🔥OFF THE PRESS: Best Dose of UFH for Antepartum Inpatients? (May 14, 2024 Data)

It definitely is interesting how published data tends to have sporadic “groupings” in print. For example, last week 2 publications were released which could be placed under one “group”: prediction/prevention of spontaneous preterm birth. One publication (AJOG MFM) presented a systematic review and meta-analysis on universal cervical length screening. The second publication, SMFM’s consult series # 70, pertains to the management of a short cervix in individuals without a history of spontaneous preterm birth. In this episode, we will review these 2 similar, yet different, publications and make sense of all! 👍👍👍

It’s exciting to know that we are practicing a type of medicine that is alive and ever-evolving! Such is the case regarding our clinical practice/management of gestational diabetes. In this episode, we will review brand new (as of May 21, 2024) clinical guidance from the ACOG regarding gestational diabetes. Should we be screening for diabetes before 24 weeks? Is there one diagnostic threshold which is suggested for use over the other (CC versus NDDG)? And is it possible to screen for postpartum DM as early as 2 days after delivery?😳 Listen in and find out.

The United States began adding fluoride to community water supplies in 1945. At that time, Grand Rapids, Michigan became the first community in the world to add fluoride to tapwater. Over the last several years, with an increase in reporting and media stories over the last 3 months, fluorinated drinking water has come under scrutiny and controversy. Does fluoride in drinking water affect children in the womb? Is this a cause of altered neurocognitive development? Does this lower IQ scores? This is a very HOT topic and there’s more fuel towards this fire with a publication which was released on May 20, 2024 in JAMA Network Open. In this episode, we will lay out the facts of this study, and why this must be interpreted with more than just face value. So grab your favorite fluorinated water beverage, and listen in!

Podcast family, this episode is recorded on the last day of the ACOG ACSM. Wanted to share with you some encouragement that I received from our podcast family members over these last 2 to 3 days. AND of course, in typical style, I’ll share with you a brand new publication which was released on May 17, 2024 in the AJOG (GRAY Journal) regarding “optimal dose of antenatal corticosteroids”. And lastly, I’ll share 3 Special Announcements, as an FYI.

We all can agree that we need a new ally against the foe of pre-term birth. With the disappointing results regarding the (lack of) efficacy of progesterone in reducing preterm birth, the search is out for a new, effective tool to reduce pre-term birth rates. Enter: the Lioness(tm) device. In this episode, we will review a new “safety and efficacy” study published today (May 16, 2024) in the AJOG. Is this ready for prime time? And how does this device work? Listen in for details.

Unbelievable timing! In our immediate past episode, we discussed the controversy surrounding pharmacoprophylaxis for antepartum inpatients. Just 3 days from that episode, a new RCT has been published in the Green Journal (Obstet Gynecol) discussing this very subject! This new RCT (published May 14, 2024) investigates the “best dose” of unfractionated heparin (UFH) during antepartum admissions? is there an advantage to “gestational – age based” dosing? Or should standard UFH dosing be used?

All of us can agree that the rates of obesity are progressively climbing, not just in the US, but globally. Obesity is a known independent risk factor in pregnancy for VTE. Several professional societies (ACOG, CMQCC, RCOG, SMFM) have clear recommendations for VTE pharmacoprophylaxis in patients considered at high risk. These include having a high risk thrombophilia, having a personal history of VTE, or having multiple risk factors. But these recommendations address POSTPARTUM prophylaxis. The ACOG does not specifically address inpatient prophylaxis during the antepartum interval. However, in cases of prolonged antepartum admission, where ambulation may be slightly limited, there is concern that the hypercoagulable state of pregnancy, together with obesity, may raise the risk of VTE in these antepartum patients. To be clear, no professional organization or guidelines recommend strict bedrest for pregnancy complications. Is VTE pharmacoprophylaxis endorsed in these admitted antepartum patients? The answer is both YES and NO. The use of heparin based agents in this group is controversial, with published expert opinions having a dichotomy of thought. Plus, recent data (2023) has raised questions regarding pharmacoprophylaxis’ efficacy in the postpartum interval. nonetheless, at the end of the episode, will provide some common sense approaches to VTE prevention in the admitted antepartum, obese patient. (With a special shout-out to our podcast family in Australia.).

Bacterial vaginosis (BV) is known as a normal vaginal microbiota resulting in low lactobacilli; it affects one-quarter to one-third of reproductive-age women. The BV treatment landscape has not appreciably changed in decades: in the US, metronidazole and clindamycin are recommended as first-line treatments for symptomatic BV, and secnidazole and tinidazole are used as alternatives. Although these treatments are effective in the short term, up to 60% of women experience BV recurrence within 1 year of treatment. Some have more frequent recurrences. Suppressive vaginal metronidazole fails for 25% of patients and leads to secondary vulvovaginal candidiasis (VVC) in up to 40%, and many patients have BV recurrence after stopping suppressive therapy. But now a “new” therapeutic option has been in print and is attracting a lot of attention. DQC has been available in other parts of the world for decades, and recently published results from a new European clinical investigation (May 2024) adds more reassuring date. This has led many in the United States to call for trials in this country to begin FDA approval. Listen in for details.

Preterm birth is the leading cause of death in newborns and children. Tocolytic drugs aim to delay preterm birth by suppressing uterine contractions to allow time for administration of corticosteroids for fetal lung maturation, magnesium sulphate for neuroprotection, and transport to a facility with appropriate neonatal care facilities. However, there is still uncertainty about their effectiveness and safety. Plus, more than 90% of the data regarding tocolytic use comes from patients with threatened preterm labor with intact membranes, with (according to the WHO) only 9% of available data is regarding patients with ruptured membranes. But in May 2024, a new publication adds further information to this subset of patients. In this episode, we will review this ongoing controversy regarding the benefits of tocolytic therapy, and when they may provide the most efficacy. And yes, of course, we will provide the ACOG guidance as well.

Haemorrhage, hypertensive disorders, and sepsis are responsible for more than half of maternal deaths worldwide. Further, it is estimated that for every death, there are 50 pregnant people with life-threatening morbidity from sepsis. Heartbreakingly, the incidence of puerperal sepsis has risen over the last decade, in some cases doubling, with increasing rates of severe sepsis contributing to mortality. Underlying this trend is increasing virulence of group A streptococcal (GAS) infection. This is suspected to be due to the predominance of emm1 and emm28 genotypes, which have higher associations with mortality, as well as increasing maternal risk factors for infection such as obesity and DM. PLUS, certain GAS antibiotic resistance is on the rise. Group A streptococcus infection remains an important contributor to pregnancy and puerperal morbidity and mortality. Early recognition, diagnosis and aggressive management are Important for favorable outcomes given the serious risk of sepsis and streptococcal toxic shock syndrome. In this episode, we will highlight this alarming rise of Group A strep in the peripartum period including the most recent 2021 International Society for Infectious Disease in Obstetrics and Gynecology (ISIDOG) guidelines regarding GAS in pregnancy. Listen in for details.