Meta-análisis muestra que aspirina iniciada tempranamente reduce RCIU y preeclampsia
Publicado el 14.08.2010
Un meta-análisis de E.Bujold (Quebec) muestra que la administración de aspirina (en dosis bajas) en pacientes con factores de riesgo, redujo a la mitad la frecuencia de preeclampsia y RCIU cuando se administra antes de las 16 semanas (full text).
Obstet Gynecol. 2010 Aug;116(2 Pt 1):402-14.
Prevention of preeclampsia and intrauterine growth restriction with aspirin started in early pregnancy: a meta-analysis.
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Bujold E, Roberge S, Lacasse Y, Bureau M, Audibert F, Marcoux S, Forest JC, Giguère Y.
Department of Obstetrics and Gynecology, Faculty of Medicine, Laval University, Québec, Canada. emmanuel.bujold@crchul.ulaval.ca
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Department of Obstetrics and Gynecology, Faculty of Medicine, Laval University, Québec, Canada. emmanuel.bujold@crchul.ulaval.ca
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Abstract
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OBJECTIVE:
To estimate the effect of low-dose aspirin started in early pregnancy on the incidence of preeclampsia and intrauterine growth restriction (IUGR). DATA SOURCES: A systematic review and meta-analysis were performed through electronic database searches (PubMed, Cochrane, Embase).
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METHODS OF STUDY SELECTION:
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METHODS OF STUDY SELECTION:
Randomized controlled trials of pregnant women at risk of preeclampsia who were assigned to receive aspirin or placebo (or no treatment) were reviewed. Secondary outcomes included IUGR, severe preeclampsia and preterm birth. The effect of aspirin was analyzed as a function of gestational age at initiation of the intervention (16 weeks of gestation or less, 16 weeks of gestation or more).
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TABULATION, INTEGRATION, AND RESULTS: Thirty-four randomized controlled trials met the inclusion criteria, including 27 studies (11,348 women) with follow-up for the outcome of preeclampsia. Low-dose aspirin started at 16 weeks or earlier was associated with a significantreduction in preeclampsia (relative risk [RR] 0.47, 95% confidence interval [CI] 0.34-0.65, prevalence in 9.3% treated compared with 21.3% control) and IUGR (RR 0.44, 95% CI 0.30-0.65, 7% treated compared with 16.3% control), whereas aspirin started after 16 weeks was not (preeclampsia: RR 0.81, 95% CI 0.63-1.03, prevalence in 7.3% treated compared with 8.1% control; IUGR: RR 0.98, 95% CI 0.87-1.10, 10.3% treated compared with 10.5% control). Low-dose aspirin started at 16 weeks or earlier also was associated with a reduction in severe preeclampsia (RR 0.09, 95% CI 0.02-0.37, 0.7% treated compared with 15.0% control), gestational hypertension (RR 0.62, 95% CI 0.45-0.84, 16.7% treated compared with 29.7% control), and preterm birth (RR 0.22, 95% CI 0.10-0.49, 3.5% treated compared with 16.9% control). Of note, all studies for which aspirin had been started at 16 weeks or earlier included women identified to be at moderate or high risk for preeclampsia.
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CONCLUSION:
Low-dose aspirin initiated in early pregnancy is an efficient method of reducing the incidence of preeclampsia and IUGR.
ACOG publica nuevas guías para la prueba de parto post-cesárea
Publicado el 14.08.2010
ACOG publica nuevas guías para la prueba de parto post-cesárea
Publicado el 14.08.2010
En pacientes bien seleccionadas, la prueba de parto post-cesárea es apropiada y conveniente. El ACOG admite ahora que pacientes con gemelos, 2 cesáreas previas u otras condiciones puedan ser sometidas a prueba de parto previo consentimiento de las partes.
July 21, 2010
Ob-Gyns Issue Less Restrictive VBAC Guidelines
Washington, DC -- Attempting a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans, according to guidelines released today by The American College of Obstetricians and Gynecologists.
Thecesarean delivery rate in the US increased dramatically over the past four decades, from 5% in 1970 to over 31% in 2007. Before 1970, the standard practice was to perform a repeat cesarean after a prior cesarean birth. During the 1970s, as women achieved successful VBACs, itbecame viewed as a reasonable option for some women. Over time, the VBAC rate increased from just over 5% in 1985 to 28% by 1996, but then began a steady decline. By 2006, the VBAC rate fell to 8.5%, a decrease that reflects the restrictions that some hospitals and insurers placed on trial of labor after cesarean (TOLAC) as well as decisions by patients when presented with the risks and benefits.
