Insights from outside BJOG
2019; Wiley; Volume: 126; Issue: 7 Linguagem: Inglês
10.1111/1471-0528.15795
ISSN1471-0528
Autores Tópico(s)Maternal Mental Health During Pregnancy and Postpartum
ResumoOne of the treatment options for retained products of conception following a miscarriage is surgical evacuation. It is a commonly performed procedure as it expediently resolves a situation that is unpredictable and potentially infective. To reduce the risk of infection and its sequelae, prophylactic antibiotics are often administered but their use is not consistent nor is it based on empirical evidence. In an attempt to resolve the situation, a randomised trial was set up in Malawi, Pakistan, Tanzania and Uganda. Patients were treated with a single pre-operative dose of doxycycline plus metronidazole (400 mg each orally) or placebo (Lissauer et al. N Engl J Med 2019;380:1012–21). The outcome was the presence or absence of pelvic infection, defined as a purulent discharge, pyrexia, uterine tenderness and leucocytosis. More than 1500 patients were recruited to each arm of the study and the sepsis rates were: The data are significant or not, depending on the strictness of the signs and symptoms chosen. Adverse effects were similar in the active medication and placebo groups. The drugs are inexpensive so their use in these circumstances is in the balance (Serwadda N Engl J Med 2019;380:1075–6). The results of this well-conducted trial in low- and middle-income countries are open to interpretation. It is a clinical call that the surgeon must make and should be individualised to each patient and her circumstances. Dementia, especially Alzheimer's disease (AD), is an age-related phenomenon and women generally outlive men. Two-thirds of AD sufferers are women so it is important to identify any risk or preventive strategies that apply to women concerning the development of AD and the use of menopausal hormone therapy is one such factor. To date, research has been mostly reassuring that hormone therapy does not have a deleterious effect on the development of AD but whether its use confers a benefit in those women with vasomotor symptoms is unknown (Maki et al. BMJ 2019;364:l877). Adding to the mixed picture of evidence is a case–control study from Finland suggesting an association between hormone use and AD over the last two decades. Researchers found that slightly more women with AD had a history of hormone use according to their drug registry (19% versus 17%) and postulated a link between menopausal hormone therapy and AD (Savolainen-Peltonen et al. BMJ 2019;364:l665). However, any such link must remain speculative for a number of reasons. The Finnish study suggests an association and not a strong one at that, and does not provide any direct evidence. The connection is circumstantial and is not robust enough to alter clinical practice, which is that menopausal hormone therapy should be used for the treatment of bothersome vasomotor symptoms. It should preferably be started within 10 years of the onset of menopause and may be continued indefinitely provided all remains well. If the woman has a raised risk of venous thromboembolism the transdermal route is preferable (W. H. Utian, pers. comm.). Patients should be assured that hormone therapy does not result in early adverse effects on cognitive function. In an encouraging long-term (44 years) study from Sweden, it was shown that cognitive and physical activity can ward off the development of dementia in women (Najar et al. Neurology 2019;92:e1322–30). The reduction in risk was substantial, cheap, risk-free and confirms the many previous ‘use it or lose it’ articles that exercising one's body and brain has advantages to both. Initiating leisure-time physical activity in adulthood is also associated with mortality benefits (Saint-Maurice et al. JAMA Netw Open 2019;2:e190355). Three recent articles add to our knowledge about the non-surgical management of symptomatic uterine fibroids. The first is from the USA and describes the use of oral ulipristal acetate in a placebo-controlled trial (Liu et al. Obstet Gynecol 2018;132:1241–51). Two doses of ulipristal (5 and 10 mg) were given, and the percentage of patients achieving amenorrhoea observed. Initially, 42% and 55% of participants taking low- and high-dose ulipristal, respectively, and none of the placebo recipients reached the prescribed objective, mostly within 10 days of commencement. Hot flushes were noted in 8% (low dose), 12% (high dose) and 2% (placebo) of patients, which the authors describe as ‘well tolerated’. It should, however, be noted that ulipristal acetate has had warnings concerning hepato-toxicity published