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March of Dimes Award-Winning Study Identifies New Approach to Personalize Prevention of Preterm Birth

New research findings may soon help doctors personalize preterm birth prevention treatments by identifying which women at higher risk for preterm birth will be helped by progesterone injections. Injections of one type of progesterone, a synthetic form of a hormone naturally produced during pregnancy, have been shown to reduce the risk of recurrent preterm births More »

Study Suggests Women 35 and Older are at Decreased Risk of Having Anatomically Abnormal Child

In a study to be presented on Feb. 6 at 3 p.m. CST, at the Society for Maternal-Fetal Medicine’s annual meeting, The Pregnancy Meeting™, in New Orleans, researchers will report that women ages 35 and older are at a decreased risk of having a child with a major congenital malformation, after excluding chromosomal abnormalities. Advanced More »

Study Finds Multifaceted Intervention Leads to Significant Reduction of Cesarean Deliveries and Neonatal Morbidity

In a study to be presented on Feb. 6 in an oral plenary session at 8 a.m. CST, at the Society for Maternal-Fetal Medicine’s annual meeting, The Pregnancy Meeting™, in New Orleans, researchers will report that Cesarean deliveries reviews and best practices implementation are effective to provide optimal care by an appropriate management of medical More »

Study Finds Remifentanil Patient Controlled Analgesia Not as Effective as Epidural Analgesia in Managing Pain Relief during Labor

In a study to be presented on Feb. 7 at 1:30 p.m. CST, at the Society for Maternal-Fetal Medicine’s annual meeting, The Pregnancy Meeting™, in New Orleans, researchers will report findings which suggest remifentanil patient controlled analgesia is not equivalent to epidural analgesia for pain, pain appreciation scores, and overall satisfaction in women who request More »

Study Finds Obesity during Pregnancy is Independent Risk Factor for Long-Term Cardiovascular Morbidity

In a study to be presented on Feb. 7 at 2:45 p.m. CST, at the Society for Maternal-Fetal Medicine’s annual meeting, The Pregnancy Meeting ™, in New Orleans, researchers will report that obesity during pregnancy is an independent risk factor for long-term cardiovascular morbidity, and these complications tend to occur at a younger age. Researchers More »

Physicians Weigh in on Study in The Lancet on Use of Antenatal Corticosteroids in Prevention of Pre-term Birth

The Society for Maternal-Fetal Medicine (organization representing physicians specializing in high-risk pregnancy) weighed in on the Antenatal Corticosteroids Trial that was published in yesterday’s issue of The Lancet. The study was designed to test whether a multifaceted intervention consisting of provider training, tools to identify women at increased risk for preterm birth, and corticosteroids given to the mother improves outcomes of the baby over usual care in these settings.

While giving corticosteroids to the mother in the U.S. has been shown to improve outcome of preterm babies, the Trial showed no benefit and maybe even some harm. SMFM has reviewed the evidence and concluded that the results of the Trial should not alter practice in the U.S. The Trial was specific to the health care settings involved in the study and would not be applicable to the settings in the U.S. There are several reasons why corticosteroids would be of benefit in the U.S. but not in low-resource settings. The technology and neonatal care available in the U.S. was not available to the Trial and would have likely changed the results. For example, women in the Trial did not have access to ultrasound, most delivered in a non-hospital setting, and neonatal intensive care was not available.

The Society for Maternal-Fetal Medicine commends the National Institute of Child Health and Development for supporting studies in low-resource settings and the investigators for completing such a complex study. It is important to evaluate treatments in the specific practice settings where they will be used rather than applying what has been proven beneficial in other settings. While this trial should inform practice and recommendations in similar settings to the ones included, it should not alter the management of women at risk for preterm birth in the US. Antenatal administering of corticosteroids to these women remains one of the most important measures to decrease neonatal mortality and morbidity in the U.S. Until further evidence becomes available from ongoing studies (e.g. Antenatal Late Preterm Steroid),
the use of antenatal corticosteroids should be limited to women at risk for preterm birth who are less than 34 weeks’ gestation.

