TBD Meeting (2840-24)

NATIONAL HARBOR, MARYLAND — Implementation of a standardized induction of labor protocol had no significant effect on the rates of cesarean delivery in patients with obesity, based on data from more than 5000 individuals.

Previous research has shown that the risk for cesarean delivery increases by 5% with each 1-kg/m² increase in body mass index (BMI) among nulliparous patients, said Melissa Riegel, MD, of the University of Pennsylvania, Philadelphia, in a presentation at the meeting sponsored by the Society for Maternal-Fetal Medicine. (abstract 82).

Research on the relationship between obesity and higher cesarean delivery rates “has been clouded by the inability to reduce variation in care,” Dr. Riegel said at the meeting sponsored by the Society for Maternal Fetal Medicine. Failed induction of labor (IOL) is a leading indicator for cesarean delivery, and cesarean delivery is 80% more likely in patients with obesity undergoing IOL than in normal-weight patients, Dr. Riegel said.

Possible explanations for these differences include provider factors such as variability in care management, conscious and unconscious biases, or physiologic differences in patients with obesity such as elevated hormones, differences in the labor curve, and higher doses of oxytocin and prostaglandins, Dr. Riegel said.

Dr. Riegel and colleagues hypothesized that differences in cesarean delivery rates would persist despite a standardized labor induction protocol, thereby supporting the effects of factors other than variations in care on increased cesarean delivery risk after IOL in patients with obesity.

The researchers reviewed data from two sites comparing 2-year periods before and after implementation of an IOL protocol from 2018 to 2022. The study population included nulliparous women with singleton pregnancies at term who underwent IOL with intact membranes and unfavorable cervices, and had a BMI of at least 30 kg/m² at delivery. The preimplementation group (PRE) included 2480 individuals and the postimplementation group (POST) included 2651 individuals. Patients were divided into weight classes based on BMI: 30-34.9; 35-39.9; ≥40.

The standardized protocol consisted of active labor management with cervical exams, with an amniotomy by the time of the first exam with 4 cm or greater cervical dilation, and further intervention with medication such as oxytocin or an intrauterine pressure catheter if no cervical change was noted after 2 hours.

In a multivariate analysis, the overall cesarean delivery rate was 24.9% before the protocol implementation and 26.0% in the postimplementation group. There were no differences in the risk of cesarean delivery in any obesity class from the PRE to POST period.

In addition, no significant differences appeared in the secondary outcomes of duration of labor, maternal morbidity, or neonatal morbidity, Dr. Riegel said. Nonreassuring fetal heart rate tracing was the most common reason for cesarean delivery across all obesity classes and the PRE and POST groups.

Study limitations included the use of data from only two sites, but the results were strengthened by the large sample size, said Dr. Reigel. The results indicate that reducing variation in IOL management had no significant effect on the relationship between obesity and cesarean delivery and support underlying physiologic explanations, she said.
 

Making the Case for Physiology

“By standardizing induction practices, we were able to minimize differences in care and better answer why the increased cesarean delivery rate exists in this patient population,” Dr. Riegel said in an interview. The findings were in line with the primary hypothesis that standardized induction would not affect cesarean delivery rates in patients with obesity, she said. Instead, the findings support potential physiologic differences as “the driving force behind this relationship,” she added.

Looking ahead, “There is a role for translational work to investigate the specific biological changes in patients with obesity that might contribute to an increased risk of cesarean delivery and there is also a role for investigating the effectiveness of different labor induction interventions specifically in patients with obesity,” Dr. Riegel said.
 

Different Induction Protocols Needed for Obese Patients?

“Given that severe maternal morbidity and mortality are continuing to increase in the United States, this study is critical, as we know that both cesarean delivery and obesity are driving factors in increasing maternal morbidity,” said Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, Georgia, in an interview.

However, the novel takeaway message from the current study is that patients with obesity were more likely to require cesarean delivery even with a protocol in which variation in labor induction techniques are minimized, said Dr. Platner, who was not involved in the study. “This leads to the question of [whether] we should have different standards or protocols for our patients with obesity, as well as a need for clear counseling for these patients early on in pregnancy,” she said.

As for further research, “It would be interesting to see if the risk of cesarean delivery changed based on class of obesity, and the primary drivers of cesarean delivery in this study,” Dr. Platner said. “Additionally, it would be helpful to know how much pitocin was needed for patients, based on their BMI category, to achieve successful vaginal delivery,” she noted.

The study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Development. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Implementation of a standardized induction of labor protocol had no significant effect on the rates of cesarean delivery in patients with obesity, based on data from more than 5000 individuals.

Previous research has shown that the risk for cesarean delivery increases by 5% with each 1-kg/m² increase in body mass index (BMI) among nulliparous patients, said Melissa Riegel, MD, of the University of Pennsylvania, Philadelphia, in a presentation at the meeting sponsored by the Society for Maternal-Fetal Medicine. (abstract 82).

Research on the relationship between obesity and higher cesarean delivery rates “has been clouded by the inability to reduce variation in care,” Dr. Riegel said at the meeting sponsored by the Society for Maternal Fetal Medicine. Failed induction of labor (IOL) is a leading indicator for cesarean delivery, and cesarean delivery is 80% more likely in patients with obesity undergoing IOL than in normal-weight patients, Dr. Riegel said.

Possible explanations for these differences include provider factors such as variability in care management, conscious and unconscious biases, or physiologic differences in patients with obesity such as elevated hormones, differences in the labor curve, and higher doses of oxytocin and prostaglandins, Dr. Riegel said.

Dr. Riegel and colleagues hypothesized that differences in cesarean delivery rates would persist despite a standardized labor induction protocol, thereby supporting the effects of factors other than variations in care on increased cesarean delivery risk after IOL in patients with obesity.

The researchers reviewed data from two sites comparing 2-year periods before and after implementation of an IOL protocol from 2018 to 2022. The study population included nulliparous women with singleton pregnancies at term who underwent IOL with intact membranes and unfavorable cervices, and had a BMI of at least 30 kg/m² at delivery. The preimplementation group (PRE) included 2480 individuals and the postimplementation group (POST) included 2651 individuals. Patients were divided into weight classes based on BMI: 30-34.9; 35-39.9; ≥40.

The standardized protocol consisted of active labor management with cervical exams, with an amniotomy by the time of the first exam with 4 cm or greater cervical dilation, and further intervention with medication such as oxytocin or an intrauterine pressure catheter if no cervical change was noted after 2 hours.

In a multivariate analysis, the overall cesarean delivery rate was 24.9% before the protocol implementation and 26.0% in the postimplementation group. There were no differences in the risk of cesarean delivery in any obesity class from the PRE to POST period.

In addition, no significant differences appeared in the secondary outcomes of duration of labor, maternal morbidity, or neonatal morbidity, Dr. Riegel said. Nonreassuring fetal heart rate tracing was the most common reason for cesarean delivery across all obesity classes and the PRE and POST groups.

Study limitations included the use of data from only two sites, but the results were strengthened by the large sample size, said Dr. Reigel. The results indicate that reducing variation in IOL management had no significant effect on the relationship between obesity and cesarean delivery and support underlying physiologic explanations, she said.
 

Making the Case for Physiology

“By standardizing induction practices, we were able to minimize differences in care and better answer why the increased cesarean delivery rate exists in this patient population,” Dr. Riegel said in an interview. The findings were in line with the primary hypothesis that standardized induction would not affect cesarean delivery rates in patients with obesity, she said. Instead, the findings support potential physiologic differences as “the driving force behind this relationship,” she added.

Looking ahead, “There is a role for translational work to investigate the specific biological changes in patients with obesity that might contribute to an increased risk of cesarean delivery and there is also a role for investigating the effectiveness of different labor induction interventions specifically in patients with obesity,” Dr. Riegel said.
 

Different Induction Protocols Needed for Obese Patients?

“Given that severe maternal morbidity and mortality are continuing to increase in the United States, this study is critical, as we know that both cesarean delivery and obesity are driving factors in increasing maternal morbidity,” said Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, Georgia, in an interview.

However, the novel takeaway message from the current study is that patients with obesity were more likely to require cesarean delivery even with a protocol in which variation in labor induction techniques are minimized, said Dr. Platner, who was not involved in the study. “This leads to the question of [whether] we should have different standards or protocols for our patients with obesity, as well as a need for clear counseling for these patients early on in pregnancy,” she said.

As for further research, “It would be interesting to see if the risk of cesarean delivery changed based on class of obesity, and the primary drivers of cesarean delivery in this study,” Dr. Platner said. “Additionally, it would be helpful to know how much pitocin was needed for patients, based on their BMI category, to achieve successful vaginal delivery,” she noted.

The study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Development. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Implementation of a standardized induction of labor protocol had no significant effect on the rates of cesarean delivery in patients with obesity, based on data from more than 5000 individuals.

Previous research has shown that the risk for cesarean delivery increases by 5% with each 1-kg/m² increase in body mass index (BMI) among nulliparous patients, said Melissa Riegel, MD, of the University of Pennsylvania, Philadelphia, in a presentation at the meeting sponsored by the Society for Maternal-Fetal Medicine. (abstract 82).

