A new Practice Bulletin has been released by The American College of Obstetricians and Gynecologists (ACOG) recommending that pregnant women use their asthma medication at the lowest dose possible to manage symptoms. They also recommended that women with moderate-to-severe asthma are monitored during pregnancy for fetal growth restriction and any indicators of preterm birth.
The inflammation in the airways caused by asthma attacks, which results in a shortness of breath, may deprive the fetus of oxygen. Attacks have been linked to growth restriction of the fetus, increased prematurity, fetal complications, and morbidity and mortality in the mother.
As there are an increasing number of asthma patients in the USA, the ACOG felt that it was important to formalize the current recommendations for obstetricians and gynecologists.
As each women with asthma will be affected differently when pregnant, it is important that their lung function is monitored, and fetal growth restriction and preterm birth risk should be assessed by ultrasound in the first trimester if possible. In addition, those with poorly controlled asthma, moderate-to-severe asthma or those recovering from a severe asthma attack should be monitored from 32 weeks onwards with ultrasound examinations to assess fetal activity and growth.
Asthmatic women are also advised to avoid triggers and allergens or to reduce them as much as possible in their environment and in the home. Medications taken to prevent attacks or to treat the patient when an attack has occurred are advised to be modified so that only the minimum required dose is administered. Those receiving immunotherapy are advised to continue with treatment but it is not advised that women be started on immunotherapy when pregnant to reduce the chance of anaphylaxis that could cause maternal or fetal death. It is also advised that women are well educated regarding management of asthma in pregnancy and that medication should be used if necessary in labor, after delivery and during breastfeeding.
“Research consistently shows that women with well-controlled asthma can have healthy pregnancies with excellent maternal and perinatal outcomes” advised Mitchell Dombrowski, ACOG Fellow, who contributed to the guidelines. “The ultimate goal of controlling asthma during pregnancy is to ensure that the fetus continues to get adequate oxygen by preventing asthma attacks.”
Source: ACOG. Practice bulletin 90, asthma in pregnancy. Obstet. Gynecol. 111(2), 457–464 (2008).
IVF success may be increased by acupuncture
A recent review suggests that women who have acupuncture while undergoing IVF are more likely to get pregnant than those not receiving acupuncture.
The review included data from seven published trials, including a total of 1366 women who were undergoing IVF. The seven trials compared the results of IVF with acupuncture given within 1 day of embryo transfer, sham acupuncture and no additional treatment.
Participants of the study were given acupuncture at inconsistent times in relation to embryo transfer; however, the women received the acupuncture either immediately before or immediately after the embryo transplantation.
Results from the study indicate that there is a 65% increase in the chance of getting pregnant with IVF when acupuncture is administered compared with sham acupuncture or no additional treatment. However, the researchers advise that the odds ratio overestimates the rate significantly in this context. The authors found that in a subset of trials, where there was a high baseline pregnancy with no acupuncture, the benefit of acupuncture was nonsignificant.
While these preliminary data are encouraging, subsequent studies will be required before any firm conclusions can be drawn on the benefit of acupuncture therapy in patients undergoing IVF.
Source: Manheimer E, Zhang G, Udoff G et al. Effects of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilisation: systematic review and meta-analysis. BMJ (2008) (Epub ahead of print).
Long-term protection against ovarian cancer may be provided by oral contraceptives
Research published in The Lancet suggests that oral contraceptives provide long-term protection against ovarian cancer. The study authors found that taking the pill for 15 years halved the risk of contracting ovarian cancer. They also concluded that even 30 years after cessation of pill use the risk of developing ovarian cancer was reduced significantly. This is the first study that indicates the duration of protection provided from taking the pill even after it has stopped being used.
The study was conducted by the Collaborative Group on Epidemiological Studies of Ovarian Cancer and provided a meta-analysis of 45 epidemiological studies. These studies were conducted in 21 different countries and all investigated oral contraceptive use and the associated risk of ovarian cancer. Of these studies, 32 were case–control retrospective studies of women who had developed ovarian cancer and who had been questioned about their past oral contraceptive intake and compared with controls who did not have cancer. The other 13 were cohort studies observing women over time and monitoring their oral contraceptive intake and subsequent ovarian cancer development.
In total, data were available for 87,303 women without cancer and 23,257 women diagnosed with ovarian cancer between 1973 and 2001. The results from the study demonstrated that 31% of women with ovarian cancer and 37% of controls had used oral contraceptives. In addition, the authors found that for every 5 years of additional oral contraceptive use, women reduced their chances of contracting ovarian cancer by 20%.
