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CME / ABIM MOC / CE

Does At-Term Timed Birth Reduce Preeclampsia Risk?

  • Authors: News Author: Marilynn Larkin; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 5/19/2023
  • Valid for credit through: 5/19/2024
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for cardiologists, critical care clinicians, obstetricians/gynecologists/women’s health clinicians, pediatricians, nurses, physician assistants, and other members of the health care team for pregnant women who may be at risk for preeclampsia.

The goal of this activity is for learners to be better able to describe optimal preeclampsia screening and timing of birth strategy for prevention of term preeclampsia.

Upon completion of this activity, participants will:

  • Assess optimal preeclampsia screening and timing of birth strategy for prevention of term preeclampsia, based on a secondary analysis of data from a prospective nonintervention cohort study
  • Evaluate the clinical implications of optimal preeclampsia screening and timing of birth strategy for prevention of term preeclampsia, based on a secondary analysis of data from a prospective nonintervention cohort study, based on a systematic review and meta-analysis
  • Outline implications for the healthcare team


Disclosures

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All relevant financial relationships for anyone with the ability to control the content of this educational activity are listed below and have been mitigated. Others involved in the planning of this activity have no relevant financial relationships.


News Author

  • Marilynn Larkin

    Freelance writer, Medscape

    Disclosures

    Marilynn Larkin has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships.

Editor/Nurse Planner

  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Leigh Schmidt, MSN, RN, CNE, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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CME / ABIM MOC / CE

Does At-Term Timed Birth Reduce Preeclampsia Risk?

Authors: News Author: Marilynn Larkin; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 5/19/2023

Valid for credit through: 5/19/2024

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Clinical Context

Worldwide, preeclampsia is a leading cause of maternal and perinatal mortality, complicating 2% to 4% of pregnancies. Preterm preeclampsia (approximately one quarter of preeclampsia cases) has higher per pregnancy risk for complications than term disease.

Members of the healthcare team who care for pregnant women who may be at risk for preeclampsia must remain vigilant in their screening practices but should also stay abreast of the newest studies on potential future risk mitigation strategies.

Risk-stratified timing of birth at term may reduce a mother’s risk for preeclampsia by half, analysis of a large UK cohort suggests.

Study Synopsis and Perspective

In this observational analysis of nearly 90,000 pregnancies, at-term preeclampsia occurred with similar frequency among women routinely screened during the first trimester and among at-risk women screened during the third trimester.

Timed birth strategies include scheduled labor inductions and cesarean deliveries.

Overall, on average, at-risk women delivered at 40 weeks, with two thirds experiencing spontaneous onset of labor. About one fourth had cesarean deliveries.

“We anticipated that timed birth at 37 weeks could reduce the occurrence of more than half of preeclampsia, [but] this is not an intervention that could be recommended, as complications for the baby would be increased,” Laura A. Magee, MD, of King’s College London, United Kingdom, told theheart.org | Medscape Cardiology.

“However, we were delighted to see that a personalized approach to timed birth, based on an individual woman’s risk for preeclampsia, could prevent a similar number of cases of preeclampsia, with fewer women requiring timed birth, and at later gestational ages, when newborn problems would be less frequent.”

Although not currently recommended to prevent at-term preeclampsia, “timed birth by labor induction is a very common timing of birth strategy,” she noted. “At least one third of women currently undergo labor induction at term gestational age, and 1 in 6 choose to deliver by elective cesarean.”

The study was published online April 10 in Hypertension.

Screening at 35 to 36 Weeks Superior

The investigators analyzed data from a nonintervention cohort study of singleton pregnancies delivering at 24 or more weeks, without major anomalies, at 2 UK hospitals.

At routine visits at 11 to 13 weeks’ gestation, 57,131 pregnancies were screened and 1,138 term preeclampsia cases developed.

Most of these women were in their early 30s, self-identified as White, and had a body mass index at the upper limits of normal. About 10% were smokers; fewer than 3% had a medical history of high blood pressure, type 2 diabetes, or autoimmune disease; and 3.9% reported a family history of preeclampsia.

At 35 to 36 weeks, in a different cohort, 29,035 pregnancies were screened and term preeclampsia developed in 619 women. Demographics and pregnancy characteristics were similar to those screened at 11 to 13 weeks, although the average body mass index was higher (in the overweight range), and there were fewer Black women, although they still made up 10% of the screened population.

Patient-specific preeclampsia risks were determined by the National Institute for Health and Care Excellence (NICE) guidance and by the Fetal Medicine Foundation competing-risks model, available through an online calculator.

Timing of birth for term preeclampsia prevention was evaluated at 37, 38, 39, and 40 weeks or, depending on preeclampsia risk, by the competing-risks model at 35 to 36 weeks.

The primary outcomes were the proportion of term preeclampsia prevented and the number needed to deliver to prevent a single term preeclampsia case.

The investigators found that overall, the proportion of term preeclampsia prevented was highest, and number needed to deliver lowest, for preeclampsia screening at 35 to 36 weeks, rather than at 11 to 13 weeks.

For delivery at 37 weeks, fewer cases of preeclampsia were prevented with NICE criteria (28.8%) than with the competing-risks model (59.8%), and the number needed to deliver was higher (16.4 vs 6.9, respectively).

At 35 to 36 weeks, the risk-stratified approach had similar preeclampsia prevention (57.2%) and number needed to deliver (8.4), but fewer women would be induced at 37 weeks (1.2% vs 8.8%).