Research on the relationship between obesity and higher cesarean delivery rates “has been clouded by the inability to reduce variation in care,” Dr. Riegel said at the meeting sponsored by the Society for Maternal Fetal Medicine. Failed induction of labor (IOL) is a leading indicator for cesarean delivery, and cesarean delivery is 80% more likely in patients with obesity undergoing IOL than in normal-weight patients, Dr. Riegel said.

Possible explanations for these differences include provider factors such as variability in care management, conscious and unconscious biases, or physiologic differences in patients with obesity such as elevated hormones, differences in the labor curve, and higher doses of oxytocin and prostaglandins, Dr. Riegel said.

Dr. Riegel and colleagues hypothesized that differences in cesarean delivery rates would persist despite a standardized labor induction protocol, thereby supporting the effects of factors other than variations in care on increased cesarean delivery risk after IOL in patients with obesity.

The researchers reviewed data from two sites comparing 2-year periods before and after implementation of an IOL protocol from 2018 to 2022. The study population included nulliparous women with singleton pregnancies at term who underwent IOL with intact membranes and unfavorable cervices, and had a BMI of at least 30 kg/m² at delivery. The preimplementation group (PRE) included 2480 individuals and the postimplementation group (POST) included 2651 individuals. Patients were divided into weight classes based on BMI: 30-34.9; 35-39.9; ≥40.

The standardized protocol consisted of active labor management with cervical exams, with an amniotomy by the time of the first exam with 4 cm or greater cervical dilation, and further intervention with medication such as oxytocin or an intrauterine pressure catheter if no cervical change was noted after 2 hours.

In a multivariate analysis, the overall cesarean delivery rate was 24.9% before the protocol implementation and 26.0% in the postimplementation group. There were no differences in the risk of cesarean delivery in any obesity class from the PRE to POST period.

In addition, no significant differences appeared in the secondary outcomes of duration of labor, maternal morbidity, or neonatal morbidity, Dr. Riegel said. Nonreassuring fetal heart rate tracing was the most common reason for cesarean delivery across all obesity classes and the PRE and POST groups.

Study limitations included the use of data from only two sites, but the results were strengthened by the large sample size, said Dr. Reigel. The results indicate that reducing variation in IOL management had no significant effect on the relationship between obesity and cesarean delivery and support underlying physiologic explanations, she said.
 

Making the Case for Physiology

“By standardizing induction practices, we were able to minimize differences in care and better answer why the increased cesarean delivery rate exists in this patient population,” Dr. Riegel said in an interview. The findings were in line with the primary hypothesis that standardized induction would not affect cesarean delivery rates in patients with obesity, she said. Instead, the findings support potential physiologic differences as “the driving force behind this relationship,” she added.

Looking ahead, “There is a role for translational work to investigate the specific biological changes in patients with obesity that might contribute to an increased risk of cesarean delivery and there is also a role for investigating the effectiveness of different labor induction interventions specifically in patients with obesity,” Dr. Riegel said.
 

Different Induction Protocols Needed for Obese Patients?

“Given that severe maternal morbidity and mortality are continuing to increase in the United States, this study is critical, as we know that both cesarean delivery and obesity are driving factors in increasing maternal morbidity,” said Marissa Platner, MD, a maternal-fetal medicine specialist at Emory University, Atlanta, Georgia, in an interview.

However, the novel takeaway message from the current study is that patients with obesity were more likely to require cesarean delivery even with a protocol in which variation in labor induction techniques are minimized, said Dr. Platner, who was not involved in the study. “This leads to the question of [whether] we should have different standards or protocols for our patients with obesity, as well as a need for clear counseling for these patients early on in pregnancy,” she said.

As for further research, “It would be interesting to see if the risk of cesarean delivery changed based on class of obesity, and the primary drivers of cesarean delivery in this study,” Dr. Platner said. “Additionally, it would be helpful to know how much pitocin was needed for patients, based on their BMI category, to achieve successful vaginal delivery,” she noted.

The study was supported by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Development. The researchers had no financial conflicts to disclose. Dr. Platner had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Rates of maternal morbidity in individuals with placenta accreta were similar with alternative strategies to cesarean hysterectomy regardless of the severity of the condition, based on data from 60 individuals.

Currently, the recommended management strategy for placenta accreta spectrum (PAS) is a cesarean hysterectomy, but data are lacking on alternative strategies, especially for individuals wishing to keep their uterus and potentially preserve fertility, Farah H. Amro, MD, of the University of Texas Health Science Center at Houston McGovern Medical School said in a presentation at the Pregnancy Meeting (abstract 70).

Alternative options are being studied worldwide, including delayed hysterectomy (typically performed at 4-6 weeks postpartum), Dr. Amro said at the meeting, which was sponsored by the Society for Maternal-Fetal Medicine.

At UT Houston, delayed hysterectomy is performed for more aggressive PAS that involves parametrial invasion, and the placenta left in situ until resorption/passage for those wishing to keep their uterus, Dr. Amro said in an interview.

In a cohort study at UT Houston, a level IV academic center, Dr. Amro and colleagues evaluated outcomes in 60 individuals with suspected PAS who were given three management options after extensive counseling. Of these, 29 opted for a cesarean hysterectomy (CH); 16 opted for delayed interval hysterectomy (IH) performed 4-6 weeks after delivery; and 15 individuals with a preference for uterine preservation were assigned to conservative management.

The study occurred between January 2020 and July 2023. The primary outcome was composite maternal morbidity, which was further divided into composite acute morbidity (within 24 hours from cesarean delivery or hysterectomy) and composite delayed morbidity (24 hours or more postoperatively). Secondary outcomes included total estimated blood loss, need for blood transfusion, unplanned hospital readmission, and pathology diagnosis.

Overall maternal morbidity rates were 55%, 56%, and 53% in the CH, IH, and CM groups, respectively, although those who were planned for IH and CM had more severe PAS.

The planned procedure was performed in 90% of the CH patients. Approximately 20% of patients in the IH and CM groups underwent unplanned procedures. No cases of sepsis or maternal death occurred, and uterine infection rates were 0%, 6%, and 13% in the CH, IH, and CM groups, respectively.

Patients in the CM and IH groups were significantly less likely to require blood transfusions than those in the CH group. In addition, composite delayed morbidity (24 hours or more after surgery) was similar among the groups, with rates of 31%, 38%, and 33% for CH, IH, and CM, respectively (P = .94). These results are important, given the concerns regarding leaving a placenta in situ after cesarean delivery, said Dr. Amro.

The findings were limited by several factors including the use of data from a single site, the lack of randomization, patient compliance, and cost effectiveness. However, the results were strengthened by the diverse population and comparison of novel approaches that aren’t frequently utilized In the United States, as well as the large volume of PAS cases treated in a relatively short time frame, Dr. Amro said.
 

More Options Empower Mothers

Overall, the results support the use of delayed hysterectomy and conservative management as safe alternatives to cesarean hysterectomy, especially in those with severe PAS (opting for IH Instead of CH) and those seeking to preserve the uterus (CM), Dr. Amro said. However, these alternative options can be offered only to patients who can engage in frequent postpartum follow-up and live close to the hospital; with the CM group, resorption/passage of the placenta may take as long as 6 months in some cases, she explained.

The greatest concerns with leaving the placenta in place in PAS patients are the risk of infection or subsequent hemorrhage, Dr. Amro said in an interview. However, the current study showed that the infection rate was not as high as anticipated, and the frequency of unplanned procedures occurred in only 20%, which should alleviate some of these concerns, she said.

“We have completed 28 cases of conservative management since 2015, four have gone on to successful pregnancy with no cases of PAS in the subsequent pregnancies,” Dr. Amro said. Conservative management gives mothers another option, she added. “Moms feel empowered by being given a choice, especially for those that want to keep their uterus for fertility or religious/cultural considerations, and many opt for CM.”

The next step is to take the conservative management strategy to larger groups at other centers to replicate the results in other locations, said Dr. Amro. “Also, we are looking at the utility of other interventions such as uterine artery embolization and performing delayed dilation and curettage to help with passage of the placenta in those opting for CM.”
 

Study Supports Safety of Conservative Management

“There are patients that may want to preserve their reproductive organs in the face of an accreta (such as for religious, cultural, and personal reasons), and this study helps address some of the safety considerations with conservative approaches,” Corrina M. Oxford-Horrey, MD, a maternal-fetal medicine specialist at Weill Cornell Medicine, New York, said in an interview.

“I was surprised that there was not a lot of infectious morbidity (such as sepsis) in the cohorts; that was helpful to see,” said Dr. Oxford-Horrey, who served as a moderator for the session in which the study was presented.

Based on the study findings, “nontraditional approaches to placenta accreta spectrum management may be reasonable, given similar overall postoperative composite morbidity between the groups,” she said.

As for additional research, replicating the study in a multicenter fashion would add to the generalizability of the findings, Dr. Oxford-Horrey said.

