic levels in the fetus, which is not a good thing,” Dr. Wu said. “You obviously don’t want to have monoclonal antibodies in the baby.”

Nix the PUVA

While one study found no link between psoralen plus UVA (PUVA) and birth defects (Arch Dermatol. 1993 Mar;129[3]:320-3), there’s still a theoretical risk, Dr. Wu said. He recommended that the treatment be avoided during pregnancy.

Watch for waxing and waning

Dr. Wu pointed to a small 2005 study that suggested that psoriasis activity declines during pregnancy. The study used different measures, finding that psoriasis improved by 30% (based on at least a 3% change in body surface area) or 55% (based on patient self-reporting). But it flares after pregnancy as reported by 65% of women surveyed; a body surface area analysis found that psoriasis worsened in 41% (Arch Dermatol. 2005 May;141[5]:601-6).

Dr. Wu reports various relationships (research, consultation and speaking) with 15 pharmaceutical companies. SDEF and this news organization are owned by the same parent company.

A policy of universal screening of perinatal depression for women receiving prenatal care at an academic medical center led to more regular screening of depression, and made it more likely that women with postpartum depression would be referred for treatment, according to recent research published in Obstetrics & Gynecology.

©monkeybusinessimages/Thinkstock

Emily S. Miller, MD, MPH, at Northwestern University, Chicago, and colleagues performed a retrospective study of 5,127 women receiving prenatal care at the center between 2008 and 2015. They divided the group into those who were at the center before (n = 1,122) and after (n = 4,005) initiation of a policy on universal perinatal depression screening, which consisted of two antenatal screenings at the first prenatal visit and third trimester, and one postpartum screening.

After initiation of the policy, screening increased during the first trimester (0.1% vs. 66%; P less than .001), the third trimester (0% vs. 43%; P less than .001), and at the postpartum visit (70% vs. 90%; P less than .001). Screening continued to increase at both prenatal visits, while screening prevalence remained the same for the postpartum visit. Women who had a positive result after postpartum depression screening were more than twice as likely to receive treatment or a referral for their depression in the post-policy group (30% vs. 65%).

Katrina S. Mark, MD, associate professor of the department of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, said in an interview that the study “brings attention to an incredibly important topic.

“The researchers in this study found that, after implementation of a new policy regarding antenatal and postpartum depression screening, there was a significant increase in women who were screened during and after pregnancy as well as an increase in those who were appropriately treated,” she said. “Importantly, however, their intervention was not only a policy, but also provided education and resources to providers to increase awareness and knowledge surrounding the subject of depression and how to screen and treat this common condition.”

Dr. Miller and colleagues noted their study was limited because they were unable to determine whether prescriptions were filled or if referrals led to actual provider visits. Other obstacles to mental health care in the perinatal period also exist in the form of logistic barriers to appointments and stigma about mental health treatment.

“Depression is common, and screening and treatment during pregnancy and the postpartum period are extremely important to improve maternal and child health. As the authors point out, there has historically been a hesitation among obstetric providers to screen for depression,” Dr. Mark said. “My suspicion is that this hesitation is not because of a lack of awareness, but rather due to a lack of knowledge of what to do when a woman has a positive screen. In my opinion, the take-home message from this study is that implementation of a policy is possible and can lead to real change if it is accompanied by the appropriate resources and education.”

This study was funded by the Maternal-Fetal Medicine/Lumara Health Policy Award, and grants from the Eunice Kennedy Shriver National Institute of Child and Human Development and from the National Institutes of Health’s National Center for Advancing Translational Sciences. The authors reported no conflicts of interest.
 

SOURCE: Miller ES et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003369.

A policy of universal screening of perinatal depression for women receiving prenatal care at an academic medical center led to more regular screening of depression, and made it more likely that women with postpartum depression would be referred for treatment, according to recent research published in Obstetrics & Gynecology.

©monkeybusinessimages/Thinkstock

Emily S. Miller, MD, MPH, at Northwestern University, Chicago, and colleagues performed a retrospective study of 5,127 women receiving prenatal care at the center between 2008 and 2015. They divided the group into those who were at the center before (n = 1,122) and after (n = 4,005) initiation of a policy on universal perinatal depression screening, which consisted of two antenatal screenings at the first prenatal visit and third trimester, and one postpartum screening.

After initiation of the policy, screening increased during the first trimester (0.1% vs. 66%; P less than .001), the third trimester (0% vs. 43%; P less than .001), and at the postpartum visit (70% vs. 90%; P less than .001). Screening continued to increase at both prenatal visits, while screening prevalence remained the same for the postpartum visit. Women who had a positive result after postpartum depression screening were more than twice as likely to receive treatment or a referral for their depression in the post-policy group (30% vs. 65%).

Katrina S. Mark, MD, associate professor of the department of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, said in an interview that the study “brings attention to an incredibly important topic.

“The researchers in this study found that, after implementation of a new policy regarding antenatal and postpartum depression screening, there was a significant increase in women who were screened during and after pregnancy as well as an increase in those who were appropriately treated,” she said. “Importantly, however, their intervention was not only a policy, but also provided education and resources to providers to increase awareness and knowledge surrounding the subject of depression and how to screen and treat this common condition.”

Dr. Miller and colleagues noted their study was limited because they were unable to determine whether prescriptions were filled or if referrals led to actual provider visits. Other obstacles to mental health care in the perinatal period also exist in the form of logistic barriers to appointments and stigma about mental health treatment.

“Depression is common, and screening and treatment during pregnancy and the postpartum period are extremely important to improve maternal and child health. As the authors point out, there has historically been a hesitation among obstetric providers to screen for depression,” Dr. Mark said. “My suspicion is that this hesitation is not because of a lack of awareness, but rather due to a lack of knowledge of what to do when a woman has a positive screen. In my opinion, the take-home message from this study is that implementation of a policy is possible and can lead to real change if it is accompanied by the appropriate resources and education.”

This study was funded by the Maternal-Fetal Medicine/Lumara Health Policy Award, and grants from the Eunice Kennedy Shriver National Institute of Child and Human Development and from the National Institutes of Health’s National Center for Advancing Translational Sciences. The authors reported no conflicts of interest.
 

SOURCE: Miller ES et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003369.

A policy of universal screening of perinatal depression for women receiving prenatal care at an academic medical center led to more regular screening of depression, and made it more likely that women with postpartum depression would be referred for treatment, according to recent research published in Obstetrics & Gynecology.

©monkeybusinessimages/Thinkstock

Emily S. Miller, MD, MPH, at Northwestern University, Chicago, and colleagues performed a retrospective study of 5,127 women receiving prenatal care at the center between 2008 and 2015. They divided the group into those who were at the center before (n = 1,122) and after (n = 4,005) initiation of a policy on universal perinatal depression screening, which consisted of two antenatal screenings at the first prenatal visit and third trimester, and one postpartum screening.

After initiation of the policy, screening increased during the first trimester (0.1% vs. 66%; P less than .001), the third trimester (0% vs. 43%; P less than .001), and at the postpartum visit (70% vs. 90%; P less than .001). Screening continued to increase at both prenatal visits, while screening prevalence remained the same for the postpartum visit. Women who had a positive result after postpartum depression screening were more than twice as likely to receive treatment or a referral for their depression in the post-policy group (30% vs. 65%).

Katrina S. Mark, MD, associate professor of the department of obstetrics, gynecology, and reproductive sciences at the University of Maryland School of Medicine, said in an interview that the study “brings attention to an incredibly important topic.

“The researchers in this study found that, after implementation of a new policy regarding antenatal and postpartum depression screening, there was a significant increase in women who were screened during and after pregnancy as well as an increase in those who were appropriately treated,” she said. “Importantly, however, their intervention was not only a policy, but also provided education and resources to providers to increase awareness and knowledge surrounding the subject of depression and how to screen and treat this common condition.”

Dr. Miller and colleagues noted their study was limited because they were unable to determine whether prescriptions were filled or if referrals led to actual provider visits. Other obstacles to mental health care in the perinatal period also exist in the form of logistic barriers to appointments and stigma about mental health treatment.

“Depression is common, and screening and treatment during pregnancy and the postpartum period are extremely important to improve maternal and child health. As the authors point out, there has historically been a hesitation among obstetric providers to screen for depression,” Dr. Mark said. “My suspicion is that this hesitation is not because of a lack of awareness, but rather due to a lack of knowledge of what to do when a woman has a positive screen. In my opinion, the take-home message from this study is that implementation of a policy is possible and can lead to real change if it is accompanied by the appropriate resources and education.”

This study was funded by the Maternal-Fetal Medicine/Lumara Health Policy Award, and grants from the Eunice Kennedy Shriver National Institute of Child and Human Development and from the National Institutes of Health’s National Center for Advancing Translational Sciences. The authors reported no conflicts of interest.
 

SOURCE: Miller ES et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003369.

Patients who underwent medication abortion under the care of a clinician through a telemedicine service did not have any difference in outcomes, compared with patients who saw a clinician in person, according to a study in Obstetrics & Gynecology.

