Journal Club Papers
Pre-eclampsia. Lucy Chappell, Catherine A Cluver et al. The Lancet. May 2021.
A comprehensive update on all aspects of preeclampsia from the world’s leaders.
The expert authorship team walks through:
- Preeclampsia diagnosis and consensus across international guidelines
- The different ways to screen for preeclampsia, including first trimester screening
- Disease pathogenesis
- Prevention, including a close look at aspirin (dose, risk, who to give it to) and the evidence underlying other options.
- The use of PIGF and the sFlt/PIGF ratio in clinical management
- Clinical management including medications and the monitoring of mother and fetus
- What long-term health for women after preeclampsia looks like
- Where we need to be focusing our efforts to continue reducing the morbidity and mortality of preeclampsia.
- This review is THE ultimate one stop shop for the most recent updates in preeclampsia. It is well worth a read, and absolute exam gold for MRANZCOG and CMFM candidates!
Association Between Iatrogenic Delivery for Suspected Fetal Growth Restriction and Childhood School Outcomes. Selvaratnam et al JAMA. 2021
(This review is also authored by Dr Natasha Pritchard, Mercy Hospital for Women)
This Victorian retrospective, population-based cohort study used routine birth data from 2003-2013, and aimed to answer the question: When obstetricians induce pregnancies for suspected FGR (to reduce stillbirth risk), are there impacts on developmental and educational outcomes for the offspring?
- Early childhood developmental outcomes were assessed from data obtained from The Australian Early Developmental Census (AEDC), which assesses children at school entry (ages 4 – 6) across 5 developmental domains. Children were deemed developmentally vulnerable if they were in the bottom 10th percentile across two or more domains.
- Educational outcomes were obtained from The National Assessment Program – Numeracy and Literacy (NAPLAN). Developmental vulnerability was defined as below minimum standard in 2 or more of the 5 domains.
The <3rd percentile infants
In the main analysis only looking at fetuses comparing severely growth restricted (<3rd centile) who were suspected of being small (and delivered at a mean 37.9 weeks gestation) vs those <3rd centile and were not suspected of being born small (and delivered at a mean 39.4 weeks gestation):
- Compared with those <3rd centile but were not suspected of having FGR, those severely growth restricted and delivered early (n=181,902) were significantly more likely to score poorly in childhood developmental outcomes (AEDC) assessed at school entry (16.2% vs 12.7%; adjusted odds ratio, 1.36 [95% CI, 1.07-1.74]; absolute difference 3.5% [95% CI, 0.5-6.5]).
- Compared with those <3rd centile but were not suspected of having FGR, those severely growth restricted and delivered early (n=425,717) were also more likely to score poorly in childhood educational outcomes (NAPLAN) assessed at grades 3, 5 and 7 (grade 7: 4% vs 10.5%; aOR, 1.33 [95%CI, 1.04-1.70]; absolute difference 2.9% [95% CI, 0.4%-5.5%])
The >10th centile infants
- Compared with infants >10th centile not suspected of having FGR, babies >10th centile that were delivered for suspected FGR had no differences in the odds of scoring poorly on childhood outcomes (AEDC: 8.6% vs 8.1; aOR, 1.17 [95%CI, 0.95-1.45];
- The authors conclude that iatrogenic delivery for suspected FGR in severely growth restricted infants was associated with poorer school outcomes, but iatrogenic delivery for suspected FGR in infants with normal growth was not associated with poorer school outcomes.
The authors published an earlier report showing severely growth restricted infants delivered early for suspected FGR had a 3-fold increase in the odds of NICU admissions but incurred an almost 20-fold reduction in stillbirth (0.8 per 1000 compared to 16.4 per 1000) and a 4.6-fold reduction in total perinatal death (Selvaratnam et al. J. Paediatrics & Childhealth, 2020).
The second point to note is that those in the early delivery group birthed at a significantly early gestation and this is likely to account for the differences seen in educational outcomes.
In putting all this together we suggest induction for suspected fetal growth restriction is still absolutely warranted to reduce the stillbirth risk. This study suggests we might reconsider when we book inductions for suspected FGR and there is now a reason to avoid going too early (e.g. 37 weeks vs close monitoring and delivering well into the 38th week. Or even 39 weeks).