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"Thecurrent cesarean rate is undeniably high and absolutely concerns us as ob-gyns," said Richard N. Waldman, MD, president of The College. "These VBAC guidelines emphasize the need for thorough counseling of benefits and risks, shared patient-doctor decision making, and the importance of patient autonomy. Moving forward, we need to work collaboratively with our patients and our colleagues, hospitals, and insurers to swing the pendulum back to fewer cesareans and a more reasonable VBAC rate."
Inkeeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC. In addition, "The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC," said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from Northwestern University in Chicago.
VBAC Counseling on Benefits and Risks
"In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complicationsfrom a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriatecandidates who attempt VBAC will be successful. A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery. It may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy,bowel and bladder injury, transfusion, infection, and abnormal placentaconditions (placenta previa and placenta accreta).
Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails. A successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat cesarean.
Uterine Rupture
The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%—butif it occurs, it is an emergency situation. A uterine rupture can causeserious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.
"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote thesafest environment for labor and delivery, not to restrict women's access to VBAC."
Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place formanaging emergency uterine ruptures, however rarely they may occur, Dr.Grobman added.
The College says that restrictive VBAC policies should not be used to forcewomen to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center.
Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is published in the August 2010 issue of Obstetrics & Gynecology.
Inkeeping with past recommendations, most women with one previous cesarean delivery with a low-transverse incision are candidates for and should be counseled about VBAC and offered a TOLAC. In addition, "The College guidelines now clearly say that women with two previous low-transverse cesarean incisions, women carrying twins, and women with an unknown type of uterine scar are considered appropriate candidates for a TOLAC," said Jeffrey L. Ecker, MD, from Massachusetts General Hospital in Boston and immediate past vice chair of the Committee on Practice Bulletins-Obstetrics who co-wrote the document with William A. Grobman, MD, from Northwestern University in Chicago.
VBAC Counseling on Benefits and Risks
"In making plans for delivery, physicians and patients should consider a woman's chance of a successful VBAC as well as the risk of complicationsfrom a trial of labor, all viewed in the context of her future reproductive plans," said Dr. Ecker. Approximately 60-80% of appropriatecandidates who attempt VBAC will be successful. A VBAC avoids major abdominal surgery, lowers a woman's risk of hemorrhage and infection, and shortens postpartum recovery. It may also help women avoid the possible future risks of having multiple cesareans such as hysterectomy,bowel and bladder injury, transfusion, infection, and abnormal placentaconditions (placenta previa and placenta accreta).
Both repeat cesarean and a TOLAC carry risks including maternal hemorrhage, infection, operative injury, blood clots, hysterectomy, and death. Most maternal injury that occurs during a TOLAC happens when a repeat cesarean becomes necessary after the TOLAC fails. A successful VBAC has fewer complications than an elective repeat cesarean while a failed TOLAC has more complications than an elective repeat cesarean.
Uterine Rupture
The risk of uterine rupture during a TOLAC is low—between 0.5% and 0.9%—butif it occurs, it is an emergency situation. A uterine rupture can causeserious injury to a mother and her baby. The College maintains that a TOLAC is most safely undertaken where staff can immediately provide an emergency cesarean, but recognizes that such resources may not be universally available.
"Given the onerous medical liability climate for ob-gyns, interpretation of The College's earlier guidelines led many hospitals to refuse allowing VBACs altogether," said Dr. Waldman. "Our primary goal is to promote thesafest environment for labor and delivery, not to restrict women's access to VBAC."
Women and their physicians may still make a plan for a TOLAC in situations where there may not be "immediately available" staff to handle emergencies, but it requires a thorough discussion of the local health care system, the available resources, and the potential for incremental risk. "It is absolutely critical that a woman and her physician discuss VBAC early in the prenatal care period so that logistical plans can be made well in advance," said Dr. Grobman. And those hospitals that lack "immediately available" staff should develop a clear process for gathering them quickly and all hospitals should have a plan in place formanaging emergency uterine ruptures, however rarely they may occur, Dr.Grobman added.