Although personalized timed birth at term may be an effective way to address at-term preeclampsia, “clinicians should wait for definitive clinical trial evidence,” Dr Magee said.

“Stay Tuned”

Vesna D. Garovic, MD, PhD, Mayo Clinic, Rochester, Minnesota, and chair of the 2021 AHA Scientific Statement, ”Hypertension in Pregnancy: Diagnosis, Blood Pressure Goals, and Pharmacotherapy,” agrees.

The new data “set the stage for adequately designed and powered studies that will provide ultimate response/evidence regarding the efficacy of this approach,” she told theheart.org | Medscape Cardiology.

“Future studies need to address the safety of this approach,” she added, “as close to 10 timed/planned deliveries will be needed to prevent one case of preeclampsia.”

For now, she said, “While these preliminary data are promising, they are not sufficient to adopt timed birth in daily practice. Prospective studies that will provide sufficient evidence regarding the efficacy and safety of this approach are likely to follow. Stay tuned.”

Indeed, Dr Magee noted that the Fetal Medicine Foundation is about to launch a randomized trial of a personalized “timing of birth” strategy at term based on the preeclampsia risk described in her group’s study vs usual care at term--that is, “watchful waiting, and delivery should preeclampsia or another indication for birth develop.”

The study was supported by grants from the Fetal Medicine Foundation, UK, and various biotech companies provided reagents and relevant equipment free of charge. Dr Magee and Dr Garovic have disclosed no relevant financial relationships.

Hypertension. Published online April 10, 2023.[1]

Study Highlights

  • This secondary analysis used data from a prospective nonintervention cohort study of singleton pregnancies delivering at 24 or more weeks, without major anomalies, at 2 UK maternity hospitals.
  • At routine visits at 11 to 13 weeks, 57,131 pregnant women were screened, of whom 1,138 developed term preeclampsia.
  • Most were in their early 30s, White, and had a body mass index at the upper limits of normal; ~10% were smokers; <3% had a history of high blood pressure, type 2 diabetes, or autoimmune disease; and 3.9% had a family history of preeclampsia.
  • In a different cohort of 29,035 pregnancies screened at 35 to 36 weeks, 619 developed term preeclampsia.
  • These women had similar pregnancy characteristics and demographics to those screened at 11 to 13 weeks, except that there were fewer Blacks (10% of screened population), but they had a higher average body mass index (overweight range).
  • National Institute for Health and Care Excellence guidance and the Fetal Medicine Foundation competing-risks model determined patient-specific preeclampsia risks.
  • For each screening strategy, timing of birth for term preeclampsia prevention was assessed at gestational points that were fixed (37, 38, 39, 40 weeks) or based on preeclampsia risk by the competing-risks model at 35 to 36 weeks.
  • On average, at-risk women delivered at 40 weeks; two thirds had spontaneous onset of labor, and approximately one quarter had cesarean deliveries.
  • The proportion of term preeclampsia prevented was the highest, and number needed to deliver lowest, for screening at 35 to 36 vs 11 to 13 weeks.
  • For delivery at 37 weeks, fewer preeclampsia cases were prevented for NICE (28.8%) vs the competing-risks model (59.8%), and number needed to deliver was higher (16.4 vs 6.9).
  • The risk-stratified approach (at 35-36 weeks) had similar preeclampsia prevention (by 57.2%) and number-needed-to-deliver (8.4), but fewer women would be induced at 37 weeks (1.2% vs 8.8%).
  • The investigators concluded that frequency of term preeclampsia was similar among women routinely screened during the first trimester and among at-risk women screened during the third trimester.
  • Risk-stratified timing of birth at term may more than halve the risk for term preeclampsia, but more efficacy and safety evidence is needed from definitive clinical trials, as nearly 10 timed/planned deliveries would be needed to prevent a single preeclampsia case.
  • Preeclampsia prevention could potentially improve adverse pregnancy outcomes of term preeclampsia, but a randomized trial is needed to confirm that early term birth is not associated with increased short-term neonatal (particularly respiratory) morbidity.
  • Timed birth may be particularly useful in underresourced settings, where maternal preeclampsia is particularly challenging, most women with preeclampsia die, and timed birth can be offered easily and inexpensively.
  • Successful prevention of term preeclampsia also mandates finding strategies to address underlying cardiovascular risk, as risk factors are shared with cardiovascular disease.
  • These preliminary data are promising but are currently insufficient to implement timed birth (scheduled labor inductions and cesarean deliveries) in clinical practice.
  • Although the researchers anticipated that timed birth at 37 weeks could halve the incidence of preeclampsia, this strategy could increase infant complications and would not be recommended.
  • A patient-specific approach to timed birth, based on individual preeclampsia risk, could similarly reduce preeclampsia frequency, with fewer women needing timed birth and at later gestational ages, when newborn complications would be less common.
  • Timed birth by labor induction is not currently recommended to prevent at-term preeclampsia, but is commonly performed, with a third or more of women currently undergoing labor induction at term gestational age and 1 in 6 opting for elective cesarean.

Clinical Implications

  • Risk-stratified timing of birth at term may more than halve the risk for term preeclampsia.
  • More efficacy and safety evidence are needed from definitive clinical trials, as nearly 10 timed/planned deliveries would be needed to prevent a single case of preeclampsia.
  • Implications for the Health Care Team: Current preeclampsia screening strategies remain standard practice as these preliminary data are promising but are currently insufficient to implement timed birth in clinical practice.

 

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