in Europe, with instructions not to initiate its use until further notice. This was in early 2018 (https://www.ema.europa.eu/en/news/women-taking-esmya-uterine-fibroids-have-regular-liver-tests-while-ema-review-ongoing) and subsequent advice recommends ‘before and after’ liver function testing and limited prescription so circumspection is essential. The second article is from Japan and describes a non-inferiority trial comparing relugolix with leuprorelin for the control of heavy menstrual bleeding (Osuga et al. Obstet Gynecol 2019;133:423–33). Relugolix is a gonadotropin-releasing hormone antagonist that is prescribed as a daily dose of 40 mg orally whereas leuprorelin acetate is given as a monthly injection. In this trial involving over 250 women with symptomatic fibroids, the endpoint was a subjective, significant reduction in blood loss and the study took place over 6 months. The two drugs had similar results with daily relugolix acting more rapidly than monthly leuprorelin. Other objective measures of a reduction in fibroid volume and a rise in haemoglobin levels were comparable, allowing the researchers to demonstrate non-inferiority of the oral, daily relugolix treatment in direct comparison with monthly injections of leuprorelin. Adverse events and bone mineral density loss were similar in the two groups. The third article presents the outcomes of an ultrasonically guided radiofrequency hyper-thermal ablation trial from North America (Chudnoff et al. Obstet Gynecol 2019;133:13–22). Patients with as many as ten fibroids up to 5 cm in diameter were treated by transcervical ablation in a sponsored prospective study of 140 women. Those selected had non-pedunculated fibroids and excessive menstrual loss and wished to be treated by ‘a uterus-conserving, incision-less approach’. The endpoints were both a reduction in bleeding and no surgical intervention. The procedure was well tolerated with half the women returning to normal activity within a day and more than 95% of participants reporting symptomatic improvement at 1 year and satisfaction with their treatment. There were no device-related adverse events and a very low surgical intervention requirement. Details of the technique were published previously (Brölmann et al. Gynecol Surg 2016;13:27–35). The Centers for Disease Control and Prevention in the USA produces a poster about the effectiveness of various contraceptive methods. The point of the poster is to educate women about which contraceptive practices would suit them, their mechanisms of action and their availability. Teenage pregnancies are seldom desired in high- or middle-income countries and when they occur the outcomes are mostly disadvantageous for the woman in terms of her educational and socioeconomic status (Gigante et al. BJOG 2019;126:360–7). Each country has its views on sexual and contraceptive activity in its teenage population but how many have posters that open a conversation about the subject? The leadership in the USA, in producing a ‘national’ poster for contraceptive education, is to be commended as no single approach is likely to find favour cross-culturally or be accepted by all local communities. However, teenagers are curious – especially about sexual matters – so why should they not create posters from which their peers can learn? A national ‘Teenage Contraceptive Poster’ by adolescents and for adolescents that could be distributed on social media as well as in hardcopy format could be a source of information and guide readers to reliable data on the topic. Some posters are better than others, with patient-centred ones seeming to resonate more with readers than committee-produced documents (Anderson et al. Obstet Gynecol 2019;133:53–62). Annual revisions and competitions to have the most desirable impact and the widest distribution could make posters a national talking point. Getting responsible conversations on contraception started by teenagers is a challenge but a dynamic ‘Teenage Contraceptive Poster’ competition may be an idea that teenagers would run with and learn from. Would national organisations or groups concerned with teenage health take on a ‘Teenage Contraceptive Poster’ project? The World Health Organization (WHO) has recently published new guidelines on malaria vector control, an important part of strategies to prevent, control and eliminate this disease. Based on various sets of WHO recommendations, systematic reviews of the latest evidence and expert opinion, the guidelines aim to bring together fragmented evidence to provide guidance for national malaria programmes. Recommendations are provided on prevention, mitigation and management of insecticide