The College says that restrictive VBAC policies should not be used to forcewomen to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC. On the other hand, if, during prenatal care, a physician is uncomfortable with a patient's desire to undergo VBAC, it is appropriate to refer her to another physician or center.
Practice Bulletin #115, "Vaginal Birth after Previous Cesarean Delivery," is published in the August 2010 issue of Obstetrics & Gynecology.
Nuevas guias ACOG para trombofilias y embarazo
Publicado el 20.07.2010
Las trombofilias heredadas se asocian con un mayor riesgo de tromboembolismo y posiblemente con algunas condiciones patológicas en el embarazo. Sin embargo, existe evidencia escasa que permita sugerir la pesquisa y manejo de estas mutaciones durante el embarazo. Este documento del ACOG hace algunas sugerencias al respecto.
Estudio sugiere mejor pronóstico cuando la histerorrafia se sutura en 2 capas
Publicado el 28.06.2010
Un estudio publicado este mes en el Obstetrics and Gynecology por Bujold y cols. y que incluyó 96 casos de rotura uterina y 288 controles, sugiere que la sutura en 1 plano de la histerorrafia está asociada con una mayor frecuencia de rotura uterina y eventos neonatales adversos en el embarazo subsecuente.
The Role of Uterine Closure in the Risk of Uterine Rupture
Bujold, Emmanuel MD, MSc, FRCSC y cols.
Abstract
OBJECTIVE: To evaluate the effects of prior single-layer compared with double-layer closure on the risk of uterine rupture.
METHODS: A multicenter, case–control study was performed on women with a single, prior, low-transverse cesarean who experienced complete uterine rupture during a trial of labor. For each case, three women who underwent a trial of labor without uterine ruptureafter a prior low-transverse cesarean delivery were selected as controlparticipants. Risk factors such as prior uterine closure, suture material, diabetes, prior vaginal delivery, labor induction, cervical ripening, birth weight, prostaglandin use, maternal age, gestational age, and interdelivery interval were compared between groups. Conditional logistic regression analyses were conducted.
RESULTS: Ninety-six cases of uterine rupture, including 28 with adverse neonatal outcome, and 288 control participantswere assessed. The rate of single-layer closure was 36% (35 of 96) in the case group and 20% (58 of 288) in the control group (P<.01).In multivariable analysis, single-layer closure (odds ratio [OR] 2.69; 95% confidence interval [CI] 1.37–5.28) and birth weight greater than 3,500 g (OR 2.03; 95% CI 1.21–3.38) were linked with increased rates of uterine rupture, whereas prior vaginal birth was a protective factor (OR0.47; 95% CI 0.24–0.93). Single-layer closure was also related to uterine rupture associated with adverse neonatal outcome (OR 2.89; 95% CI 1.01–8.27).
CONCLUSION: Prior single-layer closure carries more than twice the risk of uterine rupture compared with double-layer closure. Single-layer closure should be avoided in women who could contemplate future vaginal birth after cesarean delivery.
LEVEL OF EVIDENCE: II
Distocia de hombros es sólo una de las causas de parálisis braquial
Las trombofilias heredadas se asocian con un mayor riesgo de tromboembolismo y posiblemente con algunas condiciones patológicas en el embarazo. Sin embargo, existe evidencia escasa que permita sugerir la pesquisa y manejo de estas mutaciones durante el embarazo. Este documento del ACOG hace algunas sugerencias al respecto.
Estudio sugiere mejor pronóstico cuando la histerorrafia se sutura en 2 capas
Publicado el 28.06.2010
Un estudio publicado este mes en el Obstetrics and Gynecology por Bujold y cols. y que incluyó 96 casos de rotura uterina y 288 controles, sugiere que la sutura en 1 plano de la histerorrafia está asociada con una mayor frecuencia de rotura uterina y eventos neonatales adversos en el embarazo subsecuente.
The Role of Uterine Closure in the Risk of Uterine Rupture
Bujold, Emmanuel MD, MSc, FRCSC y cols.
Abstract
OBJECTIVE: To evaluate the effects of prior single-layer compared with double-layer closure on the risk of uterine rupture.