The study received no outside funding. The researchers and Dr. Oxford-Horrey had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Rates of maternal morbidity in individuals with placenta accreta were similar with alternative strategies to cesarean hysterectomy regardless of the severity of the condition, based on data from 60 individuals.

Currently, the recommended management strategy for placenta accreta spectrum (PAS) is a cesarean hysterectomy, but data are lacking on alternative strategies, especially for individuals wishing to keep their uterus and potentially preserve fertility, Farah H. Amro, MD, of the University of Texas Health Science Center at Houston McGovern Medical School said in a presentation at the Pregnancy Meeting (abstract 70).

Alternative options are being studied worldwide, including delayed hysterectomy (typically performed at 4-6 weeks postpartum), Dr. Amro said at the meeting, which was sponsored by the Society for Maternal-Fetal Medicine.

At UT Houston, delayed hysterectomy is performed for more aggressive PAS that involves parametrial invasion, and the placenta left in situ until resorption/passage for those wishing to keep their uterus, Dr. Amro said in an interview.

In a cohort study at UT Houston, a level IV academic center, Dr. Amro and colleagues evaluated outcomes in 60 individuals with suspected PAS who were given three management options after extensive counseling. Of these, 29 opted for a cesarean hysterectomy (CH); 16 opted for delayed interval hysterectomy (IH) performed 4-6 weeks after delivery; and 15 individuals with a preference for uterine preservation were assigned to conservative management.

The study occurred between January 2020 and July 2023. The primary outcome was composite maternal morbidity, which was further divided into composite acute morbidity (within 24 hours from cesarean delivery or hysterectomy) and composite delayed morbidity (24 hours or more postoperatively). Secondary outcomes included total estimated blood loss, need for blood transfusion, unplanned hospital readmission, and pathology diagnosis.

Overall maternal morbidity rates were 55%, 56%, and 53% in the CH, IH, and CM groups, respectively, although those who were planned for IH and CM had more severe PAS.

The planned procedure was performed in 90% of the CH patients. Approximately 20% of patients in the IH and CM groups underwent unplanned procedures. No cases of sepsis or maternal death occurred, and uterine infection rates were 0%, 6%, and 13% in the CH, IH, and CM groups, respectively.

Patients in the CM and IH groups were significantly less likely to require blood transfusions than those in the CH group. In addition, composite delayed morbidity (24 hours or more after surgery) was similar among the groups, with rates of 31%, 38%, and 33% for CH, IH, and CM, respectively (P = .94). These results are important, given the concerns regarding leaving a placenta in situ after cesarean delivery, said Dr. Amro.

The findings were limited by several factors including the use of data from a single site, the lack of randomization, patient compliance, and cost effectiveness. However, the results were strengthened by the diverse population and comparison of novel approaches that aren’t frequently utilized In the United States, as well as the large volume of PAS cases treated in a relatively short time frame, Dr. Amro said.
 

More Options Empower Mothers

Overall, the results support the use of delayed hysterectomy and conservative management as safe alternatives to cesarean hysterectomy, especially in those with severe PAS (opting for IH Instead of CH) and those seeking to preserve the uterus (CM), Dr. Amro said. However, these alternative options can be offered only to patients who can engage in frequent postpartum follow-up and live close to the hospital; with the CM group, resorption/passage of the placenta may take as long as 6 months in some cases, she explained.

The greatest concerns with leaving the placenta in place in PAS patients are the risk of infection or subsequent hemorrhage, Dr. Amro said in an interview. However, the current study showed that the infection rate was not as high as anticipated, and the frequency of unplanned procedures occurred in only 20%, which should alleviate some of these concerns, she said.

“We have completed 28 cases of conservative management since 2015, four have gone on to successful pregnancy with no cases of PAS in the subsequent pregnancies,” Dr. Amro said. Conservative management gives mothers another option, she added. “Moms feel empowered by being given a choice, especially for those that want to keep their uterus for fertility or religious/cultural considerations, and many opt for CM.”

The next step is to take the conservative management strategy to larger groups at other centers to replicate the results in other locations, said Dr. Amro. “Also, we are looking at the utility of other interventions such as uterine artery embolization and performing delayed dilation and curettage to help with passage of the placenta in those opting for CM.”
 

Study Supports Safety of Conservative Management

“There are patients that may want to preserve their reproductive organs in the face of an accreta (such as for religious, cultural, and personal reasons), and this study helps address some of the safety considerations with conservative approaches,” Corrina M. Oxford-Horrey, MD, a maternal-fetal medicine specialist at Weill Cornell Medicine, New York, said in an interview.

“I was surprised that there was not a lot of infectious morbidity (such as sepsis) in the cohorts; that was helpful to see,” said Dr. Oxford-Horrey, who served as a moderator for the session in which the study was presented.

Based on the study findings, “nontraditional approaches to placenta accreta spectrum management may be reasonable, given similar overall postoperative composite morbidity between the groups,” she said.

As for additional research, replicating the study in a multicenter fashion would add to the generalizability of the findings, Dr. Oxford-Horrey said.

The study received no outside funding. The researchers and Dr. Oxford-Horrey had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Rates of maternal morbidity in individuals with placenta accreta were similar with alternative strategies to cesarean hysterectomy regardless of the severity of the condition, based on data from 60 individuals.

Currently, the recommended management strategy for placenta accreta spectrum (PAS) is a cesarean hysterectomy, but data are lacking on alternative strategies, especially for individuals wishing to keep their uterus and potentially preserve fertility, Farah H. Amro, MD, of the University of Texas Health Science Center at Houston McGovern Medical School said in a presentation at the Pregnancy Meeting (abstract 70).

Alternative options are being studied worldwide, including delayed hysterectomy (typically performed at 4-6 weeks postpartum), Dr. Amro said at the meeting, which was sponsored by the Society for Maternal-Fetal Medicine.

At UT Houston, delayed hysterectomy is performed for more aggressive PAS that involves parametrial invasion, and the placenta left in situ until resorption/passage for those wishing to keep their uterus, Dr. Amro said in an interview.

In a cohort study at UT Houston, a level IV academic center, Dr. Amro and colleagues evaluated outcomes in 60 individuals with suspected PAS who were given three management options after extensive counseling. Of these, 29 opted for a cesarean hysterectomy (CH); 16 opted for delayed interval hysterectomy (IH) performed 4-6 weeks after delivery; and 15 individuals with a preference for uterine preservation were assigned to conservative management.

The study occurred between January 2020 and July 2023. The primary outcome was composite maternal morbidity, which was further divided into composite acute morbidity (within 24 hours from cesarean delivery or hysterectomy) and composite delayed morbidity (24 hours or more postoperatively). Secondary outcomes included total estimated blood loss, need for blood transfusion, unplanned hospital readmission, and pathology diagnosis.

Overall maternal morbidity rates were 55%, 56%, and 53% in the CH, IH, and CM groups, respectively, although those who were planned for IH and CM had more severe PAS.

The planned procedure was performed in 90% of the CH patients. Approximately 20% of patients in the IH and CM groups underwent unplanned procedures. No cases of sepsis or maternal death occurred, and uterine infection rates were 0%, 6%, and 13% in the CH, IH, and CM groups, respectively.

Patients in the CM and IH groups were significantly less likely to require blood transfusions than those in the CH group. In addition, composite delayed morbidity (24 hours or more after surgery) was similar among the groups, with rates of 31%, 38%, and 33% for CH, IH, and CM, respectively (P = .94). These results are important, given the concerns regarding leaving a placenta in situ after cesarean delivery, said Dr. Amro.

The findings were limited by several factors including the use of data from a single site, the lack of randomization, patient compliance, and cost effectiveness. However, the results were strengthened by the diverse population and comparison of novel approaches that aren’t frequently utilized In the United States, as well as the large volume of PAS cases treated in a relatively short time frame, Dr. Amro said.
 

More Options Empower Mothers

Overall, the results support the use of delayed hysterectomy and conservative management as safe alternatives to cesarean hysterectomy, especially in those with severe PAS (opting for IH Instead of CH) and those seeking to preserve the uterus (CM), Dr. Amro said. However, these alternative options can be offered only to patients who can engage in frequent postpartum follow-up and live close to the hospital; with the CM group, resorption/passage of the placenta may take as long as 6 months in some cases, she explained.

The greatest concerns with leaving the placenta in place in PAS patients are the risk of infection or subsequent hemorrhage, Dr. Amro said in an interview. However, the current study showed that the infection rate was not as high as anticipated, and the frequency of unplanned procedures occurred in only 20%, which should alleviate some of these concerns, she said.

“We have completed 28 cases of conservative management since 2015, four have gone on to successful pregnancy with no cases of PAS in the subsequent pregnancies,” Dr. Amro said. Conservative management gives mothers another option, she added. “Moms feel empowered by being given a choice, especially for those that want to keep their uterus for fertility or religious/cultural considerations, and many opt for CM.”

The next step is to take the conservative management strategy to larger groups at other centers to replicate the results in other locations, said Dr. Amro. “Also, we are looking at the utility of other interventions such as uterine artery embolization and performing delayed dilation and curettage to help with passage of the placenta in those opting for CM.”
 

