Robert L. Barbieri, MD

In the United States there is an epidemic of hypertensive disorders in pregnancy, with 16% of pregnant people being diagnosed with preeclampsia, gestational hypertension, chronic hypertension, preeclampsia superimposed on chronic hypertension, HELLP, or eclampsia.¹ Preeclampsia with severe features increases the maternal risk for stroke, pulmonary edema, kidney injury, abruption, and fetal and maternal death. Preeclampsia also increases the fetal risk for growth restriction, oligohydramnios, and preterm birth.

Angiogenic factors and the pathophysiology of preeclampsia—From bench to bedside

The pathophysiology of preeclampsia is not fully characterized, but a leading theory is that placental ischemia causes increased placental production of anti-angiogenesis factors and a decrease in placental production of pro-angiogenesis factors.^2-4 Clinical studies support the theory that preeclampsia is associated with an increase in placental production of anti-angiogenesis factors, including soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin, and a decrease in the placental production of pro-angiogenesis factors, including placental growth factor (PlGF).^5-15

The US Food and Drug Administration (FDA) has recently approved an assay for the measurement of sFlt-1 (Brahms sFlt-1 Kryptor) and PlGF (Brahms sFlt-1 Kryptor) (Thermo Fisher Scientific; Waltham, Massachusetts).¹⁶ This editorial focuses on the current and evolving indications for the measurement of sFlt-1 and PlGF in obstetric practice.

FDA approval of a preeclampsia blood test

The FDA approval of the tests to measure sFlt-1 and PlGF is narrowly tailored and focused on using the sFlt-1/PlGF ratio to assess the risk of progression to preeclampsia with severe features within 2 weeks among hospitalized patients with a hypertensive disorder in pregnancy with a singleton pregnancy between 23 weeks 0 days (23w0d) and 34w6d gestation.¹⁶ The test is meant to be used in conjunction with other laboratory tests and clinical assessment. The FDA advises that the test results should not be used to diagnose preeclampsia, nor should they be used to determine the timing of delivery or timing of patient discharge.¹⁶ The sFlt-1 and PIGF measurements are both reported as pg/mL, and the sFlt-1/PlGF ratio has no units.

The FDA approval is based on clinical studies that demonstrate the effectiveness of the test in predicting the progression of a hypertensive disorder in pregnancy to preeclampsia with severe features within 2 weeks of testing. In one study, the sFlt-1/PlGF ratio was measured in 556 pregnant patients with a singleton pregnancy who were between 23w0d and 34w6d gestation and hospitalized with a hypertensivedisorder in pregnancy without severe features at study enrollment.¹⁵ Those patients receiving intravenous heparin were excluded because of the effect of heparin on sFlt-1 levels. Participants’ mean age was 31.7 years, and their mean gestational age was 30w3d. The patients’ mean body mass index (BMI) was 34.2 kg/m², with mean maximal blood pressure (BP) at enrollment of 159 mm Hg systolic and 95 mm Hg diastolic.

In this cohort, 31% of enrolled patients progressed to preeclampsia with severe features within 2 weeks. At enrollment, the median sFlt-1/PlGF ratio was greater among the patients who progressed to preeclampsia with severe features than among those who did not have progression to preeclampsia with severe features (291 vs 7). An elevated sFlt-1/PlGF ratio (determined to be a ratio ≥ 40) predicted that patients would progress to severe preeclampsiawith severe features—with positive and negative predictive values of 65% and 96%, respectively. Among the subgroup of patients with a history of chronic hypertension, an sFlt-1/PlGF ratio ≥ 40 had positive and negative predictive values of 59% and 94%, respectively. Focusing the analysis on patients who self-reported their race as Black, representing 30% of the cohort, the positive and negative predictive values for a sFlt-1/PlGF ratio ≥ 40 were 66% and 99%, respectively.¹⁵

Receiver-operating curve analyses were used to compare the predictive performance of sFlt-1/PlGF measurement versus standard clinical factors and standard laboratory results, including systolic and diastolic BP; levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatinine; and platelet count.¹⁵ The area under the curve for predicting progression to preeclampsia with severe features was much greater for the sFlt-1/PlGF test (0.92) than for systolic (0.67) and diastolic BP (0.70), AST level (0.66), ALT level (0.61), creatinine level (0.65), and platelet count (0.57).¹⁵ These results demonstrate that measuring sFlt-1/PlGF ratios is a much better way to predict the progression of preeclampsia to severe disease than measuring standard clinical and laboratory results.

Patients with a sFlt-1/PlGF ratio ≥ 40 had higher rates of adverse maternal outcomes including severe hypertension, abruption, stroke, eclampsia, pulmonary edema, thrombocytopenia, low platelets, and/or coagulation disorder, than those patients with a ratio < 40, (16.1% vs 2.8%, respectively; relative risk [RR], 5.8; 95% confidence interval [CI], 2.8 to 12.2).¹⁵ Adverse fetal and neonatal outcomes (including fetal death, small for gestational age and early delivery due to progression of disease) were more common among patients with a sFlt-1/PlGF ratio of ≥ 40 (80% vs 26%; RR, 3.1; 95% CI, 2.5–3.8).¹⁵ Many other studies support the hypothesis that the sFlt-1/PlGF ratio is predictive of adverse outcomes among patients with hypertensive disorders in pregnancy.^6-15

Applying the bottom-line study findings. Patients with a hypertensive disorder in pregnancy and a sFlt-1/PlGF ratio < 40 have a low risk of progressing to preeclampsia with severe features over the following 2 weeks, with a negative predictive value of 96%. The remarkably high negative predictive value of a sFlt-1/PlGF ratio < 40 will help obstetricians generate a care plan that optimizes the use of limited health care resources. Conversely, about two-thirds of patients with a hypertensive disorder in pregnancy and a sFlt-1/PlGF test ≥ 40 will progress to preeclampsia with severe features and may need to prepare for a preterm delivery.

Continue to: Clinical utility of the sFlt-1/PlGF ratio in obstetric triage...

Measurement of the sFlt-1/PlGF ratio may help guide clinical care among patients referred to obstetric triage or admitted to the hospital for the evaluation of suspected preeclampsia. In one study, 402 patients with a singleton pregnancy referred to the hospital for evaluation of suspected preeclampsia, had a standard evaluation plus measurement of an sFlt-1/PlGF ratio.¹³ The clinicians caring for the patients did not have access to the sFlt-1/PlGF test results. In this cohort, 16% of the patients developed preeclampsia with severe features in the 2 weeks following the initial assessment in triage. In this cohort, a normal sFlt-1/PlGF ratio reliably predicted which patients were not going to develop preeclampsia with severe features over the following 2 weeks, with a negative predictive value of 98%. Among the patients with an elevated sFlt-1/PlGF ratio, however, the positive predictive value of the test was 47% for developing preeclampsia with severe features within the 2 weeks following initial evaluation. Among patients < 34 weeks’ gestation, an elevated sFlt-1/PlGF ratio had a positive predictive value of 65%, and a negative predictive value of 98%. Other studies also have reported that the sFlt-1/PlGF ratio is of value for assessing the risk for progression to preeclampsia with severe features in patients being evaluated for suspected preeclampsia.^6,17,18

In obstetric triage, it is difficult to predict the clinical course of patients referred for the evaluation of suspected preeclampsia based on BP measurements or standard laboratory tests. The sFlt-1/PlGF test will help clinicians identify patients at low and high risk of progressing to preeclampsia with severe features.¹⁹ Patients with a normal sFlt-1/PlGF test are at low risk of developing preeclampsia with severe features over the following 2 weeks. Patients with an elevated sFlt-1/PlGF test are at higher risk of progressing to preeclampsia with severe features and may warrant more intensive obstetric care. An enhanced care program might include:

• patient education
• remote monitoring of BP or hospitalization
• more frequent assessment of fetal well-being and growth
• administration of glucocorticoids to advance fetal maturity, if indicated by the gestational age.

Twin pregnancy complicated by preeclampsia

Twin pregnancy is associated with a high risk of developing preeclampsia and fetal growth restriction. For patients with a twin pregnancy and a hypertensive disorder in pregnancy, an elevated sFlt-1/PlGF ratio is associated with the need for delivery within 2 weeks and an increased rate of adverse maternal and neonatal outcomes. In a retrospective study involving 164 patients with twin pregnancy first evaluated for suspected preeclampsia at a median gestational age of 33w4d, the sFlt-1/PlGF ratio was positively correlated with progression of preeclampsia without severe features to severe features within 2 weeks.²⁰ In this cohort, at the initial evaluation for suspected preeclampsia, the sFlt-1/PlGF ratio was lower among patients who did not need delivery within 2 weeks compared with those who were delivered within 2 weeks, 24 versus 84 (P<.001). The mean sFlt-1/PlGF ratio was 99 among patients who needed delivery within 1 week following the initial evaluation for suspected preeclampsia. Among patients who delivered within 1 week of presentation, the reasons for delivery were the development of severe hypertension, severe dyspnea, placental abruption, rising levels of serum liver function enzymes, and/or onset of the HELLP syndrome.

An important finding in this study is that a normal sFlt-1/PlGF ratio predicted that the patient would not need delivery within 2 weeks, with a negative predictive value of 96%. Other studies also have reported that an elevated sFlt-1/PlGF ratio in twin pregnancies is associated with an increased risk of adverse outcomes and early delivery.^21-23 An adequately powered multicenter study of twin pregnancies is needed to identify the sFlt-1/PlGF ratio associated with the greatest combined negative and positive predictive values.

The sFlt-1/PlGF test is a welcome addition to OB care

FDA approval of laboratory tests to measure circulating levels of sFlt-1 and PlGF will advance obstetric practice by identifying patients with a hypertensive disorder in pregnancy who are at low and high risk of developing preeclampsia with severe features within 2 weeks of the test. No laboratory test can replace the clinical judgment of obstetricians who are responsible for balancing the maternal and fetal risks that can occur in the management of a patient with a hypertensive disorder in pregnancy. The sFlt-1/PlGF ratio is highly dependable for identifying those patients with a hypertensive disorder in pregnancy who will not progress to severe disease within 2 weeks. The sFlt-1/PlGF ratio also identifies those patients with preeclampsia who are most likely to have adverse maternal and neonatal outcomes. The patients with an elevated sFlt-1/PlGF ratio may need more intensive antenatal care and consideration for transfer to a health system with a higher level of maternal and neonatal services. The sFlt-1/PlGF test is a welcome addition to obstetric care because it will improve the precision of our management of pregnant patients with hypertension. ●

rbarbieri@mdedge.com

In the United States there is an epidemic of hypertensive disorders in pregnancy, with 16% of pregnant people being diagnosed with preeclampsia, gestational hypertension, chronic hypertension, preeclampsia superimposed on chronic hypertension, HELLP, or eclampsia.¹ Preeclampsia with severe features increases the maternal risk for stroke, pulmonary edema, kidney injury, abruption, and fetal and maternal death. Preeclampsia also increases the fetal risk for growth restriction, oligohydramnios, and preterm birth.

Angiogenic factors and the pathophysiology of preeclampsia—From bench to bedside

The pathophysiology of preeclampsia is not fully characterized, but a leading theory is that placental ischemia causes increased placental production of anti-angiogenesis factors and a decrease in placental production of pro-angiogenesis factors.^2-4 Clinical studies support the theory that preeclampsia is associated with an increase in placental production of anti-angiogenesis factors, including soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin, and a decrease in the placental production of pro-angiogenesis factors, including placental growth factor (PlGF).^5-15

The US Food and Drug Administration (FDA) has recently approved an assay for the measurement of sFlt-1 (Brahms sFlt-1 Kryptor) and PlGF (Brahms sFlt-1 Kryptor) (Thermo Fisher Scientific; Waltham, Massachusetts).¹⁶ This editorial focuses on the current and evolving indications for the measurement of sFlt-1 and PlGF in obstetric practice.

FDA approval of a preeclampsia blood test

The FDA approval of the tests to measure sFlt-1 and PlGF is narrowly tailored and focused on using the sFlt-1/PlGF ratio to assess the risk of progression to preeclampsia with severe features within 2 weeks among hospitalized patients with a hypertensive disorder in pregnancy with a singleton pregnancy between 23 weeks 0 days (23w0d) and 34w6d gestation.¹⁶ The test is meant to be used in conjunction with other laboratory tests and clinical assessment. The FDA advises that the test results should not be used to diagnose preeclampsia, nor should they be used to determine the timing of delivery or timing of patient discharge.¹⁶ The sFlt-1 and PIGF measurements are both reported as pg/mL, and the sFlt-1/PlGF ratio has no units.

The FDA approval is based on clinical studies that demonstrate the effectiveness of the test in predicting the progression of a hypertensive disorder in pregnancy to preeclampsia with severe features within 2 weeks of testing. In one study, the sFlt-1/PlGF ratio was measured in 556 pregnant patients with a singleton pregnancy who were between 23w0d and 34w6d gestation and hospitalized with a hypertensivedisorder in pregnancy without severe features at study enrollment.¹⁵ Those patients receiving intravenous heparin were excluded because of the effect of heparin on sFlt-1 levels. Participants’ mean age was 31.7 years, and their mean gestational age was 30w3d. The patients’ mean body mass index (BMI) was 34.2 kg/m², with mean maximal blood pressure (BP) at enrollment of 159 mm Hg systolic and 95 mm Hg diastolic.

In this cohort, 31% of enrolled patients progressed to preeclampsia with severe features within 2 weeks. At enrollment, the median sFlt-1/PlGF ratio was greater among the patients who progressed to preeclampsia with severe features than among those who did not have progression to preeclampsia with severe features (291 vs 7). An elevated sFlt-1/PlGF ratio (determined to be a ratio ≥ 40) predicted that patients would progress to severe preeclampsiawith severe features—with positive and negative predictive values of 65% and 96%, respectively. Among the subgroup of patients with a history of chronic hypertension, an sFlt-1/PlGF ratio ≥ 40 had positive and negative predictive values of 59% and 94%, respectively. Focusing the analysis on patients who self-reported their race as Black, representing 30% of the cohort, the positive and negative predictive values for a sFlt-1/PlGF ratio ≥ 40 were 66% and 99%, respectively.¹⁵

Receiver-operating curve analyses were used to compare the predictive performance of sFlt-1/PlGF measurement versus standard clinical factors and standard laboratory results, including systolic and diastolic BP; levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatinine; and platelet count.¹⁵ The area under the curve for predicting progression to preeclampsia with severe features was much greater for the sFlt-1/PlGF test (0.92) than for systolic (0.67) and diastolic BP (0.70), AST level (0.66), ALT level (0.61), creatinine level (0.65), and platelet count (0.57).¹⁵ These results demonstrate that measuring sFlt-1/PlGF ratios is a much better way to predict the progression of preeclampsia to severe disease than measuring standard clinical and laboratory results.

Patients with a sFlt-1/PlGF ratio ≥ 40 had higher rates of adverse maternal outcomes including severe hypertension, abruption, stroke, eclampsia, pulmonary edema, thrombocytopenia, low platelets, and/or coagulation disorder, than those patients with a ratio < 40, (16.1% vs 2.8%, respectively; relative risk [RR], 5.8; 95% confidence interval [CI], 2.8 to 12.2).¹⁵ Adverse fetal and neonatal outcomes (including fetal death, small for gestational age and early delivery due to progression of disease) were more common among patients with a sFlt-1/PlGF ratio of ≥ 40 (80% vs 26%; RR, 3.1; 95% CI, 2.5–3.8).¹⁵ Many other studies support the hypothesis that the sFlt-1/PlGF ratio is predictive of adverse outcomes among patients with hypertensive disorders in pregnancy.^6-15

Applying the bottom-line study findings. Patients with a hypertensive disorder in pregnancy and a sFlt-1/PlGF ratio < 40 have a low risk of progressing to preeclampsia with severe features over the following 2 weeks, with a negative predictive value of 96%. The remarkably high negative predictive value of a sFlt-1/PlGF ratio < 40 will help obstetricians generate a care plan that optimizes the use of limited health care resources. Conversely, about two-thirds of patients with a hypertensive disorder in pregnancy and a sFlt-1/PlGF test ≥ 40 will progress to preeclampsia with severe features and may need to prepare for a preterm delivery.

Continue to: Clinical utility of the sFlt-1/PlGF ratio in obstetric triage...

Measurement of the sFlt-1/PlGF ratio may help guide clinical care among patients referred to obstetric triage or admitted to the hospital for the evaluation of suspected preeclampsia. In one study, 402 patients with a singleton pregnancy referred to the hospital for evaluation of suspected preeclampsia, had a standard evaluation plus measurement of an sFlt-1/PlGF ratio.¹³ The clinicians caring for the patients did not have access to the sFlt-1/PlGF test results. In this cohort, 16% of the patients developed preeclampsia with severe features in the 2 weeks following the initial assessment in triage. In this cohort, a normal sFlt-1/PlGF ratio reliably predicted which patients were not going to develop preeclampsia with severe features over the following 2 weeks, with a negative predictive value of 98%. Among the patients with an elevated sFlt-1/PlGF ratio, however, the positive predictive value of the test was 47% for developing preeclampsia with severe features within the 2 weeks following initial evaluation. Among patients < 34 weeks’ gestation, an elevated sFlt-1/PlGF ratio had a positive predictive value of 65%, and a negative predictive value of 98%. Other studies also have reported that the sFlt-1/PlGF ratio is of value for assessing the risk for progression to preeclampsia with severe features in patients being evaluated for suspected preeclampsia.^6,17,18

In obstetric triage, it is difficult to predict the clinical course of patients referred for the evaluation of suspected preeclampsia based on BP measurements or standard laboratory tests. The sFlt-1/PlGF test will help clinicians identify patients at low and high risk of progressing to preeclampsia with severe features.¹⁹ Patients with a normal sFlt-1/PlGF test are at low risk of developing preeclampsia with severe features over the following 2 weeks. Patients with an elevated sFlt-1/PlGF test are at higher risk of progressing to preeclampsia with severe features and may warrant more intensive obstetric care. An enhanced care program might include:

• patient education
• remote monitoring of BP or hospitalization
• more frequent assessment of fetal well-being and growth
• administration of glucocorticoids to advance fetal maturity, if indicated by the gestational age.

Twin pregnancy complicated by preeclampsia

Twin pregnancy is associated with a high risk of developing preeclampsia and fetal growth restriction. For patients with a twin pregnancy and a hypertensive disorder in pregnancy, an elevated sFlt-1/PlGF ratio is associated with the need for delivery within 2 weeks and an increased rate of adverse maternal and neonatal outcomes. In a retrospective study involving 164 patients with twin pregnancy first evaluated for suspected preeclampsia at a median gestational age of 33w4d, the sFlt-1/PlGF ratio was positively correlated with progression of preeclampsia without severe features to severe features within 2 weeks.²⁰ In this cohort, at the initial evaluation for suspected preeclampsia, the sFlt-1/PlGF ratio was lower among patients who did not need delivery within 2 weeks compared with those who were delivered within 2 weeks, 24 versus 84 (P<.001). The mean sFlt-1/PlGF ratio was 99 among patients who needed delivery within 1 week following the initial evaluation for suspected preeclampsia. Among patients who delivered within 1 week of presentation, the reasons for delivery were the development of severe hypertension, severe dyspnea, placental abruption, rising levels of serum liver function enzymes, and/or onset of the HELLP syndrome.

An important finding in this study is that a normal sFlt-1/PlGF ratio predicted that the patient would not need delivery within 2 weeks, with a negative predictive value of 96%. Other studies also have reported that an elevated sFlt-1/PlGF ratio in twin pregnancies is associated with an increased risk of adverse outcomes and early delivery.^21-23 An adequately powered multicenter study of twin pregnancies is needed to identify the sFlt-1/PlGF ratio associated with the greatest combined negative and positive predictive values.

The sFlt-1/PlGF test is a welcome addition to OB care

FDA approval of laboratory tests to measure circulating levels of sFlt-1 and PlGF will advance obstetric practice by identifying patients with a hypertensive disorder in pregnancy who are at low and high risk of developing preeclampsia with severe features within 2 weeks of the test. No laboratory test can replace the clinical judgment of obstetricians who are responsible for balancing the maternal and fetal risks that can occur in the management of a patient with a hypertensive disorder in pregnancy. The sFlt-1/PlGF ratio is highly dependable for identifying those patients with a hypertensive disorder in pregnancy who will not progress to severe disease within 2 weeks. The sFlt-1/PlGF ratio also identifies those patients with preeclampsia who are most likely to have adverse maternal and neonatal outcomes. The patients with an elevated sFlt-1/PlGF ratio may need more intensive antenatal care and consideration for transfer to a health system with a higher level of maternal and neonatal services. The sFlt-1/PlGF test is a welcome addition to obstetric care because it will improve the precision of our management of pregnant patients with hypertension. ●

rbarbieri@mdedge.com

In the United States there is an epidemic of hypertensive disorders in pregnancy, with 16% of pregnant people being diagnosed with preeclampsia, gestational hypertension, chronic hypertension, preeclampsia superimposed on chronic hypertension, HELLP, or eclampsia.¹ Preeclampsia with severe features increases the maternal risk for stroke, pulmonary edema, kidney injury, abruption, and fetal and maternal death. Preeclampsia also increases the fetal risk for growth restriction, oligohydramnios, and preterm birth.

Angiogenic factors and the pathophysiology of preeclampsia—From bench to bedside

The pathophysiology of preeclampsia is not fully characterized, but a leading theory is that placental ischemia causes increased placental production of anti-angiogenesis factors and a decrease in placental production of pro-angiogenesis factors.^2-4 Clinical studies support the theory that preeclampsia is associated with an increase in placental production of anti-angiogenesis factors, including soluble fms-like tyrosine kinase 1 (sFlt-1) and soluble endoglin, and a decrease in the placental production of pro-angiogenesis factors, including placental growth factor (PlGF).^5-15

The US Food and Drug Administration (FDA) has recently approved an assay for the measurement of sFlt-1 (Brahms sFlt-1 Kryptor) and PlGF (Brahms sFlt-1 Kryptor) (Thermo Fisher Scientific; Waltham, Massachusetts).¹⁶ This editorial focuses on the current and evolving indications for the measurement of sFlt-1 and PlGF in obstetric practice.

FDA approval of a preeclampsia blood test

The FDA approval of the tests to measure sFlt-1 and PlGF is narrowly tailored and focused on using the sFlt-1/PlGF ratio to assess the risk of progression to preeclampsia with severe features within 2 weeks among hospitalized patients with a hypertensive disorder in pregnancy with a singleton pregnancy between 23 weeks 0 days (23w0d) and 34w6d gestation.¹⁶ The test is meant to be used in conjunction with other laboratory tests and clinical assessment. The FDA advises that the test results should not be used to diagnose preeclampsia, nor should they be used to determine the timing of delivery or timing of patient discharge.¹⁶ The sFlt-1 and PIGF measurements are both reported as pg/mL, and the sFlt-1/PlGF ratio has no units.

The FDA approval is based on clinical studies that demonstrate the effectiveness of the test in predicting the progression of a hypertensive disorder in pregnancy to preeclampsia with severe features within 2 weeks of testing. In one study, the sFlt-1/PlGF ratio was measured in 556 pregnant patients with a singleton pregnancy who were between 23w0d and 34w6d gestation and hospitalized with a hypertensivedisorder in pregnancy without severe features at study enrollment.¹⁵ Those patients receiving intravenous heparin were excluded because of the effect of heparin on sFlt-1 levels. Participants’ mean age was 31.7 years, and their mean gestational age was 30w3d. The patients’ mean body mass index (BMI) was 34.2 kg/m², with mean maximal blood pressure (BP) at enrollment of 159 mm Hg systolic and 95 mm Hg diastolic.

In this cohort, 31% of enrolled patients progressed to preeclampsia with severe features within 2 weeks. At enrollment, the median sFlt-1/PlGF ratio was greater among the patients who progressed to preeclampsia with severe features than among those who did not have progression to preeclampsia with severe features (291 vs 7). An elevated sFlt-1/PlGF ratio (determined to be a ratio ≥ 40) predicted that patients would progress to severe preeclampsiawith severe features—with positive and negative predictive values of 65% and 96%, respectively. Among the subgroup of patients with a history of chronic hypertension, an sFlt-1/PlGF ratio ≥ 40 had positive and negative predictive values of 59% and 94%, respectively. Focusing the analysis on patients who self-reported their race as Black, representing 30% of the cohort, the positive and negative predictive values for a sFlt-1/PlGF ratio ≥ 40 were 66% and 99%, respectively.¹⁵

Receiver-operating curve analyses were used to compare the predictive performance of sFlt-1/PlGF measurement versus standard clinical factors and standard laboratory results, including systolic and diastolic BP; levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and creatinine; and platelet count.¹⁵ The area under the curve for predicting progression to preeclampsia with severe features was much greater for the sFlt-1/PlGF test (0.92) than for systolic (0.67) and diastolic BP (0.70), AST level (0.66), ALT level (0.61), creatinine level (0.65), and platelet count (0.57).¹⁵ These results demonstrate that measuring sFlt-1/PlGF ratios is a much better way to predict the progression of preeclampsia to severe disease than measuring standard clinical and laboratory results.

Patients with a sFlt-1/PlGF ratio ≥ 40 had higher rates of adverse maternal outcomes including severe hypertension, abruption, stroke, eclampsia, pulmonary edema, thrombocytopenia, low platelets, and/or coagulation disorder, than those patients with a ratio < 40, (16.1% vs 2.8%, respectively; relative risk [RR], 5.8; 95% confidence interval [CI], 2.8 to 12.2).¹⁵ Adverse fetal and neonatal outcomes (including fetal death, small for gestational age and early delivery due to progression of disease) were more common among patients with a sFlt-1/PlGF ratio of ≥ 40 (80% vs 26%; RR, 3.1; 95% CI, 2.5–3.8).¹⁵ Many other studies support the hypothesis that the sFlt-1/PlGF ratio is predictive of adverse outcomes among patients with hypertensive disorders in pregnancy.^6-15

Applying the bottom-line study findings. Patients with a hypertensive disorder in pregnancy and a sFlt-1/PlGF ratio < 40 have a low risk of progressing to preeclampsia with severe features over the following 2 weeks, with a negative predictive value of 96%. The remarkably high negative predictive value of a sFlt-1/PlGF ratio < 40 will help obstetricians generate a care plan that optimizes the use of limited health care resources. Conversely, about two-thirds of patients with a hypertensive disorder in pregnancy and a sFlt-1/PlGF test ≥ 40 will progress to preeclampsia with severe features and may need to prepare for a preterm delivery.

Continue to: Clinical utility of the sFlt-1/PlGF ratio in obstetric triage...

Measurement of the sFlt-1/PlGF ratio may help guide clinical care among patients referred to obstetric triage or admitted to the hospital for the evaluation of suspected preeclampsia. In one study, 402 patients with a singleton pregnancy referred to the hospital for evaluation of suspected preeclampsia, had a standard evaluation plus measurement of an sFlt-1/PlGF ratio.¹³ The clinicians caring for the patients did not have access to the sFlt-1/PlGF test results. In this cohort, 16% of the patients developed preeclampsia with severe features in the 2 weeks following the initial assessment in triage. In this cohort, a normal sFlt-1/PlGF ratio reliably predicted which patients were not going to develop preeclampsia with severe features over the following 2 weeks, with a negative predictive value of 98%. Among the patients with an elevated sFlt-1/PlGF ratio, however, the positive predictive value of the test was 47% for developing preeclampsia with severe features within the 2 weeks following initial evaluation. Among patients < 34 weeks’ gestation, an elevated sFlt-1/PlGF ratio had a positive predictive value of 65%, and a negative predictive value of 98%. Other studies also have reported that the sFlt-1/PlGF ratio is of value for assessing the risk for progression to preeclampsia with severe features in patients being evaluated for suspected preeclampsia.^6,17,18

In obstetric triage, it is difficult to predict the clinical course of patients referred for the evaluation of suspected preeclampsia based on BP measurements or standard laboratory tests. The sFlt-1/PlGF test will help clinicians identify patients at low and high risk of progressing to preeclampsia with severe features.¹⁹ Patients with a normal sFlt-1/PlGF test are at low risk of developing preeclampsia with severe features over the following 2 weeks. Patients with an elevated sFlt-1/PlGF test are at higher risk of progressing to preeclampsia with severe features and may warrant more intensive obstetric care. An enhanced care program might include:

• patient education
• remote monitoring of BP or hospitalization
• more frequent assessment of fetal well-being and growth
• administration of glucocorticoids to advance fetal maturity, if indicated by the gestational age.

Twin pregnancy complicated by preeclampsia

Twin pregnancy is associated with a high risk of developing preeclampsia and fetal growth restriction. For patients with a twin pregnancy and a hypertensive disorder in pregnancy, an elevated sFlt-1/PlGF ratio is associated with the need for delivery within 2 weeks and an increased rate of adverse maternal and neonatal outcomes. In a retrospective study involving 164 patients with twin pregnancy first evaluated for suspected preeclampsia at a median gestational age of 33w4d, the sFlt-1/PlGF ratio was positively correlated with progression of preeclampsia without severe features to severe features within 2 weeks.²⁰ In this cohort, at the initial evaluation for suspected preeclampsia, the sFlt-1/PlGF ratio was lower among patients who did not need delivery within 2 weeks compared with those who were delivered within 2 weeks, 24 versus 84 (P<.001). The mean sFlt-1/PlGF ratio was 99 among patients who needed delivery within 1 week following the initial evaluation for suspected preeclampsia. Among patients who delivered within 1 week of presentation, the reasons for delivery were the development of severe hypertension, severe dyspnea, placental abruption, rising levels of serum liver function enzymes, and/or onset of the HELLP syndrome.

An important finding in this study is that a normal sFlt-1/PlGF ratio predicted that the patient would not need delivery within 2 weeks, with a negative predictive value of 96%. Other studies also have reported that an elevated sFlt-1/PlGF ratio in twin pregnancies is associated with an increased risk of adverse outcomes and early delivery.^21-23 An adequately powered multicenter study of twin pregnancies is needed to identify the sFlt-1/PlGF ratio associated with the greatest combined negative and positive predictive values.

The sFlt-1/PlGF test is a welcome addition to OB care

FDA approval of laboratory tests to measure circulating levels of sFlt-1 and PlGF will advance obstetric practice by identifying patients with a hypertensive disorder in pregnancy who are at low and high risk of developing preeclampsia with severe features within 2 weeks of the test. No laboratory test can replace the clinical judgment of obstetricians who are responsible for balancing the maternal and fetal risks that can occur in the management of a patient with a hypertensive disorder in pregnancy. The sFlt-1/PlGF ratio is highly dependable for identifying those patients with a hypertensive disorder in pregnancy who will not progress to severe disease within 2 weeks. The sFlt-1/PlGF ratio also identifies those patients with preeclampsia who are most likely to have adverse maternal and neonatal outcomes. The patients with an elevated sFlt-1/PlGF ratio may need more intensive antenatal care and consideration for transfer to a health system with a higher level of maternal and neonatal services. The sFlt-1/PlGF test is a welcome addition to obstetric care because it will improve the precision of our management of pregnant patients with hypertension. ●

rbarbieri@mdedge.com

Respiratory syncytial virus (RSV) is a negative-sense, single-stranded, ribonucleic acid (RNA) virus that is a member of Pneumoviridae family. Two subtypes, A and B, and multiple genotypes circulate during fall and winter seasonal outbreaks of RSV.¹ RSV can cause severe lower respiratory tract disease including bronchiolitis, pneumonia, respiratory failure, and death. Each year, RSV disease causes the hospitalization of 1.5% to 2% of children younger than 6 months of age, resulting in 100 to 300 deaths.² For infants younger than 1 year, RSV infection is the leading cause of hospitalization.³ In 2023, two new treatments have become available to prevent RSV disease: nirsevimab and RSVPreF vaccine. 

Nirsevimab

Nirsevimab is an antibody to an RSV antigen. It has a long half-life and is approved for administration to infants, providing passive immunization. In contrast, administration of the RSVPreF vaccine to pregnant persons elicits active maternal immunity, resulting in the production of anti-RSV antibodies that are transferred to the fetus, resulting in passive immunity in the infant. Seasonal administration of nirsevimab and the RSV vaccine maximizes benefit to the infant and conserves limited health care resources. In temperate regions in the United States, the RSV infection season typically begins in October and peaks in December through mid-February and ends in April or May.^4,5 In southern Florida, the RSV season often begins in August to September, peaks in November through December, and ends in March.^4,5 

This editorial reviews 3 strategies for prevention of RSV infection in infants, including: 

• universal treatment of newborns with nirsevimab
• immunization of pregnant persons with an RSVpreF vaccine in the third trimester appropriately timed to occur just before the beginning or during RSV infection season
• prioritizing universal maternal RSV vaccination with reflex administration of nirsevimab to newborns when the pregnant person was  not vaccinated.⁶ 

Of note, there are no studies that have evaluated the effectiveness of combining RSVpreF vaccine and nirsevimab. The Centers for Disease Control and Prevention (CDC) does not recommend combining both RSV vaccination of pregnant persons plus nirsevimab treatment of the infant, except in limited circumstances, such as for immunocompromised pregnant people with limited antibody production or newborns who have a massive transfusion, which dilutes antibody titres.⁶ 

RSV prevention strategy 1

Universal treatment of newborns and infants  with nirsevimab 

Nirsevimab (Beyfortus, Sanofi and AstraZeneca) is an IgG 1-kappa monoclonal antibody with a long half-life that targets the prefusion conformation of the RSV F-protein, resulting in passive immunity to infection.7 Passive immunization results in rapid protection against infection because it does not require activation of the immune system. Nirsevimab is long acting due to amino acid substitutions in the Fc region, increasing binding to the neonatal Fc receptor, which protects IgG antibodies from degradation, thereby extending the antibody half-life. The terminal halflife of nirsevimab is 71 days, and the duration of protection following a single dose is at least 5 months. 

Nirsevimab is approved by the US Food and Drug Administration (FDA) for all neonates and infants born or entering their first RSV infection season and for children up to  24 months of age who are vulnerable to severe RSV during their second RSV infection season. For infants born outside the RSV infection season, nirsevimab should be administered once prior to the start of the next RSV infection season.⁷ Nirsevimab is administered as a single intramuscular injection at a dose of  50 mg for neonates and infants < 5 kg  in weight and a dose of 100 mg for neonates and infants ≥ 5 kg in weight.⁷ The list average wholesale price for both doses is $594.⁸  Nirsevimab is contraindicated for patients with a serious hypersensitivity reaction to nirsevimab or its excipients.⁷ In clinical trials, adverse reactions including rash and injection site reaction were reported in 1.2% of participants.7 Some RSV variants may be resistant to neutralization with nirsevimab.^7,9 

In a randomized clinical trial, 1,490 infants born ≥ 35 weeks’ gestation, the rates of medically-attended RSV lower respiratory tract disease (MA RSV LRTD) through 150 days of follow-up in the placebo and nirsevimab groups were 5.0% and 1.2%, respectively (P < .001).^7,10 Compared with placebo, nirsevimab reduced hospitalizations due to RSV LRTD by 60% through 150 days of follow up. In a randomized clinical trial enrolling 1,453 infants born between 29 weeks’ and < 35 weeks’ gestation, the rates of MA RSV LRTD through 150 days of follow up in the placebo and nirsevimab groups were 9.5% and 2.6%, respectively  (P < .001). In this study of infants born preterm, compared with placebo, nirsevimab reduced hospitalization due to RSV LRTD by 70% through 150 days of follow up.⁷ Nirsevimab is thought to be cost-effective at the current price per dose, but more data are needed to precisely define the magnitude of the health care savings associated with universal nirsevimab administration.^11-13 The CDC reports that the incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) of nirsevimab administration to infants is approximately $250,000, given an estimated cost of $500 for one dose of vaccine.¹⁴ 

Universal passive vaccination of newborns is recommended by many state departments of public health, which can provide the vaccine without cost to clinicians and health care facilities participating in the children’s vaccination program.

Continue to: RSV prevention strategy 2...

RSV prevention strategy 2

Universal RSV vaccination of pregnant persons from September through January 

The RSVpreF vaccine (Abryvso, Pfizer) is approved by the FDA for the active immunization of pregnant persons between 32 through 36 weeks’ gestation for the prevention of RSV LRTD in infants from birth through 6 months of age.¹⁵ Administration of the RSVpreF vaccine to pregnant people elicits the formation of antiRSV antibodies that are transferred transplacentally to the fetus, resulting in the protection of the infant from RSV during the first 6 months of life. The RSVpreF vaccine also is approved to prevent RSV LRTD in people aged ≥ 60 years. 

The RSVpreF vaccine contains the prefusion form of the RSV fusion (F) protein responsible for viral entry into host cells. The vaccine contains 60 µg of both RSV preF A and preF B recombinant proteins. The vaccine is administered as a single intramuscular dose in a volume of 0.5 mL. The vaccine is provided in a vial in a lyophilized form and must be reconstituted prior to administration. The average wholesale price of RSVPreF vaccine is $354.¹⁶ The vaccine is contraindicated for people who have had an allergic reaction to any component of the vaccine. The most commonly reported adverse reaction is injection site pain (41%).¹⁵ The FDA reports a “numerical imbalance in preterm births in Abrysvo recipients compared to placebo recipients” (5.7% vs 4.7%), and “available data are insufficient to establish or exclude a causal relationship between preterm birth and Abrysvo.”¹⁵ In rabbits there is no evidence of developmental toxicity and congenital anomalies associated with the RSVpreF vaccine. In human studies, no differences in the rate of congenital anomalies or fetal deaths were noted between RSVpreF vaccine and placebo.

 In a clinical trial, 6,975 pregnant participants 24 through  36 weeks’ gestation were randomly assigned to receive a placebo or the RSVpreF vaccine.^15,17 After birth, follow-up of infants at 180 days, showed that the rates of MA RSV LRTD among the infants in the placebo and RSVpreF vaccine groups were 3.4% and 1.6%, respectively. At 180 days, the reported rates of severe RSV LRTD in the placebo and RSVpreF vaccine groups were 1.8% and 0.5%, respectively. In this study, among the subset of pregnant participants who received the RSVpreF vaccine (n = 1,572) or placebo  (n = 1,539) at 32 through 36 weeks’ gestation, the rates of MA RSV LRTD among the infants in the placebo and RSVpreF vaccine groups were 3.6% and 1.5%, respectively. In the subset of pregnant participants vaccinated at 32 through 36 weeks’ gestation, at 180 days postvaccination, the reported rates of severe RSV LRTD in the placebo and RSVpreF vaccine groups were 1.6% and  0.4%, respectively.¹⁵ 

The CDC has recommended that the RSVpreF vaccine be administered to pregnant people 32 through 36 weeks’ gestation from September through the end of January in most of the continental United States to reduce the rate of RSV LRTD in infants.⁶ September was selected because it is 1 to 2 months before the start of the RSV season, and it takes at least 14 days for maternal vaccination to result in transplacental transfer of protective antibodies to the fetus. January was selected because it is 2 to 3 months before the anticipated end of the RSV season.⁶ The CDC also noted that, for regions with a different pattern of RSV seasonality, clinicians should follow the guidance of local public health officials. This applies to the states of Alaska, southern Florida, Hawaii, and Puerto Rico.6 The CDC recommended that infants born < 34 weeks’ gestation should receive nirsevimab.⁶ 

Maternal RSV vaccination is thought to be cost-effective for reducing RSV LRTD in infants. However, the cost-effectiveness analyses are sensitive to the pricing of the two main options: maternal RSV vaccination and nirsevimab.

