Katharine Wenstrom

The FDA’s new advice on fish: it’s complicated

The Food and Drug Administration and Environmental Protection Agency recently issued an updated draft of advice on fish consumption for pregnant and breastfeeding women, after survey data indicated that the majority of pregnant women do not eat much fish and thus may have inadequate intake of the omega 3 fatty acids eicosapentaenoic acid [EPA] and ducosahexaenoic acid [DHA]. Omega 3 fatty acids are essential components of membranes in all cells of the body and are vitally important for normal development of the brain and retinal tissues (especially myelin and retinal photoreceptors) and for maintenance of normal neurotransmission and connectivity. They also serve as substrates for the synthesis of a variety of antiinflammatory and inflammation-resolving mediators, favorably alter the production of thromboxane and prostaglandin E2, and improve cardiovascular health by preventing fatal arrhythmias and reducing triglyceride and C-reactive protein levels. Maternal ingestion of adequate quantities of fish (defined in many studies as at least 340 g of oily fish each week) has been associated with better childhood IQ scores, fine motor coordination, and communication and social skills, along with other benefits. Although the FDA did not clarify which fish to eat, it specifically advised against eating fish with the highest mercury levels and implied that fish with high levels of EPA and DHA and low levels of mercury are ideal. The FDA draft did not recommend taking omega 3 fatty acid or fish oil supplements instead of eating fish, which is advice that may reflect the fact that randomized controlled trials of DHA and EPA or fish oil supplementation generally have been disappointing and that the ideal daily dose of DHA and EPA is unknown. It seems safe to conclude that pregnant and nursing women should be advised to eat fish to benefit from naturally occurring omega 3 fatty acids, to avoid fish with high levels of mercury and other contaminants, and, if possible, to choose fish with high levels of EPA and DHA.

Malignancies in pregnancy

Malignancy complicating pregnancy is fortunately rare, affecting one in 1000 to one in 1500 pregnancies. Optimal treatment involves balancing the benefit of treatment for the mother while minimizing harm to the fetus. This balance is dependent on the extent of the disease, the recommended course of treatment, and the gestational age at which treatment is considered. Both surgery and chemotherapy are generally safe in pregnancy, whereas radiation therapy is relatively contraindicated. Iatrogenic prematurity is the most common pregnancy complication, as infants are often delivered for maternal benefit. In general, however, survival does not differ from the nonpregnant population. These patients require a multidisciplinary approach for management with providers having experience in caring for these complex patients. The aim of this review was to provide an overview for obstetricians of the diagnosis and management of malignancy in pregnancy.

Early term versus term delivery in the management of fetal growth restriction: a comparison of two protocols.

OBJECTIVE This study aims to compare two management protocols in pregnancies diagnosed with fetal growth restriction (FGR). STUDY DESIGN All singleton pregnancies diagnosed and managed with FGR at our institution during two protocol periods were analyzed. The early term protocol (January 2008-February 2010) specified delivery at 37(0/7) weeks if antenatal testing was reassuring, but did not specify the timing of delivery if umbilical artery (UA) Doppler systolic:diastolic (S:D) ratios were elevated (>95th percentile for gestational age [GA]). The term protocol (March 2010-July 2012) specified delivery at 39(0/7) weeks with normal S:D ratios and 37(0/7) weeks with elevated S:D ratios when antenatal testing was reassuring. RESULTS There were 228 and 312 women in the early term and term protocol, respectively, who met inclusion criteria. Compared with the early term group, the term group had an increased median GA at delivery (37.1 vs. 38.6%, p < 0.001), decreased deliveries less than 37(0/7) weeks (37 vs. 24%, p = 0.01) and decreased neonatal intensive care unit (NICU) admissions (38 vs. 28%, p = 0.02). CONCLUSION A protocol specifying delivery at 39(0/7) weeks when UA S:D ratios are normal and delivery at 37(0/7) weeks when UA S:D ratios are elevated when other antenatal testing is reassuring in FGR: (1) prolonged gestation, (2) decreased preterm births, and (3) decreased NICU admissions.

Are obstetrician-gynecologists satisfied with their maternal-fetal medicine consultants? A survey.

OBJECTIVE To survey generalist obstetrician-gynecologists about their satisfaction with and patterns of referral to maternal-fetal medicine (MFM) specialists. STUDY DESIGN A survey was sent three times to 1030 randomly selected American Congress of Obstetricians and Gynecologists members across the country, and results were tabulated. RESULTS A total of 516 surveys (50%) were returned; 68% of respondents were satisfied (S) with available MFM services and 31% were not satisfied (Not S). S and Not S respondents were similar with respect to age, gender, years in practice, type of practice, hours worked per week, proximity to MFM specialists, number of deliveries per year, and level of nursery in their hospital. Reasons for dissatisfaction included: MFM specialist not readily available (49%), during the day (26%), at night (35%), or on weekends (36%); MFM specialist unwilling to take care of hospitalized patients (26%); or MFM specialist does only ultrasound, chorionic villus sampling, and amniocentesis (32%). Although some generalists do not consult MFM specialists frequently, the majority of both S and Not S respondents would request an MFM consult or comanagement for 26 of 38 specific maternal, fetal, and obstetric diagnoses/complications. CONCLUSION The majority of obstetrician-gynecologists are satisfied with their MFM support. The dissatisfaction expressed by 31% of generalists might be ameliorated if individual MFM specialists increased their availability and/or broadened their scope of practice.

Impact of smoking during pregnancy on functional coagulation testing

Compounds that are systemically absorbed during the course of cigarette smoking, and their metabolites, affect the coagulation system and cause endothelial dysfunction, dyslipidemia, and platelet activation leading to a prothrombotic state. In addition, smoking increases the activity of fibrinogen, homocysteine, and C-reactive protein. We hypothesize that smoking may affect functional coagulation testing during pregnancy. A secondary analysis of 371 women pregnant with a singleton pregnancy and enrolled in a multicenter, prospective observational study of complications of factor V Leiden mutation subsequently underwent functional coagulation testing for antithrombin III, protein C antigen and activity, and protein S antigen and activity. Smoking was assessed by self-report at time of enrollment (<14 weeks). None of the functional coagulation testing results was altered by maternal smoking during pregnancy. Smoking does not affect the aforementioned functional coagulation testing results during pregnancy.

Counselling women about the risks of caesarean delivery in future pregnancies

In order to provide appropriate counselling about the risk to future pregnancies imposed by caesarean delivery, providers must be knowledgeable about and able to synthesise a multitude of variables such as institutional policies, the clinical implications of each current delivery option for future pregnancies, patient understanding of maternal and neonatal risks and benefits, the womans reasons for requesting this type of delivery and the womans desired family size. The rate of successful vaginal birth after caesarean section ranges 50–85%, with lower rates associated with both modifiable factors (gestational age >40 weeks, maternal obesity, short interpregnancy interval and increased birthweight) and non‐modifiable factors (maternal age, non‐white ethnicity, pre‐eclampsia and recurrence of the indication for the initial caesarean delivery). In future pregnancies, the risk of adverse outcomes such as haemorrhage, endometritis, operative injury, hysterectomy and maternal death goes up with each additional caesarean section.