resistance and vector control across different malaria transmission settings. In terms of interventions, guidance is provided on insecticide-treated nets (ITNs), indoor residual spraying (IRS) and larval source management (LSM). Personal protection measures are also discussed including topical repellent use in pregnant women, space spraying and housing improvements. Recommendations regarding vector control during epidemics, humanitarian emergencies and migrant and high-risk populations are also provided. Areas have been identified for further research to inform future updates of the guideline including a review of data on IRS interventions from studies other than cluster randomised controlled trials, a review of cost and cost-effectiveness data on all vector control interventions and a review on housing and on two LSM interventions (habitat modification and manipulation). WHO states that these new guidelines are a ‘living document’ and that they welcome continuous feedback to improve and update them. This data brief from the US Centers for Disease Control and Prevention National Center for Health Statistics is based on data from the 2015–2017 National Survey of Family Growth and provides a snapshot of current contraceptive use among women aged 15–49 years in the USA. The briefing states that in 2015–2017, 64.9% of women aged 15–49 years in the USA were currently using a method of contraception and the most commonly reported methods used are female sterilisation (18.6%), the pill (12.6%), the condom (8.7%) and long-acting reversible contraception (LARC; 10.3%). Figure 3 highlights the percentage of all women aged 15–49 years who were using female sterilisation, the oral contraceptive pill, male condom or LARC by age group. These data are also displayed in figure 4 stratified by Hispanic origin and race, and in figure 5 by educational attainment. Key findings include that use of LARC is higher in women aged 20–29 years (13.1%) when compared to women aged 15–19 years (8.2%). Current condom use showed no difference amongst non-Hispanic white, non-Hispanic black, and Hispanic women (approximately 7%–10%). The use of the pill increased and female sterilisation declined in women with higher educational attainment. This surveillance report, from WHO, follows on from the 2016 Global Health Sector Strategy on Sexually Transmitted Infections. The 2016 strategy reportedly aims to reduce rates of congenital syphilis (to less than 50 cases per 100 000 live births in 80% of countries) and reduce both the incidences of syphilis and gonorrhoea infections by 90% by 2030. The current report highlights progress in achieving the strategy with a table providing an overview of progress for prevention and control of selected sexually transmitted infections by WHO region. Chapter 2 focuses on progress towards elimination of mother-to-child transmission (MTCT) of syphilis and reports that between 2015 and 2018, 11 countries and territories have successfully eliminated MTCT of syphilis (Cuba, Thailand, Belarus, Moldova, Anguilla, Antigua and Barbuda, Bermuda, Cayman Islands, Montserrat, St Kitts and Nevis, and Malaysia). The guideline notes that many countries continue to have low screening rates due to lack of supply of syphilis test kits and limited access to and use of benzathine benzylpenicillin. Chapter 5 provides estimates of prevalence trends for chlamydia, gonorrhoea and syphilis using epidemic models. Chapter 7 discusses human papillomavirus (HPV) vaccination to prevent cervical cancer and presents data on the number of countries with HPV vaccination in their national immunisation schedule. Annex 1 provides a cascade of indicators for elimination of MTCT of syphilis using the most recent data reported through the Global AIDS Response Progress Reporting (GARPR) system, 2008–2017 and Annex 2 contains data on syphilis prevalence reported for female sex workers and men who have sex with men using the most recent data reported through the GARPR system, 2008–2017. U.S. Preventive Services Task Force The following guideline is now available at www.uspreventiveservicestaskforce.org Final Recommendation Statement: Screening for Elevated Blood Lead Levels in Children and Pregnant Women Society of Obstetricians and Gynaecologists of Canada (SOGC) The following guidelines are now available at www.jogc.com No. 376-Magnesium Sulphate for Fetal Neuroprotection No. 377-Hysterectomy for Benign Gynaecologic Indications American College of Obstetricians and Gynecologists (ACOG) The following guidelines are now available at www.acog.org Newborn Screening and the Role of the Obstetrician-Gynecologist (Committee Opinion), No. 778, May 2019 