Study Supports Safety of Conservative Management

“There are patients that may want to preserve their reproductive organs in the face of an accreta (such as for religious, cultural, and personal reasons), and this study helps address some of the safety considerations with conservative approaches,” Corrina M. Oxford-Horrey, MD, a maternal-fetal medicine specialist at Weill Cornell Medicine, New York, said in an interview.

“I was surprised that there was not a lot of infectious morbidity (such as sepsis) in the cohorts; that was helpful to see,” said Dr. Oxford-Horrey, who served as a moderator for the session in which the study was presented.

Based on the study findings, “nontraditional approaches to placenta accreta spectrum management may be reasonable, given similar overall postoperative composite morbidity between the groups,” she said.

As for additional research, replicating the study in a multicenter fashion would add to the generalizability of the findings, Dr. Oxford-Horrey said.

The study received no outside funding. The researchers and Dr. Oxford-Horrey had no financial conflicts to disclose.

TOPLINE:

Higher body mass index (BMI) at the start of pregnancy is associated with increased risk for adverse maternal outcomes, including preeclampsia, and neonatal complications, such as respiratory distress syndrome (RDS), in a dose-dependent manner, new research shows.

METHODOLOGY:

• Researchers conducted a retrospective study of 58,497 singleton pregnancies delivered at an urban hospital between 2013 and 2021.
• They focused on pregnancies delivered between 24 and 42 weeks of gestation, for which information about BMI at the first prenatal visit was available.
• 21.1% of mothers had class I , 9.3% had class II obesity, and 6% had class III obesity.

TAKEAWAY: 

• Obesity was associated with a dose-dependent increase in cesarean deliveries (27% of deliveries without obesity vs 46% of deliveries with class III obesity).
• Severe preeclampsia occurred in 8% of mothers without obesity and in 19% of mothers with class III obesity.
• Infants born to mothers with class III obesity were more likely than were infants born to mothers without obesity to have RDS, with a relative risk (RR) of 2.66.
• With class II obesity, the RR was 1.77. With class I obesity, the RR was 1.3.
• Obesity also was associated with increased risk for grade III-IV  (RR), 4.58 for class III obesity) and  (RR, 3.76).

IN PRACTICE:

“Infants born to patients with higher classes of obesity have significant associated morbidity including a 2 to 4 times increased risk of neonatal acidosis, grades III-IV intraventricular hemorrhage, sepsis, and RDS,” the researchers reported. 

SOURCE:

Sara I. Jones, MD, with University of Texas Southwestern Medical Center in Dallas, presented the study on February 14 at the 2024 Pregnancy Meeting of the Society for Maternal-Fetal Medicine, in National Harbor, Maryland. 

DISCLOSURES:

The researchers had no conflicts of interest to disclose.

A version of this article appeared on Medscape.com.

TOPLINE:

Higher body mass index (BMI) at the start of pregnancy is associated with increased risk for adverse maternal outcomes, including preeclampsia, and neonatal complications, such as respiratory distress syndrome (RDS), in a dose-dependent manner, new research shows.

METHODOLOGY:

• Researchers conducted a retrospective study of 58,497 singleton pregnancies delivered at an urban hospital between 2013 and 2021.
• They focused on pregnancies delivered between 24 and 42 weeks of gestation, for which information about BMI at the first prenatal visit was available.
• 21.1% of mothers had class I , 9.3% had class II obesity, and 6% had class III obesity.

TAKEAWAY: 

• Obesity was associated with a dose-dependent increase in cesarean deliveries (27% of deliveries without obesity vs 46% of deliveries with class III obesity).
• Severe preeclampsia occurred in 8% of mothers without obesity and in 19% of mothers with class III obesity.
• Infants born to mothers with class III obesity were more likely than were infants born to mothers without obesity to have RDS, with a relative risk (RR) of 2.66.
• With class II obesity, the RR was 1.77. With class I obesity, the RR was 1.3.
• Obesity also was associated with increased risk for grade III-IV  (RR), 4.58 for class III obesity) and  (RR, 3.76).

IN PRACTICE:

“Infants born to patients with higher classes of obesity have significant associated morbidity including a 2 to 4 times increased risk of neonatal acidosis, grades III-IV intraventricular hemorrhage, sepsis, and RDS,” the researchers reported. 

SOURCE:

Sara I. Jones, MD, with University of Texas Southwestern Medical Center in Dallas, presented the study on February 14 at the 2024 Pregnancy Meeting of the Society for Maternal-Fetal Medicine, in National Harbor, Maryland. 

DISCLOSURES:

The researchers had no conflicts of interest to disclose.

A version of this article appeared on Medscape.com.

TOPLINE:

Higher body mass index (BMI) at the start of pregnancy is associated with increased risk for adverse maternal outcomes, including preeclampsia, and neonatal complications, such as respiratory distress syndrome (RDS), in a dose-dependent manner, new research shows.

METHODOLOGY:

• Researchers conducted a retrospective study of 58,497 singleton pregnancies delivered at an urban hospital between 2013 and 2021.
• They focused on pregnancies delivered between 24 and 42 weeks of gestation, for which information about BMI at the first prenatal visit was available.
• 21.1% of mothers had class I , 9.3% had class II obesity, and 6% had class III obesity.

TAKEAWAY: 

• Obesity was associated with a dose-dependent increase in cesarean deliveries (27% of deliveries without obesity vs 46% of deliveries with class III obesity).
• Severe preeclampsia occurred in 8% of mothers without obesity and in 19% of mothers with class III obesity.
• Infants born to mothers with class III obesity were more likely than were infants born to mothers without obesity to have RDS, with a relative risk (RR) of 2.66.
• With class II obesity, the RR was 1.77. With class I obesity, the RR was 1.3.
• Obesity also was associated with increased risk for grade III-IV  (RR), 4.58 for class III obesity) and  (RR, 3.76).

IN PRACTICE:

“Infants born to patients with higher classes of obesity have significant associated morbidity including a 2 to 4 times increased risk of neonatal acidosis, grades III-IV intraventricular hemorrhage, sepsis, and RDS,” the researchers reported. 

SOURCE:

Sara I. Jones, MD, with University of Texas Southwestern Medical Center in Dallas, presented the study on February 14 at the 2024 Pregnancy Meeting of the Society for Maternal-Fetal Medicine, in National Harbor, Maryland. 

DISCLOSURES:

The researchers had no conflicts of interest to disclose.

A version of this article appeared on Medscape.com.

A trio of studies (abstracts 1101, 1079, and 944) presented on February 14 at the meeting sponsored by the Society for Maternal-Fetal Medicine point to the power of staying physically active during pregnancy. The work highlights the beneficial effects of exercise on a variety of outcomes, including depression, anxiety, and reducing the rate of cesarean deliveries.

“Twenty-plus years ago, there were so many recommendations for bed rest in pregnancy,” said Danielle Panelli, MD, a maternal-fetal medicine physician and research scholar at Stanford University in Stanford, California. “We’ve really come full circle on that.” The American College of Obstetricians and Gynecologists recommends pregnant people get at least 150 minutes of moderate activity or 75 minutes of vigorous activity per week. 

Dr. Panelli and colleagues looked at the association of physical activity and anxiety among three groups of pregnant people: 20 outpatients from low-risk obstetric clinics, 20 outpatients from high-risk obstetric clinics, and 19 inpatients. Participants wore accelerometer watches for up to seven days to measure physical activity. The primary outcome was mean daily step count, with secondary outcomes including metabolic equivalent tasks (METs), moderate to vigorous physical activity (MVPA), and anxiety as measured using the State-Trait Anxiety Inventory. 

Low-risk outpatients had an average daily step count of 9090 compared with high-risk outpatients at 8898 and inpatients at 6493. Compared with outpatients, inpatients also had significantly lower METs (adjusted beta, -0.20; 95% CI -0.26 to -0.13; P < .001), and MVPAs (adjusted beta, -43.6; 95% CI, -61.2 to -25.9; P < .001). Over the course of a week, steps progressively decreased for inpatients but not for women in either of the outpatient groups. Among the entire cohort, lower step counts correlated with higher anxiety scores (r = 0.30; P = .02).

“These results highlight the need for physical activity interventions, particularly for hospitalized pregnant people,” Dr. Panelli said. That could be something as simple as asking patients to walk three laps around the unit per day, she suggested.

A second study investigated the effect of physical activity during pregnancy on peripartum depression. Researchers at the University of Alabama at Birmingham reviewed data from participants in nuMoM2b, a large cohort study of pregnant women who would be delivering for the first time and had at least one medical comorbidity, such as chronic hypertension, asthma, or cardiac disease. The investigators looked at activity logs maintained by study participants and turned in at three study visits: 6-13.6 weeks, 14-21.6 weeks, and 22-29.6 weeks. 

Being physically active was associated with 15% lower odds of having an Edinburgh Postnatal Depression Score (EPDS) > 10 (adjusted odds ratio, 0.85; 95% CI, 0.72-0.99). Nine percent of people in the active group and 12% of people in the nonactive group had an EPDS > 10, which is suggestive of depression. However, a change in EPDS from visit one to three and treatment for perinatal depression did not differ by physical activity. 