It is estimated that nirsevimab may provide greater protection than maternal RSV vaccination from RSV LRTD, but the maternal RSVpreF vaccine is priced lower than nirsevimab.¹⁸ Focusing administration of RSVpreF vaccine from September through January of the RSV infection season is thought to maximize benefits to infants and reduce total cost of the vaccination program.¹⁹ With year-round RSVpreF vaccine dosing, the estimated ICER per quality-adjusted life-year (QALY) is approximately $400,000, whereas seasonal dosing reduces the cost to approximately $170,000.¹⁹ 

RSV prevention strategy 3

Vaccinate pregnant persons; reflex to newborn treatment with nirsevimab if maternal RSV vaccination did not occur

RSVpreF vaccination to all pregnant persons 32 through 36 weeks’ gestation during RSV infection season is not likely to result in 100% adherence. For instance, in a CDC-conducted survey only 47% of pregnant persons received an influenza vaccine.2 Newborns whose mothers did not receive an RSVpreF vaccine will need to be considered for treatment with nirsevimab. Collaboration and communication among obstetricians and pediatricians will be needed to avoid miscommunication and missed opportunities to treat newborns during the birth hospitalization. Enhancements in electronic health records, linking the mother’s vaccination record with the newborn’s medical record plus an added feature of electronic alerts when the mother did not receive an appropriately timed RSVpreF vaccine would improve the communication of important clinical information to the pediatrician. 

Next steps for the upcoming peak  RSV season

We are currently in the 2023–2024 RSV infection season and can expect a peak in cases of RSV between December 2023 and February 2024. The CDC recommends protecting all infants against RSV-associated LRTD. The options are to administer the maternal RSVpreF vaccine to pregnant persons or treating the infant with nirsevimab. The vaccine is just now becoming available for administration in regional pharmacies, physician practices, and health systems. Obstetrician-gynecologists should follow the recommendation of their state department of public health. As noted above, many state departments of public health are recommending that all newborns receive nirsevimab. For clinicians in those states, RSVPreF vaccination of pregnant persons is not a priority. ●

Respiratory syncytial virus (RSV) is a negative-sense, single-stranded, ribonucleic acid (RNA) virus that is a member of Pneumoviridae family. Two subtypes, A and B, and multiple genotypes circulate during fall and winter seasonal outbreaks of RSV.¹ RSV can cause severe lower respiratory tract disease including bronchiolitis, pneumonia, respiratory failure, and death. Each year, RSV disease causes the hospitalization of 1.5% to 2% of children younger than 6 months of age, resulting in 100 to 300 deaths.² For infants younger than 1 year, RSV infection is the leading cause of hospitalization.³ In 2023, two new treatments have become available to prevent RSV disease: nirsevimab and RSVPreF vaccine. 

Nirsevimab

Nirsevimab is an antibody to an RSV antigen. It has a long half-life and is approved for administration to infants, providing passive immunization. In contrast, administration of the RSVPreF vaccine to pregnant persons elicits active maternal immunity, resulting in the production of anti-RSV antibodies that are transferred to the fetus, resulting in passive immunity in the infant. Seasonal administration of nirsevimab and the RSV vaccine maximizes benefit to the infant and conserves limited health care resources. In temperate regions in the United States, the RSV infection season typically begins in October and peaks in December through mid-February and ends in April or May.^4,5 In southern Florida, the RSV season often begins in August to September, peaks in November through December, and ends in March.^4,5 

This editorial reviews 3 strategies for prevention of RSV infection in infants, including: 

• universal treatment of newborns with nirsevimab
• immunization of pregnant persons with an RSVpreF vaccine in the third trimester appropriately timed to occur just before the beginning or during RSV infection season
• prioritizing universal maternal RSV vaccination with reflex administration of nirsevimab to newborns when the pregnant person was  not vaccinated.⁶ 

Of note, there are no studies that have evaluated the effectiveness of combining RSVpreF vaccine and nirsevimab. The Centers for Disease Control and Prevention (CDC) does not recommend combining both RSV vaccination of pregnant persons plus nirsevimab treatment of the infant, except in limited circumstances, such as for immunocompromised pregnant people with limited antibody production or newborns who have a massive transfusion, which dilutes antibody titres.⁶ 

RSV prevention strategy 1

Universal treatment of newborns and infants  with nirsevimab 

Nirsevimab (Beyfortus, Sanofi and AstraZeneca) is an IgG 1-kappa monoclonal antibody with a long half-life that targets the prefusion conformation of the RSV F-protein, resulting in passive immunity to infection.7 Passive immunization results in rapid protection against infection because it does not require activation of the immune system. Nirsevimab is long acting due to amino acid substitutions in the Fc region, increasing binding to the neonatal Fc receptor, which protects IgG antibodies from degradation, thereby extending the antibody half-life. The terminal halflife of nirsevimab is 71 days, and the duration of protection following a single dose is at least 5 months. 

Nirsevimab is approved by the US Food and Drug Administration (FDA) for all neonates and infants born or entering their first RSV infection season and for children up to  24 months of age who are vulnerable to severe RSV during their second RSV infection season. For infants born outside the RSV infection season, nirsevimab should be administered once prior to the start of the next RSV infection season.⁷ Nirsevimab is administered as a single intramuscular injection at a dose of  50 mg for neonates and infants < 5 kg  in weight and a dose of 100 mg for neonates and infants ≥ 5 kg in weight.⁷ The list average wholesale price for both doses is $594.⁸  Nirsevimab is contraindicated for patients with a serious hypersensitivity reaction to nirsevimab or its excipients.⁷ In clinical trials, adverse reactions including rash and injection site reaction were reported in 1.2% of participants.7 Some RSV variants may be resistant to neutralization with nirsevimab.^7,9 

In a randomized clinical trial, 1,490 infants born ≥ 35 weeks’ gestation, the rates of medically-attended RSV lower respiratory tract disease (MA RSV LRTD) through 150 days of follow-up in the placebo and nirsevimab groups were 5.0% and 1.2%, respectively (P < .001).^7,10 Compared with placebo, nirsevimab reduced hospitalizations due to RSV LRTD by 60% through 150 days of follow up. In a randomized clinical trial enrolling 1,453 infants born between 29 weeks’ and < 35 weeks’ gestation, the rates of MA RSV LRTD through 150 days of follow up in the placebo and nirsevimab groups were 9.5% and 2.6%, respectively  (P < .001). In this study of infants born preterm, compared with placebo, nirsevimab reduced hospitalization due to RSV LRTD by 70% through 150 days of follow up.⁷ Nirsevimab is thought to be cost-effective at the current price per dose, but more data are needed to precisely define the magnitude of the health care savings associated with universal nirsevimab administration.^11-13 The CDC reports that the incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) of nirsevimab administration to infants is approximately $250,000, given an estimated cost of $500 for one dose of vaccine.¹⁴ 

Universal passive vaccination of newborns is recommended by many state departments of public health, which can provide the vaccine without cost to clinicians and health care facilities participating in the children’s vaccination program.

Continue to: RSV prevention strategy 2...

RSV prevention strategy 2

Universal RSV vaccination of pregnant persons from September through January 

The RSVpreF vaccine (Abryvso, Pfizer) is approved by the FDA for the active immunization of pregnant persons between 32 through 36 weeks’ gestation for the prevention of RSV LRTD in infants from birth through 6 months of age.¹⁵ Administration of the RSVpreF vaccine to pregnant people elicits the formation of antiRSV antibodies that are transferred transplacentally to the fetus, resulting in the protection of the infant from RSV during the first 6 months of life. The RSVpreF vaccine also is approved to prevent RSV LRTD in people aged ≥ 60 years. 

The RSVpreF vaccine contains the prefusion form of the RSV fusion (F) protein responsible for viral entry into host cells. The vaccine contains 60 µg of both RSV preF A and preF B recombinant proteins. The vaccine is administered as a single intramuscular dose in a volume of 0.5 mL. The vaccine is provided in a vial in a lyophilized form and must be reconstituted prior to administration. The average wholesale price of RSVPreF vaccine is $354.¹⁶ The vaccine is contraindicated for people who have had an allergic reaction to any component of the vaccine. The most commonly reported adverse reaction is injection site pain (41%).¹⁵ The FDA reports a “numerical imbalance in preterm births in Abrysvo recipients compared to placebo recipients” (5.7% vs 4.7%), and “available data are insufficient to establish or exclude a causal relationship between preterm birth and Abrysvo.”¹⁵ In rabbits there is no evidence of developmental toxicity and congenital anomalies associated with the RSVpreF vaccine. In human studies, no differences in the rate of congenital anomalies or fetal deaths were noted between RSVpreF vaccine and placebo.

 In a clinical trial, 6,975 pregnant participants 24 through  36 weeks’ gestation were randomly assigned to receive a placebo or the RSVpreF vaccine.^15,17 After birth, follow-up of infants at 180 days, showed that the rates of MA RSV LRTD among the infants in the placebo and RSVpreF vaccine groups were 3.4% and 1.6%, respectively. At 180 days, the reported rates of severe RSV LRTD in the placebo and RSVpreF vaccine groups were 1.8% and 0.5%, respectively. In this study, among the subset of pregnant participants who received the RSVpreF vaccine (n = 1,572) or placebo  (n = 1,539) at 32 through 36 weeks’ gestation, the rates of MA RSV LRTD among the infants in the placebo and RSVpreF vaccine groups were 3.6% and 1.5%, respectively. In the subset of pregnant participants vaccinated at 32 through 36 weeks’ gestation, at 180 days postvaccination, the reported rates of severe RSV LRTD in the placebo and RSVpreF vaccine groups were 1.6% and  0.4%, respectively.¹⁵ 

The CDC has recommended that the RSVpreF vaccine be administered to pregnant people 32 through 36 weeks’ gestation from September through the end of January in most of the continental United States to reduce the rate of RSV LRTD in infants.⁶ September was selected because it is 1 to 2 months before the start of the RSV season, and it takes at least 14 days for maternal vaccination to result in transplacental transfer of protective antibodies to the fetus. January was selected because it is 2 to 3 months before the anticipated end of the RSV season.⁶ The CDC also noted that, for regions with a different pattern of RSV seasonality, clinicians should follow the guidance of local public health officials. This applies to the states of Alaska, southern Florida, Hawaii, and Puerto Rico.6 The CDC recommended that infants born < 34 weeks’ gestation should receive nirsevimab.⁶ 

Maternal RSV vaccination is thought to be cost-effective for reducing RSV LRTD in infants. However, the cost-effectiveness analyses are sensitive to the pricing of the two main options: maternal RSV vaccination and nirsevimab.

It is estimated that nirsevimab may provide greater protection than maternal RSV vaccination from RSV LRTD, but the maternal RSVpreF vaccine is priced lower than nirsevimab.¹⁸ Focusing administration of RSVpreF vaccine from September through January of the RSV infection season is thought to maximize benefits to infants and reduce total cost of the vaccination program.¹⁹ With year-round RSVpreF vaccine dosing, the estimated ICER per quality-adjusted life-year (QALY) is approximately $400,000, whereas seasonal dosing reduces the cost to approximately $170,000.¹⁹ 

RSV prevention strategy 3

Vaccinate pregnant persons; reflex to newborn treatment with nirsevimab if maternal RSV vaccination did not occur

RSVpreF vaccination to all pregnant persons 32 through 36 weeks’ gestation during RSV infection season is not likely to result in 100% adherence. For instance, in a CDC-conducted survey only 47% of pregnant persons received an influenza vaccine.2 Newborns whose mothers did not receive an RSVpreF vaccine will need to be considered for treatment with nirsevimab. Collaboration and communication among obstetricians and pediatricians will be needed to avoid miscommunication and missed opportunities to treat newborns during the birth hospitalization. Enhancements in electronic health records, linking the mother’s vaccination record with the newborn’s medical record plus an added feature of electronic alerts when the mother did not receive an appropriately timed RSVpreF vaccine would improve the communication of important clinical information to the pediatrician. 

Next steps for the upcoming peak  RSV season

We are currently in the 2023–2024 RSV infection season and can expect a peak in cases of RSV between December 2023 and February 2024. The CDC recommends protecting all infants against RSV-associated LRTD. The options are to administer the maternal RSVpreF vaccine to pregnant persons or treating the infant with nirsevimab. The vaccine is just now becoming available for administration in regional pharmacies, physician practices, and health systems. Obstetrician-gynecologists should follow the recommendation of their state department of public health. As noted above, many state departments of public health are recommending that all newborns receive nirsevimab. For clinicians in those states, RSVPreF vaccination of pregnant persons is not a priority. ●

Respiratory syncytial virus (RSV) is a negative-sense, single-stranded, ribonucleic acid (RNA) virus that is a member of Pneumoviridae family. Two subtypes, A and B, and multiple genotypes circulate during fall and winter seasonal outbreaks of RSV.¹ RSV can cause severe lower respiratory tract disease including bronchiolitis, pneumonia, respiratory failure, and death. Each year, RSV disease causes the hospitalization of 1.5% to 2% of children younger than 6 months of age, resulting in 100 to 300 deaths.² For infants younger than 1 year, RSV infection is the leading cause of hospitalization.³ In 2023, two new treatments have become available to prevent RSV disease: nirsevimab and RSVPreF vaccine. 

Nirsevimab

Nirsevimab is an antibody to an RSV antigen. It has a long half-life and is approved for administration to infants, providing passive immunization. In contrast, administration of the RSVPreF vaccine to pregnant persons elicits active maternal immunity, resulting in the production of anti-RSV antibodies that are transferred to the fetus, resulting in passive immunity in the infant. Seasonal administration of nirsevimab and the RSV vaccine maximizes benefit to the infant and conserves limited health care resources. In temperate regions in the United States, the RSV infection season typically begins in October and peaks in December through mid-February and ends in April or May.^4,5 In southern Florida, the RSV season often begins in August to September, peaks in November through December, and ends in March.^4,5 

This editorial reviews 3 strategies for prevention of RSV infection in infants, including: 

• universal treatment of newborns with nirsevimab
• immunization of pregnant persons with an RSVpreF vaccine in the third trimester appropriately timed to occur just before the beginning or during RSV infection season
• prioritizing universal maternal RSV vaccination with reflex administration of nirsevimab to newborns when the pregnant person was  not vaccinated.⁶ 

Of note, there are no studies that have evaluated the effectiveness of combining RSVpreF vaccine and nirsevimab. The Centers for Disease Control and Prevention (CDC) does not recommend combining both RSV vaccination of pregnant persons plus nirsevimab treatment of the infant, except in limited circumstances, such as for immunocompromised pregnant people with limited antibody production or newborns who have a massive transfusion, which dilutes antibody titres.⁶ 

RSV prevention strategy 1

Universal treatment of newborns and infants  with nirsevimab 

Nirsevimab (Beyfortus, Sanofi and AstraZeneca) is an IgG 1-kappa monoclonal antibody with a long half-life that targets the prefusion conformation of the RSV F-protein, resulting in passive immunity to infection.7 Passive immunization results in rapid protection against infection because it does not require activation of the immune system. Nirsevimab is long acting due to amino acid substitutions in the Fc region, increasing binding to the neonatal Fc receptor, which protects IgG antibodies from degradation, thereby extending the antibody half-life. The terminal halflife of nirsevimab is 71 days, and the duration of protection following a single dose is at least 5 months. 

Nirsevimab is approved by the US Food and Drug Administration (FDA) for all neonates and infants born or entering their first RSV infection season and for children up to  24 months of age who are vulnerable to severe RSV during their second RSV infection season. For infants born outside the RSV infection season, nirsevimab should be administered once prior to the start of the next RSV infection season.⁷ Nirsevimab is administered as a single intramuscular injection at a dose of  50 mg for neonates and infants < 5 kg  in weight and a dose of 100 mg for neonates and infants ≥ 5 kg in weight.⁷ The list average wholesale price for both doses is $594.⁸  Nirsevimab is contraindicated for patients with a serious hypersensitivity reaction to nirsevimab or its excipients.⁷ In clinical trials, adverse reactions including rash and injection site reaction were reported in 1.2% of participants.7 Some RSV variants may be resistant to neutralization with nirsevimab.^7,9 

In a randomized clinical trial, 1,490 infants born ≥ 35 weeks’ gestation, the rates of medically-attended RSV lower respiratory tract disease (MA RSV LRTD) through 150 days of follow-up in the placebo and nirsevimab groups were 5.0% and 1.2%, respectively (P < .001).^7,10 Compared with placebo, nirsevimab reduced hospitalizations due to RSV LRTD by 60% through 150 days of follow up. In a randomized clinical trial enrolling 1,453 infants born between 29 weeks’ and < 35 weeks’ gestation, the rates of MA RSV LRTD through 150 days of follow up in the placebo and nirsevimab groups were 9.5% and 2.6%, respectively  (P < .001). In this study of infants born preterm, compared with placebo, nirsevimab reduced hospitalization due to RSV LRTD by 70% through 150 days of follow up.⁷ Nirsevimab is thought to be cost-effective at the current price per dose, but more data are needed to precisely define the magnitude of the health care savings associated with universal nirsevimab administration.^11-13 The CDC reports that the incremental cost-effectiveness ratio (ICER) per quality-adjusted life year (QALY) of nirsevimab administration to infants is approximately $250,000, given an estimated cost of $500 for one dose of vaccine.¹⁴ 

Universal passive vaccination of newborns is recommended by many state departments of public health, which can provide the vaccine without cost to clinicians and health care facilities participating in the children’s vaccination program.

Continue to: RSV prevention strategy 2...

RSV prevention strategy 2

Universal RSV vaccination of pregnant persons from September through January 

The RSVpreF vaccine (Abryvso, Pfizer) is approved by the FDA for the active immunization of pregnant persons between 32 through 36 weeks’ gestation for the prevention of RSV LRTD in infants from birth through 6 months of age.¹⁵ Administration of the RSVpreF vaccine to pregnant people elicits the formation of antiRSV antibodies that are transferred transplacentally to the fetus, resulting in the protection of the infant from RSV during the first 6 months of life. The RSVpreF vaccine also is approved to prevent RSV LRTD in people aged ≥ 60 years. 

The RSVpreF vaccine contains the prefusion form of the RSV fusion (F) protein responsible for viral entry into host cells. The vaccine contains 60 µg of both RSV preF A and preF B recombinant proteins. The vaccine is administered as a single intramuscular dose in a volume of 0.5 mL. The vaccine is provided in a vial in a lyophilized form and must be reconstituted prior to administration. The average wholesale price of RSVPreF vaccine is $354.¹⁶ The vaccine is contraindicated for people who have had an allergic reaction to any component of the vaccine. The most commonly reported adverse reaction is injection site pain (41%).¹⁵ The FDA reports a “numerical imbalance in preterm births in Abrysvo recipients compared to placebo recipients” (5.7% vs 4.7%), and “available data are insufficient to establish or exclude a causal relationship between preterm birth and Abrysvo.”¹⁵ In rabbits there is no evidence of developmental toxicity and congenital anomalies associated with the RSVpreF vaccine. In human studies, no differences in the rate of congenital anomalies or fetal deaths were noted between RSVpreF vaccine and placebo.

 In a clinical trial, 6,975 pregnant participants 24 through  36 weeks’ gestation were randomly assigned to receive a placebo or the RSVpreF vaccine.^15,17 After birth, follow-up of infants at 180 days, showed that the rates of MA RSV LRTD among the infants in the placebo and RSVpreF vaccine groups were 3.4% and 1.6%, respectively. At 180 days, the reported rates of severe RSV LRTD in the placebo and RSVpreF vaccine groups were 1.8% and 0.5%, respectively. In this study, among the subset of pregnant participants who received the RSVpreF vaccine (n = 1,572) or placebo  (n = 1,539) at 32 through 36 weeks’ gestation, the rates of MA RSV LRTD among the infants in the placebo and RSVpreF vaccine groups were 3.6% and 1.5%, respectively. In the subset of pregnant participants vaccinated at 32 through 36 weeks’ gestation, at 180 days postvaccination, the reported rates of severe RSV LRTD in the placebo and RSVpreF vaccine groups were 1.6% and  0.4%, respectively.¹⁵ 

The CDC has recommended that the RSVpreF vaccine be administered to pregnant people 32 through 36 weeks’ gestation from September through the end of January in most of the continental United States to reduce the rate of RSV LRTD in infants.⁶ September was selected because it is 1 to 2 months before the start of the RSV season, and it takes at least 14 days for maternal vaccination to result in transplacental transfer of protective antibodies to the fetus. January was selected because it is 2 to 3 months before the anticipated end of the RSV season.⁶ The CDC also noted that, for regions with a different pattern of RSV seasonality, clinicians should follow the guidance of local public health officials. This applies to the states of Alaska, southern Florida, Hawaii, and Puerto Rico.6 The CDC recommended that infants born < 34 weeks’ gestation should receive nirsevimab.⁶ 

Maternal RSV vaccination is thought to be cost-effective for reducing RSV LRTD in infants. However, the cost-effectiveness analyses are sensitive to the pricing of the two main options: maternal RSV vaccination and nirsevimab.

It is estimated that nirsevimab may provide greater protection than maternal RSV vaccination from RSV LRTD, but the maternal RSVpreF vaccine is priced lower than nirsevimab.¹⁸ Focusing administration of RSVpreF vaccine from September through January of the RSV infection season is thought to maximize benefits to infants and reduce total cost of the vaccination program.¹⁹ With year-round RSVpreF vaccine dosing, the estimated ICER per quality-adjusted life-year (QALY) is approximately $400,000, whereas seasonal dosing reduces the cost to approximately $170,000.¹⁹ 

RSV prevention strategy 3

Vaccinate pregnant persons; reflex to newborn treatment with nirsevimab if maternal RSV vaccination did not occur

RSVpreF vaccination to all pregnant persons 32 through 36 weeks’ gestation during RSV infection season is not likely to result in 100% adherence. For instance, in a CDC-conducted survey only 47% of pregnant persons received an influenza vaccine.2 Newborns whose mothers did not receive an RSVpreF vaccine will need to be considered for treatment with nirsevimab. Collaboration and communication among obstetricians and pediatricians will be needed to avoid miscommunication and missed opportunities to treat newborns during the birth hospitalization. Enhancements in electronic health records, linking the mother’s vaccination record with the newborn’s medical record plus an added feature of electronic alerts when the mother did not receive an appropriately timed RSVpreF vaccine would improve the communication of important clinical information to the pediatrician. 

Next steps for the upcoming peak  RSV season

We are currently in the 2023–2024 RSV infection season and can expect a peak in cases of RSV between December 2023 and February 2024. The CDC recommends protecting all infants against RSV-associated LRTD. The options are to administer the maternal RSVpreF vaccine to pregnant persons or treating the infant with nirsevimab. The vaccine is just now becoming available for administration in regional pharmacies, physician practices, and health systems. Obstetrician-gynecologists should follow the recommendation of their state department of public health. As noted above, many state departments of public health are recommending that all newborns receive nirsevimab. For clinicians in those states, RSVPreF vaccination of pregnant persons is not a priority. ●

VMS, also known as hot flashes, night sweats, or cold sweats, occur for the majority of perimenopausal and menopausal women.¹ In one study, the mean duration of clinically significant VMS was 5 years, and one-third of participants continued to have bothersome hot flashes 10 or more years after the onset of menopause.² VMS may contribute to disrupted sleep patterns and depressed mood.³

All obstetrician-gynecologists know that estradiol and other estrogens are highly effective in the treatment of bothersome VMS. A meta-analysis reported that the frequency of VMS was reduced by 60% to 80% with oral estradiol (1 mg/day), transdermal estradiol(0.05 mg/day), and conjugated estrogen (0.625 mg).⁴ Breast tenderness and irregular uterine bleeding are common side effects of estrogen treatment of VMS. Estrogen treatment is contraindicated in patients with estrogen-responsive cancers, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, and some cases of inherited thrombophilia. For these patients, an important option is the nonhormonal treatment of VMS, and several nonhormonal medications have been demonstrated to be effective therapy (TABLE 1). In this editorial I will review the medication treatment of VMS with escitalopram, paroxetine, gabapentin, and fezolinetant.

Escitalopram and paroxetine

Escitalopram and paroxetine have been shown to reduce VMS more than placebo in multiple clinical trials.^5-10 In addition, escitalopram and paroxetine, at the doses tested, may be more effective for the treatment of VMS than sertraline, citalopram, or fluoxetine.¹¹ In one trial assessing the efficacy of escitalopram to treat VMS, 205 patients with VMS were randomly assigned to 8 weeks of treatment with placebo or escitalopram.⁵ The initial escitalopram dose was 10 mg daily. At week 4:

• if VMS frequency was reduced by ≥ 50%, the patient remained on the 10-mg dose
• if VMS frequency was reduced by < 50%, the escitalopram dose was increased to 20 mg daily.

Following 8 weeks of treatment, the frequency of VMS decreased for patients in the placebo and escitalopram groups by 33% and 47%, respectively. Similar results have been reported in other studies.⁶

Paroxetine at a dose of 7.5 mg/day administered at bedtime is approved by the US Food and Drug Administration (FDA) for the treatment of VMS. In a pivotal study, 1,112 patients with VMS were randomly assigned to receive a placebo or paroxetine 7.5 mg at bedtime.⁹ In the 12-week study the reported decrease in mean weekly frequency of VMS for patients in the placebo and paroxetine groups were -37 and -44, respectively.⁹ Paroxetine 7.5 mg also reduced awakenings per night attributed to VMS and increased nighttime sleep duration.¹⁰

Depressed mood is prevalent among perimenopausal and postmenopausal patients.¹² Prescribing escitalopram or paroxetine for VMS also may improve mood. Venlafaxine and desvenlafaxine are effective for the treatment of VMS;^13,14 however, I seldom prescribe these medications for VMS because in my experience they are associated with more bothersome side effects, including dry mouth, decreased appetite, nausea, and insomnia than escitalopram or low-dose paroxetine.

Continue to: Gabapentin...

Gabapentin

Numerous randomized clinical trials have reported that gabapentin is superior to placebo for the treatment of VMS.¹⁵ In one trial, 420 patients with breast cancer and VMS were randomly assigned to 8 weeks of treatment with placebo, gabapentin 300 mg/day (G300), or gabapentin 900 mg/day (G900) in 3 divided doses.¹⁶ Following 8 weeks of treatment, reduction in hot-flash severity score among patients receiving placebo, G300, or G900 was 15%, 31%, and 46%, respectively. Fatigue and somnolence were reported more frequently among patients taking gabapentin 900 mg/day. In a small trial, 60 patients with VMS were randomized to receive placebo, conjugated estrogen (0.2625 mg/day),or gabapentin (target dose of 2,400 mg/day in 3 divided doses).¹⁷ Following 12 weeks of treatment, the patient-reported decrease in VMS for those taking placebo, estrogen, or gabapentin was 54%, 72%, and 71%, respectively.

High-dose gabapentin treatment was associated with side effects of headache and dizziness more often than placebo or estrogen. Although gabapentin is not a treatment for insomnia, in my practice if a menopausal patient has prominent and bothersome symptoms of sleep disturbance and mild VMS symptoms, I will consider a trial of low-dose gabapentin. Some experts recommend initiating gabapentin at a dose of 100 mgdaily before bedtime to assess the effectiveness of a low dose that seldom causes significant side effects.

ILLUSTRATION: ZONDA/ZAZA STUDIO/SHUTTERSTOCK

Fezolinetant

In a study of genetic variation associated with VMS, investigators discovered that nucleic acid variation in the neurokinin 3 (NK3) receptor was strongly associated with the prevalence of VMS, suggesting that this receptor is in the causal pathway to menopausal VMS.¹⁸ Additional research demonstrated that the kisspeptin/neurokinin B/dynorphin (KNDy) neurons, which are involved in the control of hypothalamic thermoregulation, are stimulated by neurokinin B, acting through the NK3 receptor, and suppressed by estradiol. A reduction in hypothalamic estrogen results in unopposed neurokinin B activity, which stimulates KNDy neurons, destabilizing the hypothalamic thermoregulatory center, causing vasodilation, which is perceived as hot flashes and sweating followed by chills.¹⁹

Fezolinetant is a high-affinity NK3 receptor antagonist that blocks the activity of neurokinin B, stabilizing the hypothalamic thermoregulatory center, thereby suppressing hot flashes. It is approved by the FDA for the treatment of moderate to severe VMS due to menopause using a fixed dose of 45 mg daily.²⁰ In one clinical trial, 500 menopausal patients with bothersome VMS were randomly assigned to 12 weeks of treatment with placebo, fezolinetant 30 mg/day, or fezolinetant 45 mg/day. Following 12 weeks of treatment, the reported frequency rates of VMS among patients in the placebo, F30, and F45 groups were reduced by 43%, 61%, and 64%, respectively.²¹ In addition, following 12 weeks of treatment, the severity of VMS rates among patients in the placebo, F30, and F45 groups were reduced by 20%, 26%, and 32%, respectively.

Fezolinetant improved the quality of sleep and was associated with an improvement in patient-reported quality of life. Following 12 weeks of treatment, sleep quality among patients in the placebo, F30, and F45 groups was reported to be “much or moderately better” in 34%, 45%, and 54% of the patients, respectively.²¹ Similar results were reported in a companion study.²²

Fezolinetant is contraindicated for patients with liver cirrhosis or severe renal impairment (estimated glomerular filtration rate of < 30 mL/min/1.73 m2). Before initiating treatment, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin (total and direct). Fezolinetant should not be prescribed if any of these tests are greater than twice the upper limit of normal. These tests should be repeated at 3, 6, and 9 months, and if the patient reports symptoms or signs of liver injury (nausea, vomiting, jaundice). Fezolinetant is metabolized by CYP1A2 and should not be prescribed to patients taking strong CYP1A2 inhibitors. The most common side effects associated with fezolinetant treatment are abdominal pain (4.3%), diarrhea (3.9%), insomnia (3.9%), back pain (3.0%), and hepatic transaminase elevation (2.3%). Fezolinetant has not been thoroughly evaluated in patients older than age 65. Following an oral dose of the medication, the median maximum concentration is reached in 1.5 hours, and the half-life is estimated to be 10 hours.²⁰ Of all the medications discussed in this editorial, fezolinetant is the most expensive.

Effective VMS treatment improves overall health

Estrogen therapy is the gold standard treatment of VMS. However, many menopausal patients with bothersome VMS prefer not to take estrogen, and some have a medical condition that is a contraindication to estrogen treatment. The nonhormonal medication options for the treatment of VMS include escitalopram, paroxetine, gabapentin, and fezolinetant. Patients value the ability to choose the treatment they prefer, among all available hormonal and nonhormonal medication options. For mid-life women, effectively treating bothersome VMS is only one of many interventions that improves health. Optimal health is best achieved with²³:

• high-quality diet
• daily physical activity
• appropriate body mass index
• nicotine avoidance
• a healthy sleep schedule
• normal blood pressure, lipid, and glucose levels.

Women who have a high-quality diet; daily physical activity; an appropriate body mass index; and normal blood pressure, cholesterol, and glucose levels are estimated to live 9 disease-free years longer than other women.²⁴ ●

VMS, also known as hot flashes, night sweats, or cold sweats, occur for the majority of perimenopausal and menopausal women.¹ In one study, the mean duration of clinically significant VMS was 5 years, and one-third of participants continued to have bothersome hot flashes 10 or more years after the onset of menopause.² VMS may contribute to disrupted sleep patterns and depressed mood.³

All obstetrician-gynecologists know that estradiol and other estrogens are highly effective in the treatment of bothersome VMS. A meta-analysis reported that the frequency of VMS was reduced by 60% to 80% with oral estradiol (1 mg/day), transdermal estradiol(0.05 mg/day), and conjugated estrogen (0.625 mg).⁴ Breast tenderness and irregular uterine bleeding are common side effects of estrogen treatment of VMS. Estrogen treatment is contraindicated in patients with estrogen-responsive cancers, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, and some cases of inherited thrombophilia. For these patients, an important option is the nonhormonal treatment of VMS, and several nonhormonal medications have been demonstrated to be effective therapy (TABLE 1). In this editorial I will review the medication treatment of VMS with escitalopram, paroxetine, gabapentin, and fezolinetant.

Escitalopram and paroxetine

Escitalopram and paroxetine have been shown to reduce VMS more than placebo in multiple clinical trials.^5-10 In addition, escitalopram and paroxetine, at the doses tested, may be more effective for the treatment of VMS than sertraline, citalopram, or fluoxetine.¹¹ In one trial assessing the efficacy of escitalopram to treat VMS, 205 patients with VMS were randomly assigned to 8 weeks of treatment with placebo or escitalopram.⁵ The initial escitalopram dose was 10 mg daily. At week 4:

• if VMS frequency was reduced by ≥ 50%, the patient remained on the 10-mg dose
• if VMS frequency was reduced by < 50%, the escitalopram dose was increased to 20 mg daily.

Following 8 weeks of treatment, the frequency of VMS decreased for patients in the placebo and escitalopram groups by 33% and 47%, respectively. Similar results have been reported in other studies.⁶

Paroxetine at a dose of 7.5 mg/day administered at bedtime is approved by the US Food and Drug Administration (FDA) for the treatment of VMS. In a pivotal study, 1,112 patients with VMS were randomly assigned to receive a placebo or paroxetine 7.5 mg at bedtime.⁹ In the 12-week study the reported decrease in mean weekly frequency of VMS for patients in the placebo and paroxetine groups were -37 and -44, respectively.⁹ Paroxetine 7.5 mg also reduced awakenings per night attributed to VMS and increased nighttime sleep duration.¹⁰

Depressed mood is prevalent among perimenopausal and postmenopausal patients.¹² Prescribing escitalopram or paroxetine for VMS also may improve mood. Venlafaxine and desvenlafaxine are effective for the treatment of VMS;^13,14 however, I seldom prescribe these medications for VMS because in my experience they are associated with more bothersome side effects, including dry mouth, decreased appetite, nausea, and insomnia than escitalopram or low-dose paroxetine.

Continue to: Gabapentin...

Gabapentin

Numerous randomized clinical trials have reported that gabapentin is superior to placebo for the treatment of VMS.¹⁵ In one trial, 420 patients with breast cancer and VMS were randomly assigned to 8 weeks of treatment with placebo, gabapentin 300 mg/day (G300), or gabapentin 900 mg/day (G900) in 3 divided doses.¹⁶ Following 8 weeks of treatment, reduction in hot-flash severity score among patients receiving placebo, G300, or G900 was 15%, 31%, and 46%, respectively. Fatigue and somnolence were reported more frequently among patients taking gabapentin 900 mg/day. In a small trial, 60 patients with VMS were randomized to receive placebo, conjugated estrogen (0.2625 mg/day),or gabapentin (target dose of 2,400 mg/day in 3 divided doses).¹⁷ Following 12 weeks of treatment, the patient-reported decrease in VMS for those taking placebo, estrogen, or gabapentin was 54%, 72%, and 71%, respectively.

High-dose gabapentin treatment was associated with side effects of headache and dizziness more often than placebo or estrogen. Although gabapentin is not a treatment for insomnia, in my practice if a menopausal patient has prominent and bothersome symptoms of sleep disturbance and mild VMS symptoms, I will consider a trial of low-dose gabapentin. Some experts recommend initiating gabapentin at a dose of 100 mgdaily before bedtime to assess the effectiveness of a low dose that seldom causes significant side effects.

ILLUSTRATION: ZONDA/ZAZA STUDIO/SHUTTERSTOCK

Fezolinetant

In a study of genetic variation associated with VMS, investigators discovered that nucleic acid variation in the neurokinin 3 (NK3) receptor was strongly associated with the prevalence of VMS, suggesting that this receptor is in the causal pathway to menopausal VMS.¹⁸ Additional research demonstrated that the kisspeptin/neurokinin B/dynorphin (KNDy) neurons, which are involved in the control of hypothalamic thermoregulation, are stimulated by neurokinin B, acting through the NK3 receptor, and suppressed by estradiol. A reduction in hypothalamic estrogen results in unopposed neurokinin B activity, which stimulates KNDy neurons, destabilizing the hypothalamic thermoregulatory center, causing vasodilation, which is perceived as hot flashes and sweating followed by chills.¹⁹

Fezolinetant is a high-affinity NK3 receptor antagonist that blocks the activity of neurokinin B, stabilizing the hypothalamic thermoregulatory center, thereby suppressing hot flashes. It is approved by the FDA for the treatment of moderate to severe VMS due to menopause using a fixed dose of 45 mg daily.²⁰ In one clinical trial, 500 menopausal patients with bothersome VMS were randomly assigned to 12 weeks of treatment with placebo, fezolinetant 30 mg/day, or fezolinetant 45 mg/day. Following 12 weeks of treatment, the reported frequency rates of VMS among patients in the placebo, F30, and F45 groups were reduced by 43%, 61%, and 64%, respectively.²¹ In addition, following 12 weeks of treatment, the severity of VMS rates among patients in the placebo, F30, and F45 groups were reduced by 20%, 26%, and 32%, respectively.

Fezolinetant improved the quality of sleep and was associated with an improvement in patient-reported quality of life. Following 12 weeks of treatment, sleep quality among patients in the placebo, F30, and F45 groups was reported to be “much or moderately better” in 34%, 45%, and 54% of the patients, respectively.²¹ Similar results were reported in a companion study.²²

Fezolinetant is contraindicated for patients with liver cirrhosis or severe renal impairment (estimated glomerular filtration rate of < 30 mL/min/1.73 m2). Before initiating treatment, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin (total and direct). Fezolinetant should not be prescribed if any of these tests are greater than twice the upper limit of normal. These tests should be repeated at 3, 6, and 9 months, and if the patient reports symptoms or signs of liver injury (nausea, vomiting, jaundice). Fezolinetant is metabolized by CYP1A2 and should not be prescribed to patients taking strong CYP1A2 inhibitors. The most common side effects associated with fezolinetant treatment are abdominal pain (4.3%), diarrhea (3.9%), insomnia (3.9%), back pain (3.0%), and hepatic transaminase elevation (2.3%). Fezolinetant has not been thoroughly evaluated in patients older than age 65. Following an oral dose of the medication, the median maximum concentration is reached in 1.5 hours, and the half-life is estimated to be 10 hours.²⁰ Of all the medications discussed in this editorial, fezolinetant is the most expensive.

Effective VMS treatment improves overall health

Estrogen therapy is the gold standard treatment of VMS. However, many menopausal patients with bothersome VMS prefer not to take estrogen, and some have a medical condition that is a contraindication to estrogen treatment. The nonhormonal medication options for the treatment of VMS include escitalopram, paroxetine, gabapentin, and fezolinetant. Patients value the ability to choose the treatment they prefer, among all available hormonal and nonhormonal medication options. For mid-life women, effectively treating bothersome VMS is only one of many interventions that improves health. Optimal health is best achieved with²³:

• high-quality diet
• daily physical activity
• appropriate body mass index
• nicotine avoidance
• a healthy sleep schedule
• normal blood pressure, lipid, and glucose levels.