“To the extent that state bans on telemedicine for abortion rest on arguments of improved patient safety, the findings of this and previous studies do not support such contentions,” Julia E. Kohn, PhD, MPA, from Planned Parenthood Federation of America in New York and colleagues wrote.

Dr. Kohn, with colleagues from Ibis Reproductive Health, Bixby Center for Global Reproductive Health, and the University of California, San Francisco, assessed the outcomes of 5,952 patients who underwent medication abortion either through a telemedicine visit (738 patients) or in-person visit (5,214 patients). In the telemedicine group, the patients took mifepristone in view of the clinician over a secure videoconference platform followed by misoprostol 48 hours later as dispensed by a health center. Patients in the telemedicine group had a slightly older gestational age (50 days), compared with patients in the standard-care group (49 days).

Telemedicine patients received the same on-site care as those patients who saw a clinician in person, including informed consent, lab testing, and ultrasound scans. Patients who received care over telemedicine also received the same follow-up instructions as those who received standard of care, which consisted of an ultrasound evaluation 1-2 weeks after the visit, or human chorionic gonadotropin (hCG) testing.

While telemedicine patients were less likely to follow up at 45 days than were patients who received standard care (60% vs. 77%; prevalence ratio, 0.83; 95% confidence interval, 0.78-0.88), they also were less likely to have an ongoing pregnancy at follow-up (0.5% vs. 1.8%; adjusted odds ratio, 0.23; 95% CI, 0.14–0.39) or undergo an aspiration procedure (1% vs. 5%; aOR, 0.28; 95% CI, 0.17–0.46) than were standard-of-care patients. With regard to adverse events, the rate was less than 1% for each group, and the researchers reported no maternal deaths in either group.

Eve Espey, MD, MPH, professor and chair of the department of obstetrics and gynecology and director of the family planning fellowship at the University of New Mexico, Albuquerque, commented that this study expands the evidence of positive outcomes of telemedicine abortion to four new states: Alaska, Idaho, Nevada, and Washington.

“Abortion access is limited in the large rural states in which the study was conducted; across the country, abortion access is increasingly limited by restrictive legislation including telemedicine abortion bans,” she said in an interview. “This reassuring study helps demonstrate the safety of telemedicine medication abortion and highlights the role of telemedicine in improving health equity by increasing access to a critical health care service.”

The researchers said the results were limited in that most telemedicine care was centered in one state, Nevada, and the sample size was inadequate to do per-state comparisons of in-person visits and telemedicine. In addition, follow-up data was available for 75% of patients, which meant approximately one-fourth of patients did not follow up with the health center.

The Susan T. Buffett Foundation provided a grant for this study. Dr. Grossman receives consulting payments from Planned Parenthood Federation of America for work related to telemedicine for medication abortion. The other authors reported no relevant conflicts of interest.

SOURCE: Kohn JE et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003357.

Patients who underwent medication abortion under the care of a clinician through a telemedicine service did not have any difference in outcomes, compared with patients who saw a clinician in person, according to a study in Obstetrics & Gynecology.

“To the extent that state bans on telemedicine for abortion rest on arguments of improved patient safety, the findings of this and previous studies do not support such contentions,” Julia E. Kohn, PhD, MPA, from Planned Parenthood Federation of America in New York and colleagues wrote.

Dr. Kohn, with colleagues from Ibis Reproductive Health, Bixby Center for Global Reproductive Health, and the University of California, San Francisco, assessed the outcomes of 5,952 patients who underwent medication abortion either through a telemedicine visit (738 patients) or in-person visit (5,214 patients). In the telemedicine group, the patients took mifepristone in view of the clinician over a secure videoconference platform followed by misoprostol 48 hours later as dispensed by a health center. Patients in the telemedicine group had a slightly older gestational age (50 days), compared with patients in the standard-care group (49 days).

Telemedicine patients received the same on-site care as those patients who saw a clinician in person, including informed consent, lab testing, and ultrasound scans. Patients who received care over telemedicine also received the same follow-up instructions as those who received standard of care, which consisted of an ultrasound evaluation 1-2 weeks after the visit, or human chorionic gonadotropin (hCG) testing.

While telemedicine patients were less likely to follow up at 45 days than were patients who received standard care (60% vs. 77%; prevalence ratio, 0.83; 95% confidence interval, 0.78-0.88), they also were less likely to have an ongoing pregnancy at follow-up (0.5% vs. 1.8%; adjusted odds ratio, 0.23; 95% CI, 0.14–0.39) or undergo an aspiration procedure (1% vs. 5%; aOR, 0.28; 95% CI, 0.17–0.46) than were standard-of-care patients. With regard to adverse events, the rate was less than 1% for each group, and the researchers reported no maternal deaths in either group.

Eve Espey, MD, MPH, professor and chair of the department of obstetrics and gynecology and director of the family planning fellowship at the University of New Mexico, Albuquerque, commented that this study expands the evidence of positive outcomes of telemedicine abortion to four new states: Alaska, Idaho, Nevada, and Washington.

“Abortion access is limited in the large rural states in which the study was conducted; across the country, abortion access is increasingly limited by restrictive legislation including telemedicine abortion bans,” she said in an interview. “This reassuring study helps demonstrate the safety of telemedicine medication abortion and highlights the role of telemedicine in improving health equity by increasing access to a critical health care service.”

The researchers said the results were limited in that most telemedicine care was centered in one state, Nevada, and the sample size was inadequate to do per-state comparisons of in-person visits and telemedicine. In addition, follow-up data was available for 75% of patients, which meant approximately one-fourth of patients did not follow up with the health center.

The Susan T. Buffett Foundation provided a grant for this study. Dr. Grossman receives consulting payments from Planned Parenthood Federation of America for work related to telemedicine for medication abortion. The other authors reported no relevant conflicts of interest.

SOURCE: Kohn JE et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003357.

Patients who underwent medication abortion under the care of a clinician through a telemedicine service did not have any difference in outcomes, compared with patients who saw a clinician in person, according to a study in Obstetrics & Gynecology.

“To the extent that state bans on telemedicine for abortion rest on arguments of improved patient safety, the findings of this and previous studies do not support such contentions,” Julia E. Kohn, PhD, MPA, from Planned Parenthood Federation of America in New York and colleagues wrote.

Dr. Kohn, with colleagues from Ibis Reproductive Health, Bixby Center for Global Reproductive Health, and the University of California, San Francisco, assessed the outcomes of 5,952 patients who underwent medication abortion either through a telemedicine visit (738 patients) or in-person visit (5,214 patients). In the telemedicine group, the patients took mifepristone in view of the clinician over a secure videoconference platform followed by misoprostol 48 hours later as dispensed by a health center. Patients in the telemedicine group had a slightly older gestational age (50 days), compared with patients in the standard-care group (49 days).

Telemedicine patients received the same on-site care as those patients who saw a clinician in person, including informed consent, lab testing, and ultrasound scans. Patients who received care over telemedicine also received the same follow-up instructions as those who received standard of care, which consisted of an ultrasound evaluation 1-2 weeks after the visit, or human chorionic gonadotropin (hCG) testing.

While telemedicine patients were less likely to follow up at 45 days than were patients who received standard care (60% vs. 77%; prevalence ratio, 0.83; 95% confidence interval, 0.78-0.88), they also were less likely to have an ongoing pregnancy at follow-up (0.5% vs. 1.8%; adjusted odds ratio, 0.23; 95% CI, 0.14–0.39) or undergo an aspiration procedure (1% vs. 5%; aOR, 0.28; 95% CI, 0.17–0.46) than were standard-of-care patients. With regard to adverse events, the rate was less than 1% for each group, and the researchers reported no maternal deaths in either group.

Eve Espey, MD, MPH, professor and chair of the department of obstetrics and gynecology and director of the family planning fellowship at the University of New Mexico, Albuquerque, commented that this study expands the evidence of positive outcomes of telemedicine abortion to four new states: Alaska, Idaho, Nevada, and Washington.

“Abortion access is limited in the large rural states in which the study was conducted; across the country, abortion access is increasingly limited by restrictive legislation including telemedicine abortion bans,” she said in an interview. “This reassuring study helps demonstrate the safety of telemedicine medication abortion and highlights the role of telemedicine in improving health equity by increasing access to a critical health care service.”

The researchers said the results were limited in that most telemedicine care was centered in one state, Nevada, and the sample size was inadequate to do per-state comparisons of in-person visits and telemedicine. In addition, follow-up data was available for 75% of patients, which meant approximately one-fourth of patients did not follow up with the health center.

The Susan T. Buffett Foundation provided a grant for this study. Dr. Grossman receives consulting payments from Planned Parenthood Federation of America for work related to telemedicine for medication abortion. The other authors reported no relevant conflicts of interest.

SOURCE: Kohn JE et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003357.

Children exposed to opioids via maternal use during pregnancy were at increased risk of perinatal and postnatal physical and neurodevelopmental disabilities, according to data from more than 8,000 children.

Antonio_Diaz/Thinkstock

Previous studies have shown the increased risk of a range of health problems associated with maternal opioid use, including neonatal abstinence syndrome (NAS), but data on the long-term consequences of in utero opioid exposure are limited, wrote Romuladus E. Azuine, DrPH, MPH, of the U.S. Department of Health and Human Services, Rockville, Md., and colleagues.

