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CDC Updates Its Guidelines on Postpartum Contraceptive Use
In recognition of excess risk for venous thromboembolism after delivery, timing of postpartum initiation of combined hormonal contraception is restricted.

The U.S. Medical Eligibility Criteria for Contraceptive Use, first published in 2010 by the CDC (JW Womens Health Jun 24 2010), continue to evolve as new data are incorporated. Now, a new update provides guidance about postpartum contraceptive use. The immediate postpartum period — defined as the first 42 days following delivery — is associated with 22- to 84-fold higher risk for venous thromboembolism (VTE) than that in nonpregnant or nonpostpartum reproductive-age women. The modest excess risk for VTE associated with estrogen-containing contraceptives has prompted a recommendation that use of these contraceptive options be restricted during the postpartum period. Fertile ovulation is unlikely until at least 42 days postpartum, lending support to delayed use of these methods. Highlights of the updated guidelines are as follows:

•Combined hormonal contraceptives should not be used during the first 21 days postpartum (category 4; unacceptable health risk).
•During postpartum days 21 through 42, women without risk factors for VTE can begin combined hormonal contraceptives (category 2; advantages generally outweigh risks).
•Presence of risk factors (e.g., age 35, previous VTE, preeclampsia, recent cesarean delivery) warrant a category 3 rating (risks usually outweigh advantages) with a possible increase to category 4 in the presence of other VTE risk factors (e.g., obesity, smoking).
•After 42 days postpartum, use of combined hormonal contraceptives is unrestricted in non–breast-feeding women.
•Recommendations for progestin-only methods (levonorgestrel-releasing intrauterine devices, implants, depot medroxyprogesterone acetate injections, and progestin-only pills) remain unchanged; such methods (as well as copper intrauterine devices) can be initiated immediately postpartum.
Comment: Excess risk for VTE during the early postpartum period drives these more-restrictive recommendations for combined hormonal contraceptive use. This new CDC guidance does not change recommendations specific to breast-feeding women (MMWR Recomm Rep 2010; 59:1). Many U.S. women have additional risk factors for VTE; we must target changes in lifestyle factors such as smoking and obesity, while tailoring contraceptive prescribing practices during the postpartum period.

— Anne A. Moore, WHNP/ANP-BC, FAANP

Published in Journal Watch Women's Health July 28, 2011

Citation(s):
Centers for Disease Control and Prevention (CDC). Update to CDC's U.S. Medical Eligibility Criteria for Contraceptive Use, 2010: Revised recommendations for the use of contraceptive methods during the postpartum period. MMWR Morb Mortal Wkly Rep 2011 Jul 8; 60:878.
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Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry.
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Extremely preterm infant mortality rates and cesarean deliveries in the United States.
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Mammograms: More New Screening Guidelines
The American College of Obstetricians and Gynecologists now recommends annual screening beginning at age 40.

Previous guidelines from the American College of Obstetricians and Gynecologists (ACOG) recommended screening every 1 to 2 years for women in their 40s and annual screens beginning at age 50 (JW Womens Health Apr 21 2011). Now, two critical observations have provided the underpinnings for the ACOG's decision to recommend annual screening for women in their 40s:

•Mean sojourn time (the period during which tumors can be detected by screening before they become symptomatic) is shorter in women who are younger than 50 compared with older women. More-aggressive tumors characteristically have shorter sojourn times.
•Reductions in mortality associated with screening are similar for women in their 40s and 50s.
More-frequent screening is associated with more false-positive screens. Because of the high rate of false-positive screens and the large number of screens needed to prevent one breast cancer death among women in their 40s, the 2009 U.S. Preventive Services Task Force guidelines recommended that routine screening mammography be deferred until women reach age 50 and that screening be biennial (JW Womens Health Nov 16 2009). The new ACOG guidance acknowledges these concerns as well as the potential for false-positive mammograms to cause anxiety. Nonetheless, the ACOG also points out that U.S. women generally cope well with such anxiety.

The ACOG continues to recommend clinical breast exams annually for women who are aged 40 and every 1 to 3 years for younger women (age range, 20–39). In addition, the ACOG encourages breast self-awareness for women who are aged 20.

