News from September 2010

Test for Preeclampsia could be available in Five Years

September 23, 2010

An international consortium of scientists has discovered that a combination of 14 metabolites in the blood predict with a high likelihood the chance of a pregnant woman developing preeclampsia [1].

They are now hoping to develop a blood test using these metabolites that could be performed in early pregnancy and would have a number of practical uses, says the lead author of the research, Dr Louise C Kenny (Cork University, Ireland), who reports the findings, along with her colleagues, online September 13, 2010 in Hypertension.

“It’s very much about translating these findings into a meaningful clinical test,” she told heartwire , estimating that such an assay could be available within the next five years.

Risk Stratification Will Help Target Likely Sufferers and Save Money

Kenny and colleagues explain that preeclampsia affects around 5% of pregnancies; it globally afflicts four million women every year and remains a leading cause of maternal death as well as being responsible for significant fetal and infant morbidity and mortality. In addition, preeclampsia has future healthcare implications for women, with anyone affected having an increased risk of hypertension, coronary artery disease, stroke, and type 2 diabetes mellitus in later life.

The precise etiology of preeclampsia is unclear, but accumulating evidence suggests that it results from a complex interaction between a poorly perfused placenta and a maternal response to placental-derived triggers, which results in widespread vascular endothelial-cell dysfunction.

Kenny explains that currently, “the whole basis of antenatal care is to detect preeclampsia early—blood-pressure checks and urine dips—so if we had a test in the first or second trimester that could sensitively and accurately predict risk—and, more important, detect those at low risk—it would change how we perform antenatal care, and the healthcare economic savings would be enormous. We could target limited resources and focus increased maternal and fetal surveillance on the women at greatest risk.”

And although the only cure for preeclampsia is delivery of the baby and placenta, there are some interventions, such as aspirin therapy, that, “if given early enough, can reduce the risk of severe preeclampsia by about a third,” she adds, “but obviously, even with something as simple as aspirin, there are side effects, and it may be detrimental in pregnant women at low risk of preeclampsia. This is all about risk stratification, so that we can personalize healthcare.”

Also, there are a number of compounds in the early stages of development for preeclampsia, “and everything we know about the disease suggests that to prevent it we are going to have to give drugs in early pregnancy and likely for the duration of pregnancy,” she notes, so knowing who to target is key. “Obviously, we don’t want to expose every pregnant woman to trial drugs; we need to know who is at greatest risk. But in those patients you would imagine the risks of drug therapy would be outweighed by the potential benefits.”

Finally, Kenny says they hope that some of the more unusual metabolites they have discovered to have an association with preeclampsia might yield new biological insights into the origins of the disease process and reveal novel pathways for drug development.

The international consortium is now working to develop a blood test to be performed in early pregnancy, with funding from the Wellcome Trust among others, which they hope will have a fairly rapid turnaround for results.

The metabolomic discovery program is funded by the Wellcome Trust and by Science Foundation Ireland. Kenny is a Science Foundation Ireland principal investigator.

(article taken from Medscape Business of Medicine)

For the full article please find the link here

Mothers not getting enough 'good quality' sleep: American Journal of Obstetrics & Gynecology

September 17, 2010

Contrary to popular belief, new mothers may often get a decent amount of sleep in their babies’ first few months—but it’s not a good-quality sleep, a new study suggests.

The study, which followed 74 new moms, found that on average, the women got just over 7 hours of sleep per night during their babies’ first four months. That is within what’s generally recommended for adults, and, based on past studies, more than the average American gets.

On the other hand, the study found, that sleep is also frequently disrupted—with the women typically being awake for a total of two hours overnight.

The finding may not sound surprising, especially to parents. But the study does challenge a central assumption about new mothers’ typical sleep patterns, according to lead researcher Dr. Hawley E. Montgomery-Downs, an assistant professor of psychology at West Virginia University in Morgantown.

That assumption, she told Reuters Health, has been that most new moms are sleep-deprived—that is, not getting enough hours of sleep.

So the advice on how to combat daytime fatigue has focused on countering sleep deprivation, Dr. Montgomery-Downs said—such as the age-old adage to “nap when your baby naps.”

But the current results, reported online August 19th in the American Journal of Obstetrics & Gynecology, suggest that new mothers’ highly fragmented sleep is what’s behind their daytime fatigue.