Women who have a high-quality diet; daily physical activity; an appropriate body mass index; and normal blood pressure, cholesterol, and glucose levels are estimated to live 9 disease-free years longer than other women.²⁴ ●

VMS, also known as hot flashes, night sweats, or cold sweats, occur for the majority of perimenopausal and menopausal women.¹ In one study, the mean duration of clinically significant VMS was 5 years, and one-third of participants continued to have bothersome hot flashes 10 or more years after the onset of menopause.² VMS may contribute to disrupted sleep patterns and depressed mood.³

All obstetrician-gynecologists know that estradiol and other estrogens are highly effective in the treatment of bothersome VMS. A meta-analysis reported that the frequency of VMS was reduced by 60% to 80% with oral estradiol (1 mg/day), transdermal estradiol(0.05 mg/day), and conjugated estrogen (0.625 mg).⁴ Breast tenderness and irregular uterine bleeding are common side effects of estrogen treatment of VMS. Estrogen treatment is contraindicated in patients with estrogen-responsive cancers, coronary heart disease, myocardial infarction, stroke, venous thromboembolism, and some cases of inherited thrombophilia. For these patients, an important option is the nonhormonal treatment of VMS, and several nonhormonal medications have been demonstrated to be effective therapy (TABLE 1). In this editorial I will review the medication treatment of VMS with escitalopram, paroxetine, gabapentin, and fezolinetant.

Escitalopram and paroxetine

Escitalopram and paroxetine have been shown to reduce VMS more than placebo in multiple clinical trials.^5-10 In addition, escitalopram and paroxetine, at the doses tested, may be more effective for the treatment of VMS than sertraline, citalopram, or fluoxetine.¹¹ In one trial assessing the efficacy of escitalopram to treat VMS, 205 patients with VMS were randomly assigned to 8 weeks of treatment with placebo or escitalopram.⁵ The initial escitalopram dose was 10 mg daily. At week 4:

• if VMS frequency was reduced by ≥ 50%, the patient remained on the 10-mg dose
• if VMS frequency was reduced by < 50%, the escitalopram dose was increased to 20 mg daily.

Following 8 weeks of treatment, the frequency of VMS decreased for patients in the placebo and escitalopram groups by 33% and 47%, respectively. Similar results have been reported in other studies.⁶

Paroxetine at a dose of 7.5 mg/day administered at bedtime is approved by the US Food and Drug Administration (FDA) for the treatment of VMS. In a pivotal study, 1,112 patients with VMS were randomly assigned to receive a placebo or paroxetine 7.5 mg at bedtime.⁹ In the 12-week study the reported decrease in mean weekly frequency of VMS for patients in the placebo and paroxetine groups were -37 and -44, respectively.⁹ Paroxetine 7.5 mg also reduced awakenings per night attributed to VMS and increased nighttime sleep duration.¹⁰

Depressed mood is prevalent among perimenopausal and postmenopausal patients.¹² Prescribing escitalopram or paroxetine for VMS also may improve mood. Venlafaxine and desvenlafaxine are effective for the treatment of VMS;^13,14 however, I seldom prescribe these medications for VMS because in my experience they are associated with more bothersome side effects, including dry mouth, decreased appetite, nausea, and insomnia than escitalopram or low-dose paroxetine.

Continue to: Gabapentin...

Gabapentin

Numerous randomized clinical trials have reported that gabapentin is superior to placebo for the treatment of VMS.¹⁵ In one trial, 420 patients with breast cancer and VMS were randomly assigned to 8 weeks of treatment with placebo, gabapentin 300 mg/day (G300), or gabapentin 900 mg/day (G900) in 3 divided doses.¹⁶ Following 8 weeks of treatment, reduction in hot-flash severity score among patients receiving placebo, G300, or G900 was 15%, 31%, and 46%, respectively. Fatigue and somnolence were reported more frequently among patients taking gabapentin 900 mg/day. In a small trial, 60 patients with VMS were randomized to receive placebo, conjugated estrogen (0.2625 mg/day),or gabapentin (target dose of 2,400 mg/day in 3 divided doses).¹⁷ Following 12 weeks of treatment, the patient-reported decrease in VMS for those taking placebo, estrogen, or gabapentin was 54%, 72%, and 71%, respectively.

High-dose gabapentin treatment was associated with side effects of headache and dizziness more often than placebo or estrogen. Although gabapentin is not a treatment for insomnia, in my practice if a menopausal patient has prominent and bothersome symptoms of sleep disturbance and mild VMS symptoms, I will consider a trial of low-dose gabapentin. Some experts recommend initiating gabapentin at a dose of 100 mgdaily before bedtime to assess the effectiveness of a low dose that seldom causes significant side effects.

ILLUSTRATION: ZONDA/ZAZA STUDIO/SHUTTERSTOCK

Fezolinetant

In a study of genetic variation associated with VMS, investigators discovered that nucleic acid variation in the neurokinin 3 (NK3) receptor was strongly associated with the prevalence of VMS, suggesting that this receptor is in the causal pathway to menopausal VMS.¹⁸ Additional research demonstrated that the kisspeptin/neurokinin B/dynorphin (KNDy) neurons, which are involved in the control of hypothalamic thermoregulation, are stimulated by neurokinin B, acting through the NK3 receptor, and suppressed by estradiol. A reduction in hypothalamic estrogen results in unopposed neurokinin B activity, which stimulates KNDy neurons, destabilizing the hypothalamic thermoregulatory center, causing vasodilation, which is perceived as hot flashes and sweating followed by chills.¹⁹

Fezolinetant is a high-affinity NK3 receptor antagonist that blocks the activity of neurokinin B, stabilizing the hypothalamic thermoregulatory center, thereby suppressing hot flashes. It is approved by the FDA for the treatment of moderate to severe VMS due to menopause using a fixed dose of 45 mg daily.²⁰ In one clinical trial, 500 menopausal patients with bothersome VMS were randomly assigned to 12 weeks of treatment with placebo, fezolinetant 30 mg/day, or fezolinetant 45 mg/day. Following 12 weeks of treatment, the reported frequency rates of VMS among patients in the placebo, F30, and F45 groups were reduced by 43%, 61%, and 64%, respectively.²¹ In addition, following 12 weeks of treatment, the severity of VMS rates among patients in the placebo, F30, and F45 groups were reduced by 20%, 26%, and 32%, respectively.

Fezolinetant improved the quality of sleep and was associated with an improvement in patient-reported quality of life. Following 12 weeks of treatment, sleep quality among patients in the placebo, F30, and F45 groups was reported to be “much or moderately better” in 34%, 45%, and 54% of the patients, respectively.²¹ Similar results were reported in a companion study.²²

Fezolinetant is contraindicated for patients with liver cirrhosis or severe renal impairment (estimated glomerular filtration rate of < 30 mL/min/1.73 m2). Before initiating treatment, serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin (total and direct). Fezolinetant should not be prescribed if any of these tests are greater than twice the upper limit of normal. These tests should be repeated at 3, 6, and 9 months, and if the patient reports symptoms or signs of liver injury (nausea, vomiting, jaundice). Fezolinetant is metabolized by CYP1A2 and should not be prescribed to patients taking strong CYP1A2 inhibitors. The most common side effects associated with fezolinetant treatment are abdominal pain (4.3%), diarrhea (3.9%), insomnia (3.9%), back pain (3.0%), and hepatic transaminase elevation (2.3%). Fezolinetant has not been thoroughly evaluated in patients older than age 65. Following an oral dose of the medication, the median maximum concentration is reached in 1.5 hours, and the half-life is estimated to be 10 hours.²⁰ Of all the medications discussed in this editorial, fezolinetant is the most expensive.

Effective VMS treatment improves overall health

Estrogen therapy is the gold standard treatment of VMS. However, many menopausal patients with bothersome VMS prefer not to take estrogen, and some have a medical condition that is a contraindication to estrogen treatment. The nonhormonal medication options for the treatment of VMS include escitalopram, paroxetine, gabapentin, and fezolinetant. Patients value the ability to choose the treatment they prefer, among all available hormonal and nonhormonal medication options. For mid-life women, effectively treating bothersome VMS is only one of many interventions that improves health. Optimal health is best achieved with²³:

• high-quality diet
• daily physical activity
• appropriate body mass index
• nicotine avoidance
• a healthy sleep schedule
• normal blood pressure, lipid, and glucose levels.

Women who have a high-quality diet; daily physical activity; an appropriate body mass index; and normal blood pressure, cholesterol, and glucose levels are estimated to live 9 disease-free years longer than other women.²⁴ ●

The Centers for Disease Control and Prevention (CDC) reported 106,699 deaths in 2021 from drug overdose, with the majority being linked to synthetic opioids, including fentanyl and tramadol.¹ This number compares with 42,795 deaths due to motor vehicle accidents and 48,183 deaths due to suicide in 2021.^2,3 Most of the opioid overdose deaths occurred among people aged 25 to 64 years, the peak age of patients cared for by obstetrician-gynecologists. Among pregnant and postpartum persons, mortality due to drug overdose has increased by 81% between 2017 and 2020.⁴

Among pregnant and postpartum patients, drug overdose death is more common than suicide, and the risk for drug overdose death appears to be greatest in the year following delivery.^5,6 In many cases, postpartum patients with OUD have had multiple contacts with the health care system prior to their death, showing that there is an opportunity for therapeutic intervention before the death occurred.⁷ Medication-assisted recovery for OUD involves a comprehensive array of interventions including medication, counseling, and social support. Medication treatment of OUD with BUP or methadone reduces the risk for death but is underutilized among patients with OUD.^6,8 Recent federal legislation has removed restrictions on the use of BUP, increasing the opportunity for primary care clinicians to prescribe it for the treatment of OUD.⁹

Screening and diagnosis of OUD

Screening for OUD is recommended for patients who are at risk for opioid misuse (ie, those who are taking/have taken opioid medications). The OWLS (Overuse, Worrying, Losing interest, and feeling Slowed down, sluggish, or sedated) screening tool is used to detect prescription medication OUD and has 4 questions¹⁰:

1. In the past 3 months did you use your opioid medicines for other purposes—for example, to help you sleep or to help with stress or worry?

2. In the past 3 months did opioid medicines cause you to feel slowed down, sluggish, or sedated?

3. In the past 3 months did opioid medicines cause you to lose interest in your usual activities?

4. In the past 3 months did you worry about your use of opioid medicines? 

Patient agreement with 3 or 4 questions indicates a positive screening test.

If the patient has a positive screening test, a formal diagnosis of OUD can be made using the 11 symptoms outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.¹¹ The diagnosis of mild (2 to 3 symptoms), moderate (4 to 5 symptoms), or severe OUD (6 or more symptoms) is made based on the number of symptoms the patient reports.

Buprenorphine treatment of OUD in primary care

The role of primary care clinicians in the medication treatment of OUD is increasing. Using a nationwide system that tracks prescription medications, investigators reported that, in 2004, psychiatrists wrote 32.2% of all BUP prescriptions; in 2021, however, only 10% of such prescriptions were provided by psychiatrists, with most prescriptions written by non-psychiatrist physicians, nurse practitioners, and physician assistants that year.¹² Innovative telehealth approaches to consultation and medication treatment of OUD are now available—one example is QuickMD.¹³ Such sites are designed to remove barriers to initiating medication treatment of OUD.

The role of primary care clinicians in the management of OUD using BUP and buprenorphine-naloxone (BUP-NAL) has increased due to many factors, including:

• the removal of US Food and Drug Administration (FDA) barriers to prescribing BUP
• the epidemic of OUD and the small size of the addiction specialist workforce, necessitating that primary care clinicians become engaged in the treatment of OUD
• an increase in unobserved initiation of BUP among ambulatory patients, and a parallel decrease in cases of observed initiation in addiction center settings
• the reframing of OUD as a chronic medical problem, with many similarities to diabetes, obesity, dyslipidemia, and hypertension.

Similar to other diseases managed by primary care clinicians, OUD requires long-term chronic treatment with a medicine that, if taken as directed, provides excellent outcomes. Primary care clinicians who prescribe BUP also can optimize longitudinal care for comorbid disorders such as hypertension and diabetes, which are prevalent in people with OUD.

In 2019, New Jersey implemented new guidelines for the treatment of OUD, removing prior authorization barriers, increasing reimbursement for office-based OUD treatment, and establishing regional centers of excellence. The implementation of the new guidelines was followed by a marked increase in BUP prescribers among primary care clinicians, emergency medicine physicians, and advanced practice clinicians.¹⁴

To estimate the public health impact of BUP prescribing by primary care clinicians, investigators simulated patient outcomes in 3 scenarios¹⁵:

1. primary care clinicians refer patients to addiction specialists for OUD treatment

2. primary care clinicians provide BUP services in their practice

3. primary care clinicians provide BUP and harm reduction kits containing syringes and wound care supplies in their practice. 

Strategies 2 and 3 resulted in 14% fewer deaths due to opioid overdose, an increased life expectancy of approximately 2.7 years, and reduced hospital costs. For strategy 3, the incremental cost per life-year saved was $34,400. The investigators noted that prescribing BUP in primary care practice increases practice costs.¹⁵

Treatment with BUP reduces death from opioid overdose, improves patient health, decreases use of illicit opioids, and reduces patient cravings for opioids. BUP is a safe medication and is associated with fewer adverse effects than insulin or warfarin.¹⁶

Continue to: Methadone treatment of OUD...

Methadone is a full opioid agonist approved by the FDA for the treatment of severe pain or OUD. Methadone treatment of OUD is strictly regulated and typically is ordered and administered at an opioid treatment program that is federally licensed. Methadone for OUD treatment cannot be prescribed by a physician to a pharmacy, limiting its use in primary care practice. Methadone used to treat OUD is ordered and dispensed at opioid-treatment programs. Take-home doses of methadone may be available to patients after adherence to the regimen has been established. When used long-term, higher doses of methadone are associated with better adherence, but these higher doses can cause respiratory depression. In a study of 189 pregnant patients taking methadone to treat OUD, daily doses of 60 mg or greater were associated with better treatment retention at delivery and 60 days postpartum, as well as less use of nonprescription opioids.¹⁷ Under limited circumstances methadone can be ordered and dispensed for hospitalized patients with OUD.

Medication treatment of OUD in obstetrics

In the United States, the prevalence of OUD among pregnant patients hospitalized for delivery more than quadrupled from 1999 through 2014.¹⁸ BUP and methadone commonly are used to treat OUD during pregnancy.¹⁹ Among pregnant patients about 5% of buprenorphine prescriptions are written by obstetricians.²⁰ An innovative approach to initiating BUP for pregnant patients with OUD is to use unobserved initiation, which involves outpatient discontinuation of nonprescription opioids to induce mild to moderate withdrawal symptoms followed by initiation of BUP treatment. In one cohort study, 55 pregnant patients used an unobserved outpatient protocol to initiate BUP treatment; 80% of the patients previously had used methadone or BUP. No patient experienced a precipitated withdrawal and 96% of patients returned for their office visit 1 week after initiation of treatment. Eighty-six percent of patients remained in treatment 3 months following initiation of BUP.²¹

Compared with methadone, BUP treatment during pregnancy may result in lower rates of neonatal abstinence syndrome. In one study of pregnant patients who were using methadone (n = 5,056) or BUP (n = 11,272) in late pregnancy, neonatal abstinence syndrome was diagnosed in 69.2% and 52.0% of newborns, respectively (adjusted relative risk, 0.73; 95% confidence interval, 0.71–0.75).²² In addition, compared with methadone, the use of BUP was associated with a reduced risk for low birth weight (14.9% vs 8.3%) and a lower risk for preterm birth (24.9% vs 14.4%). In this study, there were no differences in maternal obstetric outcomes when comparing BUP versus methadone treatment. Similar results have been reported in a meta-analysis analyzing the use of methadone and BUP during pregnancy.²³ Studies performed to date have not shown an increased risk of congenital anomalies with the use of BUP-NAL during pregnancy.^24,25

Although there may be differences in newborn outcomes with BUP and methadone, the American College of Obstetricians and Gynecologists does not recommend switching from methadone to BUP during pregnancy because precipitated withdrawal may occur.²⁶ Based on recent studies, the American Society of Addiction Medicine has advised that it is safe to prescribe pregnant patients either BUP or BUP-NAL.^27,28

Medication treatment of OUD with or without intensive counseling

The FDA recently reviewed literature related to the advantages and challenges of combining intensive counseling with medication treatment of OUD.²⁹ The FDA noted that treatment saves lives and encouraged clinicians to initiate medication treatment of OUD or refer the patient to an appropriate clinician or treatment center. Combining medication treatment of OUD with intensive counseling is associated with greater treatment adherence and reduced health care costs. For example, in one study of 4,987 patients with OUD, initiation of counseling within 8 weeks of the start of medication treatment and a BUP dose of 16 mg or greater daily were associated with increased adherence to treatment.³⁰ For patients receiving a BUP dose of less than 16 mg daily, treatment adherence with and without counseling was approximately 325 and 230 days, respectively. When the dose of BUP was 16 mg or greater, treatment adherence with and without counseling was approximately 405 and 320 days, respectively.³⁰

Counseling should always be offered to patients initiating medication treatment of OUD. It should be noted that counseling alone is not a highly effective treatment for OUD.³¹ The FDA recently advised that the lack of availability of intensive counseling should not prevent clinicians from initiating BUP for the treatment of OUD.²⁹ OUD is associated with a high mortalityrate and if counseling is not possible, medication treatment should be initiated. Substantial evidence demonstrates that medication treatment of OUD is associated with many benefits.¹⁶ The FDA advisory committee concluded that OUD treatment decisions should use shared decision making and be supportive and patient centered.²⁹

The opportunities for medication treatment of OUD in primary care practice have expanded due to the recent FDA removal of restrictions on the use of BUP and heightened awareness of the positive public health impact of medication treatment. Challenges to the medication treatment of OUD remain, including stigmatization of OUD, barriers to insurance coverage for BUP, practice costs of treating OUD, and gaps in clinical education. For many pregnant patients, their main point of contact with health care is their obstetrician. By incorporating OUD treatment in pregnancy care, obstetricians will improve the health of the mother and newborn, contributing to the well-being of current and future generations. ●

The Centers for Disease Control and Prevention (CDC) reported 106,699 deaths in 2021 from drug overdose, with the majority being linked to synthetic opioids, including fentanyl and tramadol.¹ This number compares with 42,795 deaths due to motor vehicle accidents and 48,183 deaths due to suicide in 2021.^2,3 Most of the opioid overdose deaths occurred among people aged 25 to 64 years, the peak age of patients cared for by obstetrician-gynecologists. Among pregnant and postpartum persons, mortality due to drug overdose has increased by 81% between 2017 and 2020.⁴

Among pregnant and postpartum patients, drug overdose death is more common than suicide, and the risk for drug overdose death appears to be greatest in the year following delivery.^5,6 In many cases, postpartum patients with OUD have had multiple contacts with the health care system prior to their death, showing that there is an opportunity for therapeutic intervention before the death occurred.⁷ Medication-assisted recovery for OUD involves a comprehensive array of interventions including medication, counseling, and social support. Medication treatment of OUD with BUP or methadone reduces the risk for death but is underutilized among patients with OUD.^6,8 Recent federal legislation has removed restrictions on the use of BUP, increasing the opportunity for primary care clinicians to prescribe it for the treatment of OUD.⁹

Screening and diagnosis of OUD

Screening for OUD is recommended for patients who are at risk for opioid misuse (ie, those who are taking/have taken opioid medications). The OWLS (Overuse, Worrying, Losing interest, and feeling Slowed down, sluggish, or sedated) screening tool is used to detect prescription medication OUD and has 4 questions¹⁰:

1. In the past 3 months did you use your opioid medicines for other purposes—for example, to help you sleep or to help with stress or worry?

2. In the past 3 months did opioid medicines cause you to feel slowed down, sluggish, or sedated?

3. In the past 3 months did opioid medicines cause you to lose interest in your usual activities?

4. In the past 3 months did you worry about your use of opioid medicines? 

Patient agreement with 3 or 4 questions indicates a positive screening test.

If the patient has a positive screening test, a formal diagnosis of OUD can be made using the 11 symptoms outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.¹¹ The diagnosis of mild (2 to 3 symptoms), moderate (4 to 5 symptoms), or severe OUD (6 or more symptoms) is made based on the number of symptoms the patient reports.

Buprenorphine treatment of OUD in primary care

The role of primary care clinicians in the medication treatment of OUD is increasing. Using a nationwide system that tracks prescription medications, investigators reported that, in 2004, psychiatrists wrote 32.2% of all BUP prescriptions; in 2021, however, only 10% of such prescriptions were provided by psychiatrists, with most prescriptions written by non-psychiatrist physicians, nurse practitioners, and physician assistants that year.¹² Innovative telehealth approaches to consultation and medication treatment of OUD are now available—one example is QuickMD.¹³ Such sites are designed to remove barriers to initiating medication treatment of OUD.

The role of primary care clinicians in the management of OUD using BUP and buprenorphine-naloxone (BUP-NAL) has increased due to many factors, including:

• the removal of US Food and Drug Administration (FDA) barriers to prescribing BUP
• the epidemic of OUD and the small size of the addiction specialist workforce, necessitating that primary care clinicians become engaged in the treatment of OUD
• an increase in unobserved initiation of BUP among ambulatory patients, and a parallel decrease in cases of observed initiation in addiction center settings
• the reframing of OUD as a chronic medical problem, with many similarities to diabetes, obesity, dyslipidemia, and hypertension.

Similar to other diseases managed by primary care clinicians, OUD requires long-term chronic treatment with a medicine that, if taken as directed, provides excellent outcomes. Primary care clinicians who prescribe BUP also can optimize longitudinal care for comorbid disorders such as hypertension and diabetes, which are prevalent in people with OUD.

In 2019, New Jersey implemented new guidelines for the treatment of OUD, removing prior authorization barriers, increasing reimbursement for office-based OUD treatment, and establishing regional centers of excellence. The implementation of the new guidelines was followed by a marked increase in BUP prescribers among primary care clinicians, emergency medicine physicians, and advanced practice clinicians.¹⁴

To estimate the public health impact of BUP prescribing by primary care clinicians, investigators simulated patient outcomes in 3 scenarios¹⁵:

1. primary care clinicians refer patients to addiction specialists for OUD treatment

2. primary care clinicians provide BUP services in their practice

3. primary care clinicians provide BUP and harm reduction kits containing syringes and wound care supplies in their practice. 

Strategies 2 and 3 resulted in 14% fewer deaths due to opioid overdose, an increased life expectancy of approximately 2.7 years, and reduced hospital costs. For strategy 3, the incremental cost per life-year saved was $34,400. The investigators noted that prescribing BUP in primary care practice increases practice costs.¹⁵

Treatment with BUP reduces death from opioid overdose, improves patient health, decreases use of illicit opioids, and reduces patient cravings for opioids. BUP is a safe medication and is associated with fewer adverse effects than insulin or warfarin.¹⁶

Continue to: Methadone treatment of OUD...

Methadone is a full opioid agonist approved by the FDA for the treatment of severe pain or OUD. Methadone treatment of OUD is strictly regulated and typically is ordered and administered at an opioid treatment program that is federally licensed. Methadone for OUD treatment cannot be prescribed by a physician to a pharmacy, limiting its use in primary care practice. Methadone used to treat OUD is ordered and dispensed at opioid-treatment programs. Take-home doses of methadone may be available to patients after adherence to the regimen has been established. When used long-term, higher doses of methadone are associated with better adherence, but these higher doses can cause respiratory depression. In a study of 189 pregnant patients taking methadone to treat OUD, daily doses of 60 mg or greater were associated with better treatment retention at delivery and 60 days postpartum, as well as less use of nonprescription opioids.¹⁷ Under limited circumstances methadone can be ordered and dispensed for hospitalized patients with OUD.

Medication treatment of OUD in obstetrics

In the United States, the prevalence of OUD among pregnant patients hospitalized for delivery more than quadrupled from 1999 through 2014.¹⁸ BUP and methadone commonly are used to treat OUD during pregnancy.¹⁹ Among pregnant patients about 5% of buprenorphine prescriptions are written by obstetricians.²⁰ An innovative approach to initiating BUP for pregnant patients with OUD is to use unobserved initiation, which involves outpatient discontinuation of nonprescription opioids to induce mild to moderate withdrawal symptoms followed by initiation of BUP treatment. In one cohort study, 55 pregnant patients used an unobserved outpatient protocol to initiate BUP treatment; 80% of the patients previously had used methadone or BUP. No patient experienced a precipitated withdrawal and 96% of patients returned for their office visit 1 week after initiation of treatment. Eighty-six percent of patients remained in treatment 3 months following initiation of BUP.²¹

Compared with methadone, BUP treatment during pregnancy may result in lower rates of neonatal abstinence syndrome. In one study of pregnant patients who were using methadone (n = 5,056) or BUP (n = 11,272) in late pregnancy, neonatal abstinence syndrome was diagnosed in 69.2% and 52.0% of newborns, respectively (adjusted relative risk, 0.73; 95% confidence interval, 0.71–0.75).²² In addition, compared with methadone, the use of BUP was associated with a reduced risk for low birth weight (14.9% vs 8.3%) and a lower risk for preterm birth (24.9% vs 14.4%). In this study, there were no differences in maternal obstetric outcomes when comparing BUP versus methadone treatment. Similar results have been reported in a meta-analysis analyzing the use of methadone and BUP during pregnancy.²³ Studies performed to date have not shown an increased risk of congenital anomalies with the use of BUP-NAL during pregnancy.^24,25

Although there may be differences in newborn outcomes with BUP and methadone, the American College of Obstetricians and Gynecologists does not recommend switching from methadone to BUP during pregnancy because precipitated withdrawal may occur.²⁶ Based on recent studies, the American Society of Addiction Medicine has advised that it is safe to prescribe pregnant patients either BUP or BUP-NAL.^27,28

Medication treatment of OUD with or without intensive counseling

The FDA recently reviewed literature related to the advantages and challenges of combining intensive counseling with medication treatment of OUD.²⁹ The FDA noted that treatment saves lives and encouraged clinicians to initiate medication treatment of OUD or refer the patient to an appropriate clinician or treatment center. Combining medication treatment of OUD with intensive counseling is associated with greater treatment adherence and reduced health care costs. For example, in one study of 4,987 patients with OUD, initiation of counseling within 8 weeks of the start of medication treatment and a BUP dose of 16 mg or greater daily were associated with increased adherence to treatment.³⁰ For patients receiving a BUP dose of less than 16 mg daily, treatment adherence with and without counseling was approximately 325 and 230 days, respectively. When the dose of BUP was 16 mg or greater, treatment adherence with and without counseling was approximately 405 and 320 days, respectively.³⁰

Counseling should always be offered to patients initiating medication treatment of OUD. It should be noted that counseling alone is not a highly effective treatment for OUD.³¹ The FDA recently advised that the lack of availability of intensive counseling should not prevent clinicians from initiating BUP for the treatment of OUD.²⁹ OUD is associated with a high mortalityrate and if counseling is not possible, medication treatment should be initiated. Substantial evidence demonstrates that medication treatment of OUD is associated with many benefits.¹⁶ The FDA advisory committee concluded that OUD treatment decisions should use shared decision making and be supportive and patient centered.²⁹

The opportunities for medication treatment of OUD in primary care practice have expanded due to the recent FDA removal of restrictions on the use of BUP and heightened awareness of the positive public health impact of medication treatment. Challenges to the medication treatment of OUD remain, including stigmatization of OUD, barriers to insurance coverage for BUP, practice costs of treating OUD, and gaps in clinical education. For many pregnant patients, their main point of contact with health care is their obstetrician. By incorporating OUD treatment in pregnancy care, obstetricians will improve the health of the mother and newborn, contributing to the well-being of current and future generations. ●

The Centers for Disease Control and Prevention (CDC) reported 106,699 deaths in 2021 from drug overdose, with the majority being linked to synthetic opioids, including fentanyl and tramadol.¹ This number compares with 42,795 deaths due to motor vehicle accidents and 48,183 deaths due to suicide in 2021.^2,3 Most of the opioid overdose deaths occurred among people aged 25 to 64 years, the peak age of patients cared for by obstetrician-gynecologists. Among pregnant and postpartum persons, mortality due to drug overdose has increased by 81% between 2017 and 2020.⁴

Among pregnant and postpartum patients, drug overdose death is more common than suicide, and the risk for drug overdose death appears to be greatest in the year following delivery.^5,6 In many cases, postpartum patients with OUD have had multiple contacts with the health care system prior to their death, showing that there is an opportunity for therapeutic intervention before the death occurred.⁷ Medication-assisted recovery for OUD involves a comprehensive array of interventions including medication, counseling, and social support. Medication treatment of OUD with BUP or methadone reduces the risk for death but is underutilized among patients with OUD.^6,8 Recent federal legislation has removed restrictions on the use of BUP, increasing the opportunity for primary care clinicians to prescribe it for the treatment of OUD.⁹

Screening and diagnosis of OUD

Screening for OUD is recommended for patients who are at risk for opioid misuse (ie, those who are taking/have taken opioid medications). The OWLS (Overuse, Worrying, Losing interest, and feeling Slowed down, sluggish, or sedated) screening tool is used to detect prescription medication OUD and has 4 questions¹⁰:

1. In the past 3 months did you use your opioid medicines for other purposes—for example, to help you sleep or to help with stress or worry?

2. In the past 3 months did opioid medicines cause you to feel slowed down, sluggish, or sedated?

3. In the past 3 months did opioid medicines cause you to lose interest in your usual activities?

4. In the past 3 months did you worry about your use of opioid medicines? 

Patient agreement with 3 or 4 questions indicates a positive screening test.

If the patient has a positive screening test, a formal diagnosis of OUD can be made using the 11 symptoms outlined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.¹¹ The diagnosis of mild (2 to 3 symptoms), moderate (4 to 5 symptoms), or severe OUD (6 or more symptoms) is made based on the number of symptoms the patient reports.

Buprenorphine treatment of OUD in primary care

The role of primary care clinicians in the medication treatment of OUD is increasing. Using a nationwide system that tracks prescription medications, investigators reported that, in 2004, psychiatrists wrote 32.2% of all BUP prescriptions; in 2021, however, only 10% of such prescriptions were provided by psychiatrists, with most prescriptions written by non-psychiatrist physicians, nurse practitioners, and physician assistants that year.¹² Innovative telehealth approaches to consultation and medication treatment of OUD are now available—one example is QuickMD.¹³ Such sites are designed to remove barriers to initiating medication treatment of OUD.

The role of primary care clinicians in the management of OUD using BUP and buprenorphine-naloxone (BUP-NAL) has increased due to many factors, including:

• the removal of US Food and Drug Administration (FDA) barriers to prescribing BUP
• the epidemic of OUD and the small size of the addiction specialist workforce, necessitating that primary care clinicians become engaged in the treatment of OUD
• an increase in unobserved initiation of BUP among ambulatory patients, and a parallel decrease in cases of observed initiation in addiction center settings
• the reframing of OUD as a chronic medical problem, with many similarities to diabetes, obesity, dyslipidemia, and hypertension.

Similar to other diseases managed by primary care clinicians, OUD requires long-term chronic treatment with a medicine that, if taken as directed, provides excellent outcomes. Primary care clinicians who prescribe BUP also can optimize longitudinal care for comorbid disorders such as hypertension and diabetes, which are prevalent in people with OUD.

In 2019, New Jersey implemented new guidelines for the treatment of OUD, removing prior authorization barriers, increasing reimbursement for office-based OUD treatment, and establishing regional centers of excellence. The implementation of the new guidelines was followed by a marked increase in BUP prescribers among primary care clinicians, emergency medicine physicians, and advanced practice clinicians.¹⁴

To estimate the public health impact of BUP prescribing by primary care clinicians, investigators simulated patient outcomes in 3 scenarios¹⁵:

1. primary care clinicians refer patients to addiction specialists for OUD treatment

2. primary care clinicians provide BUP services in their practice

3. primary care clinicians provide BUP and harm reduction kits containing syringes and wound care supplies in their practice. 

Strategies 2 and 3 resulted in 14% fewer deaths due to opioid overdose, an increased life expectancy of approximately 2.7 years, and reduced hospital costs. For strategy 3, the incremental cost per life-year saved was $34,400. The investigators noted that prescribing BUP in primary care practice increases practice costs.¹⁵

Treatment with BUP reduces death from opioid overdose, improves patient health, decreases use of illicit opioids, and reduces patient cravings for opioids. BUP is a safe medication and is associated with fewer adverse effects than insulin or warfarin.¹⁶

Continue to: Methadone treatment of OUD...

Methadone is a full opioid agonist approved by the FDA for the treatment of severe pain or OUD. Methadone treatment of OUD is strictly regulated and typically is ordered and administered at an opioid treatment program that is federally licensed. Methadone for OUD treatment cannot be prescribed by a physician to a pharmacy, limiting its use in primary care practice. Methadone used to treat OUD is ordered and dispensed at opioid-treatment programs. Take-home doses of methadone may be available to patients after adherence to the regimen has been established. When used long-term, higher doses of methadone are associated with better adherence, but these higher doses can cause respiratory depression. In a study of 189 pregnant patients taking methadone to treat OUD, daily doses of 60 mg or greater were associated with better treatment retention at delivery and 60 days postpartum, as well as less use of nonprescription opioids.¹⁷ Under limited circumstances methadone can be ordered and dispensed for hospitalized patients with OUD.

Medication treatment of OUD in obstetrics

In the United States, the prevalence of OUD among pregnant patients hospitalized for delivery more than quadrupled from 1999 through 2014.¹⁸ BUP and methadone commonly are used to treat OUD during pregnancy.¹⁹ Among pregnant patients about 5% of buprenorphine prescriptions are written by obstetricians.²⁰ An innovative approach to initiating BUP for pregnant patients with OUD is to use unobserved initiation, which involves outpatient discontinuation of nonprescription opioids to induce mild to moderate withdrawal symptoms followed by initiation of BUP treatment. In one cohort study, 55 pregnant patients used an unobserved outpatient protocol to initiate BUP treatment; 80% of the patients previously had used methadone or BUP. No patient experienced a precipitated withdrawal and 96% of patients returned for their office visit 1 week after initiation of treatment. Eighty-six percent of patients remained in treatment 3 months following initiation of BUP.²¹

Compared with methadone, BUP treatment during pregnancy may result in lower rates of neonatal abstinence syndrome. In one study of pregnant patients who were using methadone (n = 5,056) or BUP (n = 11,272) in late pregnancy, neonatal abstinence syndrome was diagnosed in 69.2% and 52.0% of newborns, respectively (adjusted relative risk, 0.73; 95% confidence interval, 0.71–0.75).²² In addition, compared with methadone, the use of BUP was associated with a reduced risk for low birth weight (14.9% vs 8.3%) and a lower risk for preterm birth (24.9% vs 14.4%). In this study, there were no differences in maternal obstetric outcomes when comparing BUP versus methadone treatment. Similar results have been reported in a meta-analysis analyzing the use of methadone and BUP during pregnancy.²³ Studies performed to date have not shown an increased risk of congenital anomalies with the use of BUP-NAL during pregnancy.^24,25

Although there may be differences in newborn outcomes with BUP and methadone, the American College of Obstetricians and Gynecologists does not recommend switching from methadone to BUP during pregnancy because precipitated withdrawal may occur.²⁶ Based on recent studies, the American Society of Addiction Medicine has advised that it is safe to prescribe pregnant patients either BUP or BUP-NAL.^27,28

Medication treatment of OUD with or without intensive counseling

The FDA recently reviewed literature related to the advantages and challenges of combining intensive counseling with medication treatment of OUD.²⁹ The FDA noted that treatment saves lives and encouraged clinicians to initiate medication treatment of OUD or refer the patient to an appropriate clinician or treatment center. Combining medication treatment of OUD with intensive counseling is associated with greater treatment adherence and reduced health care costs. For example, in one study of 4,987 patients with OUD, initiation of counseling within 8 weeks of the start of medication treatment and a BUP dose of 16 mg or greater daily were associated with increased adherence to treatment.³⁰ For patients receiving a BUP dose of less than 16 mg daily, treatment adherence with and without counseling was approximately 325 and 230 days, respectively. When the dose of BUP was 16 mg or greater, treatment adherence with and without counseling was approximately 405 and 320 days, respectively.³⁰

Counseling should always be offered to patients initiating medication treatment of OUD. It should be noted that counseling alone is not a highly effective treatment for OUD.³¹ The FDA recently advised that the lack of availability of intensive counseling should not prevent clinicians from initiating BUP for the treatment of OUD.²⁹ OUD is associated with a high mortalityrate and if counseling is not possible, medication treatment should be initiated. Substantial evidence demonstrates that medication treatment of OUD is associated with many benefits.¹⁶ The FDA advisory committee concluded that OUD treatment decisions should use shared decision making and be supportive and patient centered.²⁹

The opportunities for medication treatment of OUD in primary care practice have expanded due to the recent FDA removal of restrictions on the use of BUP and heightened awareness of the positive public health impact of medication treatment. Challenges to the medication treatment of OUD remain, including stigmatization of OUD, barriers to insurance coverage for BUP, practice costs of treating OUD, and gaps in clinical education. For many pregnant patients, their main point of contact with health care is their obstetrician. By incorporating OUD treatment in pregnancy care, obstetricians will improve the health of the mother and newborn, contributing to the well-being of current and future generations. ●

Postpartum hemorrhage (PPH) is a common complication of birth. In 2019, 4.3% of births in the United States were complicated by at least one episode of PPH.¹ Major causes of PPH include uterine atony, retained products of conception, reproductive tract trauma, and coagulopathy.² Active management of the third stage of labor with the routine administration of postpartum uterotonics reduces the risk of PPH.^3,4

PPH treatment requires a systematic approach using appropriate uterotonic medications, tranexamic acid, and procedures performed in a timely sequence to resolve the hemorrhage. Following vaginal birth, procedures that do not require a laparotomy to treat PPH include uterine massage, uterine evacuation to remove retained placental tissue, repair of lacerations, uterine balloon tamponade (UBT), uterine packing, a vacuum-induced hemorrhage control device (VHCD; JADA, Organon), and uterine artery embolization. Following cesarean birth, with an open laparotomy incision, interventions to treat PPH due to atony include vascular ligation, uterine compression sutures, UBT, VHCD, hysterectomy, and pelvic packing.²

Over the past 2 decades, UBT has been widely used for the treatment of PPH with a success rate in observational studies of approximately 86%.⁵ The uterine balloon creates pressure against the wall of the uterus permitting accumulation of platelets at bleeding sites, enhancing the activity of the clotting system. The uterine balloon provides direct pressure on the bleeding site(s). It is well known in trauma care that the first step to treat a bleeding wound is to apply direct pressure to the bleeding site. During the third stage of labor, a natural process is tetanic uterine contraction, which constricts myometrial vessels and the placenta bed. Placing a balloon in the uterus and inflating the balloon to 200 mL to 500 mL may delay the involution of the uterus that should occur following birth. An observation of great interest is the insight that inducing a vacuum in the uterine cavity may enhance tetanic uterine contraction and constriction of the myometrial vessels. Vacuum-induced hemorrhage control is discussed in detail in this editorial.

