Category: Obstetrics & Gynaecology

Categories : Obstetrics & GynaecologyTags :

Cannabis Use during Pregnancy is on the Rise

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As cannabis becomes increasingly legalised, for medical or recreational purposes, its use during pregnancy is increasing, along with the potential for abuse or dependence.

A new study, published in JAMA Psychiatry, explored the magnitude and nature of cannabis use disorders during pregnancy by examining hospital discharge codes. Most of those hospitalisations were for childbirth.

The study found that the proportion of hospitalised pregnant patients identified with cannabis use disorder (defined as cannabis use with clinically significant impairment or distress) rose 150% from 2010 to 2018.

Largest such study so far
“This is the largest study to document the scale of cannabis use disorder in prenatal hospitalisations,” said study co-author Claudia Lugo-Candelas, PhD, assistant professor of clinical medical psychology in Columbia University’s Department of Psychiatry. She notes the study found that pregnant patients with the condition had sharply higher levels of depression, anxiety, and nausea – results of clinical concern.  

“It’s a red flag that patients may not be getting the treatment they need,” Dr Lugo-Candelas said.

Some pregnant patients use cannabis instead of prescribed medications, thinking it’s a safer choice as cannabis legalisation has eased safety fears. However, both the American Academy of Pediatrics (AAP) and the American College of Obstetricians and Gynecologists (ACOG) have recommended against using cannabis while pregnant, chiefly because of known and unknown fetal effects. Concerns for maternal effects focus on smoking or vaping risks, not mental health.

The study identified 249 084 hospitalised pregnant patients with cannabis use disorder, who were classified into three sub-groups: those with cannabis use disorder only; those with use disorders for cannabis and other controlled substances; and those with cannabis use disorder and other non-controlled substances (alcohol, tobacco). Data was matched against equivalent patients without any substance use disorders.

Mood disorders more common
Researchers found that those with the cannabis condition were more likely to be younger (ages 15 to 24), Black non-Hispanic, and to not have private insurance.

Researchers analysed patients records for depression, anxiety, trauma, and ADHD, and a broader category of mood-related disorders. Medical conditions measured included chronic pain, epilepsy, multiple sclerosis, nausea, and vomiting.

All disorder sub-groups had elevated rates of nearly every factor studied. Patients with cannabis use disorder alone had triple the levels of depression and anxiety than patients with no use conditions. Mood-related disorders affected 58% of those with cannabis use disorder compared to 5% without.

“The least other substance use you have, the more that cannabis use makes a difference,” Dr Lugo-Candelas said. “That’s really striking.”

High levels of were also seen in the cannabis use disorder hospitalisations, but whether that was due to patients using cannabis to mitigate nausea, or due to cannabis use, which can cause a vomiting syndrome, or a symptom of pregnancy is unknown. Study co-author Angélica Meinhofer, PhD, assistant professor of population health sciences at Weill Cornell Medicine, noted that many states allow medical use of cannabis for nausea and vomiting.

While screening for cannabis during pregnancy could help, doctors could be reluctant to ask about use due to mandatory reporting rules. Patient education could help get them treatment earlier, especially with co-occurring psychiatric problems.

“Hopefully these findings will motivate better conversations between pregnant patients and their health care providers,” said Meinhofer.

The authors stress they aren’t arguing for or against cannabis use in pregnancy. Research on prenatal effects of the disorder is still largely lacking, though frequent use has been linked to low birth weight and other adverse outcomes. Their study, the researchers say, instead underscores the need to further explore the disorder and its links to psychiatric and medical conditions.

The increase of cannabis use by pregnant patients demands immediate investigation. “This is a population that’s showing a level of distress that is very, very high,” said Dr Lugo-Candelas. “Care and attention need to be rolled out.”

Source: Columbia University Irving Medical Center

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Low Vitamin D in Pregnancy Can Raise Autism Risk

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Low maternal vitamin D intake during pregnancy can affect the development of autism in the child along with various other factors, according to a new study from the University of Turku, Finland, and Columbia University, USA.

The study, published in the Biological Psychiatry journal, included 1558 cases of autism spectrum disorder (ASD) and an equal number of matched controls born in Finland between January 1987 and December 2004, followed up until December 2015. 

Maternal vitamin D deficiency during pregnancy was linked to a 44% increased risk of ASD in the offspring, compared to women with sufficient vitamin D. 

The result persisted even when accounting for maternal age, immigration, smoking, psychopathology, substance abuse, the gestational week of blood draw, season of blood collection, and gestational age.

“The results are significant for public health as vitamin D deficiency is readily preventable,” said first author, Professor Andre Sourander from the University of Turku.