To view The Lancet study, go to: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2961651-2/fulltext

Society for Maternal-Fetal Medicine Recognizes Need to Reduce America’s Infant Mortality Rate

WASHINGTON,  Sept. 10, 2014—In recognition of September as National Infant Mortality Awareness Month, the Society for Maternal-Fetal Medicine encourages its members, U.S. policymakers and citizens to recognize the need to reduce America’s infant mortality rate. Despite recent declines, the rates of infant mortality in the U.S. remain at the bottom of the list of developing countries.

 

One key factor that will improve SMFM’s goals of reducing infant mortality is to reduce preterm birth –the leading cause of infant morbidity and mortality. Preterm birth accounts for nearly 70 percent of infant deaths, and women in the U.S. suffer among the highest preterm birth rates in the world: one in nine babies born in the United States (11.5 percent) is delivered before 37 completed weeks of gestation.  While babies born before 32 weeks represent only 2 percent of all births, they result in half (54 percent) of infant deaths.  The rate of infant mortality for babies born very low birth weight (less than 1,500 grams) is 100 times higher than that for babies born weighing more than 2,500 grams.

 

Reducing infant mortality starts with preventing pregnancy complications that result in preterm birth, including preterm labor, preeclampsia, and placental dysfunction. SMFM  strongly believes that wider implementation of guidelines on the use of progesterone and cervical cerclage to reduce preterm birth as published in 2012 by SMFM, the American Congress of Obstetricians and Gynecologists  and American College of Nurse-Midwives would go a long way to reducing infant mortality rates in this country. Along those lines, SMFM, along with ACOG and ACNM sent a letter on August 13 to U.S. Department of Health and Human Services Secretary Sylvia Mathews Burwell regarding this very issue.

 

Other areas for improvement include wider use of low dose aspirin to prevent preeclampsia, strategies for smoking cessation, appropriate use of antibiotics to prevent neonatal Group B Strep sepsis, timely corticosteroid administration to accelerate fetal lung maturity, Doppler ultrasound for management of fetal growth restriction, and strategies to prolong pregnancy in women with preterm premature rupture of the membranes. Any initiative to decrease infant mortality by improving pregnancy outcomes should address racial and ethnic health disparities as well as improving pre-pregnancy health and access to prenatal and inter-pregnancy care. While these approaches should decrease infant mortality to some degree, reducing it further will require investment in more research in order to improve our understanding of the etiology, prevention, and management of these pregnancy complications.

 

As high-risk pregnancy doctors and caregivers to those most vulnerable women and their babies, SMFM members are in the unique position to deal with obstetrical conditions that, in aggregate, have the largest impact on infant mortality. Those include preterm birth, preeclampsia, congenital anomalies, perinatal infections and utero-placental insufficiency. SMFM is committed to ensuring that our nation’s mothers and babies are the healthiest they can be.

 

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The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine.  The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed.  For more information visit www.smfm.org.

SMFM Releases Paper on Activity Restriction in Pregnancy

WASHINGTON, Sept. 2, 2014—In a new guideline, the Society for Maternal-Fetal Medicine has recommended against the routine use of bed rest in pregnancy.

“There is no evidence that bed rest improves outcomes”, says Anthony Sciscione, DO, director of Delaware Center for Maternal and Fetal Medicine and one of the co-authors of the guideline. “However, there is evidence that bed rest can be harmful for moms, babies, and families.”

About one in five women are placed on bed rest during their pregnancy. Surveys have shown that both ob/gyns and maternal-fetal medicine specialists prescribe activity restriction and bed rest, even though most of the physicians surveyed do not expect that doing so will actually improve pregnancy outcomes.

Restriction of activity in pregnancy is also known as “bed rest,” or “modified bed rest” and has been recommended for a number of potential complications such as preterm (before 37 weeks gestation) contractions, a dilated cervix from preterm labor, a short cervix, preterm premature rupture of membranes (water breaking before 37 weeks gestation and before the onset of labor), elevated blood pressure, preeclampsia, inadequate growth of baby, placenta previa, risk of miscarriage, multiple gestations (e.g. twin pregnancies),  and others.

In the guideline, the Society points out that bed rest has not been shown to reduce the chance of preterm delivery in women either at risk or already experiencing preterm labor.  One study found that preterm birth was more common in women already at risk of preterm birth when they were placed on any type of work or non-work related activity restriction, both at home and in the hospital.  There is also no data indicating that activity restriction is of benefit for any obstetric condition.