Vacuum-induced hemorrhage control device

A new device for the treatment of PPH due to uterine atony is the JADA VHCD (FIGURE), which generates negative intrauterine pressure causing the uterus to contract, thereby constricting myometrial vessels and reducing uterine bleeding. The JADA VHCD system is indicated to provide control and treatment of abnormal postpartum uterine bleeding following vaginal or cesarean birth caused by uterine atony when conservative management is indicated.⁶

ILLUSTRATION: MARY ELLEN NIATAS FOR OBG MANAGEMENT

System components

The JADA VHCD consists of a leading portion intended to be inserted into the uterine cavity, which consists of a silicone elliptical loop with 20 vacuum pores. A soft shield covers the vacuum loop to reduce the risk of the vacuum pores being clogged with biological material, including blood and clots. The elliptical loop is attached to a catheter intended for connection to a vacuum source set to 80 mm Hg ±10 mm Hg (hospital wall suction or portable suction device) with an in-line cannister to collect blood. Approximately 16 cm from the tip of the elliptical loop is a balloon that should be positioned in the upper vagina, not inside the cervix, and inflated with fluid (60 mL to 120 mL) through a dedicated port to occlude the vagina, thereby preserving a stable intrauterine vacuum.

Continue to: Correct usage...

Correct usage

A simple mnemonic to facilitate use of the JADA VHCD is “120/80”—fill the vaginal balloon with 120 mL of sterile fluid and attach the tubing to a source that is set to provide 80 mm Hg of vacuum with an in-line collection cannister. The VHCD may not work correctly if there is a substantial amount of blood in the uterus. Clinical experts advise that an important step prior to placing the elliptical loop in the uterus is to perform a sweep of the uterine cavity with a hand or instrument to remove clots and ensure there is no retained placental tissue. It is preferable to assemble the suction tubing, syringe, sterile fluid, and other instruments (eg, forceps, speculum) needed to insert the device prior to attempting to place the VHCD. When the elliptical loop is compressed for insertion, it is about 2 cm in diameter, necessitating that the cervix be dilated sufficiently to accommodate the device.

Immediately after placing the VHCD, contractions can be monitored by physical examination and the amount of ongoing bleeding can be estimated by observing the amount of blood accumulating in the cannister. Rapid onset of a palpable increase in uterine tone is a prominent feature of successful treatment of PPH with the VHCD. The VHCD should be kept in the uterus with active suction for at least 1 hour. Taping the tubing to the inner thigh may help stabilize the device. Once bleeding is controlled, prior to removing the device, the vacuum should be discontinued, and bleeding activityshould be assessed for at least 30 minutes. If the patient is stable, the vaginal balloon can be deflated, followed by removal of the device. The VHCD should be removed within 24 hours of placement.⁶

The JADA VHCD system should not be used with ongoing intrauterine pregnancy, untreated uterine rupture, unresolved uterine inversion, current cervical cancer, or serious infection of the uterus.⁶ The VHCD has not been evaluated for effectiveness in the treatment of placenta accreta or coagulopathy. The VHCD has not been specifically evaluated for safety and effectiveness in patients < 34 weeks’ duration, but clinicians report successful use of the device in cases of PPH that have occurred in the second and early-third trimesters. If the device can be appropriately placed with the elliptical loop in the uterus and the balloon in the vagina, it is theoretically possible to use the device for cases of PPH occurring before 34 weeks’ gestation.

When using the JADA VHCD system, it is important to simultaneously provide cardiovascular support, appropriate transfusion of blood products and timely surgical intervention, if indicated. All obstetricians know that in complicated cases of PPH, where conservative measures have not worked, uterine artery embolization or hysterectomy may be the only interventions that will prevent serious patient morbidity.

Effectiveness data

The VHCD has not been evaluated against an alternative approach, such as UBT, in published randomized clinical trials. However, prospective cohort studies have reported that the JADA is often successful in the treatment of PPH.^7-10

In a multicenter cohort study of 107 patients with PPH, including 91 vaginal and 16 cesarean births, 100 patients (93%) were successfully treated with the JADA VHCD.⁷ Median blood loss before application of the system was 870 mL with vaginal birth and 1,300 mL with cesarean birth. Definitive control of the hemorrhage was observed at a median of 3 minutes after initiation of the intrauterine vacuum. In this study, 32% of patients had reproductive tract lacerations that needed to be repaired, and 2 patients required a hysterectomy. Forty patients required a blood transfusion.

Two patients were treated with a Bakri UBT when the VHCD did not resolve the PPH. In this cohort, the vacuum was applied for a median duration of 144 minutes, and a median total device dwell time was 191 minutes. Compared with UBT, the JADA VHCD intrauterine dwell time was shorter, facilitating patient progression and early transfer to the postpartum unit. The physicians who participated in the study reported that the device was easy to use. The complications reported in this cohort were minor and included endometritis (5 cases), vaginal infection (2 cases), and disruption of a vaginal laceration repair (1 case).⁷

Novel approaches to generating an intrauterine vacuum to treat PPH

The JADA VHCD is the only vacuum device approved by the US Food and Drug Administration (FDA) for treatment of PPH. However, clinical innovators have reported alternative approaches to generating an intrauterine vacuum using equipment designed for other purposes. In one study, a Bakri balloon was used to generate intrauterine vacuum tamponade to treat PPH.¹¹ In this study, a Bakri balloon was inserted into the uterus, and the balloon was inflated to 50 mL to 100 mL to seal the vacuum. The main Bakri port was attached to a suction aspiration device set to generate a vacuum of 450 mm Hg to 525 mm Hg, a much greater vacuum than used with the JADA VHCD. This study included 44 cases of PPH due to uterine atony and 22 cases due to placental pathology, with successful treatment of PPH in 86% and 73% of the cases, respectively.

Another approach to generate intrauterine vacuum tamponade involves using a Levin stomach tube (FG24 or FG36), which has an open end and 4 side ports near the open tip.^12-14 The Levin stomach tube is low cost and has many favorable design features, including a rounded tip, wide-bore, and circumferentially placed side ports. The FG36 Levin stomach tube is 12 mm in diameter and has 10 mm side ports. A vacuum device set to deliver 100 mm Hg to 200 mm Hgwas used in some of the studies evaluating the Levin stomach tube for the treatment of PPH. In 3 cases of severe PPH unresponsive to standard interventions, creation of vacuum tamponade with flexible suction tubing with side ports was successful in controlling the hemorrhage.¹³

Dr. T.N. Vasudeva Panicker invented an intrauterine cannula 12 mm in diameter and 25 cm in length, with dozens of 4 mm side ports over the distal 12 cm of the cannula.¹⁵ The cannula, which is made of stainless steel or plastic, is inserted into the uterus and 700 mm Hgvacuum is applied, a level much greater than the 80 mm Hg vacuum recommended for use with the JADA VHCD. When successful, the high suction clears the uterus of blood and causes uterine contraction. In 4 cases of severe PPH, the device successfully controlled the hemorrhage. In 2 of the 4 cases the device that was initially placed became clogged with blood and needed to be replaced.

UBT vs VHCD

To date there are no published randomized controlled trials comparing Bakri UBT to the JADA VHCD. In one retrospective study, the frequency of massive transfusion of red blood cells (RBCs), defined as the transfusion of 4 units or greater of RBCs, was assessed among 78 patients treated with the Bakri UBT and 36 patients treated with the JADA VHCD.⁹ In this study, at baseline there was a non ̶ statistically significant trend for JADA VHCD to be used more frequently than the Bakri UBT in cases of PPH occurring during repeat cesarean delivery (33% vs 14%). The Bakri UBT was used more frequently than the JADA VHCD among patients having a PPH following a vaginal delivery (51% vs 31%). Both devices were used at similar rates for operative vaginal delivery (6%) and primary cesarean birth (31% VHCD and 28% UBT).

In this retrospective study, the percentage of patients treated with VHCD or UBT who received 4 or more units of RBCs was 3% and 21%, respectively (P < .01). Among patients treated with VHCD and UBT, the estimated median blood loss was 1,500 mL and 1,850 mL (P=.02), respectively. The median hemoglobin concentration at discharge was similar in the VHCD and UBT groups, 8.8 g/dL and 8.6 g/dL, respectively.⁹ A randomized controlled trial is necessary to refine our understanding of the comparative effectiveness of UBT and VHCD in controlling PPH following vaginal and cesarean birth.

A welcome addition to treatment options

Every obstetrician knows that, in the next 12 months of their practice, they will encounter multiple cases of PPH. One or two of these cases may require the physician to use every medication and procedure available for the treatment of PPH to save the life of the patient. To prepare to treat the next case of PPH rapidly and effectively, it is important for every obstetrician to develop a standardized cognitive plan for using all available treatmentmodalities in an appropriate and timely sequence, including both the Bakri balloon and the JADA VHCD. The insight that inducing an intrauterine vacuum causes uterine contraction, which may resolve PPH, is an important discovery. The JADA VHCD is a welcome addition to our armamentarium of treatments for PPH. ●
 

Postpartum hemorrhage (PPH) is a common complication of birth. In 2019, 4.3% of births in the United States were complicated by at least one episode of PPH.¹ Major causes of PPH include uterine atony, retained products of conception, reproductive tract trauma, and coagulopathy.² Active management of the third stage of labor with the routine administration of postpartum uterotonics reduces the risk of PPH.^3,4

PPH treatment requires a systematic approach using appropriate uterotonic medications, tranexamic acid, and procedures performed in a timely sequence to resolve the hemorrhage. Following vaginal birth, procedures that do not require a laparotomy to treat PPH include uterine massage, uterine evacuation to remove retained placental tissue, repair of lacerations, uterine balloon tamponade (UBT), uterine packing, a vacuum-induced hemorrhage control device (VHCD; JADA, Organon), and uterine artery embolization. Following cesarean birth, with an open laparotomy incision, interventions to treat PPH due to atony include vascular ligation, uterine compression sutures, UBT, VHCD, hysterectomy, and pelvic packing.²

Over the past 2 decades, UBT has been widely used for the treatment of PPH with a success rate in observational studies of approximately 86%.⁵ The uterine balloon creates pressure against the wall of the uterus permitting accumulation of platelets at bleeding sites, enhancing the activity of the clotting system. The uterine balloon provides direct pressure on the bleeding site(s). It is well known in trauma care that the first step to treat a bleeding wound is to apply direct pressure to the bleeding site. During the third stage of labor, a natural process is tetanic uterine contraction, which constricts myometrial vessels and the placenta bed. Placing a balloon in the uterus and inflating the balloon to 200 mL to 500 mL may delay the involution of the uterus that should occur following birth. An observation of great interest is the insight that inducing a vacuum in the uterine cavity may enhance tetanic uterine contraction and constriction of the myometrial vessels. Vacuum-induced hemorrhage control is discussed in detail in this editorial.

Vacuum-induced hemorrhage control device

A new device for the treatment of PPH due to uterine atony is the JADA VHCD (FIGURE), which generates negative intrauterine pressure causing the uterus to contract, thereby constricting myometrial vessels and reducing uterine bleeding. The JADA VHCD system is indicated to provide control and treatment of abnormal postpartum uterine bleeding following vaginal or cesarean birth caused by uterine atony when conservative management is indicated.⁶

ILLUSTRATION: MARY ELLEN NIATAS FOR OBG MANAGEMENT

System components

The JADA VHCD consists of a leading portion intended to be inserted into the uterine cavity, which consists of a silicone elliptical loop with 20 vacuum pores. A soft shield covers the vacuum loop to reduce the risk of the vacuum pores being clogged with biological material, including blood and clots. The elliptical loop is attached to a catheter intended for connection to a vacuum source set to 80 mm Hg ±10 mm Hg (hospital wall suction or portable suction device) with an in-line cannister to collect blood. Approximately 16 cm from the tip of the elliptical loop is a balloon that should be positioned in the upper vagina, not inside the cervix, and inflated with fluid (60 mL to 120 mL) through a dedicated port to occlude the vagina, thereby preserving a stable intrauterine vacuum.

Continue to: Correct usage...

Correct usage

A simple mnemonic to facilitate use of the JADA VHCD is “120/80”—fill the vaginal balloon with 120 mL of sterile fluid and attach the tubing to a source that is set to provide 80 mm Hg of vacuum with an in-line collection cannister. The VHCD may not work correctly if there is a substantial amount of blood in the uterus. Clinical experts advise that an important step prior to placing the elliptical loop in the uterus is to perform a sweep of the uterine cavity with a hand or instrument to remove clots and ensure there is no retained placental tissue. It is preferable to assemble the suction tubing, syringe, sterile fluid, and other instruments (eg, forceps, speculum) needed to insert the device prior to attempting to place the VHCD. When the elliptical loop is compressed for insertion, it is about 2 cm in diameter, necessitating that the cervix be dilated sufficiently to accommodate the device.

Immediately after placing the VHCD, contractions can be monitored by physical examination and the amount of ongoing bleeding can be estimated by observing the amount of blood accumulating in the cannister. Rapid onset of a palpable increase in uterine tone is a prominent feature of successful treatment of PPH with the VHCD. The VHCD should be kept in the uterus with active suction for at least 1 hour. Taping the tubing to the inner thigh may help stabilize the device. Once bleeding is controlled, prior to removing the device, the vacuum should be discontinued, and bleeding activityshould be assessed for at least 30 minutes. If the patient is stable, the vaginal balloon can be deflated, followed by removal of the device. The VHCD should be removed within 24 hours of placement.⁶

The JADA VHCD system should not be used with ongoing intrauterine pregnancy, untreated uterine rupture, unresolved uterine inversion, current cervical cancer, or serious infection of the uterus.⁶ The VHCD has not been evaluated for effectiveness in the treatment of placenta accreta or coagulopathy. The VHCD has not been specifically evaluated for safety and effectiveness in patients < 34 weeks’ duration, but clinicians report successful use of the device in cases of PPH that have occurred in the second and early-third trimesters. If the device can be appropriately placed with the elliptical loop in the uterus and the balloon in the vagina, it is theoretically possible to use the device for cases of PPH occurring before 34 weeks’ gestation.

When using the JADA VHCD system, it is important to simultaneously provide cardiovascular support, appropriate transfusion of blood products and timely surgical intervention, if indicated. All obstetricians know that in complicated cases of PPH, where conservative measures have not worked, uterine artery embolization or hysterectomy may be the only interventions that will prevent serious patient morbidity.

Effectiveness data

The VHCD has not been evaluated against an alternative approach, such as UBT, in published randomized clinical trials. However, prospective cohort studies have reported that the JADA is often successful in the treatment of PPH.^7-10

In a multicenter cohort study of 107 patients with PPH, including 91 vaginal and 16 cesarean births, 100 patients (93%) were successfully treated with the JADA VHCD.⁷ Median blood loss before application of the system was 870 mL with vaginal birth and 1,300 mL with cesarean birth. Definitive control of the hemorrhage was observed at a median of 3 minutes after initiation of the intrauterine vacuum. In this study, 32% of patients had reproductive tract lacerations that needed to be repaired, and 2 patients required a hysterectomy. Forty patients required a blood transfusion.

Two patients were treated with a Bakri UBT when the VHCD did not resolve the PPH. In this cohort, the vacuum was applied for a median duration of 144 minutes, and a median total device dwell time was 191 minutes. Compared with UBT, the JADA VHCD intrauterine dwell time was shorter, facilitating patient progression and early transfer to the postpartum unit. The physicians who participated in the study reported that the device was easy to use. The complications reported in this cohort were minor and included endometritis (5 cases), vaginal infection (2 cases), and disruption of a vaginal laceration repair (1 case).⁷

Novel approaches to generating an intrauterine vacuum to treat PPH

The JADA VHCD is the only vacuum device approved by the US Food and Drug Administration (FDA) for treatment of PPH. However, clinical innovators have reported alternative approaches to generating an intrauterine vacuum using equipment designed for other purposes. In one study, a Bakri balloon was used to generate intrauterine vacuum tamponade to treat PPH.¹¹ In this study, a Bakri balloon was inserted into the uterus, and the balloon was inflated to 50 mL to 100 mL to seal the vacuum. The main Bakri port was attached to a suction aspiration device set to generate a vacuum of 450 mm Hg to 525 mm Hg, a much greater vacuum than used with the JADA VHCD. This study included 44 cases of PPH due to uterine atony and 22 cases due to placental pathology, with successful treatment of PPH in 86% and 73% of the cases, respectively.

Another approach to generate intrauterine vacuum tamponade involves using a Levin stomach tube (FG24 or FG36), which has an open end and 4 side ports near the open tip.^12-14 The Levin stomach tube is low cost and has many favorable design features, including a rounded tip, wide-bore, and circumferentially placed side ports. The FG36 Levin stomach tube is 12 mm in diameter and has 10 mm side ports. A vacuum device set to deliver 100 mm Hg to 200 mm Hgwas used in some of the studies evaluating the Levin stomach tube for the treatment of PPH. In 3 cases of severe PPH unresponsive to standard interventions, creation of vacuum tamponade with flexible suction tubing with side ports was successful in controlling the hemorrhage.¹³

Dr. T.N. Vasudeva Panicker invented an intrauterine cannula 12 mm in diameter and 25 cm in length, with dozens of 4 mm side ports over the distal 12 cm of the cannula.¹⁵ The cannula, which is made of stainless steel or plastic, is inserted into the uterus and 700 mm Hgvacuum is applied, a level much greater than the 80 mm Hg vacuum recommended for use with the JADA VHCD. When successful, the high suction clears the uterus of blood and causes uterine contraction. In 4 cases of severe PPH, the device successfully controlled the hemorrhage. In 2 of the 4 cases the device that was initially placed became clogged with blood and needed to be replaced.

UBT vs VHCD

To date there are no published randomized controlled trials comparing Bakri UBT to the JADA VHCD. In one retrospective study, the frequency of massive transfusion of red blood cells (RBCs), defined as the transfusion of 4 units or greater of RBCs, was assessed among 78 patients treated with the Bakri UBT and 36 patients treated with the JADA VHCD.⁹ In this study, at baseline there was a non ̶ statistically significant trend for JADA VHCD to be used more frequently than the Bakri UBT in cases of PPH occurring during repeat cesarean delivery (33% vs 14%). The Bakri UBT was used more frequently than the JADA VHCD among patients having a PPH following a vaginal delivery (51% vs 31%). Both devices were used at similar rates for operative vaginal delivery (6%) and primary cesarean birth (31% VHCD and 28% UBT).

In this retrospective study, the percentage of patients treated with VHCD or UBT who received 4 or more units of RBCs was 3% and 21%, respectively (P < .01). Among patients treated with VHCD and UBT, the estimated median blood loss was 1,500 mL and 1,850 mL (P=.02), respectively. The median hemoglobin concentration at discharge was similar in the VHCD and UBT groups, 8.8 g/dL and 8.6 g/dL, respectively.⁹ A randomized controlled trial is necessary to refine our understanding of the comparative effectiveness of UBT and VHCD in controlling PPH following vaginal and cesarean birth.

A welcome addition to treatment options

Every obstetrician knows that, in the next 12 months of their practice, they will encounter multiple cases of PPH. One or two of these cases may require the physician to use every medication and procedure available for the treatment of PPH to save the life of the patient. To prepare to treat the next case of PPH rapidly and effectively, it is important for every obstetrician to develop a standardized cognitive plan for using all available treatmentmodalities in an appropriate and timely sequence, including both the Bakri balloon and the JADA VHCD. The insight that inducing an intrauterine vacuum causes uterine contraction, which may resolve PPH, is an important discovery. The JADA VHCD is a welcome addition to our armamentarium of treatments for PPH. ●
 

Postpartum hemorrhage (PPH) is a common complication of birth. In 2019, 4.3% of births in the United States were complicated by at least one episode of PPH.¹ Major causes of PPH include uterine atony, retained products of conception, reproductive tract trauma, and coagulopathy.² Active management of the third stage of labor with the routine administration of postpartum uterotonics reduces the risk of PPH.^3,4

PPH treatment requires a systematic approach using appropriate uterotonic medications, tranexamic acid, and procedures performed in a timely sequence to resolve the hemorrhage. Following vaginal birth, procedures that do not require a laparotomy to treat PPH include uterine massage, uterine evacuation to remove retained placental tissue, repair of lacerations, uterine balloon tamponade (UBT), uterine packing, a vacuum-induced hemorrhage control device (VHCD; JADA, Organon), and uterine artery embolization. Following cesarean birth, with an open laparotomy incision, interventions to treat PPH due to atony include vascular ligation, uterine compression sutures, UBT, VHCD, hysterectomy, and pelvic packing.²

Over the past 2 decades, UBT has been widely used for the treatment of PPH with a success rate in observational studies of approximately 86%.⁵ The uterine balloon creates pressure against the wall of the uterus permitting accumulation of platelets at bleeding sites, enhancing the activity of the clotting system. The uterine balloon provides direct pressure on the bleeding site(s). It is well known in trauma care that the first step to treat a bleeding wound is to apply direct pressure to the bleeding site. During the third stage of labor, a natural process is tetanic uterine contraction, which constricts myometrial vessels and the placenta bed. Placing a balloon in the uterus and inflating the balloon to 200 mL to 500 mL may delay the involution of the uterus that should occur following birth. An observation of great interest is the insight that inducing a vacuum in the uterine cavity may enhance tetanic uterine contraction and constriction of the myometrial vessels. Vacuum-induced hemorrhage control is discussed in detail in this editorial.

Vacuum-induced hemorrhage control device

A new device for the treatment of PPH due to uterine atony is the JADA VHCD (FIGURE), which generates negative intrauterine pressure causing the uterus to contract, thereby constricting myometrial vessels and reducing uterine bleeding. The JADA VHCD system is indicated to provide control and treatment of abnormal postpartum uterine bleeding following vaginal or cesarean birth caused by uterine atony when conservative management is indicated.⁶

ILLUSTRATION: MARY ELLEN NIATAS FOR OBG MANAGEMENT

System components

The JADA VHCD consists of a leading portion intended to be inserted into the uterine cavity, which consists of a silicone elliptical loop with 20 vacuum pores. A soft shield covers the vacuum loop to reduce the risk of the vacuum pores being clogged with biological material, including blood and clots. The elliptical loop is attached to a catheter intended for connection to a vacuum source set to 80 mm Hg ±10 mm Hg (hospital wall suction or portable suction device) with an in-line cannister to collect blood. Approximately 16 cm from the tip of the elliptical loop is a balloon that should be positioned in the upper vagina, not inside the cervix, and inflated with fluid (60 mL to 120 mL) through a dedicated port to occlude the vagina, thereby preserving a stable intrauterine vacuum.

Continue to: Correct usage...

Correct usage

A simple mnemonic to facilitate use of the JADA VHCD is “120/80”—fill the vaginal balloon with 120 mL of sterile fluid and attach the tubing to a source that is set to provide 80 mm Hg of vacuum with an in-line collection cannister. The VHCD may not work correctly if there is a substantial amount of blood in the uterus. Clinical experts advise that an important step prior to placing the elliptical loop in the uterus is to perform a sweep of the uterine cavity with a hand or instrument to remove clots and ensure there is no retained placental tissue. It is preferable to assemble the suction tubing, syringe, sterile fluid, and other instruments (eg, forceps, speculum) needed to insert the device prior to attempting to place the VHCD. When the elliptical loop is compressed for insertion, it is about 2 cm in diameter, necessitating that the cervix be dilated sufficiently to accommodate the device.

Immediately after placing the VHCD, contractions can be monitored by physical examination and the amount of ongoing bleeding can be estimated by observing the amount of blood accumulating in the cannister. Rapid onset of a palpable increase in uterine tone is a prominent feature of successful treatment of PPH with the VHCD. The VHCD should be kept in the uterus with active suction for at least 1 hour. Taping the tubing to the inner thigh may help stabilize the device. Once bleeding is controlled, prior to removing the device, the vacuum should be discontinued, and bleeding activityshould be assessed for at least 30 minutes. If the patient is stable, the vaginal balloon can be deflated, followed by removal of the device. The VHCD should be removed within 24 hours of placement.⁶

The JADA VHCD system should not be used with ongoing intrauterine pregnancy, untreated uterine rupture, unresolved uterine inversion, current cervical cancer, or serious infection of the uterus.⁶ The VHCD has not been evaluated for effectiveness in the treatment of placenta accreta or coagulopathy. The VHCD has not been specifically evaluated for safety and effectiveness in patients < 34 weeks’ duration, but clinicians report successful use of the device in cases of PPH that have occurred in the second and early-third trimesters. If the device can be appropriately placed with the elliptical loop in the uterus and the balloon in the vagina, it is theoretically possible to use the device for cases of PPH occurring before 34 weeks’ gestation.

When using the JADA VHCD system, it is important to simultaneously provide cardiovascular support, appropriate transfusion of blood products and timely surgical intervention, if indicated. All obstetricians know that in complicated cases of PPH, where conservative measures have not worked, uterine artery embolization or hysterectomy may be the only interventions that will prevent serious patient morbidity.

Effectiveness data

The VHCD has not been evaluated against an alternative approach, such as UBT, in published randomized clinical trials. However, prospective cohort studies have reported that the JADA is often successful in the treatment of PPH.^7-10

In a multicenter cohort study of 107 patients with PPH, including 91 vaginal and 16 cesarean births, 100 patients (93%) were successfully treated with the JADA VHCD.⁷ Median blood loss before application of the system was 870 mL with vaginal birth and 1,300 mL with cesarean birth. Definitive control of the hemorrhage was observed at a median of 3 minutes after initiation of the intrauterine vacuum. In this study, 32% of patients had reproductive tract lacerations that needed to be repaired, and 2 patients required a hysterectomy. Forty patients required a blood transfusion.

Two patients were treated with a Bakri UBT when the VHCD did not resolve the PPH. In this cohort, the vacuum was applied for a median duration of 144 minutes, and a median total device dwell time was 191 minutes. Compared with UBT, the JADA VHCD intrauterine dwell time was shorter, facilitating patient progression and early transfer to the postpartum unit. The physicians who participated in the study reported that the device was easy to use. The complications reported in this cohort were minor and included endometritis (5 cases), vaginal infection (2 cases), and disruption of a vaginal laceration repair (1 case).⁷

Novel approaches to generating an intrauterine vacuum to treat PPH

The JADA VHCD is the only vacuum device approved by the US Food and Drug Administration (FDA) for treatment of PPH. However, clinical innovators have reported alternative approaches to generating an intrauterine vacuum using equipment designed for other purposes. In one study, a Bakri balloon was used to generate intrauterine vacuum tamponade to treat PPH.¹¹ In this study, a Bakri balloon was inserted into the uterus, and the balloon was inflated to 50 mL to 100 mL to seal the vacuum. The main Bakri port was attached to a suction aspiration device set to generate a vacuum of 450 mm Hg to 525 mm Hg, a much greater vacuum than used with the JADA VHCD. This study included 44 cases of PPH due to uterine atony and 22 cases due to placental pathology, with successful treatment of PPH in 86% and 73% of the cases, respectively.

Another approach to generate intrauterine vacuum tamponade involves using a Levin stomach tube (FG24 or FG36), which has an open end and 4 side ports near the open tip.^12-14 The Levin stomach tube is low cost and has many favorable design features, including a rounded tip, wide-bore, and circumferentially placed side ports. The FG36 Levin stomach tube is 12 mm in diameter and has 10 mm side ports. A vacuum device set to deliver 100 mm Hg to 200 mm Hgwas used in some of the studies evaluating the Levin stomach tube for the treatment of PPH. In 3 cases of severe PPH unresponsive to standard interventions, creation of vacuum tamponade with flexible suction tubing with side ports was successful in controlling the hemorrhage.¹³

Dr. T.N. Vasudeva Panicker invented an intrauterine cannula 12 mm in diameter and 25 cm in length, with dozens of 4 mm side ports over the distal 12 cm of the cannula.¹⁵ The cannula, which is made of stainless steel or plastic, is inserted into the uterus and 700 mm Hgvacuum is applied, a level much greater than the 80 mm Hg vacuum recommended for use with the JADA VHCD. When successful, the high suction clears the uterus of blood and causes uterine contraction. In 4 cases of severe PPH, the device successfully controlled the hemorrhage. In 2 of the 4 cases the device that was initially placed became clogged with blood and needed to be replaced.

UBT vs VHCD

To date there are no published randomized controlled trials comparing Bakri UBT to the JADA VHCD. In one retrospective study, the frequency of massive transfusion of red blood cells (RBCs), defined as the transfusion of 4 units or greater of RBCs, was assessed among 78 patients treated with the Bakri UBT and 36 patients treated with the JADA VHCD.⁹ In this study, at baseline there was a non ̶ statistically significant trend for JADA VHCD to be used more frequently than the Bakri UBT in cases of PPH occurring during repeat cesarean delivery (33% vs 14%). The Bakri UBT was used more frequently than the JADA VHCD among patients having a PPH following a vaginal delivery (51% vs 31%). Both devices were used at similar rates for operative vaginal delivery (6%) and primary cesarean birth (31% VHCD and 28% UBT).

In this retrospective study, the percentage of patients treated with VHCD or UBT who received 4 or more units of RBCs was 3% and 21%, respectively (P < .01). Among patients treated with VHCD and UBT, the estimated median blood loss was 1,500 mL and 1,850 mL (P=.02), respectively. The median hemoglobin concentration at discharge was similar in the VHCD and UBT groups, 8.8 g/dL and 8.6 g/dL, respectively.⁹ A randomized controlled trial is necessary to refine our understanding of the comparative effectiveness of UBT and VHCD in controlling PPH following vaginal and cesarean birth.

A welcome addition to treatment options

Every obstetrician knows that, in the next 12 months of their practice, they will encounter multiple cases of PPH. One or two of these cases may require the physician to use every medication and procedure available for the treatment of PPH to save the life of the patient. To prepare to treat the next case of PPH rapidly and effectively, it is important for every obstetrician to develop a standardized cognitive plan for using all available treatmentmodalities in an appropriate and timely sequence, including both the Bakri balloon and the JADA VHCD. The insight that inducing an intrauterine vacuum causes uterine contraction, which may resolve PPH, is an important discovery. The JADA VHCD is a welcome addition to our armamentarium of treatments for PPH. ●
 

Obesity is a major health problem in the United States. The Centers for Disease Control and Prevention (CDC) defines the problem as weight that is higher than what is healthy for a given height, with quantitative definitions of overweight and obesity as body mass indices (BMIs) of 25 to 29.9 kg/m² and ≥ 30 kg/m², respectively.¹ The prevalence of obesity among adults in 2017 ̶ 2018 was reported by the CDC to be 42.4%.² Among women, the reported prevalence of obesity was lowest among Asian individuals (17.2%) and greatest among non-Hispanic Black individuals (56.9%), with White (39.8%) and Hispanic individuals (43.7%) having rates in between.² In a meta-analysis of prospective studies that included 4 million people who were never smokers and had no chronic disease at baseline, age- and sex-adjusted mortality rates were studied over a median of 14 years of follow-up.³ Compared with those with a BMI of 20 to 25 kg/m², people with a BMI of 30 to 34.9 kg/m² or a BMI of 35 to 39.9 kg/m² had increased risks of death of 46% and 94%, respectively, demonstrating that obesity increases this risk.³

The increased risk of death associated with obesity is caused by obesity-related diseases that cause early mortality, including diabetes mellitus (DM), dyslipidemia, hypertension, coronary heart disease, heart failure, atrial fibrillation, stroke, and venous thromboembolic events.⁴ Obesity is also associated with an increased risk of many cancers, including cancer of the endometrium, kidney, esophagus, stomach, colon, rectum, gallbladder, pancreas, liver, and breast.⁵ With regard to gynecologic disease, obesity is associated with an increased risk of fibroids and heavy menstrual bleeding.⁶ For pregnant patients, obesity is associated with increased risks of⁷:

• miscarriage and stillbirth
• preeclampsia and gestational hypertension
• gestational diabetes
• severe maternal morbidity
• postterm pregnancy
• venous thromboembolism
• endometritis.

For obese patients, weight loss can normalize blood pressure, reduce the risk of cardiovascular events, decrease the risk of cancer, and cure type 2 DM.⁸

Bariatric surgery: The gold standard treatment for reliable and sustained weight loss

All patients with obesity should be counseled to reduce caloric intake and increase physical activity. Dietary counseling provided by a nutritionist may help reinforce advice given by a provider. However, lifestyle interventions are associated with modest weight loss (<5% of bodyweight; FIGURE).⁹ The gold standard treatment for reliable and sustained weight loss is bariatric surgery.

In the Swedish Obese Subjects study, involving 2,010 people, following bariatric surgery the mean decrease in bodyweight was 23% at 2 years, with a slow increase in weight thereafter, resulting in a sustained mean weight loss of 18% at 10 years.⁸ In this study, people in the diet and exercise control group had no change in bodyweight over 10 years of follow-up.⁸ Not all eligible obese patients want to undergo bariatric surgery because it is an arduous sequential process involving 6 months of intensive preoperative preparation, bariatric surgery, recovery, and intensive postoperative follow-up. The perioperative mortality rate is 0.03% to 0.2%.¹⁰ Following bariatric surgery, additional operations may be necessary for more than 10% of patients.¹⁰ With recent breakthroughs in the medication management of obesity, patients who do not want bariatric surgery can achieve reliable weight loss of greater than 10% of body weight with glucagon-like peptide -1 (GLP-1) agonists.

ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT

GLP-1 agonist analogues: Practice-changing breakthrough in medication treatment

GLP-1, a 30 amino acid peptide, is produced by intestinal enteroendocrine cells and neurons in the medulla and hypothalamus.¹¹ GLP-1 reduces hunger cravings and causes satiety, reducing daily food intake.¹² GLP-1 also enhances the secretion of insulin, making GLP-1 agonists an effective treatment for type 2 DM. In humans and experimental animals, the administration of exogenous GLP-1 agonists decreases hunger cravings and causes satiety, reducing food intake, resulting in weight loss.¹² The synthetic GLP-1 agonists, liraglutide (Saxenda) and semaglutide (Wegovy) are approved by the US Food and Drug Administration (FDA) as anti-obesity medications.

Native GLP-1 has a short circulating half-life of approximately 2 minutes. The synthetic GLP-1 agonist medications liraglutide and semaglutide are modified to significantly increase their half-life. Liraglutide is a modified version of GLP-1 with a palmitic acid side chain and an amino acid spacer resulting in reduced degradation and a 15-hour half-life, necessitating daily administration. Semaglutide has a steric acid diacid at Lys26, a large synthetic spacer, a modification of amino acid 8 with the addition of α-aminobutyric acid and a 165-hour half-life, permitting weekly administration.¹³ For weight loss, liraglutide and semaglultide are administered by subcutaneous injection. Tirzepatide (Mounjaro) is a novel GLP-1 agonist. It is also a gastric inhibitory peptide, is FDA approved to treat type 2 DM, and is awaiting FDA approval as a weight loss medication.Tirzepatide causes substantial weight loss, similar to the effect of semaglutide.¹⁴

Semaglutide and weight loss

Semaglutide is approved by the FDA for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity in adults with a BMI ≥ 30 kg/m² or ≥ 27 kg/m² in the presence of a weight-related comorbidity. It is also FDA approved to treat type 2 DM.

In a weight loss trial, 1,961 overweight and obese patients with a mean BMI of 38 kg/m², were randomly assigned to semaglutide or placebo treatment for 68 weeks. All the participants were following a regimen that included a calorie-reduced diet and increased physical activity. The mean changes in body weight for the patients in the semaglutide and placebo treatment groups were -14.9% and -2.4%, respectively. The treatment difference was -12.4% (95% confidence interval [CI], -13.4% to -11.5%; P <.001). In this study, compared with placebo, semaglutide treatment resulted in a greater decrease in waist circumference, -5.3 in versus -1.6 in.¹⁵ A network meta-analysis of the efficacy of weight loss medicines indicates that semaglutide is the most effective medication currently FDA approved for weight loss, reliably producing substantial weight loss (FIGURE).⁹

In one randomized clinical trial, investigators directly compared the efficacy of semaglutide and liraglutide in achieving weight loss. In this trial, 338 patients were assigned randomly to treatment with semaglutide 2.4 mg weekly subcutaneous injection, liraglutide 3.0 mg daily subcutaneous injection, or placebo. All the participants were following a regimen that included a calorie-reduced diet and increased physical activity.¹⁶ After 68 weeks of treatment, the mean weight changes were -15.8%, -6.4%, and -1.9% in the semaglutide, liraglutide, and placebo groups, respectively. The difference between the semaglutide and liraglutide groups was -9.4% (95% CI, -12% to -6.8%; P <.001).¹⁶

Continue to: Semaglutide dose-escalation and contraindications...

For weight loss, the target dose of semaglutide is 2.4 mg once weekly subcutaneous injection achieved by sequential dose escalation. To give patients time to adjust to adverse effects caused by the medication, a standardized dose-escalation regimen is recommended. The FDA-approved escalation regimen for semaglutide treatment begins with a weekly subcutaneous dose of 0.25 mg for 4 weeks, followed by an increase in the weekly dosage every 4 weeks: 0.5 mg, 1.0 mg, 1.7 mg, and 2.4 mg.¹⁷ To support the dose-escalation process there are 5 unique autoinjectors that deliver the appropriate dose for the current step.

Semaglutide is contraindicated if the patient has an allergy to the medication or if there is a personal or family history of medullary thyroid cancer.¹⁷ In animal toxicology studies, semaglutide at clinically relevant dosing was associated with an increased risk of developing medullary thyroid cancer. Patients with a personal history of multiple endocrine neoplasia syndrome type 2, (medullary thyroid cancer, pheochromocytoma, and primary hyperparathyroidism) should not take semaglutide. Semaglutide may cause fetal harm and the FDA recommends discontinuing semaglutide at least 2 months before pregnancy.¹⁷ According to the FDA, the safety of semaglutide during breastfeeding has not been established. In Canada, breastfeeding is a contraindication to semaglutide treatment.¹⁸

Limitations of medication treatment of obesity

There are important limitations to semaglutide treatment of obesity, including:

• weight gain after stopping treatment
• limited medical insurance supportfor an expensive medication treatment
• bothersome adverse effects.

Weight gain posttreatment. After stopping medication treatment of obesity, weight gain occurs in most patients. However, patients may remain below baseline weight for a long time after stopping medication therapy. In one trial of 803 patients, after 20 weeks of semaglutide treatment (16-week dose-escalation phase, followed by 4 weeks on a weekly dose of 2.4 mg), the participants were randomized to 48 additional weeks of semaglutide or placebo.¹⁹ All the participants were following a regimen that included a calorie-reduced diet and increased physical activity. At the initial 20 weeks of treatment time point the mean weight change was -10.6%. Over the following 48 weeks, the patients treated with semaglutidehad an additional mean weight change of -7.9%, while the mean weight change for the placebo group was +6.9%.

Medical insurance coverage. A major barrier to semaglutide treatment of obesity is the medication’s cost. At the website GoodRx (https://www.goodrx.com/), the estimated price for a 1-month supply of semaglutide (Wegovy) is $1,350.²⁰ By contrast, a 1-month supply of phentermine-topiramate (Qsymia) is approximately $205. Currently, many medical insurance plans do not cover the cost of semaglutide treatment for weight loss. Patent protection for liraglutide may expire in the next few years, permitting the marketing of a lower-cost generic formulation, increasing the availability of the medication. However, as noted above, compared with liraglutide, semaglutide treatment results in much greater weight loss.