In a study published in JAMA Network Open, the researchers reviewed data from 8,509 mother/newborn pairs in the Boston Birth Cohort, a database that included a large urban, low-income, multiethnic population of women who had singleton births at the Boston Medical Center starting in 1998.

A total of 454 infants (5%) experienced prenatal opioid exposure. Mothers were interviewed 48-72 hours after delivery about sociodemographic factors, drug use, smoking, and alcohol use.

The risk of small for gestational age and preterm birth were significantly higher in babies exposed to opioids (OR 1.87 and OR 1.49, respectively), compared with unexposed newborns.

Children’s developmental outcomes were collected starting in 2003 based on electronic medical records. A total of 3,153 mother-newborn pairs were enrolled in a postnatal follow-up study. For preschoolers, prenatal opioid exposure was associated with increased risk of lack of expected physiological development and conduct disorder/emotional disturbance (OR 1.80 and OR 2.13, respectively), compared with unexposed children. School-aged children with prenatal opioid exposure had an increased risk of ADHD (OR 2.55).

The incidence of NAS in the study population was at least 24 per 1,000 hospital births starting in 2004, and peaked at 61 per 1,000 hospital births in 2008, but remained higher than 32 per 1,000 through 2016.

The study findings were limited by several factors including potential misclassification of opioid exposure, confounding from other pregnancy exposures, loss of many participants to follow-up, and a lack of generalizability, but the results support the need for additional research, and show that the prevalence of NAS was approximately 10 times the national average in a subset of low-income, urban, minority women, the researchers said.

“However, the effect of opioids is still difficult to disentangle from effects of other childhood exposures. Policy and programmatic efforts to prevent NAS and mitigate its health consequences require more comprehensive longitudinal and intergenerational research,” they concluded.

The study findings contribute to and support the evidence of poor neurodevelopmental and emotional/behavioral outcomes for children with prenatal exposure to opioids or a history of NAS, Susan Brogly, PhD, MSc, noted in an accompanying editorial. Other studies have shown increased risks for visual impairments including strabismus, reduced visual acuity, and delayed visual maturation.

Dr. Brogly, of Queen’s University, Kingston Health Science Center, Ontario, nonetheless noted that a child’s home environment may modify the impact of prenatal opioid exposure or NAS, as evidence has shown that children with in utero heroin exposure have improved outcomes in healthy home environments.

Although the mechanism for how opioid exposure affects development remains uncertain, she suggested that future research should address “interventions to improve health outcomes in this rapidly growing population of children, regardless of the causal mechanism of impairment.”

Dr. Brogly noted that most of the opioid-using mothers in the study by Azuine et al. were unmarried, non-Hispanic white, and multiparous, and had histories of other substance abuse. She emphasized the need for supportive communities for women at risk of opioid use, who also are more likely to have unstable housing situations and histories of sexual and physical abuse.

“The risks of poor pregnancy and child outcomes in cases of maternal opioid exposure are not because of prenatal opioid exposure alone; ongoing difficult social and environmental circumstances have an important role,” and future interventions should address these circumstances to improve long-term health of high-risk women and their children, she emphasized.

The Boston Birth Cohort study is supported in part by grants from the National Institutes of Health and the U.S. Department of Health and Human Services. None of the authors had financial conflicts to disclose.

Dr. Brogly disclosed grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development outside the submitted work.

SOURCE: Azuine RE et al. JAMA Network Open. 2019 Jun 28. doi: 10.1001/jamanetworkopen.2019.6405; Brogly S. JAMA Network Open. 2019 Jun 28. doi:10.1001/jamanetworkopen.2019.6428.

Children exposed to opioids via maternal use during pregnancy were at increased risk of perinatal and postnatal physical and neurodevelopmental disabilities, according to data from more than 8,000 children.

Antonio_Diaz/Thinkstock

Previous studies have shown the increased risk of a range of health problems associated with maternal opioid use, including neonatal abstinence syndrome (NAS), but data on the long-term consequences of in utero opioid exposure are limited, wrote Romuladus E. Azuine, DrPH, MPH, of the U.S. Department of Health and Human Services, Rockville, Md., and colleagues.

In a study published in JAMA Network Open, the researchers reviewed data from 8,509 mother/newborn pairs in the Boston Birth Cohort, a database that included a large urban, low-income, multiethnic population of women who had singleton births at the Boston Medical Center starting in 1998.

A total of 454 infants (5%) experienced prenatal opioid exposure. Mothers were interviewed 48-72 hours after delivery about sociodemographic factors, drug use, smoking, and alcohol use.

The risk of small for gestational age and preterm birth were significantly higher in babies exposed to opioids (OR 1.87 and OR 1.49, respectively), compared with unexposed newborns.

Children’s developmental outcomes were collected starting in 2003 based on electronic medical records. A total of 3,153 mother-newborn pairs were enrolled in a postnatal follow-up study. For preschoolers, prenatal opioid exposure was associated with increased risk of lack of expected physiological development and conduct disorder/emotional disturbance (OR 1.80 and OR 2.13, respectively), compared with unexposed children. School-aged children with prenatal opioid exposure had an increased risk of ADHD (OR 2.55).

The incidence of NAS in the study population was at least 24 per 1,000 hospital births starting in 2004, and peaked at 61 per 1,000 hospital births in 2008, but remained higher than 32 per 1,000 through 2016.

The study findings were limited by several factors including potential misclassification of opioid exposure, confounding from other pregnancy exposures, loss of many participants to follow-up, and a lack of generalizability, but the results support the need for additional research, and show that the prevalence of NAS was approximately 10 times the national average in a subset of low-income, urban, minority women, the researchers said.

“However, the effect of opioids is still difficult to disentangle from effects of other childhood exposures. Policy and programmatic efforts to prevent NAS and mitigate its health consequences require more comprehensive longitudinal and intergenerational research,” they concluded.

The study findings contribute to and support the evidence of poor neurodevelopmental and emotional/behavioral outcomes for children with prenatal exposure to opioids or a history of NAS, Susan Brogly, PhD, MSc, noted in an accompanying editorial. Other studies have shown increased risks for visual impairments including strabismus, reduced visual acuity, and delayed visual maturation.

Dr. Brogly, of Queen’s University, Kingston Health Science Center, Ontario, nonetheless noted that a child’s home environment may modify the impact of prenatal opioid exposure or NAS, as evidence has shown that children with in utero heroin exposure have improved outcomes in healthy home environments.

Although the mechanism for how opioid exposure affects development remains uncertain, she suggested that future research should address “interventions to improve health outcomes in this rapidly growing population of children, regardless of the causal mechanism of impairment.”

Dr. Brogly noted that most of the opioid-using mothers in the study by Azuine et al. were unmarried, non-Hispanic white, and multiparous, and had histories of other substance abuse. She emphasized the need for supportive communities for women at risk of opioid use, who also are more likely to have unstable housing situations and histories of sexual and physical abuse.

“The risks of poor pregnancy and child outcomes in cases of maternal opioid exposure are not because of prenatal opioid exposure alone; ongoing difficult social and environmental circumstances have an important role,” and future interventions should address these circumstances to improve long-term health of high-risk women and their children, she emphasized.

The Boston Birth Cohort study is supported in part by grants from the National Institutes of Health and the U.S. Department of Health and Human Services. None of the authors had financial conflicts to disclose.

Dr. Brogly disclosed grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development outside the submitted work.

SOURCE: Azuine RE et al. JAMA Network Open. 2019 Jun 28. doi: 10.1001/jamanetworkopen.2019.6405; Brogly S. JAMA Network Open. 2019 Jun 28. doi:10.1001/jamanetworkopen.2019.6428.

Children exposed to opioids via maternal use during pregnancy were at increased risk of perinatal and postnatal physical and neurodevelopmental disabilities, according to data from more than 8,000 children.

Antonio_Diaz/Thinkstock

Previous studies have shown the increased risk of a range of health problems associated with maternal opioid use, including neonatal abstinence syndrome (NAS), but data on the long-term consequences of in utero opioid exposure are limited, wrote Romuladus E. Azuine, DrPH, MPH, of the U.S. Department of Health and Human Services, Rockville, Md., and colleagues.

In a study published in JAMA Network Open, the researchers reviewed data from 8,509 mother/newborn pairs in the Boston Birth Cohort, a database that included a large urban, low-income, multiethnic population of women who had singleton births at the Boston Medical Center starting in 1998.

A total of 454 infants (5%) experienced prenatal opioid exposure. Mothers were interviewed 48-72 hours after delivery about sociodemographic factors, drug use, smoking, and alcohol use.

The risk of small for gestational age and preterm birth were significantly higher in babies exposed to opioids (OR 1.87 and OR 1.49, respectively), compared with unexposed newborns.

Children’s developmental outcomes were collected starting in 2003 based on electronic medical records. A total of 3,153 mother-newborn pairs were enrolled in a postnatal follow-up study. For preschoolers, prenatal opioid exposure was associated with increased risk of lack of expected physiological development and conduct disorder/emotional disturbance (OR 1.80 and OR 2.13, respectively), compared with unexposed children. School-aged children with prenatal opioid exposure had an increased risk of ADHD (OR 2.55).