Comment: In discussing screening mammograms with patients, we should be candid about the potential for false-positive findings and their attendant diagnostic imaging and biopsy implications. Advising women in their 40s that false-positive screens are particularly common at their age is appropriate. Ultimately, our patients will be best served if we make recommendations about breast screening in a flexible, non-judgmental manner that is sensitive to their personal values as they attempt to balance the benefits of screening against the risks associated with false-positive results.

— Andrew M. Kaunitz, MD

Published in Journal Watch Women's Health July 28, 2011

Citation(s):
ACOG Committee on Practice Bulletins–Gynecology. Practice Bulletin No. 122: Breast cancer screening. Obstet Gynecol 2011 Aug; 118:372. ([Ссылки доступны только зарегистрированным пользователям ])

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Selective serotonin reuptake inhibitors and risk for major congenital anomalies.
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FDA Says Chronic, High-Dose Fluconazole Use Might Carry Risk for Birth Defects
Long-term, high-dose use of the antifungal fluconazole (Diflucan) could cause rare birth defects if taken during the first trimester of pregnancy, the FDA warned Wednesday. The risk is only associated with 400- to 800-mg daily doses and not with the single-dose pill (150 mg).

The agency based its warning on published reports in which infants who were exposed in utero to high-dose fluconazole in the first trimester were born with rare congenital anomalies such as brachycephaly, oral cleft, joint deformities, and congenital heart disease.

In response to the findings, the drug's pregnancy category — when indicated for life-threatening fungal infections that require high doses — has been changed from C to D. The pregnancy category has not changed for the single 150-mg dose used to treat vaginal candidiasis.

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Preconception Counseling: Delivering the Promise of Healthy Mothers and Babies
Evidence of benefit is clear, but preconception care has yet to become routine.

Each year, 3% of U.S. births — more than 120,000 infants — are affected by birth defects (MMWR Morb Mortal Wkly Rep 2008; 57:1). To limit the number of families affected by such congenital anomalies, the CDC has published recommendations for improving the health of women before and during early pregnancy (MMWR Morb Mortal Wkly Rep 2006; 55:1), and the Institute of Medicine has recently identified preconception care as a core component of preventive healthcare for women (IOM. 2011. Clinical Preventive Services for Women: Closing the Gaps. Washington, DC: The National Academies Press). Nonetheless, receipt of prepregnancy health counseling is reported by less than one third of U.S. women who give birth (MMWR Surveill Summ 2007; 56:1), and substantial racial and ethnic disparities in receipt of such guidance remain an issue (MMWR Surveill Summ 2004; 53:1).

CONTRACEPTION
Helping women prepare for pregnancy is challenging, because nearly half of U.S. pregnancies are unintended (JW Womens Health Apr 19 2007). Therefore, facilitating use of effective, easy-to-use contraception until a woman is ready for pregnancy is an integral part of preconception care. Intrauterine or implantable contraceptives are the most effective options. These methods have high rates of user satisfaction (JW Womens Health May 12 2011) yet are chosen by less than 6% of contraceptive users (JW Womens Health Jun 23 2011), many of whom have never heard of them. Clinician counseling can play an important role in encouraging women to use highly effective reversible contraception while preparing for pregnancy. In addition, clinicians can help prevent unintended pregnancy by providing patients who opt for combined hormonal contraception with 12-month supplies (JW Womens Health Apr 7 2011).

FERTILITY PRESERVATION AND AWARENESS
Routine screening for chlamydia and prompt treatment of infection can help prevent pelvic adhesive disease that can cause infertility. In addition, couples should be aware of when during a woman's cycle she is most fertile and should know that, as women approach age 35, fertility wanes and risk for pregnancy complications rises.

FOLATE SUPPLEMENTATION
Neural tube defects can be prevented by adequate maternal consumption of folate around the time of conception (JW Womens Health May 28 2009); thus, all women of reproductive age (especially those who are not using effective contraception) should take daily folate supplements or multivitamins. Although these supplements are inexpensive, safe, and available over the counter, preventable neural tube defects continue to affect more than 3000 U.S. pregnancies annually, in part because many women remain unaware that folate supplements should be taken before pregnancy (MMWR Morb Mortal Wkly Rep 2008; 57:5). Accordingly, counseling about the benefits of daily folate supplementation is a key component of preconception care.