In previous work, the researchers had shown that vitamin D deficiency is also associated with increasede ADHD risk in the offspring. The serum samples were collected before the national recommendation for vitamin D supplementation during pregnancy was introduced in Finland. The current recommendation for pregnant women is a daily supplement of 10 micrograms of vitamin D throughout the year.

“Vitamin D deficiency is a major global problem,” Prof Sourander remarked.

Source: University of Turku

Categories : COVID Obstetrics & GynaecologyTags :

No Finding of Early Miscarriage Risk from COVID Vaccinations

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A new study has found no association between COVID vaccinations and risk of first-trimester miscarriages, providing further evidence of the safety of COVID vaccination during pregnancy. The findings were published in the New England Journal of Medicine.

Study co-author Dr Deshayne Fell said, “The study analysed several national health registries in Norway to compare the proportion of vaccinated women who experienced a miscarriage during the first trimester and women who were still pregnant at the end of the first trimester.”  Dr Fell, is Associate Professor in the School of Epidemiology and Public Health in the University of Ottawa’s Faculty of Medicine and a Scientist at the Children’s Hospital of Eastern Ontario (CHEO) Research Institute.

“Our study found no evidence of an increased risk for early pregnancy loss after COVID vaccination and adds to the findings from other reports supporting COVID vaccination during pregnancy,” the study authors wrote. 

“The findings are reassuring for women who were vaccinated early in pregnancy and support the growing evidence that COVID vaccination during pregnancy is safe.”

Dr Fell and colleagues found no relationship between the type of vaccine received and miscarriage. In Norway, the vaccines used included Pfizer, Moderna and AstraZeneca.

“It is important that pregnant women are vaccinated since they have a higher risk of hospitalisations and COVID-complications, and their infants are at higher risk of being born too early. Also, vaccination during pregnancy is likely to provide protection to the newborn infant against COVID infection in the first months after birth,” the study authors stressed.

Source: University of Ottawa

Categories : COVID Obstetrics & GynaecologyTags :

Post-COVID Vaccination Menstrual Changes Investigated

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A paper awaiting peer review on the MedRxiv preprint server shows that menstrual changes in women receiving after the COVID vaccine are quite common.

Many people began sharing that they experienced unexpected menstrual bleeding after being vaccinated for COVID, an emerging phenomenon which was undeniable yet understudied.

Unfortunately, dismissal by medical experts fueled greater concerns, as both vaccine hesitant and anti-vaccine individuals and organisations began to conflate the possibility of short-term menstrual changes with long-term harms to fertility. Many influencers used this well-used framing of protecting women as a means of further anti-vaccine messages.

There are many plausible biological mechanisms that could explain a relationship between an acute immune challenge such as a vaccine, its corresponding and well-known systemic effects on haemostasis and inflammation, and menstrual repair mechanisms of the uterus. The uterine reproductive system is flexible and adaptable in the face of stressors. Examples include marathon running having short term influence on hormone concentrations in the short term; short-term calorie restriction that results in a loss of menstrual cycling can be overcome by resuming normal feeding; that inflammation influences ovarian hormones; and that psychosocial stressors can correspond to cycle irregularity and yet resilience can buffer one from these harms. Typhoid, Hepatitis B, HPV vaccines have all had menstrual irregularity associated with them.  

While sustained early stressors can influence adult hormone concentrations, short-term stressors resolve and do not produce long-term effects. This is quite different from the sustained immune assault of COVID itself: studies and anecdotal reports are already demonstrating that menstrual function may be disrupted long-term, particularly in those with long COVID.

In this sample, 42% of people with regular menstrual cycles bled more heavily than usual, while 44% reported no change, after being vaccinated. Among people who typically do not menstruate, 71% of people on long-acting reversible contraceptives, 39% of people on gender-affirming hormones, and 66% of post-menopausal people reported breakthrough bleeding. We found increased/breakthrough bleeding was significantly associated with age, other vaccine side effects such as fever or fatigue, history of pregnancy or birth, and ethnicity.

Many respondents who had post-vaccine changes did not have them until fourteen days or longer post-inoculation, which extends beyond the typical seven days of adverse symptom reporting in vaccine trials.

Source: MedRxiv

Categories : COVID Obstetrics & GynaecologyTags :

Delta Variant Causes Pregnancy Complications

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Pregnant women have been a population of concern for physicians since the beginning of the COVID pandemic, and early on the frequency of caesarean delivery, preterm birth and pregnancy-related hypertension was reported to be increased in pregnant women who developed severe or critical illness from the novel coronavirus.