“One of the interesting findings are that we didn’t see any safety signals [from exercise], so there wasn’t an increase in suspected fetal growth restriction or low fluid or preterm birth, or actual birthweight being low in the people who were active,” said Charlotte McCarley, MD, a maternal-fetal medicine fellow at the University of Alabama at Birmingham, who led the research. “A lot of studies have been done that have looked at prospective exercise in pregnancy, but they exclude the cohort that we looked at for concern that there may be a safety issue.” 

In a third study, researchers at the Rambam Health Care Campus in Haifa, Israel, looked at the effect of physical activity on mode of delivery. The prospective observational analysis included 401 women with singleton pregnancies attempting vaginal deliveries. 

The researchers tracked the number of daily steps taken during gestation using validated phone apps. They adjusted their findings for age, parity, body mass index, and medical and obstetric history. 

The investigators observed a gradual decrease in physical activity as pregnancy progressed (mean of 3184 steps in the first trimester, 2700 steps in mid-pregnancy, and 2152 steps in the third trimester). The overall incidence of cesarean delivery was 10.5%. However, women who were more active during pregnancy had a significantly lower incidence of cesarean delivery. 

Area under the ROC curve, with a cut-off of 2093.5 daily steps, was 0.694 (95% CI, 0.615-0.773), resulting in a significant risk reduction in a 78% reduction in the rate of cesarean surgery (odds ratio, 0.22; 95% CI, 0.104-0.465).

More active patients also had a reduced composite outcome of gestational diabetes, gestational hypertension, and preeclampsia; less use of epidural analgesia during labor; and less postpartum hemorrhage. Preterm birth, labor induction, neonatal weight, and admission to the neonatal intensive care unit were not significantly affected, the researchers reported. 

“Maintaining an active lifestyle during pregnancy should be strongly encouraged,” they wrote. 

The investigators disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

A trio of studies (abstracts 1101, 1079, and 944) presented on February 14 at the meeting sponsored by the Society for Maternal-Fetal Medicine point to the power of staying physically active during pregnancy. The work highlights the beneficial effects of exercise on a variety of outcomes, including depression, anxiety, and reducing the rate of cesarean deliveries.

“Twenty-plus years ago, there were so many recommendations for bed rest in pregnancy,” said Danielle Panelli, MD, a maternal-fetal medicine physician and research scholar at Stanford University in Stanford, California. “We’ve really come full circle on that.” The American College of Obstetricians and Gynecologists recommends pregnant people get at least 150 minutes of moderate activity or 75 minutes of vigorous activity per week. 

Dr. Panelli and colleagues looked at the association of physical activity and anxiety among three groups of pregnant people: 20 outpatients from low-risk obstetric clinics, 20 outpatients from high-risk obstetric clinics, and 19 inpatients. Participants wore accelerometer watches for up to seven days to measure physical activity. The primary outcome was mean daily step count, with secondary outcomes including metabolic equivalent tasks (METs), moderate to vigorous physical activity (MVPA), and anxiety as measured using the State-Trait Anxiety Inventory. 

Low-risk outpatients had an average daily step count of 9090 compared with high-risk outpatients at 8898 and inpatients at 6493. Compared with outpatients, inpatients also had significantly lower METs (adjusted beta, -0.20; 95% CI -0.26 to -0.13; P < .001), and MVPAs (adjusted beta, -43.6; 95% CI, -61.2 to -25.9; P < .001). Over the course of a week, steps progressively decreased for inpatients but not for women in either of the outpatient groups. Among the entire cohort, lower step counts correlated with higher anxiety scores (r = 0.30; P = .02).

“These results highlight the need for physical activity interventions, particularly for hospitalized pregnant people,” Dr. Panelli said. That could be something as simple as asking patients to walk three laps around the unit per day, she suggested.

A second study investigated the effect of physical activity during pregnancy on peripartum depression. Researchers at the University of Alabama at Birmingham reviewed data from participants in nuMoM2b, a large cohort study of pregnant women who would be delivering for the first time and had at least one medical comorbidity, such as chronic hypertension, asthma, or cardiac disease. The investigators looked at activity logs maintained by study participants and turned in at three study visits: 6-13.6 weeks, 14-21.6 weeks, and 22-29.6 weeks. 

Being physically active was associated with 15% lower odds of having an Edinburgh Postnatal Depression Score (EPDS) > 10 (adjusted odds ratio, 0.85; 95% CI, 0.72-0.99). Nine percent of people in the active group and 12% of people in the nonactive group had an EPDS > 10, which is suggestive of depression. However, a change in EPDS from visit one to three and treatment for perinatal depression did not differ by physical activity. 

“One of the interesting findings are that we didn’t see any safety signals [from exercise], so there wasn’t an increase in suspected fetal growth restriction or low fluid or preterm birth, or actual birthweight being low in the people who were active,” said Charlotte McCarley, MD, a maternal-fetal medicine fellow at the University of Alabama at Birmingham, who led the research. “A lot of studies have been done that have looked at prospective exercise in pregnancy, but they exclude the cohort that we looked at for concern that there may be a safety issue.” 

In a third study, researchers at the Rambam Health Care Campus in Haifa, Israel, looked at the effect of physical activity on mode of delivery. The prospective observational analysis included 401 women with singleton pregnancies attempting vaginal deliveries. 

The researchers tracked the number of daily steps taken during gestation using validated phone apps. They adjusted their findings for age, parity, body mass index, and medical and obstetric history. 

The investigators observed a gradual decrease in physical activity as pregnancy progressed (mean of 3184 steps in the first trimester, 2700 steps in mid-pregnancy, and 2152 steps in the third trimester). The overall incidence of cesarean delivery was 10.5%. However, women who were more active during pregnancy had a significantly lower incidence of cesarean delivery. 

Area under the ROC curve, with a cut-off of 2093.5 daily steps, was 0.694 (95% CI, 0.615-0.773), resulting in a significant risk reduction in a 78% reduction in the rate of cesarean surgery (odds ratio, 0.22; 95% CI, 0.104-0.465).

More active patients also had a reduced composite outcome of gestational diabetes, gestational hypertension, and preeclampsia; less use of epidural analgesia during labor; and less postpartum hemorrhage. Preterm birth, labor induction, neonatal weight, and admission to the neonatal intensive care unit were not significantly affected, the researchers reported. 

“Maintaining an active lifestyle during pregnancy should be strongly encouraged,” they wrote. 

The investigators disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

A trio of studies (abstracts 1101, 1079, and 944) presented on February 14 at the meeting sponsored by the Society for Maternal-Fetal Medicine point to the power of staying physically active during pregnancy. The work highlights the beneficial effects of exercise on a variety of outcomes, including depression, anxiety, and reducing the rate of cesarean deliveries.

“Twenty-plus years ago, there were so many recommendations for bed rest in pregnancy,” said Danielle Panelli, MD, a maternal-fetal medicine physician and research scholar at Stanford University in Stanford, California. “We’ve really come full circle on that.” The American College of Obstetricians and Gynecologists recommends pregnant people get at least 150 minutes of moderate activity or 75 minutes of vigorous activity per week. 

Dr. Panelli and colleagues looked at the association of physical activity and anxiety among three groups of pregnant people: 20 outpatients from low-risk obstetric clinics, 20 outpatients from high-risk obstetric clinics, and 19 inpatients. Participants wore accelerometer watches for up to seven days to measure physical activity. The primary outcome was mean daily step count, with secondary outcomes including metabolic equivalent tasks (METs), moderate to vigorous physical activity (MVPA), and anxiety as measured using the State-Trait Anxiety Inventory. 

Low-risk outpatients had an average daily step count of 9090 compared with high-risk outpatients at 8898 and inpatients at 6493. Compared with outpatients, inpatients also had significantly lower METs (adjusted beta, -0.20; 95% CI -0.26 to -0.13; P < .001), and MVPAs (adjusted beta, -43.6; 95% CI, -61.2 to -25.9; P < .001). Over the course of a week, steps progressively decreased for inpatients but not for women in either of the outpatient groups. Among the entire cohort, lower step counts correlated with higher anxiety scores (r = 0.30; P = .02).

“These results highlight the need for physical activity interventions, particularly for hospitalized pregnant people,” Dr. Panelli said. That could be something as simple as asking patients to walk three laps around the unit per day, she suggested.

A second study investigated the effect of physical activity during pregnancy on peripartum depression. Researchers at the University of Alabama at Birmingham reviewed data from participants in nuMoM2b, a large cohort study of pregnant women who would be delivering for the first time and had at least one medical comorbidity, such as chronic hypertension, asthma, or cardiac disease. The investigators looked at activity logs maintained by study participants and turned in at three study visits: 6-13.6 weeks, 14-21.6 weeks, and 22-29.6 weeks. 