The incidence of NAS in the study population was at least 24 per 1,000 hospital births starting in 2004, and peaked at 61 per 1,000 hospital births in 2008, but remained higher than 32 per 1,000 through 2016.

The study findings were limited by several factors including potential misclassification of opioid exposure, confounding from other pregnancy exposures, loss of many participants to follow-up, and a lack of generalizability, but the results support the need for additional research, and show that the prevalence of NAS was approximately 10 times the national average in a subset of low-income, urban, minority women, the researchers said.

“However, the effect of opioids is still difficult to disentangle from effects of other childhood exposures. Policy and programmatic efforts to prevent NAS and mitigate its health consequences require more comprehensive longitudinal and intergenerational research,” they concluded.

The study findings contribute to and support the evidence of poor neurodevelopmental and emotional/behavioral outcomes for children with prenatal exposure to opioids or a history of NAS, Susan Brogly, PhD, MSc, noted in an accompanying editorial. Other studies have shown increased risks for visual impairments including strabismus, reduced visual acuity, and delayed visual maturation.

Dr. Brogly, of Queen’s University, Kingston Health Science Center, Ontario, nonetheless noted that a child’s home environment may modify the impact of prenatal opioid exposure or NAS, as evidence has shown that children with in utero heroin exposure have improved outcomes in healthy home environments.

Although the mechanism for how opioid exposure affects development remains uncertain, she suggested that future research should address “interventions to improve health outcomes in this rapidly growing population of children, regardless of the causal mechanism of impairment.”

Dr. Brogly noted that most of the opioid-using mothers in the study by Azuine et al. were unmarried, non-Hispanic white, and multiparous, and had histories of other substance abuse. She emphasized the need for supportive communities for women at risk of opioid use, who also are more likely to have unstable housing situations and histories of sexual and physical abuse.

“The risks of poor pregnancy and child outcomes in cases of maternal opioid exposure are not because of prenatal opioid exposure alone; ongoing difficult social and environmental circumstances have an important role,” and future interventions should address these circumstances to improve long-term health of high-risk women and their children, she emphasized.

The Boston Birth Cohort study is supported in part by grants from the National Institutes of Health and the U.S. Department of Health and Human Services. None of the authors had financial conflicts to disclose.

Dr. Brogly disclosed grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development outside the submitted work.

SOURCE: Azuine RE et al. JAMA Network Open. 2019 Jun 28. doi: 10.1001/jamanetworkopen.2019.6405; Brogly S. JAMA Network Open. 2019 Jun 28. doi:10.1001/jamanetworkopen.2019.6428.

Prolonged labor can result in hyponatremia, a case series showed.

dimarik/iStock/Getty Images

Sarah C. Lassey, MD, of the Brigham and Women’s Hospital, Boston, and colleagues noted that a rise in the number of women choosing a home labor means health care professionals may be more likely to encounter patients with hyponatremia secondary to prolonged labor and excessive hypotonic fluid consumption.

They presented the cases of two patients who were transferred to their labor and delivery unit with hyponatremia after a prolonged labor, published in Obstetrics & Gynecology. One woman presented with somnolence and confusion. The other woman was alert on arrival, but post partum had slurred speech and blurry vision.

“A likely mechanism for hyponatremia in these cases includes endogenous oxytocin and excessive free water consumption in the setting of hypovolemia,” they suggested.

One of the patients was managed with an intravenous infusion of normal saline and went on to make a full recovery after being monitored in the intensive care unit.

The other patient also was managed with normal saline, but her serum sodium level rose by 6 mmol/L within 3 hours of delivery, raising concern that the serum sodium correction was dangerously rapid. After consultation with a nephrologist, the patient’s saline IV was discontinued, and she was given desmopressin acetate to “reduce rapid diuresis of free water excretion,” they said.

“The goal of treatment should be to raise the serum sodium concentration by 1-2 mmol/L per hour, with a maximum increase ranging from 8 mmol/L in 24 hours to 25 mmol/L in 48 hours,” Dr. Lassey and colleagues noted. “The risk of raising the serum sodium concentration too quickly is osmotic demyelination syndrome, which has been reported with a serum sodium level increase of more than 12 mmol/L in 24 hours.”

Hyponatremia should be considered in women presenting as home birth transfers and in women undergoing prolonged labor at the hospital, they concluded. It also makes sense to perform electrolyte testing on admission for women with a long labor prior to coming to the hospital and for those whose labor becomes prolonged who drink a lot of fluids.

Considering the risks associated with hyponatremia, if suspicion is high, it may be prudent to start isotonic fluids before lab results are back, they said. Symptoms of mild hyponatremia include headache, lethargy, nausea, vomiting, and anorexia. Moderate hyponatremia can present as agitation, disorientation, and psychosis; if severe, hyponatremia may present as seizure, coma, or death.

Also alert your neonatal colleagues in cases of maternal intrapartum hyponatremia, because “neonatal serum sodium level will be reflective of the mother’s serum sodium level,” Dr. Lassey and associates added.

Dr. Daniela Carusi received payment from UptoDate. The other authors did not report any potential conflicts of interest.

SOURCE: Lassey SC et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003306.

Prolonged labor can result in hyponatremia, a case series showed.

dimarik/iStock/Getty Images

Sarah C. Lassey, MD, of the Brigham and Women’s Hospital, Boston, and colleagues noted that a rise in the number of women choosing a home labor means health care professionals may be more likely to encounter patients with hyponatremia secondary to prolonged labor and excessive hypotonic fluid consumption.

They presented the cases of two patients who were transferred to their labor and delivery unit with hyponatremia after a prolonged labor, published in Obstetrics & Gynecology. One woman presented with somnolence and confusion. The other woman was alert on arrival, but post partum had slurred speech and blurry vision.

“A likely mechanism for hyponatremia in these cases includes endogenous oxytocin and excessive free water consumption in the setting of hypovolemia,” they suggested.

One of the patients was managed with an intravenous infusion of normal saline and went on to make a full recovery after being monitored in the intensive care unit.

The other patient also was managed with normal saline, but her serum sodium level rose by 6 mmol/L within 3 hours of delivery, raising concern that the serum sodium correction was dangerously rapid. After consultation with a nephrologist, the patient’s saline IV was discontinued, and she was given desmopressin acetate to “reduce rapid diuresis of free water excretion,” they said.

“The goal of treatment should be to raise the serum sodium concentration by 1-2 mmol/L per hour, with a maximum increase ranging from 8 mmol/L in 24 hours to 25 mmol/L in 48 hours,” Dr. Lassey and colleagues noted. “The risk of raising the serum sodium concentration too quickly is osmotic demyelination syndrome, which has been reported with a serum sodium level increase of more than 12 mmol/L in 24 hours.”

Hyponatremia should be considered in women presenting as home birth transfers and in women undergoing prolonged labor at the hospital, they concluded. It also makes sense to perform electrolyte testing on admission for women with a long labor prior to coming to the hospital and for those whose labor becomes prolonged who drink a lot of fluids.

Considering the risks associated with hyponatremia, if suspicion is high, it may be prudent to start isotonic fluids before lab results are back, they said. Symptoms of mild hyponatremia include headache, lethargy, nausea, vomiting, and anorexia. Moderate hyponatremia can present as agitation, disorientation, and psychosis; if severe, hyponatremia may present as seizure, coma, or death.

Also alert your neonatal colleagues in cases of maternal intrapartum hyponatremia, because “neonatal serum sodium level will be reflective of the mother’s serum sodium level,” Dr. Lassey and associates added.

Dr. Daniela Carusi received payment from UptoDate. The other authors did not report any potential conflicts of interest.

SOURCE: Lassey SC et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003306.

Prolonged labor can result in hyponatremia, a case series showed.

dimarik/iStock/Getty Images

Sarah C. Lassey, MD, of the Brigham and Women’s Hospital, Boston, and colleagues noted that a rise in the number of women choosing a home labor means health care professionals may be more likely to encounter patients with hyponatremia secondary to prolonged labor and excessive hypotonic fluid consumption.

They presented the cases of two patients who were transferred to their labor and delivery unit with hyponatremia after a prolonged labor, published in Obstetrics & Gynecology. One woman presented with somnolence and confusion. The other woman was alert on arrival, but post partum had slurred speech and blurry vision.

“A likely mechanism for hyponatremia in these cases includes endogenous oxytocin and excessive free water consumption in the setting of hypovolemia,” they suggested.

One of the patients was managed with an intravenous infusion of normal saline and went on to make a full recovery after being monitored in the intensive care unit.

The other patient also was managed with normal saline, but her serum sodium level rose by 6 mmol/L within 3 hours of delivery, raising concern that the serum sodium correction was dangerously rapid. After consultation with a nephrologist, the patient’s saline IV was discontinued, and she was given desmopressin acetate to “reduce rapid diuresis of free water excretion,” they said.