The study also showed how the women remained protected after they had stopped using the contraceptives, although it demonstrated that this protection decreased with time. Those who were currently taking the pill and those who had stopped taking it within the last 10 years had a reduction in risk of 29%, the risk reduction declined to 19% in those who had stopped taking the pill 10–19 years previously and those who stopped taking the pill 20–29 years ago had a risk reduction of 15%.
The authors estimate that approximately 200,000 incidents of ovarian cancer and 100,000 deaths have been prevented by contraceptive pill use over the last 50 years. They anticipate that with increased use in the future and with the aging of current contraceptive pill users, the number of deaths prevented annually will increase.
The authors are not able to identify why this protection occurs but they speculate that it is the result of ovulation suppression.
Source: Collaborative Group on Epidemiological Studies of Ovarian Cancer. Ovarian cancer and oral contraceptives: collaborative reanalysis of data from 45 epidemiological studies including 23,257 women with ovarian cancer and 87,303 controls. Lancet 371, 303–314 (2008).
HPV vaccine shown to sustain efficacy in treating precancerous lesions
Virus: Human papillomavirus
Tradename: Gardasil®
Manufacturer:Merck & Co., Inc. (NJ, USA)
Trial Phase: II–III
An analysis of four Phase II and Phase III clinical trials have demonstrated that Gardasil®, a human papillomavirus (HPV) vaccine produced by Merck & Co., Inc. (NJ, USA), has maintained 98–100% efficacy in preventing both precancerous lesions and cervical cancer.
Over 20,000 women were included in the analysis and the preliminary results were impressive enough that independent monitors recommended cessation of the trial in order to administer Gardasil to the placebo group.
Elma Joura, University of Vienna, said that the results “include by far the longest follow-up for any cervical cancer vaccine in large Phase III studies and strongly substantiate the evidence that the protection provided by Gardasil will be long-lasting.”
Gardasil has been shown to prevent infection with strains 6, 11, 16 and 18. Merck advised that the results were consistent with data from a 5-year follow-up of a smaller Phase II clinical trial. They also claim that Gardasil induces immune memory providing protection against the virus by the immune system for years after the vaccine.
Data from the most recent trial were presented at the 19th International Congress on Anti-Cancer Treatment in Paris.
The advent of vaccines such as Gardasil greatly improves overall outcomes and it is hoped that this vaccine will be successful in preventing HPV in women worldwide.
Source: Reuters www.reuters.com
Women appear to prefer contraceptive ring to the patch
The first study to directly compare the contraceptive vaginal ring with the contraceptive skin patch revealed that women appeared to be more satisfied with the vaginal ring. Both methods of contraception became available in 2002 as alternatives to taking a daily pill. Both are left in place for a duration of 3 weeks during each menstrual cycle.
In total, 500 women took part in the study and, of these, 249 women used the ring and 251 used the patch. The women were randomly assigned to these groups and used their assigned method of contraception for four consecutive menstrual cycles.
The study participants were regularly physically examined, completed a questionnaire regarding their method of contraception and talked to the study authors after the study period. The overall findings suggested that the women using the ring were happier with it than those using the contraceptive patch. Mitchell Creinin (University of Pittsburgh, PA, USA) explained that those who used the ring reported fewer complications and that the majority of them preferred this method to their normal contraceptive pill.
The contraceptive patch was issued a warning in 2005 by the US FDA regarding its estrogen levels and the related risk of blood clots. Participants were made aware of this warning and five of the women using the patch said that this had influenced them and their decision to discontinue use of the patch at the end of the study.
However, the main reason for dissatisfaction with the patch was adverse side effects. “Overall, however, patch users were twice as likely to discontinue using the product by the end of the third cycle, and seven times more likely to say they had no wish to continue once the study was over,” explains Creinin. The side effects cited as reasons for discontinuation of treatment included longer periods, cramps, nausea, mood swings, skin irritation and problems with the patch falling off of the skin. Side effects associated with the ring included discomfort and frequent vaginal discharge.
This study is the first to directly compare these two methods of contraception and the authors believe that the results provide useful information for physicians and patients. “The two alternative delivery systems for combined hormonal contraceptives had not been evaluated in a single randomized trial, making it difficult for clinicians to compare and contrast these options for their patients,” concludes Creinin. He adds, “but now we can provide more accurate counseling to patients who might be interested in a non-daily birth control method.”
Source: Creinin MD, Meyn LA, Borgatta L et al. Multicenter comparison of the contraceptive ring and patch: a randomized controlled trial. Obstet. Gynecol. 111(2), 267–277 (2008).