Being physically active was associated with 15% lower odds of having an Edinburgh Postnatal Depression Score (EPDS) > 10 (adjusted odds ratio, 0.85; 95% CI, 0.72-0.99). Nine percent of people in the active group and 12% of people in the nonactive group had an EPDS > 10, which is suggestive of depression. However, a change in EPDS from visit one to three and treatment for perinatal depression did not differ by physical activity. 

“One of the interesting findings are that we didn’t see any safety signals [from exercise], so there wasn’t an increase in suspected fetal growth restriction or low fluid or preterm birth, or actual birthweight being low in the people who were active,” said Charlotte McCarley, MD, a maternal-fetal medicine fellow at the University of Alabama at Birmingham, who led the research. “A lot of studies have been done that have looked at prospective exercise in pregnancy, but they exclude the cohort that we looked at for concern that there may be a safety issue.” 

In a third study, researchers at the Rambam Health Care Campus in Haifa, Israel, looked at the effect of physical activity on mode of delivery. The prospective observational analysis included 401 women with singleton pregnancies attempting vaginal deliveries. 

The researchers tracked the number of daily steps taken during gestation using validated phone apps. They adjusted their findings for age, parity, body mass index, and medical and obstetric history. 

The investigators observed a gradual decrease in physical activity as pregnancy progressed (mean of 3184 steps in the first trimester, 2700 steps in mid-pregnancy, and 2152 steps in the third trimester). The overall incidence of cesarean delivery was 10.5%. However, women who were more active during pregnancy had a significantly lower incidence of cesarean delivery. 

Area under the ROC curve, with a cut-off of 2093.5 daily steps, was 0.694 (95% CI, 0.615-0.773), resulting in a significant risk reduction in a 78% reduction in the rate of cesarean surgery (odds ratio, 0.22; 95% CI, 0.104-0.465).

More active patients also had a reduced composite outcome of gestational diabetes, gestational hypertension, and preeclampsia; less use of epidural analgesia during labor; and less postpartum hemorrhage. Preterm birth, labor induction, neonatal weight, and admission to the neonatal intensive care unit were not significantly affected, the researchers reported. 

“Maintaining an active lifestyle during pregnancy should be strongly encouraged,” they wrote. 

The investigators disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

NATIONAL HARBOR, MARYLAND — A combination of oral antihyperglycemics was as effective as insulin for managing gestational diabetes, based on data from more than 800 individuals.

After diet control, both insulin and oral agents such as metformin and glibenclamide are used as a first-line treatment for gestational diabetes mellitus, Doortje Rademaker, MD, of Amsterdam University Medical Center, the Netherlands, said in a presentation at the Pregnancy Meeting (abstract 28).

Oral antihyperglycemic agents (OAAs) are thought to be comparable to insulin in preventing large-for-gestational-age (LGA) infants at birth and potentially more convenient for patients, Dr. Rademaker said at the Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.

Metformin and glibenclamide monotherapy as first-line treatment for gestational diabetes (GDM) are often used as patient-friendly alternatives to insulin. However, side effects are a concern, and data on the use of sequential and combined metformin and glibenclamide compared with insulin are lacking, she said.

In the study known as the SUGAR-DIP trial, Dr. Rademaker and colleagues recruited 821 women older than 18 years with singleton pregnancies between 16 weeks’ and 34 weeks’ gestation who had insufficient glycemic control with diet alone.

The study was conducted between 2016 and 2022; 409 women were randomized to OAAs and 412 to insulin. The mean age of the participants was 33 years, and 58% were White.

The OAA group received metformin initially, with the addition of up to 15 mg/day of glibenclamide in cases of insufficient glycemic control. Those who still experienced insufficient glycemic control were given insulin. The insulin group received injections according to usual standard of care.

The primary outcome was neonatal LGA, defined as birth weight above the 90th percentile. Secondary outcomes included patient satisfaction based on the Diabetes Treatment Satisfaction Questionnaire.

The intent-to-treat population included 406 women in the OAA group and 398 in the insulin group.

Overall, LGA rates were 23.9% in the OAA group vs. 19.9% in the insulin group. The absolute risk difference was 4%, with P values of .09 for noninferiority and .17 for superiority, Dr. Rademaker said in her presentation.

Notably, the OAA treatment led to lower maternal weight gain, although side effects were similar between the groups, she said. Neonates in the OAA group were significantly more likely to need intravenous glucose therapy (6.4% vs. 3.2%, P = .04). However, gestational weight gain was significantly lower in the OAA group than the insulin group (mean of 9.3 kg vs. 10.4 kg, P = .03).

Rates of maternal hypoglycemia were higher in the OAA group (21% vs. 11%), and 20% of women in the OAA group needed insulin therapy.

Serious adverse events were similar between the groups, but more side effects overall were reported in the OAA group than in the insulin group (77.9% vs. 55.9%, P < .001). The most common patient-reported side effects in the OAA group were nausea and diarrhea (nearly 40% for each), while headache and fatigue were the most common side effects in the insulin group.

Participants in both groups reported high levels of treatment satisfaction, with median scores of 5 on a scale of 0-6, Dr. Rademaker said. However, the data supported the researchers’ hypothesis of greater satisfaction with oral therapy. Patients in the OAA group were more likely to recommend their treatment to others than were those in the insulin group, with ratings of 5 vs. 4 on a scale of 0-6, and significantly more women in the OAA group said they would be inclined to continue their current treatment (5 vs. 4, P < .001 for both).

Study limitations included the open-label design. However, the results support the use of oral treatments as a noninferior alternative to insulin for preventing LGA in women with gestational diabetes, Dr. Rademaker said.
 

Data Support Orals as Effective Gestational Diabetes Option

“Treatment of gestational diabetes is important for optimal pregnancy outcomes,” Catherine Spong, MD, a maternal-fetal medicine specialist at the University of Texas Southwestern Medical Center, Dallas, said in an interview.

Although the American College of Obstetrics and Gynecology recommends insulin as the first-line therapy for gestational diabetes, many individuals opt for OAAs for the ease of an oral medication compared with injections, she said.

The current study authors evaluated whether OAAs were noninferior to insulin alone. “The size of oral [antihyperglycemic] agents suggests they can cross the placenta and may result in hypoglycemia in the fetus,” she said.

Although the overall LGA rate in the current study seems high, the rate of LGA is increased in diabetes generally, she added.

A key takeaway was that although individuals who used oral agents were more likely to recommend their treatment and to continue their therapy, 20% of these patients needed insulin therapy, Dr. Spong said.

Additional research is needed to explore the effect of gestational diabetes treatments on the fetus, Dr. Spong said in an interview. Research questions include whether hypoglycemia is more common in women who received oral agents, whether the agents crossed the placenta, and long-term effects, she said.

The study was supported by a grant from the Dutch Organization for Health Research and Development. Dr. Rademaker had no financial conflicts to disclose. One of the study coauthors disclosed serving as a consultant for ObsEva and Merck, and travel support from Merck, as well as support from the National Health and Medical Research Council. Dr. Spong had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — A combination of oral antihyperglycemics was as effective as insulin for managing gestational diabetes, based on data from more than 800 individuals.

After diet control, both insulin and oral agents such as metformin and glibenclamide are used as a first-line treatment for gestational diabetes mellitus, Doortje Rademaker, MD, of Amsterdam University Medical Center, the Netherlands, said in a presentation at the Pregnancy Meeting (abstract 28).

Oral antihyperglycemic agents (OAAs) are thought to be comparable to insulin in preventing large-for-gestational-age (LGA) infants at birth and potentially more convenient for patients, Dr. Rademaker said at the Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.

Metformin and glibenclamide monotherapy as first-line treatment for gestational diabetes (GDM) are often used as patient-friendly alternatives to insulin. However, side effects are a concern, and data on the use of sequential and combined metformin and glibenclamide compared with insulin are lacking, she said.

In the study known as the SUGAR-DIP trial, Dr. Rademaker and colleagues recruited 821 women older than 18 years with singleton pregnancies between 16 weeks’ and 34 weeks’ gestation who had insufficient glycemic control with diet alone.

The study was conducted between 2016 and 2022; 409 women were randomized to OAAs and 412 to insulin. The mean age of the participants was 33 years, and 58% were White.

The OAA group received metformin initially, with the addition of up to 15 mg/day of glibenclamide in cases of insufficient glycemic control. Those who still experienced insufficient glycemic control were given insulin. The insulin group received injections according to usual standard of care.

The primary outcome was neonatal LGA, defined as birth weight above the 90th percentile. Secondary outcomes included patient satisfaction based on the Diabetes Treatment Satisfaction Questionnaire.

The intent-to-treat population included 406 women in the OAA group and 398 in the insulin group.

Overall, LGA rates were 23.9% in the OAA group vs. 19.9% in the insulin group. The absolute risk difference was 4%, with P values of .09 for noninferiority and .17 for superiority, Dr. Rademaker said in her presentation.

Notably, the OAA treatment led to lower maternal weight gain, although side effects were similar between the groups, she said. Neonates in the OAA group were significantly more likely to need intravenous glucose therapy (6.4% vs. 3.2%, P = .04). However, gestational weight gain was significantly lower in the OAA group than the insulin group (mean of 9.3 kg vs. 10.4 kg, P = .03).