That sleep pattern, Dr. Montgomery-Downs said, is similar to what’s seen with certain sleep disorders, such as sleep apnea, where people log enough hours in bed, but get little restorative, good-quality sleep. Depending on how often a new mom is waking up, she may get few or no full cycles of sleep, Dr. Montgomery-Downs noted. And a quick daytime nap is unlikely to counter that.

“We need to think about what kinds of strategies can help consolidate sleep” for these mothers, Dr. Montgomery-Downs said. One tactic, she suggested, could be for breastfeeding moms to find time to pump milk and store it in bottles so that they do not have to be the ones to always get up with the baby.

And while quick naps might not do much, Dr. Montgomery-Downs noted that “if you’re one of the lucky parents” whose infants typically nap for at least two straight hours, taking that time to sleep could be helpful.

The 74 new mothers in the study were followed between either the second and 13th week of their infants’ lives, or between the 9th and 16th week. The women kept sleep diaries, and they also wore a wristwatch-like actigraph that recorded their movements during the night.

As noted, the researchers found that the women’s average sleep time was about what it should be, at 7.2 hours. Instead, sleep fragmentation was the issue. Relatively few mothers tried napping as a countermeasure. By the third week of their infants’ lives, less than half of the women in the study said they napped, and among those who did, the average was twice per week.

Daytime fatigue, a problem reported by many new mothers in other studies, is a concern for several reasons, according to Dr. Montgomery-Downs. One is that, in some women, sleep problems and exhaustion may contribute to postpartum depression.

Beyond that, she said, fatigue can also hinder people’s ability to drive safely or hurt their performance at work. She believes mothers’ fragmented sleep and daytime fatigue call for a reconsideration of maternity work leave in the U.S. Right now, national policy states that workplaces with 50 or more employees have to offer up to 12 weeks of unpaid leave; the U.S. is the only Western country that does not mandate some amount of paid parental leave.

So many women, Montgomery-Downs said, may have to go back to work at a time when “they should really be taking care of themselves.”

Am J Obstet Gynecol. Posted online August 19, 2010

By Amy Norton

NEW YORK (Reuters Health) Aug 30th 2010

(article taken from Medscape News)
(orginal article from Reuters Health)

Journal reports artificially sweetened soft drinks may increase risk of preterm birth

September 13, 2010

Daily consumption of artificially sweetened soft drinks may increase the risk for preterm delivery, according to the results of a Danish prospective cohort study reported in the September issue of the American Journal of Clinical Nutrition.

“Sugar-sweetened soft drinks have been linked to a number of adverse health outcomes such as high weight gain,” write Thorhallur I. Halldorsson, from Statens Serum Institut in Copenhagen, Denmark, and colleagues. “Therefore, artificially sweetened soft drinks are often promoted as an alternative. However, the safety of artificial sweeteners has been disputed, and consequences of high intakes of artificial sweeteners for pregnant women have been minimally addressed.”

The goal of the study was to evaluate the association between consumption of sugar-sweetened and artificially sweetened soft drinks and preterm delivery.

Participants were 59,334 women enrolled in the Danish National Birth Cohort from 1996 to 2002. With use of a food frequency questionnaire, soft drink consumption was evaluated in midpregnancy, and telephone interviews determined covariate information. The main study endpoint was preterm delivery, defined as less than 37 weeks of gestation.

Consumption of artificially sweetened carbonated and noncarbonated soft drinks was associated with an increased risk for preterm delivery (P for trend ≤ .001 for both variables). Compared with women who did not drink artificially sweetened carbonated soft drinks, the adjusted odds ratio (OR) for women who drank at least 1 serving daily was 1.38 (95% confidence interval [CI], 1.15 – 1.65), and the adjusted OR for women who drank at least 4 servings daily was 1.78 (95% CI, 1.19 – 2.66). These associations were noted in normal-weight as well as in overweight women. Increased risk was stronger for early preterm and moderately preterm delivery vs late-preterm delivery.

For sugar-sweetened carbonated or noncarbonated soft drinks, no apparent association with the risk for preterm delivery was observed.

“Daily intake of artificially sweetened soft drinks may increase the risk of preterm delivery,” the study authors write. “Further studies are needed to reject or confirm these findings.”

Limitations of this study include possible reverse causality, inability to implicate specific artificial sweetener(s), observational design, and unidentified or residual confounders.