METHODS: A multicenter, case–control study was performed on women with a single, prior, low-transverse cesarean who experienced complete uterine rupture during a trial of labor. For each case, three women who underwent a trial of labor without uterine ruptureafter a prior low-transverse cesarean delivery were selected as controlparticipants. Risk factors such as prior uterine closure, suture material, diabetes, prior vaginal delivery, labor induction, cervical ripening, birth weight, prostaglandin use, maternal age, gestational age, and interdelivery interval were compared between groups. Conditional logistic regression analyses were conducted.
RESULTS: Ninety-six cases of uterine rupture, including 28 with adverse neonatal outcome, and 288 control participantswere assessed. The rate of single-layer closure was 36% (35 of 96) in the case group and 20% (58 of 288) in the control group (P<.01).In multivariable analysis, single-layer closure (odds ratio [OR] 2.69; 95% confidence interval [CI] 1.37–5.28) and birth weight greater than 3,500 g (OR 2.03; 95% CI 1.21–3.38) were linked with increased rates of uterine rupture, whereas prior vaginal birth was a protective factor (OR0.47; 95% CI 0.24–0.93). Single-layer closure was also related to uterine rupture associated with adverse neonatal outcome (OR 2.89; 95% CI 1.01–8.27).
CONCLUSION: Prior single-layer closure carries more than twice the risk of uterine rupture compared with double-layer closure. Single-layer closure should be avoided in women who could contemplate future vaginal birth after cesarean delivery.
LEVEL OF EVIDENCE: II
Distocia de hombros es sólo una de las causas de parálisis braquial
Publicado el 03.06.2010
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Múltiples fenómenos que ocurren durante el embarazo y parto pueden asociarse a parálisis braquial, varios de ellos difíciles o imposibles de diagnosticar prenatalmente en la actualidad. Los invitamos a leer este interesante review del Contemporary of OB-GYN de este mes. Full text, al estilo del CEDIP.
Contemporary of OB-GYN, May 2010, Review
Brachialplexus injury in newborns is commonly ascribed to the occurrence of head rotation with entrapment of the shouldersand subsequent downward traction by the accoucheur on the fetal head, resulting in avulsion of the brachial plexus nerve rootswith permanent paralysis. A temporary loss of function may result from stretching and edema of the plexus without avulsion.In brachial plexus injury cases, plaintiff attorneys usually contend that damage to the brachial plexus is always caused bynegligence of the birth attendant. However, a review of current literature reveals evidence that additional etiologies mayunderpin brachial plexus injury and raises questions regarding the level of responsibility of the birth attendant in connectionwith the injury.
ACIDO VALPROICO SE ASOCIA SIGNIFICATIVAMENTE CON AL MENOS 6 MALFORMACIONES CONGÉNITAS
Publicado el 20.07.2010
Estudio recientemente publicado en el NEJM, derivado del EUROCAT revela que existe una asociación entre acido valproico y malformaciones congénitas fetales, aún cuando se administra en monodosis para el tratamiento de la epilepsia. Las malformaciones implicadas son la espina bífida, defectos septales cardíacos, fisura labiopalatina, hipospadia, polidactilia y craneosinostosis.
Valproic Acid Monotherapy in Pregnancy and Major Congenital Malformations
Janneke Jentink, M.Sc., Maria A. Loane, M.Sc., Helen Dolk, Dr.P.H., Ingeborg Barisic, Dr.P.H., Ester Garne, M.D., Joan K. Morris, Ph.D., Lolkje T.W. de Jong-van den Berg, Ph.D., for the EUROCAT AntiepilepticStudy Working Group
ABSTRACT
Background The use of valproic acid in the first trimester of pregnancy is associated with an increased risk of spina bifida, but data on the risks of other congenital malformations are limited.
Methods We first combined data fromeight published cohort studies (1565 pregnancies in which the women were exposed to valproic acid, among which 118 major malformations were observed) and identified 14 malformations that were significantly more common among the offspring of women who had received valproic acid during the first trimester. We then assessed the associations between use of valproic acid during the first trimester and these 14 malformations by performing a case–control study with the useof the European Surveillance of Congenital Anomalies (EUROCAT)antiepileptic-study database, which is derived from population-basedcongenital-anomaly registries. Registrations (i.e., pregnancy outcomes with malformations included in EUROCAT) withany of these 14 malformations were compared with two control groups,one consisting of infants with malformations not previously linkedto valproic acid use (control group 1), and one consisting ofinfants with chromosomal abnormalities (control group 2). Thedata set included 98,075 live births, stillbirths, or terminations with malformations among 3.8 million births in 14 European countries from 1995 through 2005.