“The goal of treatment should be to raise the serum sodium concentration by 1-2 mmol/L per hour, with a maximum increase ranging from 8 mmol/L in 24 hours to 25 mmol/L in 48 hours,” Dr. Lassey and colleagues noted. “The risk of raising the serum sodium concentration too quickly is osmotic demyelination syndrome, which has been reported with a serum sodium level increase of more than 12 mmol/L in 24 hours.”

Hyponatremia should be considered in women presenting as home birth transfers and in women undergoing prolonged labor at the hospital, they concluded. It also makes sense to perform electrolyte testing on admission for women with a long labor prior to coming to the hospital and for those whose labor becomes prolonged who drink a lot of fluids.

Considering the risks associated with hyponatremia, if suspicion is high, it may be prudent to start isotonic fluids before lab results are back, they said. Symptoms of mild hyponatremia include headache, lethargy, nausea, vomiting, and anorexia. Moderate hyponatremia can present as agitation, disorientation, and psychosis; if severe, hyponatremia may present as seizure, coma, or death.

Also alert your neonatal colleagues in cases of maternal intrapartum hyponatremia, because “neonatal serum sodium level will be reflective of the mother’s serum sodium level,” Dr. Lassey and associates added.

Dr. Daniela Carusi received payment from UptoDate. The other authors did not report any potential conflicts of interest.

SOURCE: Lassey SC et al. Obstet Gynecol. 2019. doi: 10.1097/AOG.0000000000003306.

NASHVILLE, TENN. – Opportunistic bilateral salpingectomy is gaining favor as an approach to sterilization, including in the vaginal delivery setting.

Sharon Worcester/MDedge News

“[It is] probably the newest thing on the block ... this is becoming super widespread,” Eve Espey, MD, said of the procedure during a contraceptive update at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Although evidence directly supporting bilateral salpingectomy for sterilization is lacking, there are good reasons to consider it, she said.

For example, the procedure is likely more effective than tubal ligation with no increased risk for complications, and is probably more likely to cut ovarian cancer risk than is tubal ligation, explained Dr. Espey, professor and chair of the department of obstetrics and gynecology and director of the family planning fellowship at the University of New Mexico, Albuquerque.

“So we don’t actually have good [randomized controlled trials] on effectiveness for [bilateral] salpingectomy, but it is most like a partial salpingectomy, which is highly effective, so there is reason to believe that it might be more effective,” she added. The downsides are that the procedure may take longer, it may impair ovarian blood supply, and long-term population-level data on outcomes are lacking.

ACOG said in a 2015 committee opinion that when counseling women, bilateral salpingectomy can be discussed and considered “a method that provides effective contraception,” but also stressed the need for randomized controlled trials to support any related reduction in ovarian cancer risk. That opinion (#620) was replaced in April 2019 by Committee Opinion #774, which addresses opportunistic salpingectomy for epithelial ovarian cancer prevention, and which states that “the risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization.”

“[The Society of Gynecologic Oncology] is much, much more emphatic,” Dr. Espey said, citing a 2013 Clinical Practice Statement calling for discussion and consideration of risk-reducing salpingectomy in lieu of tubal ligation for women at average risk of ovarian cancer (after childbearing).

Dr. Espey also noted that during a recent grand rounds on sterilization, about 90% of participants said they were doing bilateral salpingectomy in the setting of vaginal delivery. “So I think we’re going to see this coming not just with C-section, but also with vaginal delivery.”

Dr. Espey reported having no relevant financial disclosures.

[email protected]

NASHVILLE, TENN. – Opportunistic bilateral salpingectomy is gaining favor as an approach to sterilization, including in the vaginal delivery setting.

Sharon Worcester/MDedge News

“[It is] probably the newest thing on the block ... this is becoming super widespread,” Eve Espey, MD, said of the procedure during a contraceptive update at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Although evidence directly supporting bilateral salpingectomy for sterilization is lacking, there are good reasons to consider it, she said.

For example, the procedure is likely more effective than tubal ligation with no increased risk for complications, and is probably more likely to cut ovarian cancer risk than is tubal ligation, explained Dr. Espey, professor and chair of the department of obstetrics and gynecology and director of the family planning fellowship at the University of New Mexico, Albuquerque.

“So we don’t actually have good [randomized controlled trials] on effectiveness for [bilateral] salpingectomy, but it is most like a partial salpingectomy, which is highly effective, so there is reason to believe that it might be more effective,” she added. The downsides are that the procedure may take longer, it may impair ovarian blood supply, and long-term population-level data on outcomes are lacking.

ACOG said in a 2015 committee opinion that when counseling women, bilateral salpingectomy can be discussed and considered “a method that provides effective contraception,” but also stressed the need for randomized controlled trials to support any related reduction in ovarian cancer risk. That opinion (#620) was replaced in April 2019 by Committee Opinion #774, which addresses opportunistic salpingectomy for epithelial ovarian cancer prevention, and which states that “the risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization.”

“[The Society of Gynecologic Oncology] is much, much more emphatic,” Dr. Espey said, citing a 2013 Clinical Practice Statement calling for discussion and consideration of risk-reducing salpingectomy in lieu of tubal ligation for women at average risk of ovarian cancer (after childbearing).

Dr. Espey also noted that during a recent grand rounds on sterilization, about 90% of participants said they were doing bilateral salpingectomy in the setting of vaginal delivery. “So I think we’re going to see this coming not just with C-section, but also with vaginal delivery.”

Dr. Espey reported having no relevant financial disclosures.

[email protected]

NASHVILLE, TENN. – Opportunistic bilateral salpingectomy is gaining favor as an approach to sterilization, including in the vaginal delivery setting.

Sharon Worcester/MDedge News

“[It is] probably the newest thing on the block ... this is becoming super widespread,” Eve Espey, MD, said of the procedure during a contraceptive update at the annual clinical and scientific meeting of the American College of Obstetricians and Gynecologists.

Although evidence directly supporting bilateral salpingectomy for sterilization is lacking, there are good reasons to consider it, she said.

For example, the procedure is likely more effective than tubal ligation with no increased risk for complications, and is probably more likely to cut ovarian cancer risk than is tubal ligation, explained Dr. Espey, professor and chair of the department of obstetrics and gynecology and director of the family planning fellowship at the University of New Mexico, Albuquerque.

“So we don’t actually have good [randomized controlled trials] on effectiveness for [bilateral] salpingectomy, but it is most like a partial salpingectomy, which is highly effective, so there is reason to believe that it might be more effective,” she added. The downsides are that the procedure may take longer, it may impair ovarian blood supply, and long-term population-level data on outcomes are lacking.

ACOG said in a 2015 committee opinion that when counseling women, bilateral salpingectomy can be discussed and considered “a method that provides effective contraception,” but also stressed the need for randomized controlled trials to support any related reduction in ovarian cancer risk. That opinion (#620) was replaced in April 2019 by Committee Opinion #774, which addresses opportunistic salpingectomy for epithelial ovarian cancer prevention, and which states that “the risks and benefits of salpingectomy should be discussed with patients who desire permanent sterilization.”

“[The Society of Gynecologic Oncology] is much, much more emphatic,” Dr. Espey said, citing a 2013 Clinical Practice Statement calling for discussion and consideration of risk-reducing salpingectomy in lieu of tubal ligation for women at average risk of ovarian cancer (after childbearing).

Dr. Espey also noted that during a recent grand rounds on sterilization, about 90% of participants said they were doing bilateral salpingectomy in the setting of vaginal delivery. “So I think we’re going to see this coming not just with C-section, but also with vaginal delivery.”

Dr. Espey reported having no relevant financial disclosures.

[email protected]

Postpartum teenage mothers who use long-acting reversible contraceptives (LARC) reported using condoms half as often as their peers using non-LARC methods such as the birth control pill, vaginal ring, contraceptive patch, or injection, according to research in JAMA Pediatrics.

This highlights a need for education to lower the risk of sexually transmitted infections in this population.

©Florea Marius Catalin/iStockphoto.com

SOURCE: Kortsmit K et al. JAMA Pediatr. 2019. doi: 10.1001/jamapediatrics.2019.1136; Hoopes AJ et al. JAMA Pediatr. 2019. doi: 10.1001/jamapediatrics.2019.1133.

Postpartum teenage mothers who use long-acting reversible contraceptives (LARC) reported using condoms half as often as their peers using non-LARC methods such as the birth control pill, vaginal ring, contraceptive patch, or injection, according to research in JAMA Pediatrics.

This highlights a need for education to lower the risk of sexually transmitted infections in this population.

©Florea Marius Catalin/iStockphoto.com

SOURCE: Kortsmit K et al. JAMA Pediatr. 2019. doi: 10.1001/jamapediatrics.2019.1136; Hoopes AJ et al. JAMA Pediatr. 2019. doi: 10.1001/jamapediatrics.2019.1133.

Postpartum teenage mothers who use long-acting reversible contraceptives (LARC) reported using condoms half as often as their peers using non-LARC methods such as the birth control pill, vaginal ring, contraceptive patch, or injection, according to research in JAMA Pediatrics.

This highlights a need for education to lower the risk of sexually transmitted infections in this population.