The most common adverse effects associated with semaglutide treatment are nausea, vomiting, diarrhea, and constipation. In one randomized clinical trial involving 1,961 patients, the frequency of adverse effects reported by patients taking semaglutide incrementally above the frequency of the same adverse effect reported by patients on placebo was: nausea (27%), vomiting (18%), diarrhea (16%), constipation (14%), dyspepsia (7%), and abdominal pain (5%).¹⁵ In this study, treatment was discontinued due to adverse effects in 7% and 3% of the patients in the semaglutide and placebo groups, respectively. Experts believe that adverse effects can be minimized by increasing the dose slowly and decreasing the dose if adverse effects are bothersome to the patient.

Measuring the benefits of semaglutide weight loss

Overweight and obesity are prevalent problems with many adverse consequences, including an increased risk of death. In population studies, weight loss following bariatric surgery is associated with a substantial reduction in mortality, cancer, and heart disease compared with conventional therapy.²¹ Over the next few years, the effect of semaglutide-induced weight loss on the rate of cancer and heart disease should become clear. If semaglutide treatment of obesity is associated with a reduction in cancer and heart disease, it would be a truly breakthrough medication. ●

Obesity is a major health problem in the United States. The Centers for Disease Control and Prevention (CDC) defines the problem as weight that is higher than what is healthy for a given height, with quantitative definitions of overweight and obesity as body mass indices (BMIs) of 25 to 29.9 kg/m² and ≥ 30 kg/m², respectively.¹ The prevalence of obesity among adults in 2017 ̶ 2018 was reported by the CDC to be 42.4%.² Among women, the reported prevalence of obesity was lowest among Asian individuals (17.2%) and greatest among non-Hispanic Black individuals (56.9%), with White (39.8%) and Hispanic individuals (43.7%) having rates in between.² In a meta-analysis of prospective studies that included 4 million people who were never smokers and had no chronic disease at baseline, age- and sex-adjusted mortality rates were studied over a median of 14 years of follow-up.³ Compared with those with a BMI of 20 to 25 kg/m², people with a BMI of 30 to 34.9 kg/m² or a BMI of 35 to 39.9 kg/m² had increased risks of death of 46% and 94%, respectively, demonstrating that obesity increases this risk.³

The increased risk of death associated with obesity is caused by obesity-related diseases that cause early mortality, including diabetes mellitus (DM), dyslipidemia, hypertension, coronary heart disease, heart failure, atrial fibrillation, stroke, and venous thromboembolic events.⁴ Obesity is also associated with an increased risk of many cancers, including cancer of the endometrium, kidney, esophagus, stomach, colon, rectum, gallbladder, pancreas, liver, and breast.⁵ With regard to gynecologic disease, obesity is associated with an increased risk of fibroids and heavy menstrual bleeding.⁶ For pregnant patients, obesity is associated with increased risks of⁷:

• miscarriage and stillbirth
• preeclampsia and gestational hypertension
• gestational diabetes
• severe maternal morbidity
• postterm pregnancy
• venous thromboembolism
• endometritis.

For obese patients, weight loss can normalize blood pressure, reduce the risk of cardiovascular events, decrease the risk of cancer, and cure type 2 DM.⁸

Bariatric surgery: The gold standard treatment for reliable and sustained weight loss

All patients with obesity should be counseled to reduce caloric intake and increase physical activity. Dietary counseling provided by a nutritionist may help reinforce advice given by a provider. However, lifestyle interventions are associated with modest weight loss (<5% of bodyweight; FIGURE).⁹ The gold standard treatment for reliable and sustained weight loss is bariatric surgery.

In the Swedish Obese Subjects study, involving 2,010 people, following bariatric surgery the mean decrease in bodyweight was 23% at 2 years, with a slow increase in weight thereafter, resulting in a sustained mean weight loss of 18% at 10 years.⁸ In this study, people in the diet and exercise control group had no change in bodyweight over 10 years of follow-up.⁸ Not all eligible obese patients want to undergo bariatric surgery because it is an arduous sequential process involving 6 months of intensive preoperative preparation, bariatric surgery, recovery, and intensive postoperative follow-up. The perioperative mortality rate is 0.03% to 0.2%.¹⁰ Following bariatric surgery, additional operations may be necessary for more than 10% of patients.¹⁰ With recent breakthroughs in the medication management of obesity, patients who do not want bariatric surgery can achieve reliable weight loss of greater than 10% of body weight with glucagon-like peptide -1 (GLP-1) agonists.

ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT

GLP-1 agonist analogues: Practice-changing breakthrough in medication treatment

GLP-1, a 30 amino acid peptide, is produced by intestinal enteroendocrine cells and neurons in the medulla and hypothalamus.¹¹ GLP-1 reduces hunger cravings and causes satiety, reducing daily food intake.¹² GLP-1 also enhances the secretion of insulin, making GLP-1 agonists an effective treatment for type 2 DM. In humans and experimental animals, the administration of exogenous GLP-1 agonists decreases hunger cravings and causes satiety, reducing food intake, resulting in weight loss.¹² The synthetic GLP-1 agonists, liraglutide (Saxenda) and semaglutide (Wegovy) are approved by the US Food and Drug Administration (FDA) as anti-obesity medications.

Native GLP-1 has a short circulating half-life of approximately 2 minutes. The synthetic GLP-1 agonist medications liraglutide and semaglutide are modified to significantly increase their half-life. Liraglutide is a modified version of GLP-1 with a palmitic acid side chain and an amino acid spacer resulting in reduced degradation and a 15-hour half-life, necessitating daily administration. Semaglutide has a steric acid diacid at Lys26, a large synthetic spacer, a modification of amino acid 8 with the addition of α-aminobutyric acid and a 165-hour half-life, permitting weekly administration.¹³ For weight loss, liraglutide and semaglultide are administered by subcutaneous injection. Tirzepatide (Mounjaro) is a novel GLP-1 agonist. It is also a gastric inhibitory peptide, is FDA approved to treat type 2 DM, and is awaiting FDA approval as a weight loss medication.Tirzepatide causes substantial weight loss, similar to the effect of semaglutide.¹⁴

Semaglutide and weight loss

Semaglutide is approved by the FDA for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity in adults with a BMI ≥ 30 kg/m² or ≥ 27 kg/m² in the presence of a weight-related comorbidity. It is also FDA approved to treat type 2 DM.

In a weight loss trial, 1,961 overweight and obese patients with a mean BMI of 38 kg/m², were randomly assigned to semaglutide or placebo treatment for 68 weeks. All the participants were following a regimen that included a calorie-reduced diet and increased physical activity. The mean changes in body weight for the patients in the semaglutide and placebo treatment groups were -14.9% and -2.4%, respectively. The treatment difference was -12.4% (95% confidence interval [CI], -13.4% to -11.5%; P <.001). In this study, compared with placebo, semaglutide treatment resulted in a greater decrease in waist circumference, -5.3 in versus -1.6 in.¹⁵ A network meta-analysis of the efficacy of weight loss medicines indicates that semaglutide is the most effective medication currently FDA approved for weight loss, reliably producing substantial weight loss (FIGURE).⁹

In one randomized clinical trial, investigators directly compared the efficacy of semaglutide and liraglutide in achieving weight loss. In this trial, 338 patients were assigned randomly to treatment with semaglutide 2.4 mg weekly subcutaneous injection, liraglutide 3.0 mg daily subcutaneous injection, or placebo. All the participants were following a regimen that included a calorie-reduced diet and increased physical activity.¹⁶ After 68 weeks of treatment, the mean weight changes were -15.8%, -6.4%, and -1.9% in the semaglutide, liraglutide, and placebo groups, respectively. The difference between the semaglutide and liraglutide groups was -9.4% (95% CI, -12% to -6.8%; P <.001).¹⁶

Continue to: Semaglutide dose-escalation and contraindications...

For weight loss, the target dose of semaglutide is 2.4 mg once weekly subcutaneous injection achieved by sequential dose escalation. To give patients time to adjust to adverse effects caused by the medication, a standardized dose-escalation regimen is recommended. The FDA-approved escalation regimen for semaglutide treatment begins with a weekly subcutaneous dose of 0.25 mg for 4 weeks, followed by an increase in the weekly dosage every 4 weeks: 0.5 mg, 1.0 mg, 1.7 mg, and 2.4 mg.¹⁷ To support the dose-escalation process there are 5 unique autoinjectors that deliver the appropriate dose for the current step.

Semaglutide is contraindicated if the patient has an allergy to the medication or if there is a personal or family history of medullary thyroid cancer.¹⁷ In animal toxicology studies, semaglutide at clinically relevant dosing was associated with an increased risk of developing medullary thyroid cancer. Patients with a personal history of multiple endocrine neoplasia syndrome type 2, (medullary thyroid cancer, pheochromocytoma, and primary hyperparathyroidism) should not take semaglutide. Semaglutide may cause fetal harm and the FDA recommends discontinuing semaglutide at least 2 months before pregnancy.¹⁷ According to the FDA, the safety of semaglutide during breastfeeding has not been established. In Canada, breastfeeding is a contraindication to semaglutide treatment.¹⁸

Limitations of medication treatment of obesity

There are important limitations to semaglutide treatment of obesity, including:

• weight gain after stopping treatment
• limited medical insurance supportfor an expensive medication treatment
• bothersome adverse effects.

Weight gain posttreatment. After stopping medication treatment of obesity, weight gain occurs in most patients. However, patients may remain below baseline weight for a long time after stopping medication therapy. In one trial of 803 patients, after 20 weeks of semaglutide treatment (16-week dose-escalation phase, followed by 4 weeks on a weekly dose of 2.4 mg), the participants were randomized to 48 additional weeks of semaglutide or placebo.¹⁹ All the participants were following a regimen that included a calorie-reduced diet and increased physical activity. At the initial 20 weeks of treatment time point the mean weight change was -10.6%. Over the following 48 weeks, the patients treated with semaglutidehad an additional mean weight change of -7.9%, while the mean weight change for the placebo group was +6.9%.

Medical insurance coverage. A major barrier to semaglutide treatment of obesity is the medication’s cost. At the website GoodRx (https://www.goodrx.com/), the estimated price for a 1-month supply of semaglutide (Wegovy) is $1,350.²⁰ By contrast, a 1-month supply of phentermine-topiramate (Qsymia) is approximately $205. Currently, many medical insurance plans do not cover the cost of semaglutide treatment for weight loss. Patent protection for liraglutide may expire in the next few years, permitting the marketing of a lower-cost generic formulation, increasing the availability of the medication. However, as noted above, compared with liraglutide, semaglutide treatment results in much greater weight loss.

The most common adverse effects associated with semaglutide treatment are nausea, vomiting, diarrhea, and constipation. In one randomized clinical trial involving 1,961 patients, the frequency of adverse effects reported by patients taking semaglutide incrementally above the frequency of the same adverse effect reported by patients on placebo was: nausea (27%), vomiting (18%), diarrhea (16%), constipation (14%), dyspepsia (7%), and abdominal pain (5%).¹⁵ In this study, treatment was discontinued due to adverse effects in 7% and 3% of the patients in the semaglutide and placebo groups, respectively. Experts believe that adverse effects can be minimized by increasing the dose slowly and decreasing the dose if adverse effects are bothersome to the patient.

Measuring the benefits of semaglutide weight loss

Overweight and obesity are prevalent problems with many adverse consequences, including an increased risk of death. In population studies, weight loss following bariatric surgery is associated with a substantial reduction in mortality, cancer, and heart disease compared with conventional therapy.²¹ Over the next few years, the effect of semaglutide-induced weight loss on the rate of cancer and heart disease should become clear. If semaglutide treatment of obesity is associated with a reduction in cancer and heart disease, it would be a truly breakthrough medication. ●

Obesity is a major health problem in the United States. The Centers for Disease Control and Prevention (CDC) defines the problem as weight that is higher than what is healthy for a given height, with quantitative definitions of overweight and obesity as body mass indices (BMIs) of 25 to 29.9 kg/m² and ≥ 30 kg/m², respectively.¹ The prevalence of obesity among adults in 2017 ̶ 2018 was reported by the CDC to be 42.4%.² Among women, the reported prevalence of obesity was lowest among Asian individuals (17.2%) and greatest among non-Hispanic Black individuals (56.9%), with White (39.8%) and Hispanic individuals (43.7%) having rates in between.² In a meta-analysis of prospective studies that included 4 million people who were never smokers and had no chronic disease at baseline, age- and sex-adjusted mortality rates were studied over a median of 14 years of follow-up.³ Compared with those with a BMI of 20 to 25 kg/m², people with a BMI of 30 to 34.9 kg/m² or a BMI of 35 to 39.9 kg/m² had increased risks of death of 46% and 94%, respectively, demonstrating that obesity increases this risk.³

The increased risk of death associated with obesity is caused by obesity-related diseases that cause early mortality, including diabetes mellitus (DM), dyslipidemia, hypertension, coronary heart disease, heart failure, atrial fibrillation, stroke, and venous thromboembolic events.⁴ Obesity is also associated with an increased risk of many cancers, including cancer of the endometrium, kidney, esophagus, stomach, colon, rectum, gallbladder, pancreas, liver, and breast.⁵ With regard to gynecologic disease, obesity is associated with an increased risk of fibroids and heavy menstrual bleeding.⁶ For pregnant patients, obesity is associated with increased risks of⁷:

• miscarriage and stillbirth
• preeclampsia and gestational hypertension
• gestational diabetes
• severe maternal morbidity
• postterm pregnancy
• venous thromboembolism
• endometritis.

For obese patients, weight loss can normalize blood pressure, reduce the risk of cardiovascular events, decrease the risk of cancer, and cure type 2 DM.⁸

Bariatric surgery: The gold standard treatment for reliable and sustained weight loss

All patients with obesity should be counseled to reduce caloric intake and increase physical activity. Dietary counseling provided by a nutritionist may help reinforce advice given by a provider. However, lifestyle interventions are associated with modest weight loss (<5% of bodyweight; FIGURE).⁹ The gold standard treatment for reliable and sustained weight loss is bariatric surgery.

In the Swedish Obese Subjects study, involving 2,010 people, following bariatric surgery the mean decrease in bodyweight was 23% at 2 years, with a slow increase in weight thereafter, resulting in a sustained mean weight loss of 18% at 10 years.⁸ In this study, people in the diet and exercise control group had no change in bodyweight over 10 years of follow-up.⁸ Not all eligible obese patients want to undergo bariatric surgery because it is an arduous sequential process involving 6 months of intensive preoperative preparation, bariatric surgery, recovery, and intensive postoperative follow-up. The perioperative mortality rate is 0.03% to 0.2%.¹⁰ Following bariatric surgery, additional operations may be necessary for more than 10% of patients.¹⁰ With recent breakthroughs in the medication management of obesity, patients who do not want bariatric surgery can achieve reliable weight loss of greater than 10% of body weight with glucagon-like peptide -1 (GLP-1) agonists.

ILLUSTRATION: KIMBERLY MARTENS FOR OBG MANAGEMENT

GLP-1 agonist analogues: Practice-changing breakthrough in medication treatment

GLP-1, a 30 amino acid peptide, is produced by intestinal enteroendocrine cells and neurons in the medulla and hypothalamus.¹¹ GLP-1 reduces hunger cravings and causes satiety, reducing daily food intake.¹² GLP-1 also enhances the secretion of insulin, making GLP-1 agonists an effective treatment for type 2 DM. In humans and experimental animals, the administration of exogenous GLP-1 agonists decreases hunger cravings and causes satiety, reducing food intake, resulting in weight loss.¹² The synthetic GLP-1 agonists, liraglutide (Saxenda) and semaglutide (Wegovy) are approved by the US Food and Drug Administration (FDA) as anti-obesity medications.

Native GLP-1 has a short circulating half-life of approximately 2 minutes. The synthetic GLP-1 agonist medications liraglutide and semaglutide are modified to significantly increase their half-life. Liraglutide is a modified version of GLP-1 with a palmitic acid side chain and an amino acid spacer resulting in reduced degradation and a 15-hour half-life, necessitating daily administration. Semaglutide has a steric acid diacid at Lys26, a large synthetic spacer, a modification of amino acid 8 with the addition of α-aminobutyric acid and a 165-hour half-life, permitting weekly administration.¹³ For weight loss, liraglutide and semaglultide are administered by subcutaneous injection. Tirzepatide (Mounjaro) is a novel GLP-1 agonist. It is also a gastric inhibitory peptide, is FDA approved to treat type 2 DM, and is awaiting FDA approval as a weight loss medication.Tirzepatide causes substantial weight loss, similar to the effect of semaglutide.¹⁴

Semaglutide and weight loss

Semaglutide is approved by the FDA for chronic weight management as an adjunct to a reduced-calorie diet and increased physical activity in adults with a BMI ≥ 30 kg/m² or ≥ 27 kg/m² in the presence of a weight-related comorbidity. It is also FDA approved to treat type 2 DM.

In a weight loss trial, 1,961 overweight and obese patients with a mean BMI of 38 kg/m², were randomly assigned to semaglutide or placebo treatment for 68 weeks. All the participants were following a regimen that included a calorie-reduced diet and increased physical activity. The mean changes in body weight for the patients in the semaglutide and placebo treatment groups were -14.9% and -2.4%, respectively. The treatment difference was -12.4% (95% confidence interval [CI], -13.4% to -11.5%; P <.001). In this study, compared with placebo, semaglutide treatment resulted in a greater decrease in waist circumference, -5.3 in versus -1.6 in.¹⁵ A network meta-analysis of the efficacy of weight loss medicines indicates that semaglutide is the most effective medication currently FDA approved for weight loss, reliably producing substantial weight loss (FIGURE).⁹

In one randomized clinical trial, investigators directly compared the efficacy of semaglutide and liraglutide in achieving weight loss. In this trial, 338 patients were assigned randomly to treatment with semaglutide 2.4 mg weekly subcutaneous injection, liraglutide 3.0 mg daily subcutaneous injection, or placebo. All the participants were following a regimen that included a calorie-reduced diet and increased physical activity.¹⁶ After 68 weeks of treatment, the mean weight changes were -15.8%, -6.4%, and -1.9% in the semaglutide, liraglutide, and placebo groups, respectively. The difference between the semaglutide and liraglutide groups was -9.4% (95% CI, -12% to -6.8%; P <.001).¹⁶

Continue to: Semaglutide dose-escalation and contraindications...

For weight loss, the target dose of semaglutide is 2.4 mg once weekly subcutaneous injection achieved by sequential dose escalation. To give patients time to adjust to adverse effects caused by the medication, a standardized dose-escalation regimen is recommended. The FDA-approved escalation regimen for semaglutide treatment begins with a weekly subcutaneous dose of 0.25 mg for 4 weeks, followed by an increase in the weekly dosage every 4 weeks: 0.5 mg, 1.0 mg, 1.7 mg, and 2.4 mg.¹⁷ To support the dose-escalation process there are 5 unique autoinjectors that deliver the appropriate dose for the current step.

Semaglutide is contraindicated if the patient has an allergy to the medication or if there is a personal or family history of medullary thyroid cancer.¹⁷ In animal toxicology studies, semaglutide at clinically relevant dosing was associated with an increased risk of developing medullary thyroid cancer. Patients with a personal history of multiple endocrine neoplasia syndrome type 2, (medullary thyroid cancer, pheochromocytoma, and primary hyperparathyroidism) should not take semaglutide. Semaglutide may cause fetal harm and the FDA recommends discontinuing semaglutide at least 2 months before pregnancy.¹⁷ According to the FDA, the safety of semaglutide during breastfeeding has not been established. In Canada, breastfeeding is a contraindication to semaglutide treatment.¹⁸

Limitations of medication treatment of obesity

There are important limitations to semaglutide treatment of obesity, including:

• weight gain after stopping treatment
• limited medical insurance supportfor an expensive medication treatment
• bothersome adverse effects.

Weight gain posttreatment. After stopping medication treatment of obesity, weight gain occurs in most patients. However, patients may remain below baseline weight for a long time after stopping medication therapy. In one trial of 803 patients, after 20 weeks of semaglutide treatment (16-week dose-escalation phase, followed by 4 weeks on a weekly dose of 2.4 mg), the participants were randomized to 48 additional weeks of semaglutide or placebo.¹⁹ All the participants were following a regimen that included a calorie-reduced diet and increased physical activity. At the initial 20 weeks of treatment time point the mean weight change was -10.6%. Over the following 48 weeks, the patients treated with semaglutidehad an additional mean weight change of -7.9%, while the mean weight change for the placebo group was +6.9%.

Medical insurance coverage. A major barrier to semaglutide treatment of obesity is the medication’s cost. At the website GoodRx (https://www.goodrx.com/), the estimated price for a 1-month supply of semaglutide (Wegovy) is $1,350.²⁰ By contrast, a 1-month supply of phentermine-topiramate (Qsymia) is approximately $205. Currently, many medical insurance plans do not cover the cost of semaglutide treatment for weight loss. Patent protection for liraglutide may expire in the next few years, permitting the marketing of a lower-cost generic formulation, increasing the availability of the medication. However, as noted above, compared with liraglutide, semaglutide treatment results in much greater weight loss.

The most common adverse effects associated with semaglutide treatment are nausea, vomiting, diarrhea, and constipation. In one randomized clinical trial involving 1,961 patients, the frequency of adverse effects reported by patients taking semaglutide incrementally above the frequency of the same adverse effect reported by patients on placebo was: nausea (27%), vomiting (18%), diarrhea (16%), constipation (14%), dyspepsia (7%), and abdominal pain (5%).¹⁵ In this study, treatment was discontinued due to adverse effects in 7% and 3% of the patients in the semaglutide and placebo groups, respectively. Experts believe that adverse effects can be minimized by increasing the dose slowly and decreasing the dose if adverse effects are bothersome to the patient.

Measuring the benefits of semaglutide weight loss

Overweight and obesity are prevalent problems with many adverse consequences, including an increased risk of death. In population studies, weight loss following bariatric surgery is associated with a substantial reduction in mortality, cancer, and heart disease compared with conventional therapy.²¹ Over the next few years, the effect of semaglutide-induced weight loss on the rate of cancer and heart disease should become clear. If semaglutide treatment of obesity is associated with a reduction in cancer and heart disease, it would be a truly breakthrough medication. ●

Therapeutic hypothermia (TH) for moderate and severe neonatal encephalopathy has been shown to reduce the risk of newborn death, major neurodevelopmental disability, developmental delay, and cerebral palsy.¹ It is estimated that 8 newborns with moderate or severe neonatal encephalopathy need to be treated with TH to prevent 1 case of cerebral palsy.¹ The key elements of TH include:

• initiate hypothermia within 6 hoursof birth
• cool the newborn to a core temperature of 33.5˚ C to 34.5˚ C (92.3˚ F to 94.1˚ F) for 72 hours
• obtain brain ultrasonography to assess for intracranial hemorrhage
• obtain sequential MRI studies to assess brain structure and function
• initiate EEG monitoring for seizure activity.

During hypothermia the newborn is sedated, and oral feedings are reduced. During TH, important physiological goals are to maintain normal oxygenation, blood pressure, fluid balance, and glucose levels.^1,2

TH: The basics

Most of the major published randomized clinical trials used the following inclusion criteria to initiate TH²:

• gestational age at birth of ≥ 35 weeks
• neonate is within 6 hours of birth
• an Apgar score ≤ 5 at 10 minutes of life or prolonged resuscitation at birth or umbilical artery cord pH < 7.1 or neonatal blood gas within 60 minutes of life < 7.1
• moderate to severe encephalopathy or the presence of seizures
• absence of recognizable congenital abnormalities at birth.

However, in some institutions, expert neonatologists have developed more liberal criteria for the initiation of TH, to be considered on a case-by-case basis. These more inclusive criteria, which will result in more newborns being treated with TH, include^3:

• gestational age at birth of ≥ 34 weeks
• neonate is within 12 hours of birth
• a sentinel event at birth or Apgar score ≤ 5 at 10 minutes of life or prolonged resuscitation or umbilical artery cord pH < 7.1 or neonatal blood gas within 60 minutes of life < 7.1 or postnatal cardiopulmonary failure
• moderate to severe encephalopathy or concern for the presence of seizures.

Birth at a gestational age ≤ 34 weeks is a contraindication to TH. Relative contraindications to initiation of TH include: birth weight < 1,750 g, severe congenital anomaly, major genetic disorders, known severe metabolic disorders, major intracranial hemorrhage, severe septicemia, and uncorrectable coagulopathy.³ Adverse outcomes of TH include thrombocytopenia, cardiac arrythmia, and fat necrosis.⁴

Diagnosing neonatal encephalopathy

Neonatal encephalopathy is a clinical diagnosis, defined as abnormal neurologic function in the first few days of life in an infant born at ≥ 35 weeks’ gestation. It is divided into 3 categories: mild (Stage 1), moderate (Stage 2), and severe (Stage 3).^5,6 Institutions vary in the criteria used to differentiate mild from moderate neonatal encephalopathy, the two most frequent forms of encephalopathy. Newborns with mild encephalopathy are not routinely treated with TH because TH has not been shown to be helpful in this setting. Institutions with liberal criteria for diagnosing moderate encephalopathy will initiate TH in more cases. Involvement of a pediatric neurologist in the diagnosis of moderate encephalopathy may help confirm the diagnosis made by the primary neonatologist and provide an independent, second opinion about whether the newborn should be diagnosed with mild or moderate encephalopathy, a clinically important distinction. Physical examination and EEG findings associated with cases of mild, moderate, and severe encephalopathy are presented in TABLE 1.⁷

Continue: Obstetric factors that may be associated with neonatal encephalopathy...

Obstetric factors that may be associated with neonatal encephalopathy

In a retrospective case-control study that included 405 newborns at ≥ 35 weeks’ gestational age with neonatal encephalopathy thought to be due to hypoxia, 8 obstetric factors were identified as being associated with an increased risk of neonatal encephalopathy, including (TABLE 2)⁸:

1. an obstetric sentinel event (uterine rupture, placental abruption, umbilical cord prolapse, maternal collapse, or severe fetal bleeding)

2. shoulder dystocia

3. abnormal cardiotocogram (persistent late or variable decelerations, fetal bradycardia, and/or absent or minimal fetal heart variability)

4. failed vacuum delivery

5. prolonged rupture of the membranes (> 24 hours)

6. tight nuchal cord

7. gestational age at birth > 41 weeks

8. thick meconium. 

Genetic causes of neonatal seizures and neonatal encephalopathy

Many neonatologists practice with the belief that for a newborn with encephalopathy in the setting of a sentinel labor event, a low Apgar score at 5 minutes, an umbilical cord artery pH < 7.00, and/or an elevated lactate level, the diagnosis of hypoxic ischemic encephalopathy is warranted. However, there are many causes of neonatal encephalopathy not related to intrapartum events. For example, neonatal encephalopathy and seizures may be caused by infectious, vascular, metabolic, medications, or congenital problems.¹⁰

There are genetic disorders that can be associated with both neonatal seizures and encephalopathy, suggesting that in some cases the primary cause of the encephalopathy is a genetic problem, not management of labor. Mutations in the potassium channel and sodium channel genes are well recognized causes of neonatal seizures.^11,12 Cerebral palsy, a childhood outcome that may follow neonatal encephalopathy, also has numerous etiologies, including genetic causes. Among 1,345 children with cerebral palsy referred for exome sequencing, investigators reported that a genetic abnormality was identified in 33% of the cases.¹³ Mutations in 86 genes were identified in multiple children. Similar results have been reported in other cohorts.^14-16 Maintaining an open mind about the causes of a case of neonatal encephalopathy and not jumping to a conclusion before completing an evaluation is an optimal approach.

Parent’s evolving emotional and intellectual reaction to the initiation of TH

Initiation of TH for a newborn with encephalopathy catalyzes parents to wonder, “How did my baby develop an encephalopathy?”, “Did my obstetrician’s management of labor and delivery contribute to the outcome?” and “What is the prognosis for my baby?” These are difficult questions with high emotional valence for both patients and clinicians. Obstetricians and neonatologists should collaborate to provide consistent responses to these questions.

The presence of a low umbilical cord artery pH and high lactate in combination with a low Apgar score at 5 minutes may lead the neonatologist to diagnose hypoxic-ischemic encephalopathy in the medical record. The diagnosis of brain hypoxia and ischemia in a newborn may be interpreted by parents as meaning that labor events caused or contributed to the encephalopathy. During the 72 hours of TH, the newborn is sedated and separated from the parents, causing additional emotional stress and uncertainty. When a baby is transferred from a community hospital to a neonatal intensive care unit (NICU) at a tertiary center, the parents may be geographically separated from their baby during a critical period of time, adding to their anxiety. At some point during the care process most newborns treated with TH will have an EEG, brain ultrasound, and brain magnetic resonance imaging (MRI). These data will be discussed with the parent(s) and may cause confusion and additional stress.

The optimal approach to communicating with parents whose newborn is treated with TH continues to evolve. Best practices may include^17-20:

• in-person, regular multidisciplinary family meetings with the parents, including neonatologists, obstetricians, social service specialists and mental health experts when possible
• providing emotional support to parents, recognizing the psychological trauma of the clinical events
• encouraging parents to have physical contact with the newborn during TH
• elevating the role of the parents in the care process by having them participate in care events such as diapering the newborn
• ensuring that clinicians do not blame other clinicians for the clinical outcome
• communicating the results and interpretation of advanced physiological monitoring and imaging studies, with an emphasis on clarity, recognizing the limitations of the studies
• providing educational materials for parents about TH, early intervention programs, and support resources.

Coordinated and consistent communication with the parents is often difficult to facilitate due to many factors, including the unique perspectives and vocabularies of clinicians from different specialties and the difficulty of coordinating communications with all those involved over multiple shifts and sites of care. In terms of vocabulary, neonatologists are comfortable with making a diagnosis of hypoxic-ischemic encephalopathy in a newborn, but obstetricians would prefer that neonatologists use the more generic diagnosis of encephalopathy, holding judgment on the cause until additional data are available. In terms of coordinating communication over multiple shifts and sites of care, interactions between an obstetrician and their patient typically occurs in the postpartum unit, while interactions between neonatologists and parents occur in the NICU.

Parents of a baby with neonatal encephalopathy undergoing TH may have numerous traumatic experiences during the care process. For weeks or months after birth, they may recall or dream about the absence of sounds from their newborn at birth, the resuscitation events including chest compressions and intubation, the shivering of the baby during TH, and the jarring pivot from the expectation of holding and bonding with a healthy newborn to the reality of a sick newborn requiring intensive care. Obstetricians are also traumatized by these events and support from peers and mental health experts may help them recognize, explore, and adapt to the trauma. Neonatologists believe that TH can help improve the childhood outcomes of newborns with encephalopathy, a goal endorsed by all clinicians and family members. ●

Therapeutic hypothermia (TH) for moderate and severe neonatal encephalopathy has been shown to reduce the risk of newborn death, major neurodevelopmental disability, developmental delay, and cerebral palsy.¹ It is estimated that 8 newborns with moderate or severe neonatal encephalopathy need to be treated with TH to prevent 1 case of cerebral palsy.¹ The key elements of TH include:

• initiate hypothermia within 6 hoursof birth
• cool the newborn to a core temperature of 33.5˚ C to 34.5˚ C (92.3˚ F to 94.1˚ F) for 72 hours
• obtain brain ultrasonography to assess for intracranial hemorrhage
• obtain sequential MRI studies to assess brain structure and function
• initiate EEG monitoring for seizure activity.

During hypothermia the newborn is sedated, and oral feedings are reduced. During TH, important physiological goals are to maintain normal oxygenation, blood pressure, fluid balance, and glucose levels.^1,2

TH: The basics

Most of the major published randomized clinical trials used the following inclusion criteria to initiate TH²:

• gestational age at birth of ≥ 35 weeks
• neonate is within 6 hours of birth
• an Apgar score ≤ 5 at 10 minutes of life or prolonged resuscitation at birth or umbilical artery cord pH < 7.1 or neonatal blood gas within 60 minutes of life < 7.1
• moderate to severe encephalopathy or the presence of seizures
• absence of recognizable congenital abnormalities at birth.

However, in some institutions, expert neonatologists have developed more liberal criteria for the initiation of TH, to be considered on a case-by-case basis. These more inclusive criteria, which will result in more newborns being treated with TH, include^3:

• gestational age at birth of ≥ 34 weeks
• neonate is within 12 hours of birth
• a sentinel event at birth or Apgar score ≤ 5 at 10 minutes of life or prolonged resuscitation or umbilical artery cord pH < 7.1 or neonatal blood gas within 60 minutes of life < 7.1 or postnatal cardiopulmonary failure
• moderate to severe encephalopathy or concern for the presence of seizures.

Birth at a gestational age ≤ 34 weeks is a contraindication to TH. Relative contraindications to initiation of TH include: birth weight < 1,750 g, severe congenital anomaly, major genetic disorders, known severe metabolic disorders, major intracranial hemorrhage, severe septicemia, and uncorrectable coagulopathy.³ Adverse outcomes of TH include thrombocytopenia, cardiac arrythmia, and fat necrosis.⁴

Diagnosing neonatal encephalopathy

Neonatal encephalopathy is a clinical diagnosis, defined as abnormal neurologic function in the first few days of life in an infant born at ≥ 35 weeks’ gestation. It is divided into 3 categories: mild (Stage 1), moderate (Stage 2), and severe (Stage 3).^5,6 Institutions vary in the criteria used to differentiate mild from moderate neonatal encephalopathy, the two most frequent forms of encephalopathy. Newborns with mild encephalopathy are not routinely treated with TH because TH has not been shown to be helpful in this setting. Institutions with liberal criteria for diagnosing moderate encephalopathy will initiate TH in more cases. Involvement of a pediatric neurologist in the diagnosis of moderate encephalopathy may help confirm the diagnosis made by the primary neonatologist and provide an independent, second opinion about whether the newborn should be diagnosed with mild or moderate encephalopathy, a clinically important distinction. Physical examination and EEG findings associated with cases of mild, moderate, and severe encephalopathy are presented in TABLE 1.⁷

Continue: Obstetric factors that may be associated with neonatal encephalopathy...

Obstetric factors that may be associated with neonatal encephalopathy

In a retrospective case-control study that included 405 newborns at ≥ 35 weeks’ gestational age with neonatal encephalopathy thought to be due to hypoxia, 8 obstetric factors were identified as being associated with an increased risk of neonatal encephalopathy, including (TABLE 2)⁸:

1. an obstetric sentinel event (uterine rupture, placental abruption, umbilical cord prolapse, maternal collapse, or severe fetal bleeding)

2. shoulder dystocia

3. abnormal cardiotocogram (persistent late or variable decelerations, fetal bradycardia, and/or absent or minimal fetal heart variability)

4. failed vacuum delivery

5. prolonged rupture of the membranes (> 24 hours)

6. tight nuchal cord

7. gestational age at birth > 41 weeks

8. thick meconium. 

Genetic causes of neonatal seizures and neonatal encephalopathy

Many neonatologists practice with the belief that for a newborn with encephalopathy in the setting of a sentinel labor event, a low Apgar score at 5 minutes, an umbilical cord artery pH < 7.00, and/or an elevated lactate level, the diagnosis of hypoxic ischemic encephalopathy is warranted. However, there are many causes of neonatal encephalopathy not related to intrapartum events. For example, neonatal encephalopathy and seizures may be caused by infectious, vascular, metabolic, medications, or congenital problems.¹⁰

There are genetic disorders that can be associated with both neonatal seizures and encephalopathy, suggesting that in some cases the primary cause of the encephalopathy is a genetic problem, not management of labor. Mutations in the potassium channel and sodium channel genes are well recognized causes of neonatal seizures.^11,12 Cerebral palsy, a childhood outcome that may follow neonatal encephalopathy, also has numerous etiologies, including genetic causes. Among 1,345 children with cerebral palsy referred for exome sequencing, investigators reported that a genetic abnormality was identified in 33% of the cases.¹³ Mutations in 86 genes were identified in multiple children. Similar results have been reported in other cohorts.^14-16 Maintaining an open mind about the causes of a case of neonatal encephalopathy and not jumping to a conclusion before completing an evaluation is an optimal approach.

Parent’s evolving emotional and intellectual reaction to the initiation of TH

Initiation of TH for a newborn with encephalopathy catalyzes parents to wonder, “How did my baby develop an encephalopathy?”, “Did my obstetrician’s management of labor and delivery contribute to the outcome?” and “What is the prognosis for my baby?” These are difficult questions with high emotional valence for both patients and clinicians. Obstetricians and neonatologists should collaborate to provide consistent responses to these questions.

The presence of a low umbilical cord artery pH and high lactate in combination with a low Apgar score at 5 minutes may lead the neonatologist to diagnose hypoxic-ischemic encephalopathy in the medical record. The diagnosis of brain hypoxia and ischemia in a newborn may be interpreted by parents as meaning that labor events caused or contributed to the encephalopathy. During the 72 hours of TH, the newborn is sedated and separated from the parents, causing additional emotional stress and uncertainty. When a baby is transferred from a community hospital to a neonatal intensive care unit (NICU) at a tertiary center, the parents may be geographically separated from their baby during a critical period of time, adding to their anxiety. At some point during the care process most newborns treated with TH will have an EEG, brain ultrasound, and brain magnetic resonance imaging (MRI). These data will be discussed with the parent(s) and may cause confusion and additional stress.

The optimal approach to communicating with parents whose newborn is treated with TH continues to evolve. Best practices may include^17-20:

• in-person, regular multidisciplinary family meetings with the parents, including neonatologists, obstetricians, social service specialists and mental health experts when possible
• providing emotional support to parents, recognizing the psychological trauma of the clinical events
• encouraging parents to have physical contact with the newborn during TH
• elevating the role of the parents in the care process by having them participate in care events such as diapering the newborn
• ensuring that clinicians do not blame other clinicians for the clinical outcome
• communicating the results and interpretation of advanced physiological monitoring and imaging studies, with an emphasis on clarity, recognizing the limitations of the studies
• providing educational materials for parents about TH, early intervention programs, and support resources.

Coordinated and consistent communication with the parents is often difficult to facilitate due to many factors, including the unique perspectives and vocabularies of clinicians from different specialties and the difficulty of coordinating communications with all those involved over multiple shifts and sites of care. In terms of vocabulary, neonatologists are comfortable with making a diagnosis of hypoxic-ischemic encephalopathy in a newborn, but obstetricians would prefer that neonatologists use the more generic diagnosis of encephalopathy, holding judgment on the cause until additional data are available. In terms of coordinating communication over multiple shifts and sites of care, interactions between an obstetrician and their patient typically occurs in the postpartum unit, while interactions between neonatologists and parents occur in the NICU.