Rates of maternal hypoglycemia were higher in the OAA group (21% vs. 11%), and 20% of women in the OAA group needed insulin therapy.

Serious adverse events were similar between the groups, but more side effects overall were reported in the OAA group than in the insulin group (77.9% vs. 55.9%, P < .001). The most common patient-reported side effects in the OAA group were nausea and diarrhea (nearly 40% for each), while headache and fatigue were the most common side effects in the insulin group.

Participants in both groups reported high levels of treatment satisfaction, with median scores of 5 on a scale of 0-6, Dr. Rademaker said. However, the data supported the researchers’ hypothesis of greater satisfaction with oral therapy. Patients in the OAA group were more likely to recommend their treatment to others than were those in the insulin group, with ratings of 5 vs. 4 on a scale of 0-6, and significantly more women in the OAA group said they would be inclined to continue their current treatment (5 vs. 4, P < .001 for both).

Study limitations included the open-label design. However, the results support the use of oral treatments as a noninferior alternative to insulin for preventing LGA in women with gestational diabetes, Dr. Rademaker said.
 

Data Support Orals as Effective Gestational Diabetes Option

“Treatment of gestational diabetes is important for optimal pregnancy outcomes,” Catherine Spong, MD, a maternal-fetal medicine specialist at the University of Texas Southwestern Medical Center, Dallas, said in an interview.

Although the American College of Obstetrics and Gynecology recommends insulin as the first-line therapy for gestational diabetes, many individuals opt for OAAs for the ease of an oral medication compared with injections, she said.

The current study authors evaluated whether OAAs were noninferior to insulin alone. “The size of oral [antihyperglycemic] agents suggests they can cross the placenta and may result in hypoglycemia in the fetus,” she said.

Although the overall LGA rate in the current study seems high, the rate of LGA is increased in diabetes generally, she added.

A key takeaway was that although individuals who used oral agents were more likely to recommend their treatment and to continue their therapy, 20% of these patients needed insulin therapy, Dr. Spong said.

Additional research is needed to explore the effect of gestational diabetes treatments on the fetus, Dr. Spong said in an interview. Research questions include whether hypoglycemia is more common in women who received oral agents, whether the agents crossed the placenta, and long-term effects, she said.

The study was supported by a grant from the Dutch Organization for Health Research and Development. Dr. Rademaker had no financial conflicts to disclose. One of the study coauthors disclosed serving as a consultant for ObsEva and Merck, and travel support from Merck, as well as support from the National Health and Medical Research Council. Dr. Spong had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — A combination of oral antihyperglycemics was as effective as insulin for managing gestational diabetes, based on data from more than 800 individuals.

After diet control, both insulin and oral agents such as metformin and glibenclamide are used as a first-line treatment for gestational diabetes mellitus, Doortje Rademaker, MD, of Amsterdam University Medical Center, the Netherlands, said in a presentation at the Pregnancy Meeting (abstract 28).

Oral antihyperglycemic agents (OAAs) are thought to be comparable to insulin in preventing large-for-gestational-age (LGA) infants at birth and potentially more convenient for patients, Dr. Rademaker said at the Pregnancy Meeting, sponsored by the Society for Maternal-Fetal Medicine.

Metformin and glibenclamide monotherapy as first-line treatment for gestational diabetes (GDM) are often used as patient-friendly alternatives to insulin. However, side effects are a concern, and data on the use of sequential and combined metformin and glibenclamide compared with insulin are lacking, she said.

In the study known as the SUGAR-DIP trial, Dr. Rademaker and colleagues recruited 821 women older than 18 years with singleton pregnancies between 16 weeks’ and 34 weeks’ gestation who had insufficient glycemic control with diet alone.

The study was conducted between 2016 and 2022; 409 women were randomized to OAAs and 412 to insulin. The mean age of the participants was 33 years, and 58% were White.

The OAA group received metformin initially, with the addition of up to 15 mg/day of glibenclamide in cases of insufficient glycemic control. Those who still experienced insufficient glycemic control were given insulin. The insulin group received injections according to usual standard of care.

The primary outcome was neonatal LGA, defined as birth weight above the 90th percentile. Secondary outcomes included patient satisfaction based on the Diabetes Treatment Satisfaction Questionnaire.

The intent-to-treat population included 406 women in the OAA group and 398 in the insulin group.

Overall, LGA rates were 23.9% in the OAA group vs. 19.9% in the insulin group. The absolute risk difference was 4%, with P values of .09 for noninferiority and .17 for superiority, Dr. Rademaker said in her presentation.

Notably, the OAA treatment led to lower maternal weight gain, although side effects were similar between the groups, she said. Neonates in the OAA group were significantly more likely to need intravenous glucose therapy (6.4% vs. 3.2%, P = .04). However, gestational weight gain was significantly lower in the OAA group than the insulin group (mean of 9.3 kg vs. 10.4 kg, P = .03).

Rates of maternal hypoglycemia were higher in the OAA group (21% vs. 11%), and 20% of women in the OAA group needed insulin therapy.

Serious adverse events were similar between the groups, but more side effects overall were reported in the OAA group than in the insulin group (77.9% vs. 55.9%, P < .001). The most common patient-reported side effects in the OAA group were nausea and diarrhea (nearly 40% for each), while headache and fatigue were the most common side effects in the insulin group.

Participants in both groups reported high levels of treatment satisfaction, with median scores of 5 on a scale of 0-6, Dr. Rademaker said. However, the data supported the researchers’ hypothesis of greater satisfaction with oral therapy. Patients in the OAA group were more likely to recommend their treatment to others than were those in the insulin group, with ratings of 5 vs. 4 on a scale of 0-6, and significantly more women in the OAA group said they would be inclined to continue their current treatment (5 vs. 4, P < .001 for both).

Study limitations included the open-label design. However, the results support the use of oral treatments as a noninferior alternative to insulin for preventing LGA in women with gestational diabetes, Dr. Rademaker said.
 

Data Support Orals as Effective Gestational Diabetes Option

“Treatment of gestational diabetes is important for optimal pregnancy outcomes,” Catherine Spong, MD, a maternal-fetal medicine specialist at the University of Texas Southwestern Medical Center, Dallas, said in an interview.

Although the American College of Obstetrics and Gynecology recommends insulin as the first-line therapy for gestational diabetes, many individuals opt for OAAs for the ease of an oral medication compared with injections, she said.

The current study authors evaluated whether OAAs were noninferior to insulin alone. “The size of oral [antihyperglycemic] agents suggests they can cross the placenta and may result in hypoglycemia in the fetus,” she said.

Although the overall LGA rate in the current study seems high, the rate of LGA is increased in diabetes generally, she added.

A key takeaway was that although individuals who used oral agents were more likely to recommend their treatment and to continue their therapy, 20% of these patients needed insulin therapy, Dr. Spong said.

Additional research is needed to explore the effect of gestational diabetes treatments on the fetus, Dr. Spong said in an interview. Research questions include whether hypoglycemia is more common in women who received oral agents, whether the agents crossed the placenta, and long-term effects, she said.

The study was supported by a grant from the Dutch Organization for Health Research and Development. Dr. Rademaker had no financial conflicts to disclose. One of the study coauthors disclosed serving as a consultant for ObsEva and Merck, and travel support from Merck, as well as support from the National Health and Medical Research Council. Dr. Spong had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Women who experience an adverse pregnancy outcome during their first pregnancy are significantly more likely to experience either the same or any adverse pregnancy outcome in a subsequent pregnancy than are those with no adverse pregnancy outcome during a first pregnancy, based on data from more than 4000 individuals.

Adverse pregnancy outcomes (APOs) occur in approximately 20%-30% of pregnancies and contribute to significant perinatal morbidity, William A. Grobman, MD, of The Ohio State University, Columbus, said in a presentation at the Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine (abstract 17).

Risk factors for APOs include nulliparity and prior APOs, as well as age, body mass index, and blood pressure, he said. However, less is known about factors identified early in a first pregnancy that might predict an APO in a second pregnancy, he explained.

Dr. Grobman and colleagues used data from the nuMoM2b Heart Health Study, a cohort of more than 10,000 nulliparous women at eight sites in the United States.

The current study included a subset of individuals with two pregnancies of at least 20 weeks’ gestation who were followed for up to 7 years after delivery via telephone and in-person visits and for whom APO information was available.

An APO was defined as any of a range of outcomes including hypertensive disorders of pregnancy, preterm birth at less than 37 weeks’ gestation, small-for-gestational age at birth (less than 5th percentile for weight), gestational diabetes, or fetal death.

The goal of the study was to determine patterns of APOs across two pregnancies, and to identify factors in the first pregnancy that might be associated with these patterns, Dr. Grobman said.

The study population included 4253 women from the nuMOM2b; of these, 1332 (31%) experienced an APO during their first pregnancies.

Women with an APO during the first pregnancy were significantly more likely to have a second APO than were those with no initial APO (40% vs. 15%), said Dr. Grobman. Overall, the APO that occurred most frequently in the first pregnancy was the one most likely to occur in the second.