“The relative consistency of our findings for carbonated and noncarbonated soft drinks and the absence of an association for sugar-sweetened soft drinks suggest that the content of artificial sweeteners might be the causal factor,” the study authors conclude. “However, the replication of our findings in another experimental setting is warranted.”

The European Union (EU) Integrated Research Project EARNEST supported this study. The EU project EARNEST receives financial support from the Commission of the European Communities. The Danish National Birth Cohort has been financed by the March of Dimes Birth Defects Foundation, the Danish Heart Association, the Danish Medical Research Council, and the Sygekassernes Helsefond Danish National Research Foundation, Danish Pharmaceutical Association, Ministry of Health, National Board of Health, Statens Serum Institut. The study authors have disclosed no relevant financial relationships.

Am J Clin Nutr. 2010;92:626–633.

(News item taken from Medscape Medical News)

BMJ Report shows no need to delay pregnancy following miscarriage

September 10, 2010

Women may not need to delay pregnancy after an initial miscarriage, according to the results of a retrospective, Scottish population–based cohort study reported Online First August 5 in the BMJ.

“How long a couple should wait before trying for another pregnancy after a miscarriage is controversial,” write Eleanor R. Love, from the University of Aberdeen in Aberdeen, Scotland, and colleagues. “Some clinicians believe that there is little justification for delaying the next pregnancy, as an increased interpregnancy interval is unlikely to improve perinatal outcomes, whereas a new viable pregnancy and the birth of a child could enhance the women’s chances of recovery…. Current guidelines from the World Health Organization recommend that women should wait for at least six months before trying again, whereas others suggest a delay of up to 18 months, based on reports that interpregnancy intervals of 18–23 months after a live birth can enhance maternal and perinatal outcomes in the next pregnancy.”

The goal of this study was to evaluate the optimal interval to subsequent pregnancy after miscarriage in a first recorded pregnancy. At Scottish hospitals between 1981 and 2000, a total of 30,937 women who had a miscarriage in their first recorded pregnancy and subsequently became pregnant were followed up during the second pregnancy. The main study outcome was miscarriage, live birth, termination, stillbirth, or ectopic pregnancy in the second pregnancy, and secondary endpoints were rates of cesarean and preterm delivery, low birth weight infants, preeclampsia, placenta previa, placental abruption, and induced labor in the second pregnancy.

Compared with an interval of 6 to 12 months between the miscarriage and second conception, an interval less than 6 months was associated with lower risks for repeated miscarriage (adjusted odds ratio [OR], 0.66; 95% confidence interval [CI], 0.57 – 0.77), termination (OR, 0.43; 95% CI, 0.33 – 0.57), and ectopic pregnancy (OR, 0.48; 95% CI, 0.34 – 0.69). The risk for an ectopic second pregnancy was greater with an interpregnancy interval exceeding 24 months (OR, 1.97; 95% CI, 1.42 – 2.72), as was the risk for termination (OR, 2.40; 95% CI, 1.91 – 3.01).

Compared with women who had an interpregnancy interval of 6 to 12 months, those who conceived again within 6 months and had a live birth in the second pregnancy were less likely to have a cesarean delivery (OR, 0.90; 95% CI, 0.83 – 0.98), preterm delivery (OR, 0.89; 95% CI, 0.81 – 0.98), or low-birth-weight infant (OR, 0.84; 95% CI, 0.71 – 0.89). However, they were more likely to have labor induced (OR, 1.08; 95% CI, 1.02 – 1.23).

“Women who conceive within six months of an initial miscarriage have the best reproductive outcomes and lowest complication rates in a subsequent pregnancy,” the study authors write.

Limitations of this study include potential lack of uniformity in documenting gestational age and outcomes of interest as well as possible misclassification. This study also evaluated only miscarriages that led to hospital contact, and the findings therefore cannot be generalized to all women with a miscarriage.

“Our research shows that it is unnecessary for women to delay conception after a miscarriage,” the study authors conclude. “As such the current WHO [World Health Organization] guidelines may need to be reconsidered. In accordance with our results, women wanting to become pregnant soon after a miscarriage should not be discouraged.”

In an accompanying editorial, Julia Shelley, associate professor of health and social development at Deakin University in Melbourne, Australia, discusses some of the methodologic issues regarding this study and earlier studies.