©Florea Marius Catalin/iStockphoto.com

SOURCE: Kortsmit K et al. JAMA Pediatr. 2019. doi: 10.1001/jamapediatrics.2019.1136; Hoopes AJ et al. JAMA Pediatr. 2019. doi: 10.1001/jamapediatrics.2019.1133.

NEWPORT BEACH, CALIF. – When it comes to acne in adult women, look past the jawline, beyond traditional medications, and toward greater control. That’s the message of a dermatologist who spoke at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

“We should be aiming to get our patients to clear or almost clear, and we have the tools necessary to help that happen,” said Linda Stein Gold, MD, director of dermatology research at Henry Ford Hospital in Detroit.

Research suggests that acne is more common in adult women than in men, a gap that widens after age 29 years, she noted. Acne appears to affect 51% of women aged 20-29 years, she said, and prevalence dips to 15% in women older than 50 years.

About 80% of cases continue from adolescence, compared with about 20% that are new-onset during adulthood, she said. According to studies, she added, “most adult women have acne on multiple different areas of their face, not just the jawline. It’s similar to what we see in the adolescent population.”

Dr. Stein Gold offered these tips about treatment in this group of patients:
 

Inflammation

Researchers now consider that “all acne is inflammatory acne.” Be aggressive with anti-inflammatory treatment, and “continue even after the lesion is resolved” if needed to prevent scarring.

Oral contraceptives (OCs)

OCs can be helpful, but “we have to proceed with caution,” she said. A 2012 Cochrane Library review of 31 trials found that six combination OCs (COCs) “evaluated in placebo-controlled trials are effective in reducing inflammatory and noninflammatory facial acne lesions. Few important and consistent differences were found between COC types in their effectiveness for treating acne,” the review concluded (Cochrane Database Syst Rev. 2012 Jul 11;[7]:CD004425).

Results take time, however, and it “can take 3 months to see an effect, and 6 months for full effect,” Dr. Stein Gold noted.

There are multiple contraindications to the use of OCs, and they’ve been linked – controversially – to an increased risk of blood clots and breast cancer. However, risk of thrombosis also spikes – to significantly higher levels than with OC use – during pregnancy and the postpartum period, she said.
 

Spironolactone

This antihypertensive drug can be helpful, Dr. Stein Gold noted, although the one study in a 2009 Cochrane review that had acne as an outcome failed to find evidence of efficacy versus placebo (Cochrane Database Syst Rev. 2009 Apr 15;[2]:CD000194). Be aware of the boxed warning about links to cancer in rat studies, and consider the risk of potassium elevation in certain populations, she added. Watch the dose: fewer side effects are seen at 50-100 mg daily, although they’re still common, and it can take 3 months or more for improvements to appear, she said.

Truncal acne

Patients may be hesitant to mention they have acne on their chest and back. “They may not tell you about it, and you may not ask about it but [some patients] expect you to know about it and treat it,” Dr. Stein Gold said. She referred to trifarotene, a topical retinoid cream that, although not yet approved, appears to be safe and effective in treating acne on the face and trunk in phase 3 studies.

“Some people will say the trunk will get too irritated if you put a retinoid on it. But it absolutely can be used on the chest and back. The first thing I say to my patients is to expect to have redness and scaling for first 2 weeks. People pay money for that. It’s a chemical peel! It’s okay to have some sloughing; use an oil-free moisturizer.”

Dr. Stein Gold disclosed relationships with Galderma, Foamix, and Sol Gel (investigator, consultant); Valeant (consultant, speaker); and Dermira (investigator, speaker).

SDEF and this news organization are owned by the same parent company.

NEWPORT BEACH, CALIF. – When it comes to acne in adult women, look past the jawline, beyond traditional medications, and toward greater control. That’s the message of a dermatologist who spoke at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

“We should be aiming to get our patients to clear or almost clear, and we have the tools necessary to help that happen,” said Linda Stein Gold, MD, director of dermatology research at Henry Ford Hospital in Detroit.

Research suggests that acne is more common in adult women than in men, a gap that widens after age 29 years, she noted. Acne appears to affect 51% of women aged 20-29 years, she said, and prevalence dips to 15% in women older than 50 years.

About 80% of cases continue from adolescence, compared with about 20% that are new-onset during adulthood, she said. According to studies, she added, “most adult women have acne on multiple different areas of their face, not just the jawline. It’s similar to what we see in the adolescent population.”

Dr. Stein Gold offered these tips about treatment in this group of patients:
 

Inflammation

Researchers now consider that “all acne is inflammatory acne.” Be aggressive with anti-inflammatory treatment, and “continue even after the lesion is resolved” if needed to prevent scarring.

Oral contraceptives (OCs)

OCs can be helpful, but “we have to proceed with caution,” she said. A 2012 Cochrane Library review of 31 trials found that six combination OCs (COCs) “evaluated in placebo-controlled trials are effective in reducing inflammatory and noninflammatory facial acne lesions. Few important and consistent differences were found between COC types in their effectiveness for treating acne,” the review concluded (Cochrane Database Syst Rev. 2012 Jul 11;[7]:CD004425).

Results take time, however, and it “can take 3 months to see an effect, and 6 months for full effect,” Dr. Stein Gold noted.

There are multiple contraindications to the use of OCs, and they’ve been linked – controversially – to an increased risk of blood clots and breast cancer. However, risk of thrombosis also spikes – to significantly higher levels than with OC use – during pregnancy and the postpartum period, she said.
 

Spironolactone

This antihypertensive drug can be helpful, Dr. Stein Gold noted, although the one study in a 2009 Cochrane review that had acne as an outcome failed to find evidence of efficacy versus placebo (Cochrane Database Syst Rev. 2009 Apr 15;[2]:CD000194). Be aware of the boxed warning about links to cancer in rat studies, and consider the risk of potassium elevation in certain populations, she added. Watch the dose: fewer side effects are seen at 50-100 mg daily, although they’re still common, and it can take 3 months or more for improvements to appear, she said.

Truncal acne

Patients may be hesitant to mention they have acne on their chest and back. “They may not tell you about it, and you may not ask about it but [some patients] expect you to know about it and treat it,” Dr. Stein Gold said. She referred to trifarotene, a topical retinoid cream that, although not yet approved, appears to be safe and effective in treating acne on the face and trunk in phase 3 studies.

“Some people will say the trunk will get too irritated if you put a retinoid on it. But it absolutely can be used on the chest and back. The first thing I say to my patients is to expect to have redness and scaling for first 2 weeks. People pay money for that. It’s a chemical peel! It’s okay to have some sloughing; use an oil-free moisturizer.”

Dr. Stein Gold disclosed relationships with Galderma, Foamix, and Sol Gel (investigator, consultant); Valeant (consultant, speaker); and Dermira (investigator, speaker).

SDEF and this news organization are owned by the same parent company.

NEWPORT BEACH, CALIF. – When it comes to acne in adult women, look past the jawline, beyond traditional medications, and toward greater control. That’s the message of a dermatologist who spoke at Skin Disease Education Foundation’s Women’s & Pediatric Dermatology Seminar.

“We should be aiming to get our patients to clear or almost clear, and we have the tools necessary to help that happen,” said Linda Stein Gold, MD, director of dermatology research at Henry Ford Hospital in Detroit.

Research suggests that acne is more common in adult women than in men, a gap that widens after age 29 years, she noted. Acne appears to affect 51% of women aged 20-29 years, she said, and prevalence dips to 15% in women older than 50 years.

About 80% of cases continue from adolescence, compared with about 20% that are new-onset during adulthood, she said. According to studies, she added, “most adult women have acne on multiple different areas of their face, not just the jawline. It’s similar to what we see in the adolescent population.”

Dr. Stein Gold offered these tips about treatment in this group of patients:
 

Inflammation

Researchers now consider that “all acne is inflammatory acne.” Be aggressive with anti-inflammatory treatment, and “continue even after the lesion is resolved” if needed to prevent scarring.

Oral contraceptives (OCs)

OCs can be helpful, but “we have to proceed with caution,” she said. A 2012 Cochrane Library review of 31 trials found that six combination OCs (COCs) “evaluated in placebo-controlled trials are effective in reducing inflammatory and noninflammatory facial acne lesions. Few important and consistent differences were found between COC types in their effectiveness for treating acne,” the review concluded (Cochrane Database Syst Rev. 2012 Jul 11;[7]:CD004425).

Results take time, however, and it “can take 3 months to see an effect, and 6 months for full effect,” Dr. Stein Gold noted.

There are multiple contraindications to the use of OCs, and they’ve been linked – controversially – to an increased risk of blood clots and breast cancer. However, risk of thrombosis also spikes – to significantly higher levels than with OC use – during pregnancy and the postpartum period, she said.
 

Spironolactone

This antihypertensive drug can be helpful, Dr. Stein Gold noted, although the one study in a 2009 Cochrane review that had acne as an outcome failed to find evidence of efficacy versus placebo (Cochrane Database Syst Rev. 2009 Apr 15;[2]:CD000194). Be aware of the boxed warning about links to cancer in rat studies, and consider the risk of potassium elevation in certain populations, she added. Watch the dose: fewer side effects are seen at 50-100 mg daily, although they’re still common, and it can take 3 months or more for improvements to appear, she said.