Inadequate growth of the baby is often attributed to problems with blood flow to the placenta and activity restriction or bed rest is often prescribed in an effort to improve placental blood flow. Again, studies fail to show a benefit to this practice.

While there is no evidence the bed rest improves outcomes, there are several potentially harmful side effects. It’s widely known though that extended periods of activity restriction can result in muscle and bone loss.  This “deconditioning” happens to pregnant and non-pregnant individuals.  Changes can occur after only a few days of immobility and there is not a lot of information on the full impact these changes have in pregnant women.

Bed rest may also increase risk of developing blood clots in the legs (deep venous thrombosis, or DVT) and movement of clots to the lungs (pulmonary embolism, or PE). Such clots are more common among pregnant women, and limiting physical activity may compound these risks.

Lack of movement may also increase a woman’s risk of gestational diabetes, or GDM. The Society notes that being admitted to the hospital for pregnancy-related complications has been associated with a higher risk of GDM, although more studies are needed. Elevated levels of blood sugar commonly occur in non-pregnant patients placed on activity restriction.

In addition to the potential negative physical effects associated with activity restriction during pregnancy, there is also an increased risk of anxiety and depression, adverse psychological effects on the family, loss of income, and lower birth weights.

In summary, the Society for Maternal-Fetal Medicine notes that the practice of activity restriction or bed rest has very little evidence to support a benefit for mother or infant, but has well-described negative effects on the mother, newborn and the family.

The Society for Maternal-Fetal Medicine recommends against the routine use of activity restriction or bed rest during pregnancy for any indication.  To read the full paper, go to https://www.smfm.org/publications/173-activity-restriction-in-pregnancy.

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The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine.  The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed.  For more information visit www.smfm.org.

Leaders in Women’s Health Convene to Save Mothers’ Lives

WASHINGTON, March 5, 2014—The Society for Maternal-Fetal Medicine (SMFM), the American Congress of Obstetricians and Gynecologists, the Association of Women’s Health, Obstetric and Neonatal Nurses, the Centers for Disease Control and Prevention, and other groups have created the Council on Patient Safety in Women’s Health Care.

“The Council on Patient Safety in Women’s Health Care is a collaborative effort with the goal of continually improving patient safety in women’s health care through multidisciplinary collaboration that drives culture change,” said SMFM board member and council chair Alfred Abuhamad.

Despite medical advances, mothers in the U.S. are more at risk of dying from pregnancy related problems today than they were in 1990. Women in the United States are twice as likely to have a life-threatening problem during pregnancy or childbirth than women in western Europe.

This week, the council launched a web site, Safe Health Care for Every Woman. To improve care, the site provides standardized tools for Severe Maternal Morbidity review. Hospitals can use these tools to identify problems with care delivery and reduce the chance of future life-threatening events.

“As high risk pregnancy experts, maternal-fetal medicine physicians lead patient safety programs throughout the country,” said Peter Bernstein, a SMFM board member and council member. “The first step is to identify the systems issues that put families at risk, and these Severe Maternal Mortality review forms facilitate that process.”

Excessive bleeding after childbirth is a leading cause of severe morbidity and mortality for pregnant women. In April, the council will release an Obstetric Hemorrhage Patient Safety Bundle with step-by-step, evidence-based tools to manage risk, prevent adverse events, and respond and debrief.

Later in the spring, the council will share Maternal Early Warning Criteria to identify mothers who require urgent bedside evaluation. Additional planned safety bundles will provide guidance on treatment of severe hypertension and prevention of venous thromboembolism in pregnancy.

“The council has brought together nurses, midwives, physicians, patient safety specialists and industry partners to realize our vision of safe healthcare for every woman,” Abuhamad said. “Together, we improve care.”

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The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine.  The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed.  For more information visit www.smfm.org.

 

 

SMFM Physicians Recommend NIPT for High-Risk Patients

WASHINGTON, March 5, 2014—A paper published on Feb. 27, 2014 in the New England Journal of Medicine titled DNA Sequencing versus Standard Prenatal Aneuploidy Screening has garnered a great deal of media attention focused on the use of maternal serum cell-free DNA screening, or noninvasive prenatal testing (NIPT) for aneuploidy in average risk patients. The authors, supported by one of the commercial laboratories, compared NIPT with traditional screening for aneuploidy using serum analytes on a relatively small number of average risk patients. The study was too small to compare detection rates, but the authors report that the false positive rate of NIPT is lower and therefore the test “merits serious consideration as a primary screening method for fetal autosomal aneuploidy.

