Effect of low dose aspirin application during pregnancy on fetal congenital anomalies
1. Low dose aspirin is not significantly associated with congenital anomalies even when started in the first trimester.
2. Other factors found to be associated with congenital anomalies include history of previous fetal abnormalities and history of previous spontaneous abortions
Evidence Rating Level: 2 (Good)
Low dose aspirin (LDA) has been used effectively in the treatment of pre-eclampsia, as well as in patients undergoing recurrent pregnancy loss due to thrombophilia. Previous animal studies have found that high-dose aspirin in the first and second trimester was associated with a variety of congenital anomalies. Human studies have also found a possible association between aspirin and fetal gastroschisis and cryptorchidism, as well as concerns regarding premature closure of ductus arteriosus. This retrospective cohort study sought to further expand upon this literature with collected data from 2736 patients and 2856 fetuses, of which 1684 of these patients took LDA, with an average daily dose of 67.6mg. The patients in the LDA group were older, with a higher primipara rate and more previous spontaneous abortions, as well as were more likely to have chronic hypertension and rheumatic disease. Starting at the 12th week of gestation congenital anomalies were screened for every 4 weeks using ultrasound or MRI, karyotype analysis and postpartum examinations. Neonatal examinations were also conducted at birth. The rate of fetal abnormalities in the LDA group was found to be 3.3% and the rate of fetal abnormalities in the control group was found to be 2.8%, this difference was not significant (P=0.421). Many of these patients also started taking LDA in their first trimester which is a critical time for most congenital anomalies, suggesting that even at the most critical period there is no significant negative impact from the use of LDA. This study did find that previous spontaneous abortions (OR = 1.15, 95% CI: 1.01–1.31, P = 0.040) and a history of fetal malformations (OR = 3.22, 95% CI: 1.12–9.20, P = 0.029) were associated with a risk of fetal congenital abnormalities. This study was done in the Chinese population, thus further studies on the effects of LDA in different ethnic populations are needed to generalize these results. Congenital anomalies are thought to have a multifactorial and complex pathogenesis, with two of the factors found by this study to be a history of fetal abnormalities and a history of spontaneous abortions. This study does show however, that in the Chinese population LDA was not found to be associated with congenital anomalies and is likely safe to use in pregnancy for prophylaxis and treatment of other conditions.
Family Planning, Fertility, and Career Decisions Among Female Oncologists
1. 1 in 3 female oncologists report they experience infertility and 1 in 3 faced discrimination during pregnancy and/or for taking maternity leave
2. Almost all female oncologists in the study stated career plans were at least somewhat associated with the timing of starting a family
3. Female physicians in the US face infertility at a rate two times of the general population
Evidence Rating Level: 2 (Good)
1 in 4 female physicians in the US experience infertility, at a rate more than twice that of the general population. Studies have found that many women delay childbearing for professional advancement, with female physicians having their first child 7.4 years later than the general population, at a point where they are already considered advanced maternal age. This study surveyed over 1000 female oncologists to understand the barriers to family planning in the context of career, the association of fertility treatment with career decisions and to assess experiences of pregnancy-based discrimination among female oncologists. The age of survey participants ranged from 25 to 60 years, of which most were married and working full time, and most of which also had children. 24.2% of the participants said family planning was associated with their career decisions of academic vs private practice and 94.7% stated their career plans were at least somewhat associated with the timing of when to start a family. Positive factors associated with fertility planning were found to be a supportive partner, income as an attending physician, nearby family support, having a female mentor/role model and a supportive program during training. Negative factors associated with fertility planning were long work hours and heavy workload, concern for fertility, income as a trainee, lacking nearby family support and a bad or non-existent maternity leave policy. Additionally, of all respondents who had been pregnant, 2/3 had some sort of pregnancy complication. 1/3 of respondents reported having a miscarriage and 1/3 reported difficulty with infertility requiring counseling and/or treatment. In addition to difficulties with pregnancy, 1/3 of respondents did not feel well supported during training surrounding issues around fertility/pregnancy, including issues such as the absence of maternity leave during training and as an attending physician. Selection bias may have been a concern in this study as social media users chose to participate and some may have been subject to recall bias. Despite these limitations, it is clear that further changes are needed in medical education and training to support women in family planning.
1. Gonadotropin-releasing hormone analogue is not associated with subsequent gender affirming hormone use
2. Gonadotropin-releasing hormone analogue and its benefits on mental health and cosmetics can be used without an increased likelihood of further hormone use
Evidence Rating Level: 2 (Good)
1.8% of high school students in the US identify as transgender. Gonadotropin releasing hormone analogues (GnRHa) can be used to reversibly suppress further pubertal development. In those with gender dysphoria. Reversibly halting the development of secondary sex characteristics and allowing one to fully confirm gender identity before making a decision about gender affirming treatment plays a strong positive role in those with gender dysphoria. Treatment can improve global functioning, depression, suicidal ideation, and overall behavioural and emotional problems. Additionally, pubertal suppression can also affect cosmetic outcomes, decreasing the need for further interventions such as surgeries. Prior studies have shown that 96.5-98.1% of individuals who started GnRHa then also used gender affirming hormones with irreversible effects, leading some to believe that GnRHa treatment advances the decision to use gender affirming hormones, prior to an age of cognitive maturity. This retrospective cohort study examined the association between GnRHa use and use of gender affirming hormones among transgender youth. The 434 youth in the study had an initial health care encounter for gender dysphoria between the ages of 10 and 17, with at least one medical encounter after the age of 14. They were also required to be capable of providing meaningful informed consent. It was found that younger patients were more likely to be started on GnRHa. Compared with patients without GnRHa use, GnRHa use was associated with a longer median gap between the initial appointment and starting gender-affirming hormones (1.8 years [95% CI, 1.1-2.4 years] vs 1.0 years [95% CI, 0.8-1.2 years]) and a lower hazard of starting gender-affirming hormones (hazard ratio, 0.52; 95% CI, 0.37-0.71). This study only included children of active or retired members of the US military, and likely had higher socioeconomic standing, higher levels of parental education, better health coverage and more geographic mobility making it difficult to generalize the findings. Overall however, in this cohort study, GnRHa was not associated with increased hazard of subsequent gender affirming use, suggesting that the benefits can be offered to youth with gender dysphoria with concern for inappropriately increasing rates of gender affirming hormone use.