In May and June this year, there was a lull in COVID cases and hospitalisations, to the relief of physicians at the University of Alabama at Birmingham Hospital and their pregnant patients. However, the Delta variant soon caused a rise in cases, hospitalisations and deaths across the US state of Alabama. Along with this there was a seemingly higher number of pregnant patients with COVID in hospitals and intensive care units than in previous surges.

“We saw an alarming increase in pregnant patients hospitalised with the Delta variant in July and August,” said Akila Subramaniam, MD, associate professor in UAB’s Division of Maternal-Fetal Medicine. “Even more, many of our patients were delivering pre-term because of the effects of the virus on these women.”

Researchers tracked admission rates and maternal and neonatal outcomes of pregnant COVID patients at UAB Hospital from March 22, 2020, to Aug. 18, 2021. Outcomes were compared between pre-Delta and Delta groups, with preliminary findings seriousindicating  morbidity and adverse outcomes associated with the Delta variant and pregnancy.

Prior to the Delta variant, UAB Hospital saw the highest admission of pregnant women with active COVID in July 2020. A total of 28 pregnant patients were admitted that month, three of whom were admitted to the intensive care unit. In comparison, 39 pregnant patients, with 11 in ICU, were hospitalised in just the first 18 days of August.

“Pregnant women are a high-risk population with low-vaccination rates overall,” said Jodie Dionne, MD, associate director of UAB Global Health in the Center for Women’s Reproductive Health and associate professor in the Division of Infectious Diseases. “There is misinformation circulating that causes doubt in the vaccines or downplays the effect of the virus. This study highlights how dangerous contracting the virus, especially the Delta variant, can be for the mom and baby.”

From the study’s early findings, the UAB researchers emphasize recommendations from the Society of Maternal-Fetal Medicine, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention to vaccinate pregnant patients to mitigate severe perinatal morbidity and mortality.

The findings were published in the journal of Obstetrics and Gynecology.

Source: University of Alabama at Birmingham

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Black US Women at Increased Risk of Birth Complication

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Black US women are more likely than their white counterparts to experience a serious complication during labour or delivery, particularly due to systemic inflammation.

Systemic inflammation was one of four categories identified by the researchers when they looked for patterns in patients who experienced severe maternal morbidity (SMM) – an unexpected outcome of labour and delivery resulting in significant short- or long-term health consequences, including death. 

Women can experience multiple complications or events associated with SMM such as kidney failure and eclampsia. The study found these complications or events can occur within four categories: systemic inflammation (includes shock, abnormal blood clotting, adult respiratory distress syndrome [ARDS] and ventilation); cardiovascular events (includes kidney failure, eclampsia and cerebrovascular events such as aneurysm); admission to the intensive care unit; and haemorrhage leading to blood transfusion.

Black women were found to be at higher risk than white women in all four SMM categories, with the highest proportion experiencing SMM due to systemic inflammation.

“Previous studies have reported the higher the number of SMM complications or events a woman experiences, the higher the likelihood of death, but our study is the first to look at how these complications and events group together and their association with outcomes,” said lead author Andrea Ibarra, MD, MS, assistant professor of anesthesiology and perioperative medicine at the University of Pittsburgh School of Medicine. “We determined characteristics such as race, obesity and diabetes can identify which women are at higher risk of severe events, including death, in the various categories. That insight can spur efforts to develop new obstetric protocols and guidelines to improve care.”

Researchers reviewed records of 97 492 deliveries at one institution between 2008 and 2017 and determined that 2666 (2.7%) included an SMM event, with 49 women dying within a year of delivery. They found 44% of the deliveries associated with SMM were pre-term. Black women had higher rates of SMM (4.1%) than white women (2.4%).

Risk factors for all-category SMM included race, having pre-existing diabetes or having preeclampsia. Caesarean delivery was an additional risk factor for the haemorrhage category. Additional risk factors relating to women who fell in the systemic inflammation category were depression and social determinants, including low income or not graduating from high school.

“This research is crucial because most maternal morbidity is preventable,” said Dr Ibarra. “By identifying factors that put women at high risk of developing SMM complications or events, we can allocate more resources toward perinatal care.”

The findings were presented at the ANESTHESIOLOGY® 2021 annual meeting.

Source: American Society of Anesthesiologists

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Minimal Risk Found for Home Birth With a Licensed Midwife

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Minimal Risk Found for Home Birth With a Licensed Midwife
In the US state of Washington, a planned home birth with a licensed midwife is just as safe as a birth at a licensed birth centre, according to researchers from the University of British Columbia and Bastyr University.

The research team of midwives, epidemiologists and obstetricians came to this conclusion after analysing outcomes of community births in Washington state between 2015 and 2020. The findings were reported in Obstetrics & Gynecology. A previous US study had shown that pregnancy outcomes with care provided by midwives had lower risks of caesarean and preterm birth than those with physician care.