Association Between BNT162b2 Vaccination and Incidence of SARS-CoV-2 Infection in Pregnant Women. Goldshtein et al. JAMA. July 2021
(Also authored by Dr Hannah Gordon, Mercy Hospital for Women)
In Australia, women at any stage of pregnancy are now eligible for the BNT162b2 (Pfizer-BioNTech) vaccine. However, pregnant women were originally excluded from RCTs assessing the safety and efficacy of COVID-19 trials. Thus, until now it has not been clear whether pregnancy women benefit from vaccination in the same way as the general population.
- This retrospective cohort study from Israel included 7530 Pfizer-vaccinated pregnant women, matched with 7530 unvaccinated pregnant women, and investigated COVID-19 infection at 28 days or more following first dose of vaccine.
- During the median follow up of 37 days (range 0 – 70 days), there were 118 (1.6%) COVID-19 infections within the vaccinated group vs 202 (2.7%) in the unvaccinated group.
- A greater benefit of vaccination was found 28 days post vaccination (primary outcome), with 10 COVID-19 infections within the vaccinated group and 46 in the unvaccinated group after this time (28 – 70 days post). This gave an adjusted hazard ratio of 0.22 (95% CI, 0.11-0.43) and a vaccine efficacy of 78%.
- Most Covid-affected participants were symptomatic (89%), irrespective of vaccination status, and 0.2% of vaccinated, and 0.3% of unvaccinated women required hospitalisation.
- Vaccination-related side-effects were reported by 68 women, and none were considered severe, with the most reported including headache, general weakness, non-specified pain and stomach pain.
- During the study period 2,814 women gave birth. Importantly, there were no significant differences in pregnancy outcomes between the two groups, including rates of preeclampsia, intrauterine growth restriction, infant birth weight, miscarriage and stillbirth.
Because testing was done on an as-need basis, the study may have overlooked participants with asymptomatic illness. Additionally, participants were followed from their first dose, thus it is likely efficacy would increase after the second.
Despite some limitations, and being an observational study, this paper evidences the effectiveness of the Pfizer vaccine for pregnant women, during a period where the delta variant was present in Israel, and should provide reassurance for those considering vaccination during pregnancy.
Widespread implementation of a low-cost telehealth service in the delivery of antenatal care during the COVID-19 pandemic: an interrupted time-series analysis. Palmer et al. Lancet. July 2021.
This retrospective observational study examined routine birth data from Monash Health. It compared the detection of adverse obstetric outcomes between two time periods – the first, a pre-COVID ‘conventional antenatal care period’ (1 Jan 2018 – 20 March 2020) and the second, a post-COVID 19 ‘integrated care period’ including telehealth (April 20 – July 26 2020). For clarity we will present ‘integrated care period’ as the ‘COVID era’.
- Primary outcomes included detection of fetal growth restriction, pre-eclampsia, and gestational diabetes. Secondary outcomes were stillbirth, NICU admission and preterm birth (<37 weeks).
- During the conventional care period (prior to COVID), 20,031 women gave birth with 2,292 giving birth during the ‘COVID era’.
- More than half the consultations (53%) during the ‘COVID era’ were by telehealth (voice or video call).
- No differences were found between the care periods, for low or high-risk models of care, with regards to:
- Fetal growth restriction (babies <3rd percentile: 2% in low-risk care during both periods, p=0.72; 5% in high-risk care during both periods, p=0.50).
- Stillbirths (1% during both periods for low-risk care, p=79; 2% during both periods for high-risk care, p=0.70)
- Pre-eclampsia (3% during both periods for low-risk care, p=0.70; 9% for integrated care and 7% for conventional care for high-risk care, p=0.15)
- Gestational diabetes (22% during both periods for low-risk care, p=0.89; 30% for integrated care and 26% for conventional care for high-risk p=0.06)
- The authors conclude that antenatal care during the COVID era where telehealth was commonly used was not associated with a change in adverse pregnancy outcomes or complications, compared with conventional care. Telehealth seems safe and should be considered as part of routine antenatal care in the future.
In this report more women failed to attend their scheduled consultations during COVID era care than during conventional care (8% vs 5%, p<0.001). While the data is reassuring, it may have been underpowered to detect differences for some important adverse outcomes, especially stillbirth. Hence, ongoing surveillance of the performance of Telehealth is warranted.