Parents of a baby with neonatal encephalopathy undergoing TH may have numerous traumatic experiences during the care process. For weeks or months after birth, they may recall or dream about the absence of sounds from their newborn at birth, the resuscitation events including chest compressions and intubation, the shivering of the baby during TH, and the jarring pivot from the expectation of holding and bonding with a healthy newborn to the reality of a sick newborn requiring intensive care. Obstetricians are also traumatized by these events and support from peers and mental health experts may help them recognize, explore, and adapt to the trauma. Neonatologists believe that TH can help improve the childhood outcomes of newborns with encephalopathy, a goal endorsed by all clinicians and family members. ●

Therapeutic hypothermia (TH) for moderate and severe neonatal encephalopathy has been shown to reduce the risk of newborn death, major neurodevelopmental disability, developmental delay, and cerebral palsy.¹ It is estimated that 8 newborns with moderate or severe neonatal encephalopathy need to be treated with TH to prevent 1 case of cerebral palsy.¹ The key elements of TH include:

• initiate hypothermia within 6 hoursof birth
• cool the newborn to a core temperature of 33.5˚ C to 34.5˚ C (92.3˚ F to 94.1˚ F) for 72 hours
• obtain brain ultrasonography to assess for intracranial hemorrhage
• obtain sequential MRI studies to assess brain structure and function
• initiate EEG monitoring for seizure activity.

During hypothermia the newborn is sedated, and oral feedings are reduced. During TH, important physiological goals are to maintain normal oxygenation, blood pressure, fluid balance, and glucose levels.^1,2

TH: The basics

Most of the major published randomized clinical trials used the following inclusion criteria to initiate TH²:

• gestational age at birth of ≥ 35 weeks
• neonate is within 6 hours of birth
• an Apgar score ≤ 5 at 10 minutes of life or prolonged resuscitation at birth or umbilical artery cord pH < 7.1 or neonatal blood gas within 60 minutes of life < 7.1
• moderate to severe encephalopathy or the presence of seizures
• absence of recognizable congenital abnormalities at birth.

However, in some institutions, expert neonatologists have developed more liberal criteria for the initiation of TH, to be considered on a case-by-case basis. These more inclusive criteria, which will result in more newborns being treated with TH, include^3:

• gestational age at birth of ≥ 34 weeks
• neonate is within 12 hours of birth
• a sentinel event at birth or Apgar score ≤ 5 at 10 minutes of life or prolonged resuscitation or umbilical artery cord pH < 7.1 or neonatal blood gas within 60 minutes of life < 7.1 or postnatal cardiopulmonary failure
• moderate to severe encephalopathy or concern for the presence of seizures.

Birth at a gestational age ≤ 34 weeks is a contraindication to TH. Relative contraindications to initiation of TH include: birth weight < 1,750 g, severe congenital anomaly, major genetic disorders, known severe metabolic disorders, major intracranial hemorrhage, severe septicemia, and uncorrectable coagulopathy.³ Adverse outcomes of TH include thrombocytopenia, cardiac arrythmia, and fat necrosis.⁴

Diagnosing neonatal encephalopathy

Neonatal encephalopathy is a clinical diagnosis, defined as abnormal neurologic function in the first few days of life in an infant born at ≥ 35 weeks’ gestation. It is divided into 3 categories: mild (Stage 1), moderate (Stage 2), and severe (Stage 3).^5,6 Institutions vary in the criteria used to differentiate mild from moderate neonatal encephalopathy, the two most frequent forms of encephalopathy. Newborns with mild encephalopathy are not routinely treated with TH because TH has not been shown to be helpful in this setting. Institutions with liberal criteria for diagnosing moderate encephalopathy will initiate TH in more cases. Involvement of a pediatric neurologist in the diagnosis of moderate encephalopathy may help confirm the diagnosis made by the primary neonatologist and provide an independent, second opinion about whether the newborn should be diagnosed with mild or moderate encephalopathy, a clinically important distinction. Physical examination and EEG findings associated with cases of mild, moderate, and severe encephalopathy are presented in TABLE 1.⁷

Continue: Obstetric factors that may be associated with neonatal encephalopathy...

Obstetric factors that may be associated with neonatal encephalopathy

In a retrospective case-control study that included 405 newborns at ≥ 35 weeks’ gestational age with neonatal encephalopathy thought to be due to hypoxia, 8 obstetric factors were identified as being associated with an increased risk of neonatal encephalopathy, including (TABLE 2)⁸:

1. an obstetric sentinel event (uterine rupture, placental abruption, umbilical cord prolapse, maternal collapse, or severe fetal bleeding)

2. shoulder dystocia

3. abnormal cardiotocogram (persistent late or variable decelerations, fetal bradycardia, and/or absent or minimal fetal heart variability)

4. failed vacuum delivery

5. prolonged rupture of the membranes (> 24 hours)

6. tight nuchal cord

7. gestational age at birth > 41 weeks

8. thick meconium. 

Genetic causes of neonatal seizures and neonatal encephalopathy

Many neonatologists practice with the belief that for a newborn with encephalopathy in the setting of a sentinel labor event, a low Apgar score at 5 minutes, an umbilical cord artery pH < 7.00, and/or an elevated lactate level, the diagnosis of hypoxic ischemic encephalopathy is warranted. However, there are many causes of neonatal encephalopathy not related to intrapartum events. For example, neonatal encephalopathy and seizures may be caused by infectious, vascular, metabolic, medications, or congenital problems.¹⁰

There are genetic disorders that can be associated with both neonatal seizures and encephalopathy, suggesting that in some cases the primary cause of the encephalopathy is a genetic problem, not management of labor. Mutations in the potassium channel and sodium channel genes are well recognized causes of neonatal seizures.^11,12 Cerebral palsy, a childhood outcome that may follow neonatal encephalopathy, also has numerous etiologies, including genetic causes. Among 1,345 children with cerebral palsy referred for exome sequencing, investigators reported that a genetic abnormality was identified in 33% of the cases.¹³ Mutations in 86 genes were identified in multiple children. Similar results have been reported in other cohorts.^14-16 Maintaining an open mind about the causes of a case of neonatal encephalopathy and not jumping to a conclusion before completing an evaluation is an optimal approach.

Parent’s evolving emotional and intellectual reaction to the initiation of TH

Initiation of TH for a newborn with encephalopathy catalyzes parents to wonder, “How did my baby develop an encephalopathy?”, “Did my obstetrician’s management of labor and delivery contribute to the outcome?” and “What is the prognosis for my baby?” These are difficult questions with high emotional valence for both patients and clinicians. Obstetricians and neonatologists should collaborate to provide consistent responses to these questions.

The presence of a low umbilical cord artery pH and high lactate in combination with a low Apgar score at 5 minutes may lead the neonatologist to diagnose hypoxic-ischemic encephalopathy in the medical record. The diagnosis of brain hypoxia and ischemia in a newborn may be interpreted by parents as meaning that labor events caused or contributed to the encephalopathy. During the 72 hours of TH, the newborn is sedated and separated from the parents, causing additional emotional stress and uncertainty. When a baby is transferred from a community hospital to a neonatal intensive care unit (NICU) at a tertiary center, the parents may be geographically separated from their baby during a critical period of time, adding to their anxiety. At some point during the care process most newborns treated with TH will have an EEG, brain ultrasound, and brain magnetic resonance imaging (MRI). These data will be discussed with the parent(s) and may cause confusion and additional stress.

The optimal approach to communicating with parents whose newborn is treated with TH continues to evolve. Best practices may include^17-20:

• in-person, regular multidisciplinary family meetings with the parents, including neonatologists, obstetricians, social service specialists and mental health experts when possible
• providing emotional support to parents, recognizing the psychological trauma of the clinical events
• encouraging parents to have physical contact with the newborn during TH
• elevating the role of the parents in the care process by having them participate in care events such as diapering the newborn
• ensuring that clinicians do not blame other clinicians for the clinical outcome
• communicating the results and interpretation of advanced physiological monitoring and imaging studies, with an emphasis on clarity, recognizing the limitations of the studies
• providing educational materials for parents about TH, early intervention programs, and support resources.

Coordinated and consistent communication with the parents is often difficult to facilitate due to many factors, including the unique perspectives and vocabularies of clinicians from different specialties and the difficulty of coordinating communications with all those involved over multiple shifts and sites of care. In terms of vocabulary, neonatologists are comfortable with making a diagnosis of hypoxic-ischemic encephalopathy in a newborn, but obstetricians would prefer that neonatologists use the more generic diagnosis of encephalopathy, holding judgment on the cause until additional data are available. In terms of coordinating communication over multiple shifts and sites of care, interactions between an obstetrician and their patient typically occurs in the postpartum unit, while interactions between neonatologists and parents occur in the NICU.

Parents of a baby with neonatal encephalopathy undergoing TH may have numerous traumatic experiences during the care process. For weeks or months after birth, they may recall or dream about the absence of sounds from their newborn at birth, the resuscitation events including chest compressions and intubation, the shivering of the baby during TH, and the jarring pivot from the expectation of holding and bonding with a healthy newborn to the reality of a sick newborn requiring intensive care. Obstetricians are also traumatized by these events and support from peers and mental health experts may help them recognize, explore, and adapt to the trauma. Neonatologists believe that TH can help improve the childhood outcomes of newborns with encephalopathy, a goal endorsed by all clinicians and family members. ●

Photo: Iryna Inshyna/Shutterstock

For many decades, the limit of newborn viability was at approximately 24 weeks’ gestation. Recent advances in pregnancy and neonatal care suggest that the new limit of viability is 22 (22 weeks and 0 days to 22 weeks and 6 days) or 23 (23 weeks and 0 days to 23 weeks and 6 days) weeks of gestation. In addition, data from observational cohort studies indicate that for infants born at 22 and 23 weeks’ gestation, survival is dependent on a course of antenatal steroids administered prior to birth plus intensive respiratory and cardiovascular support at delivery and in the neonatal intensive care unit (NICU).

Antenatal steroids: Critical for survival at 22 and 23 weeks of gestation

Most studies of birth outcomes at 22 and 23 weeks’ gestation rely on observational cohorts where unmeasured differences among the maternal-fetal dyads that received or did not receive a specific treatment confounds the interpretation of the data. However, data from multiple large observational cohorts suggest that between 22 and 24 weeks of gestation, completion of a course of antenatal steroids will optimize infant outcomes. Particularly noteworthy was the observation that the incremental survival benefit of antenatal steroids was greatest at 22 and 23 weeks’ gestation (TABLE 1).¹ Similar results have been reported by Rossi and colleagues (TABLE 2).²

The importance of a completed course of antenatal steroids before birth was confirmed in another cohort study of 431 infants born in 2016 to 2019 at 22 weeks and 0 days’ to 23 weeks and 6 days’ gestation.³ Survival to discharge occurred in 53.9% of infants who received a full course of antenatal steroids before birth and 35.5% among those who did not receive antenatal steroids.^.3 Survival to discharge without major neonatal morbidities was 26.9% in those who received a full course of antenatal steroids and 10% among those who did not. In this cohort, major neonatal morbidities included severe intracranial hemorrhage, cystic periventricular leukomalacia, severe bronchopulmonary dysplasia, surgical necrotizing enterocolitis, or severe retinopathy of prematurity requiring treatment.

The American College of Obstetricians and Gynecologists (ACOG) recommends against antenatal steroids prior to 22 weeks and 0 days gestation.⁴ However, some neonatologists might recommend that antenatal steroids be given starting at 21 weeks and 5 days of gestation if birth is anticipated in the 22nd week of gestation and the patient prefers aggressive treatment of the newborn.

Active respiratory and cardiovascular support improves newborn outcomes

To maximize survival, infants born at 22 and 23 weeks’ gestation always require intensive active treatment at birth and in the following days in the NICU. Active treatment may include respiratory support, surfactant treatment, pressors, closure of a patent ductus arteriosus, transfusion of red blood cells, and parenteral nutrition. In one observational cohort study, active treatment at birth was not routinely provided at 22 and 23 weeks’ gestation but was routinely provided at later gestational ages (TABLE 3A).⁵ Not surprisingly, active treatment, especially at early gestational ages, is associated with improved survival to discharge. For example, at 22 weeks’ gestation, survival to discharge in infants who received or did not receive intensive active treatment was 28% and 0%, respectively.⁵ However, specific clinical characteristics of the pregnant patient and newborn may have influenced which infants were actively treated, confounding interpretation of the observation. In this cohort of extremely premature newborns, survival to hospital discharge increased substantially between 22 weeks and 26 weeks of gestational age (TABLE 3B).⁵

Many of the surviving infants needed chronic support treatment. Among surviving infants born at 22 weeks and 26 weeks, chronic support treatments were being used by 22.6% and 10.6% of infants, respectively, 2 years after birth.⁵ For surviving infants born at 22 weeks, the specific chronic support treatments included gastrostomy or feeding tube (19.4%), oxygen (9.7%), pulse oximeter (9.7%), and/or tracheostomy (3.2%). For surviving infants born at 26 weeks’ gestation, the specific chronic support treatments included gastrotomy or feeding tube (8.5%), pulse oximeter (4.4%), oxygen (3.2%), tracheostomy (2.3%), an apnea monitor (1.5%), and/or ventilator or continuous positive airway pressure (1.1%).⁵

Continue to: Evolving improvement in infant outcomes...

In 1963, Jacqueline Bouvier Kennedy went into preterm labor at 34 weeks of gestation and delivered her son Patrick at a community facility. Due to severe respiratory distress syndrome, Patrick was transferred to the Boston Children’s Hospital, and he died shortly thereafter.⁶ Sixty years later, due to advances in obstetric and neonatal care, death from respiratory distress syndrome at 34 weeks of gestation is uncommon in the United States.

Infant outcomes following birth at 22 and 23 weeks’ gestation continue to improve. An observational cohort study from Sweden reported that at 22 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 10% and 30%, respectively.⁷ Similarly, at 23 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 52% and 61%, respectively.⁷ However, most of the surviving infants in this cohort had one or more major neonatal morbidities, including intraventricular hemorrhage grade 3 or 4; periventricular leukomalacia; necrotizing enterocolitis; retinopathy of prematurity grade 3, 4, or 5; or severe bronchopulmonary dysplasia.⁷

In a cohort of infants born in Japan at 22 to 24 weeks of gestation, there was a notable decrease in major neurodisability at 3 years of age for births occurring in 2 epochs, 2003 to 2007 and 2008 to 2012.⁸ When comparing outcomes in 2003 to 2007 versus 2008 to 2012, the change in rate of various major complications included the following: cerebral palsy (15.9% vs 9.5%), visual impairment (13.6% vs 4.4%), blindness (4.8% vs 1.3%), and hearing impairment (2.6% vs 1.0%). In contrast, the rate of cognitive impairment, defined as less than 70% of standard test performance for chronological age, was similar in the 2 time periods (36.5% and 37.9%, respectively).⁸ Based on data reported between 2000 and 2020, a systematic review and meta-analysis by Backes and colleagues concluded that there has been substantial improvement in the survival of infants born at 22 weeks of gestation.⁹

The small baby unit

A feature of modern medicine is the relentless evolution of new clinical subspecialties and sub-subspecialties. NICUs evolved from newborn nurseries to serve the needs of the most severely ill newborns, with care provided by a cadre of highly trained subspecialized neonatologists and neonatal nurses. A new era is dawning, with some NICUs developing a sub-subspecialized small baby unit to care for infants born between 22 and 26 weeks of gestation. These units often are staffed by clinicians with a specific interest in optimizing the care of extremely preterm infants, providing continuity of care over a long hospitalization.¹⁰ The benefits of a small baby unit may include:

• relentless standardization and adherence to the best intensive care practices
• daily use of checklists
• strict adherence to central line care
• timely extubation and transition to continuous positive airway pressure
• adherence to breastfeeding guidelines
• limiting the number of clinicians responsible for the patient
• promotion of kangaroo care
• avoidance of noxious stimuli.^10,11

Continue to: Ethical and clinical issues...

Providing clinical care to infants born at the edge of viability is challenging and raises many ethical and clinical concerns.^12,13 For an infant born at the edge of viability, clinicians and parents do not want to initiate a care process that improves survival but results in an extremely poor quality of life. At the same time, clinicians and parents do not want to withhold care that could help an extremely premature newborn survive and thrive. Consequently, the counseling process is complex and requires coordination between the obstetrical and neonatology disciplines, involving physicians and nurses from both. A primary consideration in deciding to institute active treatment at birth is the preference of the pregnant patient and the patient’s trusted family members. A thorough discussion of these issues is beyond the scope of this editorial. ACOG provides detailed advice about the approach to counseling patients who face the possibility of a periviable birth.¹⁴

To help standardize the counseling process, institutions may find it helpful to recommend that clinicians consistently use a calculator to provide newborn outcome data to patients. The National Institute of Child Health and Human Development’s Extremely Preterm Birth Outcomes calculator uses the following inputs:

• gestational age
• estimated birth weight
• sex
• singleton/multiple gestation
• antenatal steroid treatment.

It also provides the following outputs as percentages:

• survival with active treatment at birth
• survival without active treatment at birth
• profound neurodevelopmental impairment
• moderate to severe neurodevelopmental impairment
• blindness
• deafness
• moderate to severe cerebral palsy
• cognitive developmental delay.¹⁵

A full assessment of all known clinical factors should influence the interpretation of the output from the clinical calculator. An alternativeis to use data from the Vermont Oxford Network. NICUs with sufficient clinical volume may prefer to use their own outcome data in the counseling process.

Institutions and clinical teams may improve the consistency of the counseling process by identifying criteria for 3 main treatment options:

• clinical situations where active treatment at birth is not generally offered (eg, <22 weeks’ gestation)
• clinical situations where active treatment at birth is almost always routinely provided (eg, >25 weeks’ gestation)
• clinical situations where patient preferences are especially important in guiding the use of active treatment.

Most institutions do not routinely offer active treatment of the newborn at a gestational age of less than 22 weeks and 0 days. Instead, comfort care often is provided for these newborns. Most institutions routinely provide active treatment at birth beginning at 24 or 25 weeks’ gestation unless unique risk factors or comorbidities warrant not providing active treatment (TABLE 3A). Some professional societies recommend setting a threshold for recommending active treatment at birth. For example, the British Association of Perinatal Medicine recommends that if there is 50% or higher probability of survival without severe disability, active treatment at birth should be considered because it is in the best interest of the newborn.¹⁶ In the hours and days following birth, the clinical course of the newborn greatly influences the treatment plan and care goals. After the initial resuscitation, if the clinical condition of an extremely preterm infant worsens and the prognosis is grim, a pivot to palliative care may be considered.

Final thoughts

Periviability is the earliest stage of fetal development where there is a reasonable chance, but not a high likelihood, of survival outside the womb. For decades, the threshold for periviability was approximately 24 weeks of gestation. With current obstetrical and neonatal practice, the new threshold for periviability is 22 to 23 weeks of gestation, but death prior to hospital discharge occurs in approximately half of these newborns. For the survivors, lifelong neurodevelopmental complications and pulmonary disease are common. Obstetricians play a key role in counseling patients who are at risk of giving birth before 24 weeks of gestation. Given the challenges faced by an infant born at 22 and 23 weeks’ gestation, pregnant patients and trusted family members should approach the decision to actively resuscitate the newborn with caution. However, if the clinical team, patient, and trusted family members agree to pursue active treatment, completion of a course of antenatal steroids and appropriate respiratory and cardiovascular support at birth are key to improving long-term outcomes. ●
 

Photo: Iryna Inshyna/Shutterstock

For many decades, the limit of newborn viability was at approximately 24 weeks’ gestation. Recent advances in pregnancy and neonatal care suggest that the new limit of viability is 22 (22 weeks and 0 days to 22 weeks and 6 days) or 23 (23 weeks and 0 days to 23 weeks and 6 days) weeks of gestation. In addition, data from observational cohort studies indicate that for infants born at 22 and 23 weeks’ gestation, survival is dependent on a course of antenatal steroids administered prior to birth plus intensive respiratory and cardiovascular support at delivery and in the neonatal intensive care unit (NICU).

Antenatal steroids: Critical for survival at 22 and 23 weeks of gestation

Most studies of birth outcomes at 22 and 23 weeks’ gestation rely on observational cohorts where unmeasured differences among the maternal-fetal dyads that received or did not receive a specific treatment confounds the interpretation of the data. However, data from multiple large observational cohorts suggest that between 22 and 24 weeks of gestation, completion of a course of antenatal steroids will optimize infant outcomes. Particularly noteworthy was the observation that the incremental survival benefit of antenatal steroids was greatest at 22 and 23 weeks’ gestation (TABLE 1).¹ Similar results have been reported by Rossi and colleagues (TABLE 2).²

The importance of a completed course of antenatal steroids before birth was confirmed in another cohort study of 431 infants born in 2016 to 2019 at 22 weeks and 0 days’ to 23 weeks and 6 days’ gestation.³ Survival to discharge occurred in 53.9% of infants who received a full course of antenatal steroids before birth and 35.5% among those who did not receive antenatal steroids.^.3 Survival to discharge without major neonatal morbidities was 26.9% in those who received a full course of antenatal steroids and 10% among those who did not. In this cohort, major neonatal morbidities included severe intracranial hemorrhage, cystic periventricular leukomalacia, severe bronchopulmonary dysplasia, surgical necrotizing enterocolitis, or severe retinopathy of prematurity requiring treatment.

The American College of Obstetricians and Gynecologists (ACOG) recommends against antenatal steroids prior to 22 weeks and 0 days gestation.⁴ However, some neonatologists might recommend that antenatal steroids be given starting at 21 weeks and 5 days of gestation if birth is anticipated in the 22nd week of gestation and the patient prefers aggressive treatment of the newborn.

Active respiratory and cardiovascular support improves newborn outcomes

To maximize survival, infants born at 22 and 23 weeks’ gestation always require intensive active treatment at birth and in the following days in the NICU. Active treatment may include respiratory support, surfactant treatment, pressors, closure of a patent ductus arteriosus, transfusion of red blood cells, and parenteral nutrition. In one observational cohort study, active treatment at birth was not routinely provided at 22 and 23 weeks’ gestation but was routinely provided at later gestational ages (TABLE 3A).⁵ Not surprisingly, active treatment, especially at early gestational ages, is associated with improved survival to discharge. For example, at 22 weeks’ gestation, survival to discharge in infants who received or did not receive intensive active treatment was 28% and 0%, respectively.⁵ However, specific clinical characteristics of the pregnant patient and newborn may have influenced which infants were actively treated, confounding interpretation of the observation. In this cohort of extremely premature newborns, survival to hospital discharge increased substantially between 22 weeks and 26 weeks of gestational age (TABLE 3B).⁵

Many of the surviving infants needed chronic support treatment. Among surviving infants born at 22 weeks and 26 weeks, chronic support treatments were being used by 22.6% and 10.6% of infants, respectively, 2 years after birth.⁵ For surviving infants born at 22 weeks, the specific chronic support treatments included gastrostomy or feeding tube (19.4%), oxygen (9.7%), pulse oximeter (9.7%), and/or tracheostomy (3.2%). For surviving infants born at 26 weeks’ gestation, the specific chronic support treatments included gastrotomy or feeding tube (8.5%), pulse oximeter (4.4%), oxygen (3.2%), tracheostomy (2.3%), an apnea monitor (1.5%), and/or ventilator or continuous positive airway pressure (1.1%).⁵

Continue to: Evolving improvement in infant outcomes...

In 1963, Jacqueline Bouvier Kennedy went into preterm labor at 34 weeks of gestation and delivered her son Patrick at a community facility. Due to severe respiratory distress syndrome, Patrick was transferred to the Boston Children’s Hospital, and he died shortly thereafter.⁶ Sixty years later, due to advances in obstetric and neonatal care, death from respiratory distress syndrome at 34 weeks of gestation is uncommon in the United States.

Infant outcomes following birth at 22 and 23 weeks’ gestation continue to improve. An observational cohort study from Sweden reported that at 22 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 10% and 30%, respectively.⁷ Similarly, at 23 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 52% and 61%, respectively.⁷ However, most of the surviving infants in this cohort had one or more major neonatal morbidities, including intraventricular hemorrhage grade 3 or 4; periventricular leukomalacia; necrotizing enterocolitis; retinopathy of prematurity grade 3, 4, or 5; or severe bronchopulmonary dysplasia.⁷

In a cohort of infants born in Japan at 22 to 24 weeks of gestation, there was a notable decrease in major neurodisability at 3 years of age for births occurring in 2 epochs, 2003 to 2007 and 2008 to 2012.⁸ When comparing outcomes in 2003 to 2007 versus 2008 to 2012, the change in rate of various major complications included the following: cerebral palsy (15.9% vs 9.5%), visual impairment (13.6% vs 4.4%), blindness (4.8% vs 1.3%), and hearing impairment (2.6% vs 1.0%). In contrast, the rate of cognitive impairment, defined as less than 70% of standard test performance for chronological age, was similar in the 2 time periods (36.5% and 37.9%, respectively).⁸ Based on data reported between 2000 and 2020, a systematic review and meta-analysis by Backes and colleagues concluded that there has been substantial improvement in the survival of infants born at 22 weeks of gestation.⁹

The small baby unit

A feature of modern medicine is the relentless evolution of new clinical subspecialties and sub-subspecialties. NICUs evolved from newborn nurseries to serve the needs of the most severely ill newborns, with care provided by a cadre of highly trained subspecialized neonatologists and neonatal nurses. A new era is dawning, with some NICUs developing a sub-subspecialized small baby unit to care for infants born between 22 and 26 weeks of gestation. These units often are staffed by clinicians with a specific interest in optimizing the care of extremely preterm infants, providing continuity of care over a long hospitalization.¹⁰ The benefits of a small baby unit may include:

• relentless standardization and adherence to the best intensive care practices
• daily use of checklists
• strict adherence to central line care
• timely extubation and transition to continuous positive airway pressure
• adherence to breastfeeding guidelines
• limiting the number of clinicians responsible for the patient
• promotion of kangaroo care
• avoidance of noxious stimuli.^10,11

Continue to: Ethical and clinical issues...

Providing clinical care to infants born at the edge of viability is challenging and raises many ethical and clinical concerns.^12,13 For an infant born at the edge of viability, clinicians and parents do not want to initiate a care process that improves survival but results in an extremely poor quality of life. At the same time, clinicians and parents do not want to withhold care that could help an extremely premature newborn survive and thrive. Consequently, the counseling process is complex and requires coordination between the obstetrical and neonatology disciplines, involving physicians and nurses from both. A primary consideration in deciding to institute active treatment at birth is the preference of the pregnant patient and the patient’s trusted family members. A thorough discussion of these issues is beyond the scope of this editorial. ACOG provides detailed advice about the approach to counseling patients who face the possibility of a periviable birth.¹⁴

To help standardize the counseling process, institutions may find it helpful to recommend that clinicians consistently use a calculator to provide newborn outcome data to patients. The National Institute of Child Health and Human Development’s Extremely Preterm Birth Outcomes calculator uses the following inputs:

• gestational age
• estimated birth weight
• sex
• singleton/multiple gestation
• antenatal steroid treatment.

It also provides the following outputs as percentages:

• survival with active treatment at birth
• survival without active treatment at birth
• profound neurodevelopmental impairment
• moderate to severe neurodevelopmental impairment
• blindness
• deafness
• moderate to severe cerebral palsy
• cognitive developmental delay.¹⁵

A full assessment of all known clinical factors should influence the interpretation of the output from the clinical calculator. An alternativeis to use data from the Vermont Oxford Network. NICUs with sufficient clinical volume may prefer to use their own outcome data in the counseling process.

Institutions and clinical teams may improve the consistency of the counseling process by identifying criteria for 3 main treatment options:

• clinical situations where active treatment at birth is not generally offered (eg, <22 weeks’ gestation)
• clinical situations where active treatment at birth is almost always routinely provided (eg, >25 weeks’ gestation)
• clinical situations where patient preferences are especially important in guiding the use of active treatment.

Most institutions do not routinely offer active treatment of the newborn at a gestational age of less than 22 weeks and 0 days. Instead, comfort care often is provided for these newborns. Most institutions routinely provide active treatment at birth beginning at 24 or 25 weeks’ gestation unless unique risk factors or comorbidities warrant not providing active treatment (TABLE 3A). Some professional societies recommend setting a threshold for recommending active treatment at birth. For example, the British Association of Perinatal Medicine recommends that if there is 50% or higher probability of survival without severe disability, active treatment at birth should be considered because it is in the best interest of the newborn.¹⁶ In the hours and days following birth, the clinical course of the newborn greatly influences the treatment plan and care goals. After the initial resuscitation, if the clinical condition of an extremely preterm infant worsens and the prognosis is grim, a pivot to palliative care may be considered.

Final thoughts

Periviability is the earliest stage of fetal development where there is a reasonable chance, but not a high likelihood, of survival outside the womb. For decades, the threshold for periviability was approximately 24 weeks of gestation. With current obstetrical and neonatal practice, the new threshold for periviability is 22 to 23 weeks of gestation, but death prior to hospital discharge occurs in approximately half of these newborns. For the survivors, lifelong neurodevelopmental complications and pulmonary disease are common. Obstetricians play a key role in counseling patients who are at risk of giving birth before 24 weeks of gestation. Given the challenges faced by an infant born at 22 and 23 weeks’ gestation, pregnant patients and trusted family members should approach the decision to actively resuscitate the newborn with caution. However, if the clinical team, patient, and trusted family members agree to pursue active treatment, completion of a course of antenatal steroids and appropriate respiratory and cardiovascular support at birth are key to improving long-term outcomes. ●
 

Photo: Iryna Inshyna/Shutterstock

For many decades, the limit of newborn viability was at approximately 24 weeks’ gestation. Recent advances in pregnancy and neonatal care suggest that the new limit of viability is 22 (22 weeks and 0 days to 22 weeks and 6 days) or 23 (23 weeks and 0 days to 23 weeks and 6 days) weeks of gestation. In addition, data from observational cohort studies indicate that for infants born at 22 and 23 weeks’ gestation, survival is dependent on a course of antenatal steroids administered prior to birth plus intensive respiratory and cardiovascular support at delivery and in the neonatal intensive care unit (NICU).

Antenatal steroids: Critical for survival at 22 and 23 weeks of gestation

Most studies of birth outcomes at 22 and 23 weeks’ gestation rely on observational cohorts where unmeasured differences among the maternal-fetal dyads that received or did not receive a specific treatment confounds the interpretation of the data. However, data from multiple large observational cohorts suggest that between 22 and 24 weeks of gestation, completion of a course of antenatal steroids will optimize infant outcomes. Particularly noteworthy was the observation that the incremental survival benefit of antenatal steroids was greatest at 22 and 23 weeks’ gestation (TABLE 1).¹ Similar results have been reported by Rossi and colleagues (TABLE 2).²

The importance of a completed course of antenatal steroids before birth was confirmed in another cohort study of 431 infants born in 2016 to 2019 at 22 weeks and 0 days’ to 23 weeks and 6 days’ gestation.³ Survival to discharge occurred in 53.9% of infants who received a full course of antenatal steroids before birth and 35.5% among those who did not receive antenatal steroids.^.3 Survival to discharge without major neonatal morbidities was 26.9% in those who received a full course of antenatal steroids and 10% among those who did not. In this cohort, major neonatal morbidities included severe intracranial hemorrhage, cystic periventricular leukomalacia, severe bronchopulmonary dysplasia, surgical necrotizing enterocolitis, or severe retinopathy of prematurity requiring treatment.

The American College of Obstetricians and Gynecologists (ACOG) recommends against antenatal steroids prior to 22 weeks and 0 days gestation.⁴ However, some neonatologists might recommend that antenatal steroids be given starting at 21 weeks and 5 days of gestation if birth is anticipated in the 22nd week of gestation and the patient prefers aggressive treatment of the newborn.

Active respiratory and cardiovascular support improves newborn outcomes

To maximize survival, infants born at 22 and 23 weeks’ gestation always require intensive active treatment at birth and in the following days in the NICU. Active treatment may include respiratory support, surfactant treatment, pressors, closure of a patent ductus arteriosus, transfusion of red blood cells, and parenteral nutrition. In one observational cohort study, active treatment at birth was not routinely provided at 22 and 23 weeks’ gestation but was routinely provided at later gestational ages (TABLE 3A).⁵ Not surprisingly, active treatment, especially at early gestational ages, is associated with improved survival to discharge. For example, at 22 weeks’ gestation, survival to discharge in infants who received or did not receive intensive active treatment was 28% and 0%, respectively.⁵ However, specific clinical characteristics of the pregnant patient and newborn may have influenced which infants were actively treated, confounding interpretation of the observation. In this cohort of extremely premature newborns, survival to hospital discharge increased substantially between 22 weeks and 26 weeks of gestational age (TABLE 3B).⁵

Many of the surviving infants needed chronic support treatment. Among surviving infants born at 22 weeks and 26 weeks, chronic support treatments were being used by 22.6% and 10.6% of infants, respectively, 2 years after birth.⁵ For surviving infants born at 22 weeks, the specific chronic support treatments included gastrostomy or feeding tube (19.4%), oxygen (9.7%), pulse oximeter (9.7%), and/or tracheostomy (3.2%). For surviving infants born at 26 weeks’ gestation, the specific chronic support treatments included gastrotomy or feeding tube (8.5%), pulse oximeter (4.4%), oxygen (3.2%), tracheostomy (2.3%), an apnea monitor (1.5%), and/or ventilator or continuous positive airway pressure (1.1%).⁵

Continue to: Evolving improvement in infant outcomes...

In 1963, Jacqueline Bouvier Kennedy went into preterm labor at 34 weeks of gestation and delivered her son Patrick at a community facility. Due to severe respiratory distress syndrome, Patrick was transferred to the Boston Children’s Hospital, and he died shortly thereafter.⁶ Sixty years later, due to advances in obstetric and neonatal care, death from respiratory distress syndrome at 34 weeks of gestation is uncommon in the United States.

Infant outcomes following birth at 22 and 23 weeks’ gestation continue to improve. An observational cohort study from Sweden reported that at 22 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 10% and 30%, respectively.⁷ Similarly, at 23 weeks’ gestation, the percentage of live-born infants who survived to 1-year post birth in 2004 to 2007 and 2014 to 2016 was 52% and 61%, respectively.⁷ However, most of the surviving infants in this cohort had one or more major neonatal morbidities, including intraventricular hemorrhage grade 3 or 4; periventricular leukomalacia; necrotizing enterocolitis; retinopathy of prematurity grade 3, 4, or 5; or severe bronchopulmonary dysplasia.⁷

In a cohort of infants born in Japan at 22 to 24 weeks of gestation, there was a notable decrease in major neurodisability at 3 years of age for births occurring in 2 epochs, 2003 to 2007 and 2008 to 2012.⁸ When comparing outcomes in 2003 to 2007 versus 2008 to 2012, the change in rate of various major complications included the following: cerebral palsy (15.9% vs 9.5%), visual impairment (13.6% vs 4.4%), blindness (4.8% vs 1.3%), and hearing impairment (2.6% vs 1.0%). In contrast, the rate of cognitive impairment, defined as less than 70% of standard test performance for chronological age, was similar in the 2 time periods (36.5% and 37.9%, respectively).⁸ Based on data reported between 2000 and 2020, a systematic review and meta-analysis by Backes and colleagues concluded that there has been substantial improvement in the survival of infants born at 22 weeks of gestation.⁹

The small baby unit

A feature of modern medicine is the relentless evolution of new clinical subspecialties and sub-subspecialties. NICUs evolved from newborn nurseries to serve the needs of the most severely ill newborns, with care provided by a cadre of highly trained subspecialized neonatologists and neonatal nurses. A new era is dawning, with some NICUs developing a sub-subspecialized small baby unit to care for infants born between 22 and 26 weeks of gestation. These units often are staffed by clinicians with a specific interest in optimizing the care of extremely preterm infants, providing continuity of care over a long hospitalization.¹⁰ The benefits of a small baby unit may include:

• relentless standardization and adherence to the best intensive care practices
• daily use of checklists
• strict adherence to central line care
• timely extubation and transition to continuous positive airway pressure
• adherence to breastfeeding guidelines
• limiting the number of clinicians responsible for the patient
• promotion of kangaroo care
• avoidance of noxious stimuli.^10,11

Continue to: Ethical and clinical issues...

Providing clinical care to infants born at the edge of viability is challenging and raises many ethical and clinical concerns.^12,13 For an infant born at the edge of viability, clinicians and parents do not want to initiate a care process that improves survival but results in an extremely poor quality of life. At the same time, clinicians and parents do not want to withhold care that could help an extremely premature newborn survive and thrive. Consequently, the counseling process is complex and requires coordination between the obstetrical and neonatology disciplines, involving physicians and nurses from both. A primary consideration in deciding to institute active treatment at birth is the preference of the pregnant patient and the patient’s trusted family members. A thorough discussion of these issues is beyond the scope of this editorial. ACOG provides detailed advice about the approach to counseling patients who face the possibility of a periviable birth.¹⁴

To help standardize the counseling process, institutions may find it helpful to recommend that clinicians consistently use a calculator to provide newborn outcome data to patients. The National Institute of Child Health and Human Development’s Extremely Preterm Birth Outcomes calculator uses the following inputs:

• gestational age
• estimated birth weight
• sex
• singleton/multiple gestation
• antenatal steroid treatment.

It also provides the following outputs as percentages:

• survival with active treatment at birth
• survival without active treatment at birth
• profound neurodevelopmental impairment
• moderate to severe neurodevelopmental impairment
• blindness
• deafness
• moderate to severe cerebral palsy
• cognitive developmental delay.¹⁵

A full assessment of all known clinical factors should influence the interpretation of the output from the clinical calculator. An alternativeis to use data from the Vermont Oxford Network. NICUs with sufficient clinical volume may prefer to use their own outcome data in the counseling process.

Institutions and clinical teams may improve the consistency of the counseling process by identifying criteria for 3 main treatment options:

• clinical situations where active treatment at birth is not generally offered (eg, <22 weeks’ gestation)
• clinical situations where active treatment at birth is almost always routinely provided (eg, >25 weeks’ gestation)
• clinical situations where patient preferences are especially important in guiding the use of active treatment.

Most institutions do not routinely offer active treatment of the newborn at a gestational age of less than 22 weeks and 0 days. Instead, comfort care often is provided for these newborns. Most institutions routinely provide active treatment at birth beginning at 24 or 25 weeks’ gestation unless unique risk factors or comorbidities warrant not providing active treatment (TABLE 3A). Some professional societies recommend setting a threshold for recommending active treatment at birth. For example, the British Association of Perinatal Medicine recommends that if there is 50% or higher probability of survival without severe disability, active treatment at birth should be considered because it is in the best interest of the newborn.¹⁶ In the hours and days following birth, the clinical course of the newborn greatly influences the treatment plan and care goals. After the initial resuscitation, if the clinical condition of an extremely preterm infant worsens and the prognosis is grim, a pivot to palliative care may be considered.

Final thoughts

Periviability is the earliest stage of fetal development where there is a reasonable chance, but not a high likelihood, of survival outside the womb. For decades, the threshold for periviability was approximately 24 weeks of gestation. With current obstetrical and neonatal practice, the new threshold for periviability is 22 to 23 weeks of gestation, but death prior to hospital discharge occurs in approximately half of these newborns. For the survivors, lifelong neurodevelopmental complications and pulmonary disease are common. Obstetricians play a key role in counseling patients who are at risk of giving birth before 24 weeks of gestation. Given the challenges faced by an infant born at 22 and 23 weeks’ gestation, pregnant patients and trusted family members should approach the decision to actively resuscitate the newborn with caution. However, if the clinical team, patient, and trusted family members agree to pursue active treatment, completion of a course of antenatal steroids and appropriate respiratory and cardiovascular support at birth are key to improving long-term outcomes. ●
 

First trimester miscarriage, the presence of a nonviable intrauterine pregnancy before 13 weeks’ gestation, is a common complication occurring in approximately 15% of clinical pregnancies.^1,2 The goals for the holistic management of first-trimester miscarriage are to 1) reduce the risk of complications such as excessive bleeding and infection, 2) ensure that the patient is supported during a time of great distress, and 3) optimally counsel the patient about treatment options and elicit the patient’s preferences for care.³ To resolve a miscarriage, the intrauterine pregnancy tissue must be expelled, restoring normal reproductive function.