Truncal acne

Patients may be hesitant to mention they have acne on their chest and back. “They may not tell you about it, and you may not ask about it but [some patients] expect you to know about it and treat it,” Dr. Stein Gold said. She referred to trifarotene, a topical retinoid cream that, although not yet approved, appears to be safe and effective in treating acne on the face and trunk in phase 3 studies.

“Some people will say the trunk will get too irritated if you put a retinoid on it. But it absolutely can be used on the chest and back. The first thing I say to my patients is to expect to have redness and scaling for first 2 weeks. People pay money for that. It’s a chemical peel! It’s okay to have some sloughing; use an oil-free moisturizer.”

Dr. Stein Gold disclosed relationships with Galderma, Foamix, and Sol Gel (investigator, consultant); Valeant (consultant, speaker); and Dermira (investigator, speaker).

SDEF and this news organization are owned by the same parent company.

Pregnancy management and outcomes have improved markedly for women with SLE over the past 2 decades, but there’s still progress to be made, research shows.

A retrospective cohort study led by rheumatologist Bella Mehta, MBBS, of the Hospital for Special Surgery in New York, and colleagues looked at data from the National Inpatient Sample database involving 93,820 pregnant women with SLE and 78,045,054 without SLE who were hospitalized in the United States between 1998 and 2015.

The results showed that over the 18-year study period, in-hospital maternal deaths per 100,000 admissions declined among patients with as well as those without SLE (442 vs. 13 for 1998-2000 and less than 50 vs. 10 for 2013-2015), although the decrease was greater in women with SLE (difference in trends, P less than .002).

Fetal mortality declined both for patients with SLE (268 deaths per 10,000 deliveries in 1998-2000 vs. 153 in 2013-2015) and those without SLE (72 deaths per 10,000 deliveries in 1998-2000 vs. 66 in 2013-2015).

“Although the decrease in fetal mortality seems somewhat greater in patients with SLE than those without it, the difference in trends is not statistically significant (P = .064),” the study authors noted in their paper, published in Annals of Internal Medicine.

Although patients with SLE in their study showed greater progress in rates of preeclampsia or eclampsia and length of stay, they still had worse outcomes in all measures when compared against women without SLE, the authors noted.

“Our study provides nationwide evidence that SLE pregnancy outcomes have become markedly better in the past 2 decades and continue to improve. However, SLE pregnancy risks remain high, and more work is needed to ensure good pregnancy outcomes among women with SLE,” they concluded.

Writing in an accompanying editorial, Megan E.B. Clowse, MD, of Duke University, Durham, N.C., noted that although the study findings of a progressive reduction in maternal mortality seemed very likely, the absolute decrease seen – from 140 maternal deaths per 100,000 births to fewer than 50 in 2013-2015 – warranted some reflection (Ann Intern Med. 2019;171:212-3. doi: 10.7326/M19-1667).

“SLE pregnancy management has not advanced within the past 5 years to an extent great enough to explain such a large drop in mortality,” she wrote.

There were also question marks around whether the NIS data should be used to analyze very rare events, such as maternal deaths in women with SLE. The SLE diagnosis in the database may also have included pregnancies in women who did not have SLE but instead had an elevated level of antinuclear antibody or lupus anticoagulant, which “may have diluted the frequency of poor outcomes,” Dr. Clowse wrote.

“For these reasons, I am concerned that the observed decline in maternal mortality may be an artifact, underestimating the ongoing risk of pregnancy for women with SLE,” Dr. Clowse wrote.

She added that recent analyses demonstrated that the use of hydroxychloroquine and aspirin in SLE pregnancy was not widespread.

“The inaugural reproductive health guidelines soon to be published by the American College of Rheumatology will have the potential to help expand state-of-the-art approaches to the management of pregnant women with SLE seen in everyday practice,” she concluded.

The study had no primary funding source and no conflicts of interest were declared. Dr. Mehta is supported by the C. Ronald MacKenzie Young Scientist Endowment Award. Dr. Clowse reported grants from GlaxoSmithKline and personal fees from UCB, both outside the submitted work.

SOURCE: Mehta B et al. Ann Intern Med. 2019;171:164-71. doi: 10.7326/M19-0120.

Pregnancy management and outcomes have improved markedly for women with SLE over the past 2 decades, but there’s still progress to be made, research shows.

A retrospective cohort study led by rheumatologist Bella Mehta, MBBS, of the Hospital for Special Surgery in New York, and colleagues looked at data from the National Inpatient Sample database involving 93,820 pregnant women with SLE and 78,045,054 without SLE who were hospitalized in the United States between 1998 and 2015.

The results showed that over the 18-year study period, in-hospital maternal deaths per 100,000 admissions declined among patients with as well as those without SLE (442 vs. 13 for 1998-2000 and less than 50 vs. 10 for 2013-2015), although the decrease was greater in women with SLE (difference in trends, P less than .002).

Fetal mortality declined both for patients with SLE (268 deaths per 10,000 deliveries in 1998-2000 vs. 153 in 2013-2015) and those without SLE (72 deaths per 10,000 deliveries in 1998-2000 vs. 66 in 2013-2015).

“Although the decrease in fetal mortality seems somewhat greater in patients with SLE than those without it, the difference in trends is not statistically significant (P = .064),” the study authors noted in their paper, published in Annals of Internal Medicine.

Although patients with SLE in their study showed greater progress in rates of preeclampsia or eclampsia and length of stay, they still had worse outcomes in all measures when compared against women without SLE, the authors noted.

“Our study provides nationwide evidence that SLE pregnancy outcomes have become markedly better in the past 2 decades and continue to improve. However, SLE pregnancy risks remain high, and more work is needed to ensure good pregnancy outcomes among women with SLE,” they concluded.

Writing in an accompanying editorial, Megan E.B. Clowse, MD, of Duke University, Durham, N.C., noted that although the study findings of a progressive reduction in maternal mortality seemed very likely, the absolute decrease seen – from 140 maternal deaths per 100,000 births to fewer than 50 in 2013-2015 – warranted some reflection (Ann Intern Med. 2019;171:212-3. doi: 10.7326/M19-1667).

“SLE pregnancy management has not advanced within the past 5 years to an extent great enough to explain such a large drop in mortality,” she wrote.

There were also question marks around whether the NIS data should be used to analyze very rare events, such as maternal deaths in women with SLE. The SLE diagnosis in the database may also have included pregnancies in women who did not have SLE but instead had an elevated level of antinuclear antibody or lupus anticoagulant, which “may have diluted the frequency of poor outcomes,” Dr. Clowse wrote.

“For these reasons, I am concerned that the observed decline in maternal mortality may be an artifact, underestimating the ongoing risk of pregnancy for women with SLE,” Dr. Clowse wrote.

She added that recent analyses demonstrated that the use of hydroxychloroquine and aspirin in SLE pregnancy was not widespread.

“The inaugural reproductive health guidelines soon to be published by the American College of Rheumatology will have the potential to help expand state-of-the-art approaches to the management of pregnant women with SLE seen in everyday practice,” she concluded.

The study had no primary funding source and no conflicts of interest were declared. Dr. Mehta is supported by the C. Ronald MacKenzie Young Scientist Endowment Award. Dr. Clowse reported grants from GlaxoSmithKline and personal fees from UCB, both outside the submitted work.

SOURCE: Mehta B et al. Ann Intern Med. 2019;171:164-71. doi: 10.7326/M19-0120.

Pregnancy management and outcomes have improved markedly for women with SLE over the past 2 decades, but there’s still progress to be made, research shows.

A retrospective cohort study led by rheumatologist Bella Mehta, MBBS, of the Hospital for Special Surgery in New York, and colleagues looked at data from the National Inpatient Sample database involving 93,820 pregnant women with SLE and 78,045,054 without SLE who were hospitalized in the United States between 1998 and 2015.

The results showed that over the 18-year study period, in-hospital maternal deaths per 100,000 admissions declined among patients with as well as those without SLE (442 vs. 13 for 1998-2000 and less than 50 vs. 10 for 2013-2015), although the decrease was greater in women with SLE (difference in trends, P less than .002).

Fetal mortality declined both for patients with SLE (268 deaths per 10,000 deliveries in 1998-2000 vs. 153 in 2013-2015) and those without SLE (72 deaths per 10,000 deliveries in 1998-2000 vs. 66 in 2013-2015).

“Although the decrease in fetal mortality seems somewhat greater in patients with SLE than those without it, the difference in trends is not statistically significant (P = .064),” the study authors noted in their paper, published in Annals of Internal Medicine.

Although patients with SLE in their study showed greater progress in rates of preeclampsia or eclampsia and length of stay, they still had worse outcomes in all measures when compared against women without SLE, the authors noted.

“Our study provides nationwide evidence that SLE pregnancy outcomes have become markedly better in the past 2 decades and continue to improve. However, SLE pregnancy risks remain high, and more work is needed to ensure good pregnancy outcomes among women with SLE,” they concluded.

Writing in an accompanying editorial, Megan E.B. Clowse, MD, of Duke University, Durham, N.C., noted that although the study findings of a progressive reduction in maternal mortality seemed very likely, the absolute decrease seen – from 140 maternal deaths per 100,000 births to fewer than 50 in 2013-2015 – warranted some reflection (Ann Intern Med. 2019;171:212-3. doi: 10.7326/M19-1667).