The study analysed data from 10 609 home and birth centre births from midwives. Births met the professional association guidelines and were within regulatory standards. This included individuals with healthy pregnancies who were carrying to term with no history of caesarean delivery, and a foetus oriented for head-first birth.

“The birth setting had no association with increased risk for either parent or baby,” said lead author Elizabeth Nethery, PhD candidate at UBC. “Our findings show that when a state has systems to support the integration of community midwives into the healthcare system as Washington has done, birth centers and homes are both safe settings for birth.”

In the US, home birth is still controversial. The American College of Obstetricians and Gynecologists (ACOG) has stated that birth is safest at a hospital or an accredited birth centre, recommending against home birth because of countrywide studies that show higher rates of neonatal death among home births.

However, individual states have wide variations in licensing requirements, regulatory status and access to medications for midwives. These variations might contribute to differences in state level outcomes and reflected in national statistics.

Washington has worked to integrate midwifery into the healthcare system, with 3.5% of all births with midwives or at state-licensed birth centres. As a result, there is a low rate of 0.57 perinatal deaths per 1000 births, comparable to other countries where home birth is well-integrated into the health system and classed as low risk by ACOG.

“Washington provides a model for midwifery care and safe community birth that could be replicated throughout the U.S.,” said Nethery. “Currently, some U.S. states currently have no licensure available for community birth midwives at all, and this could be contributing to poorer birth outcomes in those states.”

Source: University of British Columbia

Categories : COVID Obstetrics & GynaecologyTags :

Is There a Wave of Teenage Lockdown Pregnancies in SA?

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An article in The Outlier examines whether the spike in teenage pregnancies in Gauteng could signal a tsunami of teenage pregnancies caused by the lockdown and increased sexual assaults.

In August the Gauteng MEC for health, Nomathemba Mokgethi, revealed that 23 226 teenage girls had fallen pregnant in the province between April 2020 and March 2021. This came in a written response to questions from the DA tabled in the Gauteng legislature. Alarmingly, 934 of them were between the ages of 10 and 14, where the age of consent is 16.

There were 20 250 babies born to teenage mothers aged 10 to 19, according to the Gauteng MEC in a response to a question in the Gauteng Legislature; 2976 pregnancies were terminated. From the start of the year to August, 118 babies were abandoned in public hospitals, some of them likely by teenage mothers.

A preliminary understanding of the impact of the pandemic on teen pregnancies can be seen through data from the annual District Health Barometer (DHB) report, which shows the number of deliveries recorded in public health facilities.

An increase in teenage births of 28% when comparing births to teenage mothers in Gauteng reported in the DBH for 2019/2020 with the Gauteng health department’s number, 
The Gauteng health department also provided a monthly breakdown of the teenage deliveries from April 2020 to March 2021. The months with the highest number of deliveries were May, June, July and August: most of these teenage mothers would have fallen pregnant before COVID hit South Africa.

In the early stages of the COVID pandemic, schools were closed on 18 March 2020, with the hard lockdown starting on 26 March, meaning that pregnancies from that time would be delivered around December 2020, which would likely not be reflected in the DBH for 2019/2020.

Catherine Mathews, director in the Health Systems Research Unit of the South African Medical Research Council (SAMRC) said it would take time to assess the full impact school closures had on teen pregnancies.  

“We do know that schools can be an important, safe, protective environment for girls, and when schools close, children are often left unsupervised and can be more at risk of sexual violence.”

Contraception has not been readily available to girls and women, with the District Health Barometer 2019/20 noting persistent stock-outs of contraception have been reported since 2018.

The SAMRC surveyed adolescent girls, aged 15 to 24, between 1 December 2020 and 28 February 2021, to find out how they were affected by the pandemic. The Outlier looked at the results for the 15 to 19 age group. Out of the 264 participants in this age group, 23.5% stated that they were unable to obtain contraceptives, while 18.8% reported challenges in accessing condoms due to the pandemic.

But, to connect the increase in teen pregnancies to the inaccessibility of condoms and contraception alone would be to assume that the 23 226 pregnancies were a product of consensual sex, when that may not always have been the case.

Mathews said: “Violence against women and girls in the country is so pervasive in South Africa and we can’t ignore its impact on teenage pregnancy.”

The MEC Mokgethi said, “Cases of statutory rape are reported by healthcare social workers at hospitals and clinics to the Department of Social Development and SAPS,” adding that no cases of statutory rape were collected by the health department.