While this measured conclusion appears reasonable, the serious consideration that the authors propose requires further data, and the study by Bianchi et al has to be viewed in the context of its many limitations. Most importantly, the study is underpowered to compare the detection rates, and it is generally not valid to compare false-positive rates in isolation.

NIPT uses cell-free DNA from maternal serum to screen for common fetal aneuploidies with high sensitivity and specificity. It also uses next generation sequencing to directly measure fetal DNA in the maternal circulation, and clinical tests are now available using this technique. While there are differences in the methodologies employed by the commercial laboratories, overall the reported performance is similar, with detection rates for Down syndrome above 99 percent and false positive rates that are less than one percent. This makes this screening test an attractive alternative to traditional serum screening for aneuploidy for patients.

Currently, the Society for Maternal-Fetal Medicine (SMFM) recommends that NIPT is most appropriate for high-risk patients. The five high-risk criteria currently include maternal age 35 years or older at delivery, sonographic findings indicating an increased risk of aneuploidy, history of a prior pregnancy with a trisomy, positive screening results for aneuploidy, including first trimester, sequential, integrated, or quadruple screen, or parental balanced Robertsonian translocation with increased risk for trisomy 13 or 21.

This recommendation has been based primarily on the more limited evidence regarding the utility of NIPT in low- or average-risk pregnant women, and validation studies that have generally been limited to high-risk populations. Understandably, there is a keen interest in performing the same type of validation studies in a low-risk population.

The study compared only false positive rates for trisomies 18 and 21, although all commercially available products also include testing for trisomy 13 and the sex chromosomes, which have higher false positive rates. A high percentage of the samples for NIPT were collected in the third trimester – at gestational ages when clinical aneuploidy screening is not performed and is not clinically relevant, yet when fetal DNA amounts are far higher allowing better test performance. The authors compared NIPT with standard prenatal screening with a variety of first and second trimester tests that have a broad range of performance characteristics. Fewer than three percent of patients had integrated screening, which is the prenatal screening method with the best performance, including the lowest false positive rate. In addition, traditional screening can detect risk for a broad array of structural, chromosomal and perinatal abnormalities.

“The importance of these in a low-risk population may be far greater than the impact of trisomy 18 and 21, which are relatively rare in a younger maternal cohort.  It is important to note that this study included only five Down syndrome. Five cases of trisomy 21 in the population of 1909 patients represents a rate of 1 out of 381, which is substantially higher than the population risk of 1 out of 700 that would be expected in a truly “average” or “low-risk” cohort,” said Dr. Vincenzo Berghella, president of SMFM. “Finally and importantly, when considering population screening, some patients who choose NIPT will fail to obtain a result. While that number was just under 1 percent in this study, rates as high as 12 percent have been published, especially in overweight and obese women.”

SMFM has reviewed the evidence, including this recent paper, and feels that while NIPT is a promising new technology, and this new report is important and excellent news, it is not enough to change current ACOG and SMFM recommendations. Given that just eight aneuploidies were present in the entire cohort of patients, the true test performance is difficult to determine.

“Further evidence comparing costs, false positive rates for all included analyses, ability to obtain a result, and overall test performance for all detectable abnormalities in larger numbers of truly average risk patients are required to justify changing recommendations regarding population based prenatal screening from just high-risk pregnancies, to all pregnancies. We eagerly await the results of ongoing research studies which will address these issues,” said Berghella.

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The Society for Maternal-Fetal Medicine (est. 1977) is the premiere membership organization for obstetricians/gynecologists who have additional formal education and training in maternal-fetal medicine.  The society is devoted to reducing high-risk pregnancy complications by sharing expertise through continuing education to its 2,000 members on the latest pregnancy assessment and treatment methods. It also serves as an advocate for improving public policy, and expanding research funding and opportunities for maternal-fetal medicine. The group hosts an annual meeting in which groundbreaking new ideas and research in the area of maternal-fetal medicine are shared and discussed.  For more information visit www.smfm.org.

 

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