However, “the increased risk for an APO during a second pregnancy was greater for any APO in women with a history of any APO compared to women with no prior APO,” he said.

In this study, the most common APOs were gestational diabetes and hypertensive disorders of pregnancy.

“In general, no risk markers were associated with a particular pattern of APO development,” Dr. Grobman said.

However, some markers from the first trimester of the first pregnancy were significantly associated with an APO in the second pregnancy, including body mass index, age older than 35 years, blood pressure, and cardiometabolic serum analytes. Also, the magnitude of APO recurrence risk was highest among non-Hispanic Black individuals compared with other ethnicities.

The findings were limited by a lack of data on placental pathology, Dr. Grobman noted during the discussion. However, the findings underscored the need to better understand the risk factors for APOs and develop prevention strategies, he said. The results also emphasize the need to account for transitions of care for patients who experience an APO, he added.
 

Data May Inform Patient Guidance

“Patients with an adverse pregnancy outcome in a first pregnancy often experience considerable anxiety when thinking about a second pregnancy,” Joseph R. Biggio Jr., MD, a maternal-fetal medicine specialist at Ochsner Health in New Orleans, said in an interview.

“This study helps to provide insight into factors which may be associated with increased risk in a subsequent pregnancy, and importantly identifies some factors that are potentially modifiable, such as BMI and blood pressure,” said Dr. Biggio, who served as a moderator for the session in which the study was presented.

“Based on the findings from this analysis, we need research to determine whether these findings apply to not only patients having their first pregnancy, but also adverse outcomes in any pregnancy,” Dr. Biggio said in an interview. “In addition, we need to explore whether modification of any of these risk factors can improve pregnancy outcomes, so that all patients can have the birth experience that they desire,” he said.

The study received no outside funding. Dr. Grobman and Dr. Biggio had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Women who experience an adverse pregnancy outcome during their first pregnancy are significantly more likely to experience either the same or any adverse pregnancy outcome in a subsequent pregnancy than are those with no adverse pregnancy outcome during a first pregnancy, based on data from more than 4000 individuals.

Adverse pregnancy outcomes (APOs) occur in approximately 20%-30% of pregnancies and contribute to significant perinatal morbidity, William A. Grobman, MD, of The Ohio State University, Columbus, said in a presentation at the Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine (abstract 17).

Risk factors for APOs include nulliparity and prior APOs, as well as age, body mass index, and blood pressure, he said. However, less is known about factors identified early in a first pregnancy that might predict an APO in a second pregnancy, he explained.

Dr. Grobman and colleagues used data from the nuMoM2b Heart Health Study, a cohort of more than 10,000 nulliparous women at eight sites in the United States.

The current study included a subset of individuals with two pregnancies of at least 20 weeks’ gestation who were followed for up to 7 years after delivery via telephone and in-person visits and for whom APO information was available.

An APO was defined as any of a range of outcomes including hypertensive disorders of pregnancy, preterm birth at less than 37 weeks’ gestation, small-for-gestational age at birth (less than 5th percentile for weight), gestational diabetes, or fetal death.

The goal of the study was to determine patterns of APOs across two pregnancies, and to identify factors in the first pregnancy that might be associated with these patterns, Dr. Grobman said.

The study population included 4253 women from the nuMOM2b; of these, 1332 (31%) experienced an APO during their first pregnancies.

Women with an APO during the first pregnancy were significantly more likely to have a second APO than were those with no initial APO (40% vs. 15%), said Dr. Grobman. Overall, the APO that occurred most frequently in the first pregnancy was the one most likely to occur in the second.

However, “the increased risk for an APO during a second pregnancy was greater for any APO in women with a history of any APO compared to women with no prior APO,” he said.

In this study, the most common APOs were gestational diabetes and hypertensive disorders of pregnancy.

“In general, no risk markers were associated with a particular pattern of APO development,” Dr. Grobman said.

However, some markers from the first trimester of the first pregnancy were significantly associated with an APO in the second pregnancy, including body mass index, age older than 35 years, blood pressure, and cardiometabolic serum analytes. Also, the magnitude of APO recurrence risk was highest among non-Hispanic Black individuals compared with other ethnicities.

The findings were limited by a lack of data on placental pathology, Dr. Grobman noted during the discussion. However, the findings underscored the need to better understand the risk factors for APOs and develop prevention strategies, he said. The results also emphasize the need to account for transitions of care for patients who experience an APO, he added.
 

Data May Inform Patient Guidance

“Patients with an adverse pregnancy outcome in a first pregnancy often experience considerable anxiety when thinking about a second pregnancy,” Joseph R. Biggio Jr., MD, a maternal-fetal medicine specialist at Ochsner Health in New Orleans, said in an interview.

“This study helps to provide insight into factors which may be associated with increased risk in a subsequent pregnancy, and importantly identifies some factors that are potentially modifiable, such as BMI and blood pressure,” said Dr. Biggio, who served as a moderator for the session in which the study was presented.

“Based on the findings from this analysis, we need research to determine whether these findings apply to not only patients having their first pregnancy, but also adverse outcomes in any pregnancy,” Dr. Biggio said in an interview. “In addition, we need to explore whether modification of any of these risk factors can improve pregnancy outcomes, so that all patients can have the birth experience that they desire,” he said.

The study received no outside funding. Dr. Grobman and Dr. Biggio had no financial conflicts to disclose.

NATIONAL HARBOR, MARYLAND — Women who experience an adverse pregnancy outcome during their first pregnancy are significantly more likely to experience either the same or any adverse pregnancy outcome in a subsequent pregnancy than are those with no adverse pregnancy outcome during a first pregnancy, based on data from more than 4000 individuals.

Adverse pregnancy outcomes (APOs) occur in approximately 20%-30% of pregnancies and contribute to significant perinatal morbidity, William A. Grobman, MD, of The Ohio State University, Columbus, said in a presentation at the Pregnancy Meeting sponsored by the Society for Maternal-Fetal Medicine (abstract 17).

Risk factors for APOs include nulliparity and prior APOs, as well as age, body mass index, and blood pressure, he said. However, less is known about factors identified early in a first pregnancy that might predict an APO in a second pregnancy, he explained.

Dr. Grobman and colleagues used data from the nuMoM2b Heart Health Study, a cohort of more than 10,000 nulliparous women at eight sites in the United States.

The current study included a subset of individuals with two pregnancies of at least 20 weeks’ gestation who were followed for up to 7 years after delivery via telephone and in-person visits and for whom APO information was available.

An APO was defined as any of a range of outcomes including hypertensive disorders of pregnancy, preterm birth at less than 37 weeks’ gestation, small-for-gestational age at birth (less than 5th percentile for weight), gestational diabetes, or fetal death.

The goal of the study was to determine patterns of APOs across two pregnancies, and to identify factors in the first pregnancy that might be associated with these patterns, Dr. Grobman said.

The study population included 4253 women from the nuMOM2b; of these, 1332 (31%) experienced an APO during their first pregnancies.

Women with an APO during the first pregnancy were significantly more likely to have a second APO than were those with no initial APO (40% vs. 15%), said Dr. Grobman. Overall, the APO that occurred most frequently in the first pregnancy was the one most likely to occur in the second.

However, “the increased risk for an APO during a second pregnancy was greater for any APO in women with a history of any APO compared to women with no prior APO,” he said.

In this study, the most common APOs were gestational diabetes and hypertensive disorders of pregnancy.

“In general, no risk markers were associated with a particular pattern of APO development,” Dr. Grobman said.

However, some markers from the first trimester of the first pregnancy were significantly associated with an APO in the second pregnancy, including body mass index, age older than 35 years, blood pressure, and cardiometabolic serum analytes. Also, the magnitude of APO recurrence risk was highest among non-Hispanic Black individuals compared with other ethnicities.

The findings were limited by a lack of data on placental pathology, Dr. Grobman noted during the discussion. However, the findings underscored the need to better understand the risk factors for APOs and develop prevention strategies, he said. The results also emphasize the need to account for transitions of care for patients who experience an APO, he added.
 

Data May Inform Patient Guidance

“Patients with an adverse pregnancy outcome in a first pregnancy often experience considerable anxiety when thinking about a second pregnancy,” Joseph R. Biggio Jr., MD, a maternal-fetal medicine specialist at Ochsner Health in New Orleans, said in an interview.

“This study helps to provide insight into factors which may be associated with increased risk in a subsequent pregnancy, and importantly identifies some factors that are potentially modifiable, such as BMI and blood pressure,” said Dr. Biggio, who served as a moderator for the session in which the study was presented.

“Based on the findings from this analysis, we need research to determine whether these findings apply to not only patients having their first pregnancy, but also adverse outcomes in any pregnancy,” Dr. Biggio said in an interview. “In addition, we need to explore whether modification of any of these risk factors can improve pregnancy outcomes, so that all patients can have the birth experience that they desire,” he said.

The study received no outside funding. Dr. Grobman and Dr. Biggio had no financial conflicts to disclose.