”[A]ll of the studies have selection and measurement biases that cast doubt on the value and generalisability of their findings,” Dr. Shelley writes. “Of greatest concern is that women with short interpregnancy intervals are more fertile than those whose subsequent pregnancy occurs later because these women seem to have better pregnancy outcomes and fewer complications. Further research into this question may need to wait for data from more sophisticated linked primary care and hospital datasets or specifically designed research studies that can measure and account for such differences, even if they will not be able to control for them.”

This research was partially funded by the Chief Scientist’s Office in Scotland. Two of the study authors were employed by the University of Aberdeen at the time of doing this research and are independent from the funders. Ms. Love is a medical student, and another study author is employed by NHS Grampian. Dr. Shelley has disclosed no relevant financial relationships.

BMJ. 2010;341:c3967.

(This article is taken from Medscape CME)

Supplementation by Vitamin C & E may not prevent Preterm Birth: Obstetrics & Gynecology

September 7, 2010

A placebo controlled trial reported in the September issue of Obstetrics & Gynecology reports supplementation with Vitamin C & E may not reduce the risk for spontaneous preterm birth.

Please see the article below taken from Medscape CME:

August 27, 2010 — Vitamins C and E supplementation beginning at 9 to 16 weeks of gestation in nulliparous women at low risk may not reduce spontaneous preterm births, according to the results of a randomized, double-masked, placebo-controlled trial reported in the September issue of Obstetrics & Gynecology.

“Preterm [premature rupture of membranes (PROM)] has been associated with many factors, including ascorbic acid deficiency (vitamin C),” write John C. Hauth, MD, from the University of Alabama at Birmingham, and colleagues from the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. “These observations are of great importance because if vitamin C supplementation reduces the occurrence of preterm PROM, then a deficiency of vitamin C is a modifiable risk factor and supplementation would be a corrective interventional behavior. Our intent was to assess further the hypothesis that daily maternal antioxidant supplementation with vitamins C and E from early pregnancy would reduce the incidence of spontaneous preterm birth attributable to either spontaneous labor or preterm PROM.”

In the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network trial, nulliparous women at low risk were randomly assigned to daily vitamin C and E supplementation or matching placebo to determine the effect on adverse outcomes from pregnancy-associated hypertension. Participants (n = 10,154) received 1000 mg of vitamin C and 400 IU of vitamin E or placebo daily from 9 to 16 weeks of gestation until delivery. In this secondary analysis, the studied endpoints included preterm birth attributable to PROM and total spontaneous preterm births (attributable either to PROM or spontaneous labor).

Of 9968 participants with available outcome data, 4992 were in the vitamin group and 4976 in the placebo group. Of 1038 women (10.4%) who delivered preterm, 698 (7.0%) had spontaneous preterm birth, including 356 (7.1%) randomly assigned to daily vitamin C and E supplementation and 342 (6.9%) assigned to placebo. Delivery after preterm PROM occurred in 253 women (2.5%), and delivery after spontaneous preterm labor occurred in 445 (4.5%).

Compared with the placebo group, the supplementation group had similar births attributed to preterm PROM at less than 37 and 35 weeks of gestation, but fewer births before 32 weeks of gestation (0.3% vs 0.6%; adjusted odds ratio, 0.3 – 0.9). Preterm PROM occurring before 32 weeks of gestation was also less frequent in women in the vitamin group (0.36% vs 0.64%; P = .046).

Total spontaneous preterm births across gestation were similar in the placebo group and in the supplementation group.

“Maternal supplementation with vitamins C and E beginning at 9 to 16 weeks of gestation in nulliparous women at low risk did not reduce spontaneous preterm births,” the study authors write.

Limitations of this study include possible type 1 (alpha) error, as well as the clinical imprecision of determining the spontaneous preterm birth subcategories of preterm PROM or spontaneous preterm labor.

“Our results, taken in context with similar trials regarding vitamin C and E supplementation, do not support either the clinical use for prevention of spontaneous preterm birth or its neonatal sequelae or further trials of this treatment in similar populations at low risk,” the study authors conclude.

The Eunice Kennedy Shriver National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; and the National Center for Research Resources supported this study. The contents of the journal article do not necessarily represent the official view of the National Institute of Child Health and Human Development; the National Heart, Lung, and Blood Institute; the National Center for Research Resources; or the National Institutes of Health. The study authors have disclosed no relevant financial relationships.

Obstet Gynecol. 2010;116:653–658.