The options for the management of a nonviable intrauterine pregnancy include expectant management, medication treatment with mifepristone plus misoprostol or misoprostol-alone, or uterine aspiration. In the absence of uterine hemorrhage, infection, or another severe complication of miscarriage, the patient’s preferences should guide the choice of treatment. Many patients with miscarriage prioritize avoiding medical interventions and may prefer expectant management. A patient who prefers rapid and reliable completion of the pregnancy loss process may prefer uterine aspiration. If the patient prefers to avoid uterine aspiration but desires control over the time and location of the expulsion process, medication treatment may be optimal. Many other factors influence a patient’s choice of miscarriage treatment, including balancing work and childcare issues and the ease of scheduling a uterine aspiration. In counseling patients about the options for miscarriage treatment it is helpful to know the success rate of each treatment option.⁴ This editorial reviews miscarriage treatment outcomes as summarized in a recent Cochrane network meta-analysis.⁵

Uterine aspiration versus mifepristone-misoprostol

In 2 clinical trials that included 899 patients with miscarriage, successful treatment with uterine aspira-tion versus mifepristone-misoprostolwas reported in 95% and 66% of cases, respectively.^6,7

In the largest clinical trial comparing uterine aspiration to mifepristone-misoprostol, 801 patients with first-trimester miscarriage were randomly assigned to uterine aspiration or mifepristone-misoprostol.⁶ Uterine aspiration and mifepristone-misoprostol were associated with successful miscarriage treatment in 95% and 64% of cases, respectively. In the uterine aspiration group, a second uterine aspiration occurred in 5% of patients. Two patients in the uterine aspiration group needed a third uterine aspiration to resolve the miscarriage. In the mifepristone-misoprostol group, 36% of patients had a uterine aspiration. It should be noted that the trial protocol guided patients having a medication abortion to uterine aspiration if expulsion of miscarriage tissue had not occurred within 8 hours of receiving misoprostol. If the trial protocol permitted 1 to 4 weeks of monitoring after mifepristone-misoprostol treatment, the success rate with medication treatment would be greater. Six to 8 weeks following miscarriage treatment, patient-reported anxiety and depression symptoms were similar in both groups.⁶

Uterine aspiration versus misoprostol

Among 3 clinical trials that limited enrollment to patients with missed miscarriage, involving 308 patients, the success rates for uterine aspiration and misoprostol treatment was 95% and 62%, respectively.⁵

In a study sponsored by the National Institutes of Health, 652 patients with missed miscarriage or incomplete miscarriage were randomly assigned in a 1:3 ratioto uterine aspiration or misoprostol treatment (800 µg vaginally). After 8 days of follow-up, successful treatment rates among the patients treated with uterine evacuation or misoprostol was 97% and 84%, respectively.⁸ Of note, with misoprostol treatment the success rate increased from day 3 to day 8 of follow-up—from 71% to 84%.⁸

Continue to: Mifepristone-misoprostol versus misoprostol...

The combined results of 7 clinical trials of medication management of missed miscarriage that included 1,812 patients showed that successful treatment with mifepristone-misoprostol or misoprostol alone occurred in 80% and 70% of cases, respectively.⁵

Schreiber and colleagues⁹ reported a study of 300 patients with an anembryonic gestation or embryonic demise that were between 5 and 12 completed weeks of gestation and randomly assigned to treatment with mifepristone (200 mg) plus vaginal misoprostol (800 µg) administered 24 to 48 hours after mifepristone or vaginal misoprostol (800 µg) alone. Ultrasonography was performed 1 to 4 days after misoprostol administration. Successful treatment was defined as expulsion of the gestational sac plus no additional surgical or medical intervention within 30 days after treatment. In this study, the dual-medication regimen of mifepristone-misoprostol was more successful than misoprostol alone in resolving the miscarriage, 84% and 67%, respectively (relative risk [RR], 1.25; 95% CI, 1.09–1.43). Surgical evacuation of the uterus occurred less often with mifepristone-misoprostol treatment (9%) than with misoprostol monotherapy (24%) (RR, 0.37; 95% CI, 0.21 ̶ 0.68). Pelvic infection occurred in 2 patients (1.3%) in each group. Uterine bleeding managed with blood transfusion occurred in 3 patients who received mifepristone-misoprostol and 1 patient who received misoprostol alone. In this study, clinical factors, including active bleeding, parity, and gestational age did not influence treatment success with the mifepristone-misoprostol regimen.¹⁰ The mifepristone-misoprostol regimen was reported to be more cost-effective than misoprostol alone.¹¹Chu and colleagues¹² reporteda study of medication treatmentof missed miscarriage that included more than 700 patients randomly assigned to treatment with mifepristone-misoprostol or placebo-misoprostol. Missed miscarriage was diagnosed by an ultrasound demonstrating a gestational sac and a nonviable pregnancy. The doses of mifepristone and misoprostol were 200 mg and 800 µg, respectively. In this study, the misoprostol was administered 48 hours following mifepristone or placebo using a vaginal, oral, or buccal route; 90% of patients used the vaginal route. Treatment was considered successful if the patient passed the gestational sac as determined by an ultrasound performed 7 days after entry into the study. If the gestational sac was passed, the patients were asked to do a urine pregnancy test 3 weeks after entering the study to conclude their care episode. If patients did not pass the gestational sac, they were offered a second dose of misoprostol or surgical evacuation. At 7 days of follow-up, the success rates in the mifepristone-misoprostol and misoprostol-alone groups were 83% and 76%, respectively. Surgical intervention was performed in 25% of patients treated with placebo-misoprostol and 17% of patients treated with mifepristone-misoprostol (RR, 0.73; 95% CI, 0.53 ̶ 0.95; P=.021).¹² A cost-effectiveness analysis of the trial results reported that the combination of mifepristone-misoprostol was less costly than misoprostolalone for the management of missed miscarriages.¹³

Photo: Getty Images

Expectant management versus uterine aspiration

The combined results of 7 clinical trials that included a total of 1,693 patients showed that successful treatment of miscarriage with expectant management or uterine aspiration occurred in 68% and 93% of cases, respectively.⁵ In one study, 700 patients with miscarriage were randomly assigned to expectant management or uterine aspiration. Treatment was successful for 56% and 95% of patients in the expectant management and uterine aspiration groups, respectively.⁶

The Cochrane network meta-analysis concluded that cervical preparation followed by uterine aspiration may be more effective than expectant management, with a reported risk ratio (RR) of 2.12 (95% CI, 1.41–3.20) with low-certainty evidence.⁵ In addition, uterine aspiration compared with expectant management may reduce the risk of serious complications (RR, 0.55; 95% CI, 0.23–1.32), with a wide range of treatment effects in reported trials and low-certainty evidence.⁵

In the treatment of miscarriage, the efficacy of expectant management may vary by the type of miscarriage. In one study, following the identification of a miscarriage, the percent of patients who have completed the expulsion of pregnancy tissue by 14 days was reported to be 84% for incomplete miscarriage, 59% for pregnancy loss with no expulsion of tissue, and 52% with ultrasound detection of a nonviable pregnancy with a gestational sac.¹⁴

Expectant management versus mifepristone-misoprostol

Aggregated data from 3 clinical trials that included a total of 910 patients showed that successful treatment with expectant management or mifepristone-misoprostol was reported in 48% and 68% of cases, respectively.⁵ The Cochrane network meta-analysis concluded that mifepristone-misoprostol may be more effective than expectant management, with a risk ratio of 1.42 (95% CI, 1.22–1.66) with low-certainty evidence. In addition, mifepristone-misoprostol compared with expectant management may reduce the risk for serious complications (RR, 0.76; 95% CI, 0.31–1.84) with wide range of treatment effects and low-certainty evidence.⁵

Continue to: Expectant management versus misoprostol...

The combined results of 10 clinical trials that included a total of 838 patients with miscarriage, showed that successful treatment with expectant management or misoprostol-alone occurred in 44% and 75% of cases, respectively.⁵ Among 3 studies limiting enrollment to patients with missed miscarriage, successful treatment with expectant management or misoprostol-alone occurred in 32% and 70%, respectively.⁵

The Cochrane analysis concluded that misoprostol-alone may be more effective than expectant management, with a reported risk ratio of 1.30 (95% CI, 1.16–1.46) with low-certainty evidence. In addition, misoprostol-alone compared with expectant management may reduce the risk of serious complications (RR, 0.50; 95% CI, 0.22–1.15) with a wide range of treatment effects and low-certainty evidence.⁵

Patient experience of miscarriage care

Pregnancy loss is often a distressing experience, which is associated with grief, anxiety, depression, and guilt, lasting up to 2 years for some patients.^15,16 Patient dissatisfaction with miscarriage care often focuses on 4 issues: a perceived lack of emotional support, failure to elicit patient preferences for treatment, insufficient provision of information, and inconsistent posttreatment follow-up.^17-19 When caring for patients with miscarriage, key goals are to communicate medical information with empathy and to provide emotional support. In the setting of a miscarriage, it is easy for patients to perceive that the clinician is insensitive and cold.¹⁵ Expressions of sympathy, compassion, and condolence help build an emotional connection and improve trust with the patient. Communications that may be helpful include: “I am sorry for your loss,” “I wish the outcome could be different,” “Our clinical team wants to provide you the best care possible,” and “May I ask how you are feeling?” Many patients report that they would like to have been offered mental health services as part of their miscarriage care.¹⁵

The Cochrane network meta-analysis of miscarriage concluded that uterine aspiration, misoprostol-mifepristone, and misoprostol-alone were likely more effective in resolving a miscarriage than expectant management.⁵ The strength of the conclusion was limited because of significant heterogeneity among studies, including different inclusion criteria, definition of success, and length of follow-up. Clinical trials with follow-up intervals more than 7 days generally reported greater success rates with expectant¹⁴ and medication management⁸ than studies with short follow-up intervals. Generally, expectant or medication management treatment is more likely to be successful in cases of incomplete abortion than in cases of missed miscarriage.⁵

In a rank analysis of treatment efficacy, uterine aspiration was top-ranked, followed by medication management. Expectant management had the greatest probability of being associated with unplanned uterine aspiration. Based on my analysis of available miscarriage studies, I estimate that the treatment success rates are approximately:

• uterine aspiration (93% to 99%)
• misoprostol-mifepristone (66% to 84%)
• misoprostol-alone (62% to 76%)
• expectant management (32% to 68%).

Although there may be significant differences in efficacy among the treatment options, offering patients all available approaches to treatment, providing information about the relative success of each approach, and eliciting the patient preference for care ensures an optimal patient experience during a major life event. ●
 

First trimester miscarriage, the presence of a nonviable intrauterine pregnancy before 13 weeks’ gestation, is a common complication occurring in approximately 15% of clinical pregnancies.^1,2 The goals for the holistic management of first-trimester miscarriage are to 1) reduce the risk of complications such as excessive bleeding and infection, 2) ensure that the patient is supported during a time of great distress, and 3) optimally counsel the patient about treatment options and elicit the patient’s preferences for care.³ To resolve a miscarriage, the intrauterine pregnancy tissue must be expelled, restoring normal reproductive function.

The options for the management of a nonviable intrauterine pregnancy include expectant management, medication treatment with mifepristone plus misoprostol or misoprostol-alone, or uterine aspiration. In the absence of uterine hemorrhage, infection, or another severe complication of miscarriage, the patient’s preferences should guide the choice of treatment. Many patients with miscarriage prioritize avoiding medical interventions and may prefer expectant management. A patient who prefers rapid and reliable completion of the pregnancy loss process may prefer uterine aspiration. If the patient prefers to avoid uterine aspiration but desires control over the time and location of the expulsion process, medication treatment may be optimal. Many other factors influence a patient’s choice of miscarriage treatment, including balancing work and childcare issues and the ease of scheduling a uterine aspiration. In counseling patients about the options for miscarriage treatment it is helpful to know the success rate of each treatment option.⁴ This editorial reviews miscarriage treatment outcomes as summarized in a recent Cochrane network meta-analysis.⁵

Uterine aspiration versus mifepristone-misoprostol

In 2 clinical trials that included 899 patients with miscarriage, successful treatment with uterine aspira-tion versus mifepristone-misoprostolwas reported in 95% and 66% of cases, respectively.^6,7

In the largest clinical trial comparing uterine aspiration to mifepristone-misoprostol, 801 patients with first-trimester miscarriage were randomly assigned to uterine aspiration or mifepristone-misoprostol.⁶ Uterine aspiration and mifepristone-misoprostol were associated with successful miscarriage treatment in 95% and 64% of cases, respectively. In the uterine aspiration group, a second uterine aspiration occurred in 5% of patients. Two patients in the uterine aspiration group needed a third uterine aspiration to resolve the miscarriage. In the mifepristone-misoprostol group, 36% of patients had a uterine aspiration. It should be noted that the trial protocol guided patients having a medication abortion to uterine aspiration if expulsion of miscarriage tissue had not occurred within 8 hours of receiving misoprostol. If the trial protocol permitted 1 to 4 weeks of monitoring after mifepristone-misoprostol treatment, the success rate with medication treatment would be greater. Six to 8 weeks following miscarriage treatment, patient-reported anxiety and depression symptoms were similar in both groups.⁶

Uterine aspiration versus misoprostol

Among 3 clinical trials that limited enrollment to patients with missed miscarriage, involving 308 patients, the success rates for uterine aspiration and misoprostol treatment was 95% and 62%, respectively.⁵

In a study sponsored by the National Institutes of Health, 652 patients with missed miscarriage or incomplete miscarriage were randomly assigned in a 1:3 ratioto uterine aspiration or misoprostol treatment (800 µg vaginally). After 8 days of follow-up, successful treatment rates among the patients treated with uterine evacuation or misoprostol was 97% and 84%, respectively.⁸ Of note, with misoprostol treatment the success rate increased from day 3 to day 8 of follow-up—from 71% to 84%.⁸

Continue to: Mifepristone-misoprostol versus misoprostol...

The combined results of 7 clinical trials of medication management of missed miscarriage that included 1,812 patients showed that successful treatment with mifepristone-misoprostol or misoprostol alone occurred in 80% and 70% of cases, respectively.⁵

Schreiber and colleagues⁹ reported a study of 300 patients with an anembryonic gestation or embryonic demise that were between 5 and 12 completed weeks of gestation and randomly assigned to treatment with mifepristone (200 mg) plus vaginal misoprostol (800 µg) administered 24 to 48 hours after mifepristone or vaginal misoprostol (800 µg) alone. Ultrasonography was performed 1 to 4 days after misoprostol administration. Successful treatment was defined as expulsion of the gestational sac plus no additional surgical or medical intervention within 30 days after treatment. In this study, the dual-medication regimen of mifepristone-misoprostol was more successful than misoprostol alone in resolving the miscarriage, 84% and 67%, respectively (relative risk [RR], 1.25; 95% CI, 1.09–1.43). Surgical evacuation of the uterus occurred less often with mifepristone-misoprostol treatment (9%) than with misoprostol monotherapy (24%) (RR, 0.37; 95% CI, 0.21 ̶ 0.68). Pelvic infection occurred in 2 patients (1.3%) in each group. Uterine bleeding managed with blood transfusion occurred in 3 patients who received mifepristone-misoprostol and 1 patient who received misoprostol alone. In this study, clinical factors, including active bleeding, parity, and gestational age did not influence treatment success with the mifepristone-misoprostol regimen.¹⁰ The mifepristone-misoprostol regimen was reported to be more cost-effective than misoprostol alone.¹¹Chu and colleagues¹² reporteda study of medication treatmentof missed miscarriage that included more than 700 patients randomly assigned to treatment with mifepristone-misoprostol or placebo-misoprostol. Missed miscarriage was diagnosed by an ultrasound demonstrating a gestational sac and a nonviable pregnancy. The doses of mifepristone and misoprostol were 200 mg and 800 µg, respectively. In this study, the misoprostol was administered 48 hours following mifepristone or placebo using a vaginal, oral, or buccal route; 90% of patients used the vaginal route. Treatment was considered successful if the patient passed the gestational sac as determined by an ultrasound performed 7 days after entry into the study. If the gestational sac was passed, the patients were asked to do a urine pregnancy test 3 weeks after entering the study to conclude their care episode. If patients did not pass the gestational sac, they were offered a second dose of misoprostol or surgical evacuation. At 7 days of follow-up, the success rates in the mifepristone-misoprostol and misoprostol-alone groups were 83% and 76%, respectively. Surgical intervention was performed in 25% of patients treated with placebo-misoprostol and 17% of patients treated with mifepristone-misoprostol (RR, 0.73; 95% CI, 0.53 ̶ 0.95; P=.021).¹² A cost-effectiveness analysis of the trial results reported that the combination of mifepristone-misoprostol was less costly than misoprostolalone for the management of missed miscarriages.¹³

Photo: Getty Images

Expectant management versus uterine aspiration

The combined results of 7 clinical trials that included a total of 1,693 patients showed that successful treatment of miscarriage with expectant management or uterine aspiration occurred in 68% and 93% of cases, respectively.⁵ In one study, 700 patients with miscarriage were randomly assigned to expectant management or uterine aspiration. Treatment was successful for 56% and 95% of patients in the expectant management and uterine aspiration groups, respectively.⁶

The Cochrane network meta-analysis concluded that cervical preparation followed by uterine aspiration may be more effective than expectant management, with a reported risk ratio (RR) of 2.12 (95% CI, 1.41–3.20) with low-certainty evidence.⁵ In addition, uterine aspiration compared with expectant management may reduce the risk of serious complications (RR, 0.55; 95% CI, 0.23–1.32), with a wide range of treatment effects in reported trials and low-certainty evidence.⁵

In the treatment of miscarriage, the efficacy of expectant management may vary by the type of miscarriage. In one study, following the identification of a miscarriage, the percent of patients who have completed the expulsion of pregnancy tissue by 14 days was reported to be 84% for incomplete miscarriage, 59% for pregnancy loss with no expulsion of tissue, and 52% with ultrasound detection of a nonviable pregnancy with a gestational sac.¹⁴

Expectant management versus mifepristone-misoprostol

Aggregated data from 3 clinical trials that included a total of 910 patients showed that successful treatment with expectant management or mifepristone-misoprostol was reported in 48% and 68% of cases, respectively.⁵ The Cochrane network meta-analysis concluded that mifepristone-misoprostol may be more effective than expectant management, with a risk ratio of 1.42 (95% CI, 1.22–1.66) with low-certainty evidence. In addition, mifepristone-misoprostol compared with expectant management may reduce the risk for serious complications (RR, 0.76; 95% CI, 0.31–1.84) with wide range of treatment effects and low-certainty evidence.⁵

Continue to: Expectant management versus misoprostol...

The combined results of 10 clinical trials that included a total of 838 patients with miscarriage, showed that successful treatment with expectant management or misoprostol-alone occurred in 44% and 75% of cases, respectively.⁵ Among 3 studies limiting enrollment to patients with missed miscarriage, successful treatment with expectant management or misoprostol-alone occurred in 32% and 70%, respectively.⁵

The Cochrane analysis concluded that misoprostol-alone may be more effective than expectant management, with a reported risk ratio of 1.30 (95% CI, 1.16–1.46) with low-certainty evidence. In addition, misoprostol-alone compared with expectant management may reduce the risk of serious complications (RR, 0.50; 95% CI, 0.22–1.15) with a wide range of treatment effects and low-certainty evidence.⁵

Patient experience of miscarriage care

Pregnancy loss is often a distressing experience, which is associated with grief, anxiety, depression, and guilt, lasting up to 2 years for some patients.^15,16 Patient dissatisfaction with miscarriage care often focuses on 4 issues: a perceived lack of emotional support, failure to elicit patient preferences for treatment, insufficient provision of information, and inconsistent posttreatment follow-up.^17-19 When caring for patients with miscarriage, key goals are to communicate medical information with empathy and to provide emotional support. In the setting of a miscarriage, it is easy for patients to perceive that the clinician is insensitive and cold.¹⁵ Expressions of sympathy, compassion, and condolence help build an emotional connection and improve trust with the patient. Communications that may be helpful include: “I am sorry for your loss,” “I wish the outcome could be different,” “Our clinical team wants to provide you the best care possible,” and “May I ask how you are feeling?” Many patients report that they would like to have been offered mental health services as part of their miscarriage care.¹⁵

The Cochrane network meta-analysis of miscarriage concluded that uterine aspiration, misoprostol-mifepristone, and misoprostol-alone were likely more effective in resolving a miscarriage than expectant management.⁵ The strength of the conclusion was limited because of significant heterogeneity among studies, including different inclusion criteria, definition of success, and length of follow-up. Clinical trials with follow-up intervals more than 7 days generally reported greater success rates with expectant¹⁴ and medication management⁸ than studies with short follow-up intervals. Generally, expectant or medication management treatment is more likely to be successful in cases of incomplete abortion than in cases of missed miscarriage.⁵

In a rank analysis of treatment efficacy, uterine aspiration was top-ranked, followed by medication management. Expectant management had the greatest probability of being associated with unplanned uterine aspiration. Based on my analysis of available miscarriage studies, I estimate that the treatment success rates are approximately:

• uterine aspiration (93% to 99%)
• misoprostol-mifepristone (66% to 84%)
• misoprostol-alone (62% to 76%)
• expectant management (32% to 68%).

Although there may be significant differences in efficacy among the treatment options, offering patients all available approaches to treatment, providing information about the relative success of each approach, and eliciting the patient preference for care ensures an optimal patient experience during a major life event. ●
 

First trimester miscarriage, the presence of a nonviable intrauterine pregnancy before 13 weeks’ gestation, is a common complication occurring in approximately 15% of clinical pregnancies.^1,2 The goals for the holistic management of first-trimester miscarriage are to 1) reduce the risk of complications such as excessive bleeding and infection, 2) ensure that the patient is supported during a time of great distress, and 3) optimally counsel the patient about treatment options and elicit the patient’s preferences for care.³ To resolve a miscarriage, the intrauterine pregnancy tissue must be expelled, restoring normal reproductive function.

The options for the management of a nonviable intrauterine pregnancy include expectant management, medication treatment with mifepristone plus misoprostol or misoprostol-alone, or uterine aspiration. In the absence of uterine hemorrhage, infection, or another severe complication of miscarriage, the patient’s preferences should guide the choice of treatment. Many patients with miscarriage prioritize avoiding medical interventions and may prefer expectant management. A patient who prefers rapid and reliable completion of the pregnancy loss process may prefer uterine aspiration. If the patient prefers to avoid uterine aspiration but desires control over the time and location of the expulsion process, medication treatment may be optimal. Many other factors influence a patient’s choice of miscarriage treatment, including balancing work and childcare issues and the ease of scheduling a uterine aspiration. In counseling patients about the options for miscarriage treatment it is helpful to know the success rate of each treatment option.⁴ This editorial reviews miscarriage treatment outcomes as summarized in a recent Cochrane network meta-analysis.⁵

Uterine aspiration versus mifepristone-misoprostol

In 2 clinical trials that included 899 patients with miscarriage, successful treatment with uterine aspira-tion versus mifepristone-misoprostolwas reported in 95% and 66% of cases, respectively.^6,7

In the largest clinical trial comparing uterine aspiration to mifepristone-misoprostol, 801 patients with first-trimester miscarriage were randomly assigned to uterine aspiration or mifepristone-misoprostol.⁶ Uterine aspiration and mifepristone-misoprostol were associated with successful miscarriage treatment in 95% and 64% of cases, respectively. In the uterine aspiration group, a second uterine aspiration occurred in 5% of patients. Two patients in the uterine aspiration group needed a third uterine aspiration to resolve the miscarriage. In the mifepristone-misoprostol group, 36% of patients had a uterine aspiration. It should be noted that the trial protocol guided patients having a medication abortion to uterine aspiration if expulsion of miscarriage tissue had not occurred within 8 hours of receiving misoprostol. If the trial protocol permitted 1 to 4 weeks of monitoring after mifepristone-misoprostol treatment, the success rate with medication treatment would be greater. Six to 8 weeks following miscarriage treatment, patient-reported anxiety and depression symptoms were similar in both groups.⁶

Uterine aspiration versus misoprostol

Among 3 clinical trials that limited enrollment to patients with missed miscarriage, involving 308 patients, the success rates for uterine aspiration and misoprostol treatment was 95% and 62%, respectively.⁵

In a study sponsored by the National Institutes of Health, 652 patients with missed miscarriage or incomplete miscarriage were randomly assigned in a 1:3 ratioto uterine aspiration or misoprostol treatment (800 µg vaginally). After 8 days of follow-up, successful treatment rates among the patients treated with uterine evacuation or misoprostol was 97% and 84%, respectively.⁸ Of note, with misoprostol treatment the success rate increased from day 3 to day 8 of follow-up—from 71% to 84%.⁸

Continue to: Mifepristone-misoprostol versus misoprostol...

The combined results of 7 clinical trials of medication management of missed miscarriage that included 1,812 patients showed that successful treatment with mifepristone-misoprostol or misoprostol alone occurred in 80% and 70% of cases, respectively.⁵

Schreiber and colleagues⁹ reported a study of 300 patients with an anembryonic gestation or embryonic demise that were between 5 and 12 completed weeks of gestation and randomly assigned to treatment with mifepristone (200 mg) plus vaginal misoprostol (800 µg) administered 24 to 48 hours after mifepristone or vaginal misoprostol (800 µg) alone. Ultrasonography was performed 1 to 4 days after misoprostol administration. Successful treatment was defined as expulsion of the gestational sac plus no additional surgical or medical intervention within 30 days after treatment. In this study, the dual-medication regimen of mifepristone-misoprostol was more successful than misoprostol alone in resolving the miscarriage, 84% and 67%, respectively (relative risk [RR], 1.25; 95% CI, 1.09–1.43). Surgical evacuation of the uterus occurred less often with mifepristone-misoprostol treatment (9%) than with misoprostol monotherapy (24%) (RR, 0.37; 95% CI, 0.21 ̶ 0.68). Pelvic infection occurred in 2 patients (1.3%) in each group. Uterine bleeding managed with blood transfusion occurred in 3 patients who received mifepristone-misoprostol and 1 patient who received misoprostol alone. In this study, clinical factors, including active bleeding, parity, and gestational age did not influence treatment success with the mifepristone-misoprostol regimen.¹⁰ The mifepristone-misoprostol regimen was reported to be more cost-effective than misoprostol alone.¹¹Chu and colleagues¹² reporteda study of medication treatmentof missed miscarriage that included more than 700 patients randomly assigned to treatment with mifepristone-misoprostol or placebo-misoprostol. Missed miscarriage was diagnosed by an ultrasound demonstrating a gestational sac and a nonviable pregnancy. The doses of mifepristone and misoprostol were 200 mg and 800 µg, respectively. In this study, the misoprostol was administered 48 hours following mifepristone or placebo using a vaginal, oral, or buccal route; 90% of patients used the vaginal route. Treatment was considered successful if the patient passed the gestational sac as determined by an ultrasound performed 7 days after entry into the study. If the gestational sac was passed, the patients were asked to do a urine pregnancy test 3 weeks after entering the study to conclude their care episode. If patients did not pass the gestational sac, they were offered a second dose of misoprostol or surgical evacuation. At 7 days of follow-up, the success rates in the mifepristone-misoprostol and misoprostol-alone groups were 83% and 76%, respectively. Surgical intervention was performed in 25% of patients treated with placebo-misoprostol and 17% of patients treated with mifepristone-misoprostol (RR, 0.73; 95% CI, 0.53 ̶ 0.95; P=.021).¹² A cost-effectiveness analysis of the trial results reported that the combination of mifepristone-misoprostol was less costly than misoprostolalone for the management of missed miscarriages.¹³

Photo: Getty Images

Expectant management versus uterine aspiration

The combined results of 7 clinical trials that included a total of 1,693 patients showed that successful treatment of miscarriage with expectant management or uterine aspiration occurred in 68% and 93% of cases, respectively.⁵ In one study, 700 patients with miscarriage were randomly assigned to expectant management or uterine aspiration. Treatment was successful for 56% and 95% of patients in the expectant management and uterine aspiration groups, respectively.⁶

The Cochrane network meta-analysis concluded that cervical preparation followed by uterine aspiration may be more effective than expectant management, with a reported risk ratio (RR) of 2.12 (95% CI, 1.41–3.20) with low-certainty evidence.⁵ In addition, uterine aspiration compared with expectant management may reduce the risk of serious complications (RR, 0.55; 95% CI, 0.23–1.32), with a wide range of treatment effects in reported trials and low-certainty evidence.⁵

In the treatment of miscarriage, the efficacy of expectant management may vary by the type of miscarriage. In one study, following the identification of a miscarriage, the percent of patients who have completed the expulsion of pregnancy tissue by 14 days was reported to be 84% for incomplete miscarriage, 59% for pregnancy loss with no expulsion of tissue, and 52% with ultrasound detection of a nonviable pregnancy with a gestational sac.¹⁴

Expectant management versus mifepristone-misoprostol

Aggregated data from 3 clinical trials that included a total of 910 patients showed that successful treatment with expectant management or mifepristone-misoprostol was reported in 48% and 68% of cases, respectively.⁵ The Cochrane network meta-analysis concluded that mifepristone-misoprostol may be more effective than expectant management, with a risk ratio of 1.42 (95% CI, 1.22–1.66) with low-certainty evidence. In addition, mifepristone-misoprostol compared with expectant management may reduce the risk for serious complications (RR, 0.76; 95% CI, 0.31–1.84) with wide range of treatment effects and low-certainty evidence.⁵

Continue to: Expectant management versus misoprostol...

The combined results of 10 clinical trials that included a total of 838 patients with miscarriage, showed that successful treatment with expectant management or misoprostol-alone occurred in 44% and 75% of cases, respectively.⁵ Among 3 studies limiting enrollment to patients with missed miscarriage, successful treatment with expectant management or misoprostol-alone occurred in 32% and 70%, respectively.⁵

The Cochrane analysis concluded that misoprostol-alone may be more effective than expectant management, with a reported risk ratio of 1.30 (95% CI, 1.16–1.46) with low-certainty evidence. In addition, misoprostol-alone compared with expectant management may reduce the risk of serious complications (RR, 0.50; 95% CI, 0.22–1.15) with a wide range of treatment effects and low-certainty evidence.⁵

Patient experience of miscarriage care

Pregnancy loss is often a distressing experience, which is associated with grief, anxiety, depression, and guilt, lasting up to 2 years for some patients.^15,16 Patient dissatisfaction with miscarriage care often focuses on 4 issues: a perceived lack of emotional support, failure to elicit patient preferences for treatment, insufficient provision of information, and inconsistent posttreatment follow-up.^17-19 When caring for patients with miscarriage, key goals are to communicate medical information with empathy and to provide emotional support. In the setting of a miscarriage, it is easy for patients to perceive that the clinician is insensitive and cold.¹⁵ Expressions of sympathy, compassion, and condolence help build an emotional connection and improve trust with the patient. Communications that may be helpful include: “I am sorry for your loss,” “I wish the outcome could be different,” “Our clinical team wants to provide you the best care possible,” and “May I ask how you are feeling?” Many patients report that they would like to have been offered mental health services as part of their miscarriage care.¹⁵

The Cochrane network meta-analysis of miscarriage concluded that uterine aspiration, misoprostol-mifepristone, and misoprostol-alone were likely more effective in resolving a miscarriage than expectant management.⁵ The strength of the conclusion was limited because of significant heterogeneity among studies, including different inclusion criteria, definition of success, and length of follow-up. Clinical trials with follow-up intervals more than 7 days generally reported greater success rates with expectant¹⁴ and medication management⁸ than studies with short follow-up intervals. Generally, expectant or medication management treatment is more likely to be successful in cases of incomplete abortion than in cases of missed miscarriage.⁵

In a rank analysis of treatment efficacy, uterine aspiration was top-ranked, followed by medication management. Expectant management had the greatest probability of being associated with unplanned uterine aspiration. Based on my analysis of available miscarriage studies, I estimate that the treatment success rates are approximately:

• uterine aspiration (93% to 99%)
• misoprostol-mifepristone (66% to 84%)
• misoprostol-alone (62% to 76%)
• expectant management (32% to 68%).

Although there may be significant differences in efficacy among the treatment options, offering patients all available approaches to treatment, providing information about the relative success of each approach, and eliciting the patient preference for care ensures an optimal patient experience during a major life event. ●
 

Clinical care for fetal demise is complex and multidimensional, including empathic emotional support for the patient and family members who are experiencing a tragedy, investigation of the cause of the demise, and a plan for emptying the uterus. This editorial narrowly focuses on the options for treatment of fetal demise with the goal of emptying the uterus while minimizing complications.

When planning treatment of fetal demise, focus on fetal size and gestational age

Most guidelines for the treatment of fetal demise use gestational age to guide selection of a treatment.^1,2 I believe that fetal size is as important as gestational age for selecting a treatment plan. When considering treatment, there are 2 reasons why fetal size is as important as gestational age:

• The physiologic processes that caused fetal demise may have caused fetal growth restriction, resulting in a fetal size that is 2 or more weeks below expected fetal size for gestational age.
• Fetal demise may have occurred weeks before the diagnosis was made, resulting in gestational age being greater than fetal size. This editorial will use ultrasonography estimate of fetal size in gestational weeks to guide treatment recommendations. When discussing fetal size, we will use the convention of weeks-days (w-d). Twenty-five weeks and zero days gestation is represented as 25w0d.

Treatment in the second and third trimester is a 2-step process

Step 1: Cervical preparation

In most cases of first trimester fetal demise, no cervical preparation is necessary. Cervical dilation with metal dilators followed by uterine evacuation with an appropriately sized vacuum catheter is a highly successful treatment.³ However for second and third trimester fetal demise, it is best to use a 2-step process, beginning with cervical preparation followed by emptying the uterus. For example, at a fetal size of 13w0d to 16w0d, cervical preparation can be achieved by administering a single buccal dose of misoprostol 400 µg 3 to 4 hours prior to uterine evacuation or by inserting a Dilapan-S (Medicem Inc) osmotic cervical dilator 3 to 6 hours prior to uterine evacuation.^4-7 At a fetal size of 16w0d to 19w6d, cervical preparation can be achieved by placing osmotic cervical dilators 4 to 6 hours before surgical evacuation and administering buccal misoprostol 400 µg 3 hours before surgical evacuation.⁸

Alternatively, from 16w0d to 25w0d osmotic cervical dilators can be placed on day 1 of a 2-day process, and the patient can return on day 2 to have the cervical dilators removed followed by surgical evacuation of the uterus. Mifepristone 200 mg oral dose can be administered on day 1 to facilitate cervical preparation. In my practice, I use mifepristone 200 mg on day 1 when the fetal size is ≥20w0d gestation. Options for cervical preparation include use of osmotic dilators, cervical balloons, misoprostol, and/or mifepristone. These options are discussed below. With fetal demise, natural physiologic processes often have caused sufficient cervical softening and dilation that no cervical preparation is necessary and immediate uterine surgical evacuation or induction of labor can be initiated.

Step 2: Emptying the uterus

In the second and third trimesters, the approach to uterine evacuation is based on fetal size. At fetal sizes <25w0d, options for emptying the uterus include surgical evacuation with a vacuum catheter and grasping forceps or induction of labor with misoprostol followed by vaginal birth and expulsion of the placenta. At fetal sizes ˃25w0d gestation, following completion of cervical preparation, the most common approaches to uterine evacuation are induction of labor with misoprostol or oxytocin. Rarely, with a stillbirth at term, some clinicians will select hysterotomy to empty the uterus, avoiding uterine rupture during labor induction for patients at the highest risk, including those with a prior classical cesarean birth or more than 2 prior cesarean births with a low-transverse uterine incision.

Osmotic cervical dilators

The 2 most used cervical dilators are Dilapan-S, a polyacrylate-based hydrogel rod, and laminaria, dried compressed seaweed stipe (stalk) from Laminaria japonica or Laminaria digitata. Dilapan-S rods are available in diameters of 3 mm and 4 mm and rod lengths of 55 mm and 65 mm. Laminaria dilators are available in diameters of 2, 3, 4, 5, 6, 8 and 10 mm and rod length of 60 and 70 mm. Dilapan-S dilators reach near-maximal dilation in approximately 4 to 6 hours but continue to expand over the following 18 hours to achieve a maximum dilation of 3.3 to 3.6 times their dry diameter.⁹ Laminaria dilators expand to 2.7 to 2.9 times their dry diameter over 24 hours.⁹

A general rule is that as many dilators as possible should be placed until significant resistance to the placement of additional dilators is encountered.¹⁰ In my practice, for fetal size ≥20 weeks’ gestation, I place 2 Dilapan-S rods, 4 mm in diameter, 55 mm in length, and then encircle the Dilapan-S with laminaria rods that are 4 mm in diameter and 60 mm in length. Once cervical resistance to the placement of the 4 mm laminaria rods is observed, I encircle those laminaria with laminaria 2 mm in diameter, filling in the interstices between the 4 mm laminaria. The next day, cervical dilation is routinely ≥3 cm.

In a retrospective study of 491 patients undergoing pregnancy termination after 14 weeks’ gestation, with a mean gestational age of 24 weeks, compared with no osmotic cervical dilators, inserting osmotic cervical dilators the day before initiating misoprostol for induction of labor resulted in a decrease in time to delivery (428 min vs 640 min; P<.001) and a decrease in total misoprostol dose (990 µg vs 1,449 µg; P<.0001).¹¹

Cervical balloons

All clinicians know that a Foley catheter or a Cook cervical ripening balloon can be used for cervical preparation in the third trimester.^12,13 The Foley catheter also has been reported to be useful for cervical preparation in the second trimester. In one study of 43 patients 17 to 24 weeks’ gestation scheduled for a second-trimester dilation and evacuation, an intracervical Foley catheter was placed the evening before evacuation, and the balloon was inflated with 30 mL to 50 mL of saline. At the same time, mifepristone 200 mg was administered to the patients.¹⁴ The following day, dilation and evacuation was performed. In 72% of cases no additional cervical dilation was required on the day of evacuation. The investigators concluded that if osmotic cervical dilators are not available, the placement of an intracervical Foley catheter plus administration of mifepristone facilitates performance of an evacuation on the following day. If the patient prefers a 1-day procedure, the Foley can be inserted in the morning to facilitate cervical preparation, and the uterus can be evacuated in the afternoon.

Continue to: Misoprostol...