Practice Advisory Interim Guidance for Care of Obstetric Patients During a Zika Virus Outbreak Royal College of Obstetricians and Gynaecologists (RCOG) The following guidelines are now available at www.rcog.org.uk Valproate Use In Women and Girls Of Childbearing Years Prenatal Management of Pregnancies at Risk of Fetal Neonatal Alloimmune Thrombocytopenia (FNAIT) (Scientific Impact Paper No. 61) Society for Maternal-Fetal Medicine (SMFM) The following guideline is now available at www.smfm.org SMFM Consult Series #47: Sepsis during pregnancy and the puerperium These guidelines, developed by WHO, provide evidence-based recommendations for the use of uterotonics in preventing postpartum haemorrhage, which affects approximately 5% of all women giving birth and is the cause of almost one-quarter of all maternal deaths globally. The guideline considers and makes recommendations regarding the efficacy, safety and choice of uterotonics including oxytocin, carbetocin, misoprostol, ergometrine/methylergometrine, and oxytocin and ergometrine fixed-dose combination. The guideline presents the seven key priority questions used as the basis for development of the recommendations. It also presents a summary of the characteristics of uterotonic options evaluated for the prevention of postpartum haemorrhage and implementation considerations and research implications are highlighted. WO2019040461 (A1) Uterine manipulator. This patent application relates to the development of a uterine manipulator comprising a handle, shaft, inflatable balloon and cervical cup used to mobilise and position the uterus to improve visualisation during laparoscopic hysterectomy. Einarsson JI. 28 February 2019. US2019062404 (A1) Composition and method for therapeutic agent delivery during pregnancy. This patent application relates to the use of a composition comprising an elastin-like polypeptide (ELP) coupled to a therapeutic agent to enable the delivery of drug therapies to pregnant women whilst reducing the amount of the therapeutic agent that can cross the placenta. This application claims priority from US Provisional Application Serial No. 61,885,300, filed 1 October 2013. Bidwell III GL, George EM. 28 February 2019. US2019056380 (A1) Detection of risk of pre-eclampsia. This patent application relates to the identification of a number of metabolites that the inventors report are associated with early prediction of risk of hypertensive disorders (including eclampsia, mild pre-eclampsia, chronic hypertension, EPH gestosis, gestational hypertension, superimposed pre-eclampsia, HELLP syndrome or nephropathy) in pregnant women such as predicting risk of pre-eclampsia at approximately 11–17 weeks’ gestation. This application is a divisional of US application Ser. No. 14/990,231 filed 7 January 2016, which is a divisional of US application Ser. No. 13/515,323 filed 14 September 2012, now US Pat. No. 9,262,582 issued 16 February 2016, which is a 35 U.S.C. § 371 National Phase Entry Application of International Application No. PCT/EP2010/070446 filed 21 December 2010, which designates the US, and which claims benefit under 35 U.S.C. § 119(e) of US Provisional Application No. 61/288,465, filed 21 December 2009. Kenny L, Baker PN, Broadhurst D. 21 February 2019. EP3449968 (A1) Uterine cervix adhesion prevention device. This patent application relates to the invention of a device for insertion into the uterocervical canal to prevent adhesion formation and blockage in the uterine cervix after surgery and to help aid recovery. Jung MH. 6 March 2019. The Sindh High Court in Pakistan has reportedly recently introduced a ruling requiring the government to implement measures to ensure provision of and access to obstetric fistula care in the province of Sindh. The ruling includes the establishment of fistula care centres and requires the government to present a compliance report within 3 months to show that it has acted upon the court order. Source: www.reproductiverights.org Recently, the High Court of Justice in Israel has ruled to prohibit a woman from using the sperm from a donor from the USA to become pregnant because of concerns that he is already a father to over 35 children. Israeli law requires that all gamete donations are anonymous unless the couple wishes to co-parent the resulting child. Both the woman and donor in this case agreed to co-parent but the court had concerns regarding the donor's ability to provide as a father as a result of his responsibilities to his other children. Source: www.bionews.org.uk Clinicians keen to keep up-to-date regarding clinical studies that are currently recruiting may find the following informative.
Referência(s)