Data for 2020/21 for the other eight provinces are not available, so it hasn’t been possible to see if this trend is reflected there,
However, the province with the highest percentage of teenagers of mothers giving birth is the Northern Cape at 18% in 2019/20. The Eastern Cape and KwaZulu-Natal follow with 16.7% and 16.4% respectively. Gauteng’s teenage birth rate was 7.5%, the lowest of the provinces.

According to World Bank data on births among women aged 15 to 19 years, South Africa’s 68 births per 1000 women was lower than other Sub-Saharan African countries, it remains higher than the world average of 42 births per 1000 women in that age group.

Source: The Outlier

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Consensus Statement Cautions on Paracetamol Use in Pregnancy

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A consensus statement by 13 doctors in different countries suggests that pregnant people only take paracetamol/acetaminophen if it is medically necessary, Their paper, published in the journal Nature Reviews Endocrinology, the group paracetamol/acetaminophen (APAP). 

In the same journal issue, an accompanying Editorial outlines the consensus statement and noting that its authors are not calling for a ban on the drug being used, instead they are suggesting that it be taken more cautiously by pregnant women because of a possible risk of birth defects.

Research in recent years has shown that it is possible under some circumstances for APAP to alter foetal development which can herald problems with neurological, urological and reproductive disorders in the baby – the authors found evidence of birth defects in 26 out of 29 studies. The authors call for more research into the possible problems with the drug’s use by pregnant women. They also acknowledge – as do several experts in a reaction piece published on the Science Media Centre site – that APAP is the only pain management drug available for pregnant women. And they point out that medical use of APAP is generally warranted when the mother experiences problems that can negatively impact her baby –  such as having a fever. But they also note that pregnant women’s APAP use appears to have crept up into general use as it has gained a reputation as being safe to use as an all-purpose painkiller.

The expert group and the authors of the new paper notably both point out that the recommendation does not differ from that already in use by most OB/GYNs – and similar wording generally appears on bottles of products based on APAP, such as Tylenol.

The consensus statement’s authors say their intention behind the article is to bring renewed and more focused attention to the possibility of APAP use leading to certain birth defects and the conditions under which they might arise. They note that current research has shown, for example, that the risk of harm seems to rise as the duration of APAP use goes up. In light of this, they suggest pregnant women consider using the drug for short term pain management, rather than as a long-term solution.

Source: Medical Xpress

Categories : Antibiotics Obstetrics & GynaecologyTags :

Azithromycin Protects Pregnancies in Countries with Malaria

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A review has found that the common antibiotic azithromycin taken during pregnancy reduces low birth weight and premature births in countries where malaria is endemic.

The systematic review of 14 studies in African and Asia, published in The Lancet EClinicalMedicine, found that azithromycin, reduced low birth weight and prematurity but didn’t lower infant deaths, infections and hospital admissions.

Azithromycin, an inexpensive antibiotic widely used to treat chest and ear infections, has been specifically used in the past in pregnancy to treat STIs and, alongside other antimalarial drugs, to prevent adverse consequences of malaria on maternal and foetal outcomes and caesarean wound infections.

Murdoch Children’s Research Institute (MCRI) researcher Dr Maeve Hume-Nixon said it was not clear whether azithromycin would improve perinatal and neonatal outcomes in non-malaria endemic settings, and the potential harm on stillbirth rates needed further investigation.

Dr Hume-Nixon said these findings emphasised the importance of similar MCRI-led research currently being done in Fiji.

“This review found that there was uncertainty about the potential benefits of this intervention on neonatal deaths, admissions and infections, and potential harmful effects on stillbirth despite biological reasons why this intervention may have benefits for these outcomes,” she said.

“Therefore, results from studies like ours underway in Fiji will help to better understand the effect of this intervention on these outcomes.”

The Bulabula MaPei study is a randomised controlled clinical trial testing if azithromycin given to women in labour, prevents maternal and infant infections.

Globally, infections account for 21% of 2.4 million neonatal deaths per year and 52% of all under-five deaths, disproportionately occurring in low- and middle-income countries.

About five million cases of pregnancy-related infections occur in mothers each year as well, resulting in 75 000 maternal deaths.

MCRI Professor Fiona Russell said the large clinical trials in Africa and Asia, along with the MCRI-led trial in Fiji, were likely to inform global policy related to maternal child health and hopefully benefit infants and mothers around the world.

“Administration of azithromycin during labour may be a cheap and simple intervention that could be used to improve neonatal death rates in low and middle-income countries, alongside strengthening of maternal child health services,” she said. “This study, together with other large clinical trials, will add to evidence for the consideration of new international maternal and child health guidelines.”

Source: Murdoch Childrens Research Institute