Misoprostol

Misoprostol, a derivative of prostaglandin E1, is useful for both cervical preparation and induction of labor. The dose of misoprostol and the route of administration are major determinants of uterine response.^15-19 When administered by an oral route, misoprostol has fast onset and offset of action and often does not cause sustained uterine contractions. Hence, oral misoprostol, at a low dose is useful for cervical ripening, but not as useful for stimulation of sustained uterine contractions for induction of labor. When administered by a buccal or vaginal route, misoprostol has prolonged activity and often results in sustained uterine contractions. At any given dose of misoprostol, buccal and vaginal misoprostol administration are more effective than oral administration in inducing sustained uterine contractions sufficient to empty the uterus.^15-19

Mifepristone

Mifepristone, an anti-progestin, is useful for cervical preparation and sensitizing myocytes to the action of uterotonics. Progesterone reduces cell-to-cell communication among uterine myocytes, facilitating uterine quiescence by suppressing connexin 43 and other proteins. Mifepristone blocks the effect of progesterone, inducing the production of myocyte connexin 43, enhancing efficient cell-to-cell communication, permitting uterine myoctes to contract in unison, creating the potential for powerful and sustained contractions.^20-23 Randomized clinical trials report that administration of mifepristone 200 mg prior to misoprostol induced labor results in more rapid emptying of the uterus.^24-27

It takes time for mifepristone to have its full effect on uterine myocytes. Hence, most protocols recommend waiting 24 hours following mifepristone administration before initiating treatment with an agent to stimulate uterine contractions such as misoprostol or oxytocin. However, preliminary data suggest that partial benefit of mifepristone can be obtained when initiating misoprostol 3 to 5 hours after mifepristone administration.²⁸ In a study of 481 patients undergoing induction of labor in the second or third trimester, the time from initiation of misoprostol to vaginal birth was 15 hours with no mifepristone pretreatment, 13.2 hours if mifepristone was administered 3 to 5 hours before initiating misoprostol, 9.3 hours if mifepristone was administered 24 hours before initiating misoprostol, and 10.5 hours if mifepristone was administered 48 hours before initiating misoprostol.²⁸

Fetal size <25w0d gestation: Cervical preparation and surgical evacuation

For fetal demise at a fetal size less than 25w0d, if clinical experts are available, the best treatment option is cervical preparation followed by surgical evacuation of the uterus using a vacuum catheter and grasping forceps to empty the uterus.^29,30 A disadvantage of surgical evacuation of the uterus is that an intact fetus is not available for the patient to hold and mourn, and pathologic examination of an intact fetus is not possible. An alternative approach is cervical preparation followed by induction of labor using misoprostol with the goal of delivering an intact fetus. Although no prospective clinical trials are available comparing these 2 options, retrospective studies have reported that, at fetal size <25w0d gestation, compared with induction of labor, surgical evacuation of the uterus results in fewer complications,³⁰ including fewer cases of retained placenta requiring an unplanned procedure and fewer presumed uterine infections.²⁹

For surgical evacuation of fetal demise with a fetal size of <25w0d gestation, the first step on day 1 is placement of osmotic cervical dilators. In addition to osmotic cervical dilators, if the gestational age or fetal size is ≥19 weeks’ gestation an oral dose of mifepristone 200 mg to facilitate cervical preparation may be considered. On day 2, the osmotic dilators are removed and surgical evacuation is performed. In one randomized study, for pregnancies at 19 to 24 weeks’ gestation, compared with osmotic dilators alone, administration of mifepristone 200 mg at the time of placement of osmotic dilators resulted in fewer procedures that were difficult to complete.³¹ In some cases, 2 consecutive days of cervical preparation with osmotic dilators may be needed to properly prepare the cervix for uterine evacuation. For example, the cervix of a nulliparous teenage patient may require 2 days of cervical preparation with osmotic dilators to facilitate uterine evacuation. In some cases of fetal demise, the cervix is already dilated to ≥3 cm and surgical evacuation of the uterus or induction of labor can be initiated without the need for cervical preparation.

Continue to: Fetal size 14w0d to 28w6d gestation: Cervical preparation and induction of labor...

Treatment of fetal demise at 14w0d to 28w6d gestation with the goal of the vaginal birth of an intact fetus is optimized by the administration of mifepristone for cervical preparation followed by induction of labor with misoprostol.^26,27

In one clinical trial, 66 patients with fetal demise between 14w0d and 28w6d gestation were randomly assigned to receive mifepristone 200 mg or placebo followed 24 to 48 hours later with initiation of misoprostol induction of labor.²⁶ Among the patients from 14w0d to 24 weeks’ gestation, the misoprostol dose was 400 µg vaginally every 6 hours. For patients from 24w0d to 28 weeks’ gestation, the misoprostol dose was 200 µg vaginally every 4 hours. At 24 hours, a consultant obstetrician determined if additional misoprostol should be given. The median time from initiation of misoprostol to birth for the patients in the mifepristone and placebo groups was 6.8 hours and 10.5 hours (P=.002).

Compared with the patients in the placebo-misoprostol group, the patients in the mifepristone-misoprostol group required fewer doses of misoprostol (2.1 vs 3.4; P= .002) and a lower total dose of misoprostol (768 µg vs 1,182 µg; P=.003). All patients in the mifepristone group delivered within 24 hours. By contrast, 13% of the patients in the placebo group delivered more than 24 hours after the initiation of misoprostol treatment. Five patients were readmitted with retained products of conception needing suction curettage, 4 in the placebo group and 1 in the mifepristone group.²⁶

In a second clinical trial, 105 patients with fetal demise after 20 weeks of gestation were randomly assigned to receive mifepristone 200 mg or placebo.²⁷ In this study, 86% of the patients were ≥26w0d gestation, with a mean gestational age of approximately 32w2d. Thirty-six to 48 hours later, misoprostol induction of labor was initiated. Among the patients from 20 to 25 completed weeks of gestation, the misoprostoldose was 100 µg vaginally every 6 hours for a maximum of 4 doses. For patients from ≥26 weeks’ gestation, the misoprostol dose was 50 µg vaginally every 4 hours for a maximum of 6 doses. The median times from initiation of misoprostol to birth for the patients in the mifepristone and placebo groups were 9.8 hours and 16.3 hours, respectively (P=.001). Compared with the patients in the placebo-misoprostol group, the patients in the mifepristone-misoprostol group required a lower total dose of misoprostol (110 µg vs 198 µg; P<.001). Delivery within 24 hours following initiation of misoprostol occurred in 93% and 73% of the patients in the mifepristone and placebo groups, respectively (P<.001). Compared with patients in the mifepristone group, shivering occurred more frequently among patients in the placebo group (7.5% vs 19.2%; P=.09), likely because they received greater doses of misoprostol.²⁷

Fetal size ≥29w0d gestation

At a fetal size ≥29w0d gestation, if the cervix is ripe with a Bishop score of ≥7, oxytocin induction of labor is often used as a first-line treatment. If the cervix is not ripe, misoprostol induction of labor may be considered at doses less than those used in the second trimester of pregnancy.³²TABLES 1,^{1, 26, 33–36}2,³⁷ and 3³⁷ summarize regimens proposed for fetal size ≥29w0d. One regimen begins with an initial misoprostol dose of 50 µg. If adequate uterine contractions occur, the 50 µg dose is repeated every 4 hours up to 6 total doses. If contractions are inadequate, the dose can be increased to 100 µg every 4 hours for 5 additional doses.

For fetal demise after 28w0d gestation, the American College of Obstetricians and Gynecologists (ACOG)¹ recommends standard obstetric protocols for induction of labor, including standard protocols for induction of labor following a previous cesarean birth. For a patient with a history of a prior cesarean birth or major uterine surgery, ACOG recommends that management of fetal demise should prioritize the use of mechanical cervical ripening, for example with a balloon catheter, and induction of uterine contractions with oxytocin.³⁸ ACOG recommends against the use of misoprostol for cervical ripening or labor induction for patients with a stillbirth at term with a history of a cesarean birth.³⁸ Preliminary experience suggests that stillbirth protocols using misoprostol doses modestly greater than those used in the management of a pregnancy with a viable fetus may be safe.⁹ See TABLES 2 and 3.

A multidisciplinary approach can optimize compassionate care

There are many gaps in the holistic care of patients and partners experiencing fetal demise. Patients with fetal demise often report that they did not receive sufficient information about the cause of the demise and wanted more opportunity to be involved in decision making about their care.³⁹ The patient’s partner often reports feeling unacknowledged as a grieving parent.⁴⁰ Fetal demise is experienced by many patients as a tragedy, triggering feelings of grief, anger, denial, anxiety and depression, sometimes resulting in isolation and substance misuse.

Using a 5-round Delphi process, experts identified 8 core goals in the care of patients with fetal demise:

1. reduce stigma
2. provide respectful care
3. involve patients in care planning
4. attempt to provide an explanation for the demise¹
5. acknowledge the depth of the grief response and provide emotional support
6. offer information about ongoing psychological support
7. provide information about future pregnancy planning
8. provide opportunities for specialized training and support for care providers.⁴¹

Management of stillbirth is optimized by a multidisciplinary approach that includes the expert care of obstetrician-gynecologists, obstetric nurses, anesthesiologists, and expert consultation from social work, chaplaincy, and pathology. A heart-to-heart connection between clinician and patient is a key component of stillbirth care. ●

Clinical care for fetal demise is complex and multidimensional, including empathic emotional support for the patient and family members who are experiencing a tragedy, investigation of the cause of the demise, and a plan for emptying the uterus. This editorial narrowly focuses on the options for treatment of fetal demise with the goal of emptying the uterus while minimizing complications.

When planning treatment of fetal demise, focus on fetal size and gestational age

Most guidelines for the treatment of fetal demise use gestational age to guide selection of a treatment.^1,2 I believe that fetal size is as important as gestational age for selecting a treatment plan. When considering treatment, there are 2 reasons why fetal size is as important as gestational age:

• The physiologic processes that caused fetal demise may have caused fetal growth restriction, resulting in a fetal size that is 2 or more weeks below expected fetal size for gestational age.
• Fetal demise may have occurred weeks before the diagnosis was made, resulting in gestational age being greater than fetal size. This editorial will use ultrasonography estimate of fetal size in gestational weeks to guide treatment recommendations. When discussing fetal size, we will use the convention of weeks-days (w-d). Twenty-five weeks and zero days gestation is represented as 25w0d.

Treatment in the second and third trimester is a 2-step process

Step 1: Cervical preparation

In most cases of first trimester fetal demise, no cervical preparation is necessary. Cervical dilation with metal dilators followed by uterine evacuation with an appropriately sized vacuum catheter is a highly successful treatment.³ However for second and third trimester fetal demise, it is best to use a 2-step process, beginning with cervical preparation followed by emptying the uterus. For example, at a fetal size of 13w0d to 16w0d, cervical preparation can be achieved by administering a single buccal dose of misoprostol 400 µg 3 to 4 hours prior to uterine evacuation or by inserting a Dilapan-S (Medicem Inc) osmotic cervical dilator 3 to 6 hours prior to uterine evacuation.^4-7 At a fetal size of 16w0d to 19w6d, cervical preparation can be achieved by placing osmotic cervical dilators 4 to 6 hours before surgical evacuation and administering buccal misoprostol 400 µg 3 hours before surgical evacuation.⁸

Alternatively, from 16w0d to 25w0d osmotic cervical dilators can be placed on day 1 of a 2-day process, and the patient can return on day 2 to have the cervical dilators removed followed by surgical evacuation of the uterus. Mifepristone 200 mg oral dose can be administered on day 1 to facilitate cervical preparation. In my practice, I use mifepristone 200 mg on day 1 when the fetal size is ≥20w0d gestation. Options for cervical preparation include use of osmotic dilators, cervical balloons, misoprostol, and/or mifepristone. These options are discussed below. With fetal demise, natural physiologic processes often have caused sufficient cervical softening and dilation that no cervical preparation is necessary and immediate uterine surgical evacuation or induction of labor can be initiated.

Step 2: Emptying the uterus

In the second and third trimesters, the approach to uterine evacuation is based on fetal size. At fetal sizes <25w0d, options for emptying the uterus include surgical evacuation with a vacuum catheter and grasping forceps or induction of labor with misoprostol followed by vaginal birth and expulsion of the placenta. At fetal sizes ˃25w0d gestation, following completion of cervical preparation, the most common approaches to uterine evacuation are induction of labor with misoprostol or oxytocin. Rarely, with a stillbirth at term, some clinicians will select hysterotomy to empty the uterus, avoiding uterine rupture during labor induction for patients at the highest risk, including those with a prior classical cesarean birth or more than 2 prior cesarean births with a low-transverse uterine incision.

Osmotic cervical dilators

The 2 most used cervical dilators are Dilapan-S, a polyacrylate-based hydrogel rod, and laminaria, dried compressed seaweed stipe (stalk) from Laminaria japonica or Laminaria digitata. Dilapan-S rods are available in diameters of 3 mm and 4 mm and rod lengths of 55 mm and 65 mm. Laminaria dilators are available in diameters of 2, 3, 4, 5, 6, 8 and 10 mm and rod length of 60 and 70 mm. Dilapan-S dilators reach near-maximal dilation in approximately 4 to 6 hours but continue to expand over the following 18 hours to achieve a maximum dilation of 3.3 to 3.6 times their dry diameter.⁹ Laminaria dilators expand to 2.7 to 2.9 times their dry diameter over 24 hours.⁹

A general rule is that as many dilators as possible should be placed until significant resistance to the placement of additional dilators is encountered.¹⁰ In my practice, for fetal size ≥20 weeks’ gestation, I place 2 Dilapan-S rods, 4 mm in diameter, 55 mm in length, and then encircle the Dilapan-S with laminaria rods that are 4 mm in diameter and 60 mm in length. Once cervical resistance to the placement of the 4 mm laminaria rods is observed, I encircle those laminaria with laminaria 2 mm in diameter, filling in the interstices between the 4 mm laminaria. The next day, cervical dilation is routinely ≥3 cm.

In a retrospective study of 491 patients undergoing pregnancy termination after 14 weeks’ gestation, with a mean gestational age of 24 weeks, compared with no osmotic cervical dilators, inserting osmotic cervical dilators the day before initiating misoprostol for induction of labor resulted in a decrease in time to delivery (428 min vs 640 min; P<.001) and a decrease in total misoprostol dose (990 µg vs 1,449 µg; P<.0001).¹¹

Cervical balloons

All clinicians know that a Foley catheter or a Cook cervical ripening balloon can be used for cervical preparation in the third trimester.^12,13 The Foley catheter also has been reported to be useful for cervical preparation in the second trimester. In one study of 43 patients 17 to 24 weeks’ gestation scheduled for a second-trimester dilation and evacuation, an intracervical Foley catheter was placed the evening before evacuation, and the balloon was inflated with 30 mL to 50 mL of saline. At the same time, mifepristone 200 mg was administered to the patients.¹⁴ The following day, dilation and evacuation was performed. In 72% of cases no additional cervical dilation was required on the day of evacuation. The investigators concluded that if osmotic cervical dilators are not available, the placement of an intracervical Foley catheter plus administration of mifepristone facilitates performance of an evacuation on the following day. If the patient prefers a 1-day procedure, the Foley can be inserted in the morning to facilitate cervical preparation, and the uterus can be evacuated in the afternoon.

Continue to: Misoprostol...

Misoprostol

Misoprostol, a derivative of prostaglandin E1, is useful for both cervical preparation and induction of labor. The dose of misoprostol and the route of administration are major determinants of uterine response.^15-19 When administered by an oral route, misoprostol has fast onset and offset of action and often does not cause sustained uterine contractions. Hence, oral misoprostol, at a low dose is useful for cervical ripening, but not as useful for stimulation of sustained uterine contractions for induction of labor. When administered by a buccal or vaginal route, misoprostol has prolonged activity and often results in sustained uterine contractions. At any given dose of misoprostol, buccal and vaginal misoprostol administration are more effective than oral administration in inducing sustained uterine contractions sufficient to empty the uterus.^15-19

Mifepristone

Mifepristone, an anti-progestin, is useful for cervical preparation and sensitizing myocytes to the action of uterotonics. Progesterone reduces cell-to-cell communication among uterine myocytes, facilitating uterine quiescence by suppressing connexin 43 and other proteins. Mifepristone blocks the effect of progesterone, inducing the production of myocyte connexin 43, enhancing efficient cell-to-cell communication, permitting uterine myoctes to contract in unison, creating the potential for powerful and sustained contractions.^20-23 Randomized clinical trials report that administration of mifepristone 200 mg prior to misoprostol induced labor results in more rapid emptying of the uterus.^24-27

It takes time for mifepristone to have its full effect on uterine myocytes. Hence, most protocols recommend waiting 24 hours following mifepristone administration before initiating treatment with an agent to stimulate uterine contractions such as misoprostol or oxytocin. However, preliminary data suggest that partial benefit of mifepristone can be obtained when initiating misoprostol 3 to 5 hours after mifepristone administration.²⁸ In a study of 481 patients undergoing induction of labor in the second or third trimester, the time from initiation of misoprostol to vaginal birth was 15 hours with no mifepristone pretreatment, 13.2 hours if mifepristone was administered 3 to 5 hours before initiating misoprostol, 9.3 hours if mifepristone was administered 24 hours before initiating misoprostol, and 10.5 hours if mifepristone was administered 48 hours before initiating misoprostol.²⁸

Fetal size <25w0d gestation: Cervical preparation and surgical evacuation

For fetal demise at a fetal size less than 25w0d, if clinical experts are available, the best treatment option is cervical preparation followed by surgical evacuation of the uterus using a vacuum catheter and grasping forceps to empty the uterus.^29,30 A disadvantage of surgical evacuation of the uterus is that an intact fetus is not available for the patient to hold and mourn, and pathologic examination of an intact fetus is not possible. An alternative approach is cervical preparation followed by induction of labor using misoprostol with the goal of delivering an intact fetus. Although no prospective clinical trials are available comparing these 2 options, retrospective studies have reported that, at fetal size <25w0d gestation, compared with induction of labor, surgical evacuation of the uterus results in fewer complications,³⁰ including fewer cases of retained placenta requiring an unplanned procedure and fewer presumed uterine infections.²⁹

For surgical evacuation of fetal demise with a fetal size of <25w0d gestation, the first step on day 1 is placement of osmotic cervical dilators. In addition to osmotic cervical dilators, if the gestational age or fetal size is ≥19 weeks’ gestation an oral dose of mifepristone 200 mg to facilitate cervical preparation may be considered. On day 2, the osmotic dilators are removed and surgical evacuation is performed. In one randomized study, for pregnancies at 19 to 24 weeks’ gestation, compared with osmotic dilators alone, administration of mifepristone 200 mg at the time of placement of osmotic dilators resulted in fewer procedures that were difficult to complete.³¹ In some cases, 2 consecutive days of cervical preparation with osmotic dilators may be needed to properly prepare the cervix for uterine evacuation. For example, the cervix of a nulliparous teenage patient may require 2 days of cervical preparation with osmotic dilators to facilitate uterine evacuation. In some cases of fetal demise, the cervix is already dilated to ≥3 cm and surgical evacuation of the uterus or induction of labor can be initiated without the need for cervical preparation.

Continue to: Fetal size 14w0d to 28w6d gestation: Cervical preparation and induction of labor...

Treatment of fetal demise at 14w0d to 28w6d gestation with the goal of the vaginal birth of an intact fetus is optimized by the administration of mifepristone for cervical preparation followed by induction of labor with misoprostol.^26,27

In one clinical trial, 66 patients with fetal demise between 14w0d and 28w6d gestation were randomly assigned to receive mifepristone 200 mg or placebo followed 24 to 48 hours later with initiation of misoprostol induction of labor.²⁶ Among the patients from 14w0d to 24 weeks’ gestation, the misoprostol dose was 400 µg vaginally every 6 hours. For patients from 24w0d to 28 weeks’ gestation, the misoprostol dose was 200 µg vaginally every 4 hours. At 24 hours, a consultant obstetrician determined if additional misoprostol should be given. The median time from initiation of misoprostol to birth for the patients in the mifepristone and placebo groups was 6.8 hours and 10.5 hours (P=.002).

Compared with the patients in the placebo-misoprostol group, the patients in the mifepristone-misoprostol group required fewer doses of misoprostol (2.1 vs 3.4; P= .002) and a lower total dose of misoprostol (768 µg vs 1,182 µg; P=.003). All patients in the mifepristone group delivered within 24 hours. By contrast, 13% of the patients in the placebo group delivered more than 24 hours after the initiation of misoprostol treatment. Five patients were readmitted with retained products of conception needing suction curettage, 4 in the placebo group and 1 in the mifepristone group.²⁶

In a second clinical trial, 105 patients with fetal demise after 20 weeks of gestation were randomly assigned to receive mifepristone 200 mg or placebo.²⁷ In this study, 86% of the patients were ≥26w0d gestation, with a mean gestational age of approximately 32w2d. Thirty-six to 48 hours later, misoprostol induction of labor was initiated. Among the patients from 20 to 25 completed weeks of gestation, the misoprostoldose was 100 µg vaginally every 6 hours for a maximum of 4 doses. For patients from ≥26 weeks’ gestation, the misoprostol dose was 50 µg vaginally every 4 hours for a maximum of 6 doses. The median times from initiation of misoprostol to birth for the patients in the mifepristone and placebo groups were 9.8 hours and 16.3 hours, respectively (P=.001). Compared with the patients in the placebo-misoprostol group, the patients in the mifepristone-misoprostol group required a lower total dose of misoprostol (110 µg vs 198 µg; P<.001). Delivery within 24 hours following initiation of misoprostol occurred in 93% and 73% of the patients in the mifepristone and placebo groups, respectively (P<.001). Compared with patients in the mifepristone group, shivering occurred more frequently among patients in the placebo group (7.5% vs 19.2%; P=.09), likely because they received greater doses of misoprostol.²⁷

Fetal size ≥29w0d gestation

At a fetal size ≥29w0d gestation, if the cervix is ripe with a Bishop score of ≥7, oxytocin induction of labor is often used as a first-line treatment. If the cervix is not ripe, misoprostol induction of labor may be considered at doses less than those used in the second trimester of pregnancy.³²TABLES 1,^{1, 26, 33–36}2,³⁷ and 3³⁷ summarize regimens proposed for fetal size ≥29w0d. One regimen begins with an initial misoprostol dose of 50 µg. If adequate uterine contractions occur, the 50 µg dose is repeated every 4 hours up to 6 total doses. If contractions are inadequate, the dose can be increased to 100 µg every 4 hours for 5 additional doses.

For fetal demise after 28w0d gestation, the American College of Obstetricians and Gynecologists (ACOG)¹ recommends standard obstetric protocols for induction of labor, including standard protocols for induction of labor following a previous cesarean birth. For a patient with a history of a prior cesarean birth or major uterine surgery, ACOG recommends that management of fetal demise should prioritize the use of mechanical cervical ripening, for example with a balloon catheter, and induction of uterine contractions with oxytocin.³⁸ ACOG recommends against the use of misoprostol for cervical ripening or labor induction for patients with a stillbirth at term with a history of a cesarean birth.³⁸ Preliminary experience suggests that stillbirth protocols using misoprostol doses modestly greater than those used in the management of a pregnancy with a viable fetus may be safe.⁹ See TABLES 2 and 3.

A multidisciplinary approach can optimize compassionate care

There are many gaps in the holistic care of patients and partners experiencing fetal demise. Patients with fetal demise often report that they did not receive sufficient information about the cause of the demise and wanted more opportunity to be involved in decision making about their care.³⁹ The patient’s partner often reports feeling unacknowledged as a grieving parent.⁴⁰ Fetal demise is experienced by many patients as a tragedy, triggering feelings of grief, anger, denial, anxiety and depression, sometimes resulting in isolation and substance misuse.

Using a 5-round Delphi process, experts identified 8 core goals in the care of patients with fetal demise:

1. reduce stigma
2. provide respectful care
3. involve patients in care planning
4. attempt to provide an explanation for the demise¹
5. acknowledge the depth of the grief response and provide emotional support
6. offer information about ongoing psychological support
7. provide information about future pregnancy planning
8. provide opportunities for specialized training and support for care providers.⁴¹

Management of stillbirth is optimized by a multidisciplinary approach that includes the expert care of obstetrician-gynecologists, obstetric nurses, anesthesiologists, and expert consultation from social work, chaplaincy, and pathology. A heart-to-heart connection between clinician and patient is a key component of stillbirth care. ●

Clinical care for fetal demise is complex and multidimensional, including empathic emotional support for the patient and family members who are experiencing a tragedy, investigation of the cause of the demise, and a plan for emptying the uterus. This editorial narrowly focuses on the options for treatment of fetal demise with the goal of emptying the uterus while minimizing complications.

When planning treatment of fetal demise, focus on fetal size and gestational age

Most guidelines for the treatment of fetal demise use gestational age to guide selection of a treatment.^1,2 I believe that fetal size is as important as gestational age for selecting a treatment plan. When considering treatment, there are 2 reasons why fetal size is as important as gestational age:

• The physiologic processes that caused fetal demise may have caused fetal growth restriction, resulting in a fetal size that is 2 or more weeks below expected fetal size for gestational age.
• Fetal demise may have occurred weeks before the diagnosis was made, resulting in gestational age being greater than fetal size. This editorial will use ultrasonography estimate of fetal size in gestational weeks to guide treatment recommendations. When discussing fetal size, we will use the convention of weeks-days (w-d). Twenty-five weeks and zero days gestation is represented as 25w0d.

Treatment in the second and third trimester is a 2-step process

Step 1: Cervical preparation

In most cases of first trimester fetal demise, no cervical preparation is necessary. Cervical dilation with metal dilators followed by uterine evacuation with an appropriately sized vacuum catheter is a highly successful treatment.³ However for second and third trimester fetal demise, it is best to use a 2-step process, beginning with cervical preparation followed by emptying the uterus. For example, at a fetal size of 13w0d to 16w0d, cervical preparation can be achieved by administering a single buccal dose of misoprostol 400 µg 3 to 4 hours prior to uterine evacuation or by inserting a Dilapan-S (Medicem Inc) osmotic cervical dilator 3 to 6 hours prior to uterine evacuation.^4-7 At a fetal size of 16w0d to 19w6d, cervical preparation can be achieved by placing osmotic cervical dilators 4 to 6 hours before surgical evacuation and administering buccal misoprostol 400 µg 3 hours before surgical evacuation.⁸

Alternatively, from 16w0d to 25w0d osmotic cervical dilators can be placed on day 1 of a 2-day process, and the patient can return on day 2 to have the cervical dilators removed followed by surgical evacuation of the uterus. Mifepristone 200 mg oral dose can be administered on day 1 to facilitate cervical preparation. In my practice, I use mifepristone 200 mg on day 1 when the fetal size is ≥20w0d gestation. Options for cervical preparation include use of osmotic dilators, cervical balloons, misoprostol, and/or mifepristone. These options are discussed below. With fetal demise, natural physiologic processes often have caused sufficient cervical softening and dilation that no cervical preparation is necessary and immediate uterine surgical evacuation or induction of labor can be initiated.

Step 2: Emptying the uterus

In the second and third trimesters, the approach to uterine evacuation is based on fetal size. At fetal sizes <25w0d, options for emptying the uterus include surgical evacuation with a vacuum catheter and grasping forceps or induction of labor with misoprostol followed by vaginal birth and expulsion of the placenta. At fetal sizes ˃25w0d gestation, following completion of cervical preparation, the most common approaches to uterine evacuation are induction of labor with misoprostol or oxytocin. Rarely, with a stillbirth at term, some clinicians will select hysterotomy to empty the uterus, avoiding uterine rupture during labor induction for patients at the highest risk, including those with a prior classical cesarean birth or more than 2 prior cesarean births with a low-transverse uterine incision.

Osmotic cervical dilators

The 2 most used cervical dilators are Dilapan-S, a polyacrylate-based hydrogel rod, and laminaria, dried compressed seaweed stipe (stalk) from Laminaria japonica or Laminaria digitata. Dilapan-S rods are available in diameters of 3 mm and 4 mm and rod lengths of 55 mm and 65 mm. Laminaria dilators are available in diameters of 2, 3, 4, 5, 6, 8 and 10 mm and rod length of 60 and 70 mm. Dilapan-S dilators reach near-maximal dilation in approximately 4 to 6 hours but continue to expand over the following 18 hours to achieve a maximum dilation of 3.3 to 3.6 times their dry diameter.⁹ Laminaria dilators expand to 2.7 to 2.9 times their dry diameter over 24 hours.⁹

A general rule is that as many dilators as possible should be placed until significant resistance to the placement of additional dilators is encountered.¹⁰ In my practice, for fetal size ≥20 weeks’ gestation, I place 2 Dilapan-S rods, 4 mm in diameter, 55 mm in length, and then encircle the Dilapan-S with laminaria rods that are 4 mm in diameter and 60 mm in length. Once cervical resistance to the placement of the 4 mm laminaria rods is observed, I encircle those laminaria with laminaria 2 mm in diameter, filling in the interstices between the 4 mm laminaria. The next day, cervical dilation is routinely ≥3 cm.

In a retrospective study of 491 patients undergoing pregnancy termination after 14 weeks’ gestation, with a mean gestational age of 24 weeks, compared with no osmotic cervical dilators, inserting osmotic cervical dilators the day before initiating misoprostol for induction of labor resulted in a decrease in time to delivery (428 min vs 640 min; P<.001) and a decrease in total misoprostol dose (990 µg vs 1,449 µg; P<.0001).¹¹

Cervical balloons

All clinicians know that a Foley catheter or a Cook cervical ripening balloon can be used for cervical preparation in the third trimester.^12,13 The Foley catheter also has been reported to be useful for cervical preparation in the second trimester. In one study of 43 patients 17 to 24 weeks’ gestation scheduled for a second-trimester dilation and evacuation, an intracervical Foley catheter was placed the evening before evacuation, and the balloon was inflated with 30 mL to 50 mL of saline. At the same time, mifepristone 200 mg was administered to the patients.¹⁴ The following day, dilation and evacuation was performed. In 72% of cases no additional cervical dilation was required on the day of evacuation. The investigators concluded that if osmotic cervical dilators are not available, the placement of an intracervical Foley catheter plus administration of mifepristone facilitates performance of an evacuation on the following day. If the patient prefers a 1-day procedure, the Foley can be inserted in the morning to facilitate cervical preparation, and the uterus can be evacuated in the afternoon.

Continue to: Misoprostol...

Misoprostol

Misoprostol, a derivative of prostaglandin E1, is useful for both cervical preparation and induction of labor. The dose of misoprostol and the route of administration are major determinants of uterine response.^15-19 When administered by an oral route, misoprostol has fast onset and offset of action and often does not cause sustained uterine contractions. Hence, oral misoprostol, at a low dose is useful for cervical ripening, but not as useful for stimulation of sustained uterine contractions for induction of labor. When administered by a buccal or vaginal route, misoprostol has prolonged activity and often results in sustained uterine contractions. At any given dose of misoprostol, buccal and vaginal misoprostol administration are more effective than oral administration in inducing sustained uterine contractions sufficient to empty the uterus.^15-19

Mifepristone

Mifepristone, an anti-progestin, is useful for cervical preparation and sensitizing myocytes to the action of uterotonics. Progesterone reduces cell-to-cell communication among uterine myocytes, facilitating uterine quiescence by suppressing connexin 43 and other proteins. Mifepristone blocks the effect of progesterone, inducing the production of myocyte connexin 43, enhancing efficient cell-to-cell communication, permitting uterine myoctes to contract in unison, creating the potential for powerful and sustained contractions.^20-23 Randomized clinical trials report that administration of mifepristone 200 mg prior to misoprostol induced labor results in more rapid emptying of the uterus.^24-27

It takes time for mifepristone to have its full effect on uterine myocytes. Hence, most protocols recommend waiting 24 hours following mifepristone administration before initiating treatment with an agent to stimulate uterine contractions such as misoprostol or oxytocin. However, preliminary data suggest that partial benefit of mifepristone can be obtained when initiating misoprostol 3 to 5 hours after mifepristone administration.²⁸ In a study of 481 patients undergoing induction of labor in the second or third trimester, the time from initiation of misoprostol to vaginal birth was 15 hours with no mifepristone pretreatment, 13.2 hours if mifepristone was administered 3 to 5 hours before initiating misoprostol, 9.3 hours if mifepristone was administered 24 hours before initiating misoprostol, and 10.5 hours if mifepristone was administered 48 hours before initiating misoprostol.²⁸

Fetal size <25w0d gestation: Cervical preparation and surgical evacuation

For fetal demise at a fetal size less than 25w0d, if clinical experts are available, the best treatment option is cervical preparation followed by surgical evacuation of the uterus using a vacuum catheter and grasping forceps to empty the uterus.^29,30 A disadvantage of surgical evacuation of the uterus is that an intact fetus is not available for the patient to hold and mourn, and pathologic examination of an intact fetus is not possible. An alternative approach is cervical preparation followed by induction of labor using misoprostol with the goal of delivering an intact fetus. Although no prospective clinical trials are available comparing these 2 options, retrospective studies have reported that, at fetal size <25w0d gestation, compared with induction of labor, surgical evacuation of the uterus results in fewer complications,³⁰ including fewer cases of retained placenta requiring an unplanned procedure and fewer presumed uterine infections.²⁹

For surgical evacuation of fetal demise with a fetal size of <25w0d gestation, the first step on day 1 is placement of osmotic cervical dilators. In addition to osmotic cervical dilators, if the gestational age or fetal size is ≥19 weeks’ gestation an oral dose of mifepristone 200 mg to facilitate cervical preparation may be considered. On day 2, the osmotic dilators are removed and surgical evacuation is performed. In one randomized study, for pregnancies at 19 to 24 weeks’ gestation, compared with osmotic dilators alone, administration of mifepristone 200 mg at the time of placement of osmotic dilators resulted in fewer procedures that were difficult to complete.³¹ In some cases, 2 consecutive days of cervical preparation with osmotic dilators may be needed to properly prepare the cervix for uterine evacuation. For example, the cervix of a nulliparous teenage patient may require 2 days of cervical preparation with osmotic dilators to facilitate uterine evacuation. In some cases of fetal demise, the cervix is already dilated to ≥3 cm and surgical evacuation of the uterus or induction of labor can be initiated without the need for cervical preparation.

Continue to: Fetal size 14w0d to 28w6d gestation: Cervical preparation and induction of labor...

Treatment of fetal demise at 14w0d to 28w6d gestation with the goal of the vaginal birth of an intact fetus is optimized by the administration of mifepristone for cervical preparation followed by induction of labor with misoprostol.^26,27

In one clinical trial, 66 patients with fetal demise between 14w0d and 28w6d gestation were randomly assigned to receive mifepristone 200 mg or placebo followed 24 to 48 hours later with initiation of misoprostol induction of labor.²⁶ Among the patients from 14w0d to 24 weeks’ gestation, the misoprostol dose was 400 µg vaginally every 6 hours. For patients from 24w0d to 28 weeks’ gestation, the misoprostol dose was 200 µg vaginally every 4 hours. At 24 hours, a consultant obstetrician determined if additional misoprostol should be given. The median time from initiation of misoprostol to birth for the patients in the mifepristone and placebo groups was 6.8 hours and 10.5 hours (P=.002).

Compared with the patients in the placebo-misoprostol group, the patients in the mifepristone-misoprostol group required fewer doses of misoprostol (2.1 vs 3.4; P= .002) and a lower total dose of misoprostol (768 µg vs 1,182 µg; P=.003). All patients in the mifepristone group delivered within 24 hours. By contrast, 13% of the patients in the placebo group delivered more than 24 hours after the initiation of misoprostol treatment. Five patients were readmitted with retained products of conception needing suction curettage, 4 in the placebo group and 1 in the mifepristone group.²⁶

In a second clinical trial, 105 patients with fetal demise after 20 weeks of gestation were randomly assigned to receive mifepristone 200 mg or placebo.²⁷ In this study, 86% of the patients were ≥26w0d gestation, with a mean gestational age of approximately 32w2d. Thirty-six to 48 hours later, misoprostol induction of labor was initiated. Among the patients from 20 to 25 completed weeks of gestation, the misoprostoldose was 100 µg vaginally every 6 hours for a maximum of 4 doses. For patients from ≥26 weeks’ gestation, the misoprostol dose was 50 µg vaginally every 4 hours for a maximum of 6 doses. The median times from initiation of misoprostol to birth for the patients in the mifepristone and placebo groups were 9.8 hours and 16.3 hours, respectively (P=.001). Compared with the patients in the placebo-misoprostol group, the patients in the mifepristone-misoprostol group required a lower total dose of misoprostol (110 µg vs 198 µg; P<.001). Delivery within 24 hours following initiation of misoprostol occurred in 93% and 73% of the patients in the mifepristone and placebo groups, respectively (P<.001). Compared with patients in the mifepristone group, shivering occurred more frequently among patients in the placebo group (7.5% vs 19.2%; P=.09), likely because they received greater doses of misoprostol.²⁷

Fetal size ≥29w0d gestation

At a fetal size ≥29w0d gestation, if the cervix is ripe with a Bishop score of ≥7, oxytocin induction of labor is often used as a first-line treatment. If the cervix is not ripe, misoprostol induction of labor may be considered at doses less than those used in the second trimester of pregnancy.³²TABLES 1,^{1, 26, 33–36}2,³⁷ and 3³⁷ summarize regimens proposed for fetal size ≥29w0d. One regimen begins with an initial misoprostol dose of 50 µg. If adequate uterine contractions occur, the 50 µg dose is repeated every 4 hours up to 6 total doses. If contractions are inadequate, the dose can be increased to 100 µg every 4 hours for 5 additional doses.

For fetal demise after 28w0d gestation, the American College of Obstetricians and Gynecologists (ACOG)¹ recommends standard obstetric protocols for induction of labor, including standard protocols for induction of labor following a previous cesarean birth. For a patient with a history of a prior cesarean birth or major uterine surgery, ACOG recommends that management of fetal demise should prioritize the use of mechanical cervical ripening, for example with a balloon catheter, and induction of uterine contractions with oxytocin.³⁸ ACOG recommends against the use of misoprostol for cervical ripening or labor induction for patients with a stillbirth at term with a history of a cesarean birth.³⁸ Preliminary experience suggests that stillbirth protocols using misoprostol doses modestly greater than those used in the management of a pregnancy with a viable fetus may be safe.⁹ See TABLES 2 and 3.

A multidisciplinary approach can optimize compassionate care

There are many gaps in the holistic care of patients and partners experiencing fetal demise. Patients with fetal demise often report that they did not receive sufficient information about the cause of the demise and wanted more opportunity to be involved in decision making about their care.³⁹ The patient’s partner often reports feeling unacknowledged as a grieving parent.⁴⁰ Fetal demise is experienced by many patients as a tragedy, triggering feelings of grief, anger, denial, anxiety and depression, sometimes resulting in isolation and substance misuse.

Using a 5-round Delphi process, experts identified 8 core goals in the care of patients with fetal demise:

1. reduce stigma
2. provide respectful care
3. involve patients in care planning
4. attempt to provide an explanation for the demise¹
5. acknowledge the depth of the grief response and provide emotional support
6. offer information about ongoing psychological support
7. provide information about future pregnancy planning
8. provide opportunities for specialized training and support for care providers.⁴¹

Management of stillbirth is optimized by a multidisciplinary approach that includes the expert care of obstetrician-gynecologists, obstetric nurses, anesthesiologists, and expert consultation from social work, chaplaincy, and pathology. A heart-to-heart connection between clinician and patient is a key component of stillbirth care. ●