Results Exposure to valproic acid monotherapy was recorded for a total of 180 registrations, with 122 registrations in the case group, 45 in control group1, and 13 in control group 2. As compared with no use of an antiepileptic drug during the first trimester (control group 1), use of valproic acid monotherapy was associated with significantly increased risks for 6 of the 14 malformations under consideration; the adjusted odds ratios were as follows: spina bifida, 12.7 (95% confidence interval [CI], 7.7 to 20.7); atrial septal defect, 2.5 (95% CI, 1.4 to 4.4);cleft palate, 5.2 (95% CI, 2.8 to 9.9); hypospadias, 4.8 (95%CI, 2.9 to 8.1); polydactyly, 2.2 (95% CI, 1.0 to 4.5); and craniosynostosis, 6.8 (95% CI, 1.8 to 18.8). Results for exposureto valproic acid were similar to results for exposure to other antiepileptic drugs.
Conclusions The use of valproic acid monotherapy in the first trimester was associated with significantly increased risks of several congenital malformations, as compared with no use of antiepileptic drugsor with use of other antiepileptic drugs
Estudio recientemente publicado en el NEJM, derivado del EUROCAT revela que existe una asociación entre acido valproico y malformaciones congénitas fetales, aún cuando se administra en monodosis para el tratamiento de la epilepsia. Las malformaciones implicadas son la espina bífida, defectos septales cardíacos, fisura labiopalatina, hipospadia, polidactilia y craneosinostosis.
Valproic Acid Monotherapy in Pregnancy and Major Congenital Malformations
Janneke Jentink, M.Sc., Maria A. Loane, M.Sc., Helen Dolk, Dr.P.H., Ingeborg Barisic, Dr.P.H., Ester Garne, M.D., Joan K. Morris, Ph.D., Lolkje T.W. de Jong-van den Berg, Ph.D., for the EUROCAT AntiepilepticStudy Working Group
ABSTRACT
Background The use of valproic acid in the first trimester of pregnancy is associated with an increased risk of spina bifida, but data on the risks of other congenital malformations are limited.
Methods We first combined data fromeight published cohort studies (1565 pregnancies in which the women were exposed to valproic acid, among which 118 major malformations were observed) and identified 14 malformations that were significantly more common among the offspring of women who had received valproic acid during the first trimester. We then assessed the associations between use of valproic acid during the first trimester and these 14 malformations by performing a case–control study with the useof the European Surveillance of Congenital Anomalies (EUROCAT)antiepileptic-study database, which is derived from population-basedcongenital-anomaly registries. Registrations (i.e., pregnancy outcomes with malformations included in EUROCAT) withany of these 14 malformations were compared with two control groups,one consisting of infants with malformations not previously linkedto valproic acid use (control group 1), and one consisting ofinfants with chromosomal abnormalities (control group 2). Thedata set included 98,075 live births, stillbirths, or terminations with malformations among 3.8 million births in 14 European countries from 1995 through 2005.
Results Exposure to valproic acid monotherapy was recorded for a total of 180 registrations, with 122 registrations in the case group, 45 in control group1, and 13 in control group 2. As compared with no use of an antiepileptic drug during the first trimester (control group 1), use of valproic acid monotherapy was associated with significantly increased risks for 6 of the 14 malformations under consideration; the adjusted odds ratios were as follows: spina bifida, 12.7 (95% confidence interval [CI], 7.7 to 20.7); atrial septal defect, 2.5 (95% CI, 1.4 to 4.4);cleft palate, 5.2 (95% CI, 2.8 to 9.9); hypospadias, 4.8 (95%CI, 2.9 to 8.1); polydactyly, 2.2 (95% CI, 1.0 to 4.5); and craniosynostosis, 6.8 (95% CI, 1.8 to 18.8). Results for exposureto valproic acid were similar to results for exposure to other antiepileptic drugs.
Conclusions The use of valproic acid monotherapy in the first trimester was associated with significantly increased risks of several congenital malformations, as compared with no use of antiepileptic drugsor with use of other antiepileptic drugs
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