August 3, 2016

New evidence suggests that pregnant women benefit from steroid injections if they are likely to deliver between 34 and 36 6/7 weeks gestation

Steroids are routinely given to women at risk for delivery between 23 and 34 weeks gestation because studies have shown that treatment can reduce complications in premature babies.  Specifically, premature babies born in this period, whose mothers recieve steroids, have been shown to have a decreased risk of death, respiratory complications, bleeding in the brain, and overall length of neonatal intensive care unit stay.  Until now, it has been unclear if steroids would help babies born at between 34 and 36 6/7 weeks gestation (late preterm babies).  Up to 8% of all babies are born during this period and these babies remain at risk for neonatal and childhood complications.  In a study published in the April 7th edition of the New England Journal of Medicine, administration of steroids to women at risk for late preterm delivery was shown to signifcantly reduced the rate of neonatal respiratory complications.  The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) have recommended administering a course of betamethasone (steroids) to women at risk for delivery during this late preterm period.  Some possible circumstances include premature rupture of membranes, contractions with cervical dilation and planned early delivery for complications such as placenta previa.

- David D. Dowling, MD MBA

References:

Gyamfi-Bannerman  C et al. Antenatal Betamethasone for Women at Risk for Late Preterm Delivery N Engl J Med 2016;374:1311-20

ACOG Practice Advisory:  Antenatal Corticosteroid Administration in the Late Preterm Period, April 6, 2016

SMFM Statement: Implementation of the Use of Antenatal Corticosteroids in the Late Preterm Period in Women at Risk for Preterm Delivery, April, 2016


 

April 29, 2013

Increased Risk of Pregnancies Conceived by In Vitro Fertilization (IVF)

Assisted reproductive technology is typically described as handling of the eggs, sperm, or both outside of the human body, with the ultimate aim of achieving a healthy conception and pregnancy.  Procedures include in vitro fertilization, in vitro fertilization with intracytoplasmic sperm injection, fresh or frozen embryo transfer, in vitro fertilization with donor eggs, and intrauterine insemination.  It is now 35 years since the birth of the first baby with IVF in 1978.  In developed countries, approximately 4 percent of all children are born after assisted reproductive technology (ART).  This means that nearly one child in every school class has been born after ART treatment.  Over time, the live birth rate of IVF has increased from 14 percent to approximately 25 percent.

As early as 1985, there was data suggesting that IVF pregnancies were associated with an increased risk of adverse outcomes.  In one series of 244 IVF pregnancies, the rate of ectopic pregnancies and miscarriages was increased, together with the rate of preterm delivery, which was increased by a factor of 3.  After this study was published, investigators started looking more closely at the outcomes of ART pregnancies.  In a large study from Finland comparing 428 ART pregnancies compared to 928 spontaneous pregnancies, it was noted that there was a higher rate of preterm birth, low birthweight, and the need for neonatal intensive care for babies born after ART.  In a large study looking at multiple investigations comparing 12,283 IVF pregnancies with 1.9 million spontaneously-conceived singletons, it was noted that the IVF pregnancies had an increased rate of preterm delivery, low birthweight, placenta previa, gestational diabetes, and preeclampsia. As a result, IVF pregnancies, or pregnancies conceived with assisted reproductive technology, need to be followed more closely for increased rate of complications.

~ Norman B. Duerbeck, MD             

 References:

Jackson, R.A., (2004). Perinatal outcomes in singletons following in vitro fertilization: a meta-analysis. OB/GYN 103, 551-563.

Raatikainen, K., et al, (2012). Comparison of the pregnancy outcomes of subfertile women after infertility treatment and in naturally conceived pregnancies.  Human Reproduction 27, 1162-1169. 

Williams, C., et al, (2009).  Infant outcomes of assisted reproduction. Early Human Development 85, 673-677. 

Fertility Treatment in 2010, Trends and Findings, 2011, www.hfeagov.uk 

 

 

 

March 30, 2013

Study in twin pregnancy suggests that laser ablation treatment for twin-twin transfusion syndrome may be effective for more patients with this complication

Twin-twin transfusion syndrome (TTTS) complicates up to 15 % of identical twin pregnancies.  In these pregnancies, the twins can have blood vessels that allow for their circulations to communicate.  With TTTS, there is an imbalance of blood flow and distribution so that one baby, the recipient, receives an overload of blood, develops excessive amniotic fluid, and is at risk for heart failure.  The other twin, the donor, has a low blood volume which results in growth problems and low amniotic fluid.  If left untreated, the mortality rate approaches 90% and a significant number of survivors have long term neurologic disability.

The best treatment for severe TTTS is laser destruction of the communicating blood vessels between the twins.  This treatment has generally been restricted to pregnancies between 16 and 26 weeks gestation by the Food and Drug Administration because the largest study documenting the effectiveness of this treatment used these cutoffs.  There has been interest in extending the use of this treatment outside of these limits as many experts feel that treatment may be better than alternative.

In this month’s issue of the American Journal of Obstetrics and Gynecology, David Baud MD and colleagues from the University of Toronto published an interesting article comparing the outcomes of pregnancies that underwent early (<17 weeks) or late (> 26 weeks) laser destruction of communicating vessels with a conventional group (17 – 26 weeks) in patients with TTTS.  They found that the duration of the procedure, duration of pregnancy, survival rate, and complications were similar among the groups.  The investigators claim that there study is the first the report the use of this treatment at less than 16 weeks.  Additionally, their results support 2 previous small studies from Europe suggesting effectiveness in patients > 26 weeks. 

The investigators note the limitations of their retrospective study which had small numbers of patients.  However, they suggest that the current age restrictions for laser therapy should be reevaluated in light of the accumulating evidence. 

~ David D. Dowling, MD, MBA

 

Reference:  Baud D, Windrim R, Deunen J, et al.  Fetoscopic laser therapy for twin-twin transfusions syndrome before 17 and after 26 weeks’ gestation.  Am J Obstet Gynecol 2013;208:197.e1-7.