“SLE pregnancy management has not advanced within the past 5 years to an extent great enough to explain such a large drop in mortality,” she wrote.

There were also question marks around whether the NIS data should be used to analyze very rare events, such as maternal deaths in women with SLE. The SLE diagnosis in the database may also have included pregnancies in women who did not have SLE but instead had an elevated level of antinuclear antibody or lupus anticoagulant, which “may have diluted the frequency of poor outcomes,” Dr. Clowse wrote.

“For these reasons, I am concerned that the observed decline in maternal mortality may be an artifact, underestimating the ongoing risk of pregnancy for women with SLE,” Dr. Clowse wrote.

She added that recent analyses demonstrated that the use of hydroxychloroquine and aspirin in SLE pregnancy was not widespread.

“The inaugural reproductive health guidelines soon to be published by the American College of Rheumatology will have the potential to help expand state-of-the-art approaches to the management of pregnant women with SLE seen in everyday practice,” she concluded.

The study had no primary funding source and no conflicts of interest were declared. Dr. Mehta is supported by the C. Ronald MacKenzie Young Scientist Endowment Award. Dr. Clowse reported grants from GlaxoSmithKline and personal fees from UCB, both outside the submitted work.

SOURCE: Mehta B et al. Ann Intern Med. 2019;171:164-71. doi: 10.7326/M19-0120.

The decision to undergo preimplantation genetic testing for aneuploidy is associated with a small but not unimportant amount of regret among some patients undergoing fertility treatment, research suggests.

In a report published in Human Reproduction, researchers did an anonymous survey of 69 patients undergoing their first cycle of autologous preimplantation genetic testing for aneuploidy (PGT-A) at a single fertility center.

“Despite the known distress associated with many aspects of assisted reproductive technology (ART) and the many opportunities for distress among patients pursuing PGT-A, little is known about the associated patient experience and psychological risks,” wrote Dr. Kara N. Goldman of New York University Langone Fertility Center, and coauthors.

“A ‘failure’ after PGT-A can present in many forms well before other IVF losses may be experienced: Embryos may not meet criteria for biopsy, PGT-A may result in an all-aneuploid embryo cohort, or a euploid embryo may fail to implant,” the authors continued.

The mean overall decision regret scale score was 8.5 on a scale of 0-100 – with a median of 0 – and 61% of respondents said they had no regrets about undergoing preimplantation genetic testing for aneuploidy; the remaining 39% reported “any degree of regret.”

This “one-third of respondents reported some degree of regret, suggesting an important opportunity for pretest counseling and support among patients pursuing PGT-A,” Dr. Goldman and associates emphasized.

Of the respondents who then underwent euploid embryo transfer, and who had a known pregnancy outcome, the 36 with an ongoing or delivered pregnancy had significantly less decision regret than the 24 who experienced a negative pregnancy test or a miscarriage.

The study found no differences in decision regret between those aged under or over 35 years of age, those with different levels of educational attainment, or between patients who paid exclusively out of pocket compared with those with any insurance coverage.

However, greater levels of decision regret were seen in patients who had experienced a longer time since retrieval of oocytes and those who said they would consider pregnancy with donor oocytes if they were unsuccessful with IVF and PGT-A.

“Completing a cycle of IVF with PGT-A and obtaining no usable, euploid embryos results in distress, but this distress must be weighed against the alternative scenario in which a patient invests valuable time, energy, and resources into a futile embryo transfer cycle resulting in a negative pregnancy test, miscarriage, or aneuploid gestation,” the authors wrote.

When assessing the dependence of the decision regret score on demographic factors, the researchers found that patients who had learned about PGT-A from their physicians, rather than from other sources such as friends or the Internet, had the highest levels of decision regret.

There was no external funding. One coauthor declared personal fees and other support from the fertility and pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Goldman KN et al. Hum Reprod. 2019 Jun 21. doi: 10.1093/humrep/dez080.

The decision to undergo preimplantation genetic testing for aneuploidy is associated with a small but not unimportant amount of regret among some patients undergoing fertility treatment, research suggests.

In a report published in Human Reproduction, researchers did an anonymous survey of 69 patients undergoing their first cycle of autologous preimplantation genetic testing for aneuploidy (PGT-A) at a single fertility center.

“Despite the known distress associated with many aspects of assisted reproductive technology (ART) and the many opportunities for distress among patients pursuing PGT-A, little is known about the associated patient experience and psychological risks,” wrote Dr. Kara N. Goldman of New York University Langone Fertility Center, and coauthors.

“A ‘failure’ after PGT-A can present in many forms well before other IVF losses may be experienced: Embryos may not meet criteria for biopsy, PGT-A may result in an all-aneuploid embryo cohort, or a euploid embryo may fail to implant,” the authors continued.

The mean overall decision regret scale score was 8.5 on a scale of 0-100 – with a median of 0 – and 61% of respondents said they had no regrets about undergoing preimplantation genetic testing for aneuploidy; the remaining 39% reported “any degree of regret.”

This “one-third of respondents reported some degree of regret, suggesting an important opportunity for pretest counseling and support among patients pursuing PGT-A,” Dr. Goldman and associates emphasized.

Of the respondents who then underwent euploid embryo transfer, and who had a known pregnancy outcome, the 36 with an ongoing or delivered pregnancy had significantly less decision regret than the 24 who experienced a negative pregnancy test or a miscarriage.

The study found no differences in decision regret between those aged under or over 35 years of age, those with different levels of educational attainment, or between patients who paid exclusively out of pocket compared with those with any insurance coverage.

However, greater levels of decision regret were seen in patients who had experienced a longer time since retrieval of oocytes and those who said they would consider pregnancy with donor oocytes if they were unsuccessful with IVF and PGT-A.

“Completing a cycle of IVF with PGT-A and obtaining no usable, euploid embryos results in distress, but this distress must be weighed against the alternative scenario in which a patient invests valuable time, energy, and resources into a futile embryo transfer cycle resulting in a negative pregnancy test, miscarriage, or aneuploid gestation,” the authors wrote.

When assessing the dependence of the decision regret score on demographic factors, the researchers found that patients who had learned about PGT-A from their physicians, rather than from other sources such as friends or the Internet, had the highest levels of decision regret.

There was no external funding. One coauthor declared personal fees and other support from the fertility and pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Goldman KN et al. Hum Reprod. 2019 Jun 21. doi: 10.1093/humrep/dez080.

The decision to undergo preimplantation genetic testing for aneuploidy is associated with a small but not unimportant amount of regret among some patients undergoing fertility treatment, research suggests.

In a report published in Human Reproduction, researchers did an anonymous survey of 69 patients undergoing their first cycle of autologous preimplantation genetic testing for aneuploidy (PGT-A) at a single fertility center.

“Despite the known distress associated with many aspects of assisted reproductive technology (ART) and the many opportunities for distress among patients pursuing PGT-A, little is known about the associated patient experience and psychological risks,” wrote Dr. Kara N. Goldman of New York University Langone Fertility Center, and coauthors.

“A ‘failure’ after PGT-A can present in many forms well before other IVF losses may be experienced: Embryos may not meet criteria for biopsy, PGT-A may result in an all-aneuploid embryo cohort, or a euploid embryo may fail to implant,” the authors continued.

The mean overall decision regret scale score was 8.5 on a scale of 0-100 – with a median of 0 – and 61% of respondents said they had no regrets about undergoing preimplantation genetic testing for aneuploidy; the remaining 39% reported “any degree of regret.”

This “one-third of respondents reported some degree of regret, suggesting an important opportunity for pretest counseling and support among patients pursuing PGT-A,” Dr. Goldman and associates emphasized.

Of the respondents who then underwent euploid embryo transfer, and who had a known pregnancy outcome, the 36 with an ongoing or delivered pregnancy had significantly less decision regret than the 24 who experienced a negative pregnancy test or a miscarriage.

The study found no differences in decision regret between those aged under or over 35 years of age, those with different levels of educational attainment, or between patients who paid exclusively out of pocket compared with those with any insurance coverage.

However, greater levels of decision regret were seen in patients who had experienced a longer time since retrieval of oocytes and those who said they would consider pregnancy with donor oocytes if they were unsuccessful with IVF and PGT-A.

“Completing a cycle of IVF with PGT-A and obtaining no usable, euploid embryos results in distress, but this distress must be weighed against the alternative scenario in which a patient invests valuable time, energy, and resources into a futile embryo transfer cycle resulting in a negative pregnancy test, miscarriage, or aneuploid gestation,” the authors wrote.

When assessing the dependence of the decision regret score on demographic factors, the researchers found that patients who had learned about PGT-A from their physicians, rather than from other sources such as friends or the Internet, had the highest levels of decision regret.

There was no external funding. One coauthor declared personal fees and other support from the fertility and pharmaceutical sector. No other conflicts of interest were declared.

SOURCE: Goldman KN et al. Hum Reprod. 2019 Jun 21. doi: 10.1093/humrep/dez080.