1. Twin pregnancies with intrahepatic cholestasis of pregnancy (ICP) are associated with an increased risk of adverse perinatal outcomes than singletons
2. Twin pregnancies with ICP had increased total bile acid levels in maternal serum, which can be transported through the placenta
Evidence Rating Level: 2 (Good)
Intrahepatic cholestasis of pregnancy (ICP) typically presents in the late second or third trimester and has a prevalence rate ranging from 0.2-25%, with a prevalence up to five times higher in multiple pregnancies. ICP is associated with an increased risk of many adverse perinatal outcomes such as preterm birth, meconium-stained amniotic fluid, fetal distress, fetal hypoxia, sudden intrauterine fetal death, respiratory distress syndrome, neonatal asphyxia, and neonatal intensive care unit admission. Increased serum total bile acid (TBA) levels are present in twin pregnancies than in singletons, however management guidelines of ICP in twin pregnancies are unclear. This retrospective cohort study included 633 twin pregnancies and 1267 singleton pregnancies with ICP. TBA levels in maternal serum and umbilical cord blood were analyzed from 33 twin pregnancies. Regular antenatal care was performed every 2 weeks before 28 weeks and then weekly after 28 weeks, including nonstress test, ultrasound scanning and biochemical surveillance. Twin pregnancies with ICP had a higher risk of cesarean section (96.4% vs 76.1%), preterm birth (82.6% vs 19.7%), fetal distress (2.0% vs 1.3%), and neonatal intensive care unit admission (23.6% vs 5.1%) and were significantly associated with increasing TBA levels (P<0.05). Managing stillbirth is the main concern of ICP and can often lead to iatrogenic preterm birth and may play a role in the high rates of preterm birth seen in this study. This study also found a link between maternal serum TBA levels and umbilical cord blood TBA levels, indicating that TBA can be transported across the placenta, and is perhaps the mechanism leading to some of these adverse outcomes. Further studies involving larger centers are needed to further help facilitate management plans for ICP in pregnancy, especially those with multiple gestations.
1. Hip braces can be used as a non-surgical treatment to prevent hip displacement in children with non-ambulatory cerebral palsy
2. The use of hip braces resulted in a significantly decreased hip displacement over the course of 6 and 12 months
Evidence Rating Level: 2 (Good)
Musculoskeletal deformities associated with poor biomechanical alignment during growth are present in many children with cerebral palsy, with progressive hip displacement being the second most common musculoskeletal deformity. The current treatment has mainly been focused on surgery, with some nonsurgical options including braces, postural alignment seating systems, and botulinum toxin. This randomized trial included children aged 1 to 10 years with a diagnosis of cerebral palsy and quadriplegia or diplegia. 66 patients were included, with 33 randomized to the intervention group which involved a hip brace that can stabilize and protect the joint, and 33 patients randomized to the control group. The primary outcomes was the Reimers migration index (MI) on radiography, which is the percentage of femoral head that lies outside the acetabulum, assessed by 3 blinded investigators, with secondary outcomes including MI at 6 months, hip range of motion, Cobb angle, pain intensity, quality of life of the patients and their caregivers, and satisfaction scores for the brace. The MI of the intervention group was significantly decreased by a mean (SD) −2.7 (6.9) percentage points at 6 months and −3.3 (6.9) percentage points at 12 months (mean [SD] annual progression rate: 6 months, −5.4 [13.8] percentage points; 12 months, −3.3 [6.9] percentage points; P < .001). The MI of the control group was significantly increased by a mean (SD) of 5.9 (7.4) percentage points at 6 months and 9.4 (10.9) percentage points at 12 months (mean [SD] annual progression rate: 6 months, 11.8 [14.8] percentage points; 12 months, 9.4 [10.9] percentage points; P < .001). The changes in the Caregiver Priorities & Child Health Index of Life with Disabilities were favorable in the study group and reached statistical significance at the 6-month follow-up compared with the control group (difference, −14.2; 95% CI, −25.2 to −3.3). Multiple factors are associated with hip displacement, requiring complex treatments. This brace was found to be one effective method for reducing hip displacement, while also impacting function and quality of life, and perhaps reducing the need for future surgical interventions. Although this was a small sample, the results suggest that a brace can be used to delay hip surgery in patients with cerebral palsy, while having a positive impact on quality of life.
Image: PD
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