VACCINES
Before becoming pregnant, women should be up-to-date on all recommended adult immunizations, particularly those against rubella and varicella. In addition, women who become pregnant during flu season should receive inactivated flu vaccine, because pregnant women who contract influenza face serious complications (JW Womens Health Sep 30 2010). Maternal influenza immunization can lower the likelihood of prematurity and small-for-gestational-age infants.1 Nonetheless, in 2009, only one third of pregnant women in the U.S. were vaccinated against influenza.2

OPTIMIZING MATERNAL HEALTH
Maternal obesity raises risk for cesarean delivery, preeclampsia, preterm delivery, stillbirth, and obesity-related disorders in offspring.3,4 Women who are overweight (body-mass index [BMI] 25.0 kg/m2) or obese (BMI 30.0) should be encouraged to lower their risk for adverse pregnancy outcomes by endeavoring to reach a healthy weight before becoming pregnant. This is a substantial public health challenge, as obesity during reproductive age now affects more than 35% of U.S. women overall5 and more than half of black women (MMWR Morb Mortal Wkly Rep 2009; 58:740).

Health-related behaviors other than diet and exercise also are relevant as women prepare for pregnancy. Maternal smoking raises risk for stillbirth (JW Womens Health May 12 2011), and alcohol intake adversely affects fetal development.6 Although quitting smoking, drinking, and recreational drug use before conceiving is ideal, women who do not manage to do so should be encouraged to strive for abstinence throughout their pregnancies.7

Birth defects occur in 5% to 8% of offspring of women with diabetes,8 more than twice the rate in the general population. With tight glycemic control before and during pregnancy, rates of congenital malformations and birth trauma can be minimized.9 In addition, hypothyroidism must be well controlled prior to pregnancy.10

USE OF POTENTIALLY TERATOGENIC MEDICATIONS
Each year, reproductive-age women in the U.S. receive 12 million prescriptions for potentially teratogenic medications (table).11 Although many women depend on their clinicians to inform them about which medications pose risks to pregnancy,12 <20% of women who are prescribed potentially teratogenic medications in ambulatory care settings receive contraceptive counseling.11 As a result, approximately 6% of pregnancies are exposed to potentially teratogenic medications (JW Gen Med Oct 19 2004).

GENETIC SCREENING
Some families might benefit from screening for and counseling about certain genetic conditions (e.g., sickle cell anemia, thalassemia, Tay-Sachs disease, cystic fibrosis).

INTIMATE PARTNER VIOLENCE
Women and their clinicians should be aware that intimate partner violence can be exacerbated by pregnancy (JW Womens Health Oct 2 2008).

SYSTEM-BASED APPROACHES TO PRECONCEPTION COUNSELING
To facilitate provision of effective preconception and early-pregnancy care, clinicians must engage women and their partners in planning for pregnancy. Practice-based registries and electronic health records that include reminders to provide preconception counseling on an annual basis can be useful tools, but, in many cases, the first step is to ask, "When, if ever, do you hope to become pregnant?"

— Eleanor Bimla Schwarz, MD, MS

Published in Journal Watch Women's Health August 18, 2011

Citation(s):
1. Omer SB et al. Maternal influenza immunization and reduced likelihood of prematurity and small for gestational age births: A retrospective cohort study. PLoS Med 2011 May; 8:e1000441. ([Ссылки доступны только зарегистрированным пользователям ])

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2. Ding H et al. Influenza vaccination coverage among pregnant women — National 2009 H1N1 Flu Survey (NHFS). Am J Obstet Gynecol 2011 Jun; 204:Suppl 1:S96. ([Ссылки доступны только зарегистрированным пользователям ])

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3. Catalano PM and Ehrenberg HM. The short- and long-term implications of maternal obesity on the mother and her offspring. BJOG 2006 Oct; 113:1126. ([Ссылки доступны только зарегистрированным пользователям ])

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4. Ovesen P et al. Effect of prepregnancy maternal overweight and obesity on pregnancy outcome. Obstet Gynecol 2011 Aug; 118:305. ([Ссылки доступны только зарегистрированным пользователям ])

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5. Ogden CL et al. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA 2006 Apr 5; 295:1549.

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6. Carson G et al. Alcohol use and pregnancy consensus clinical guidelines. J Obstet Gynaecol Can 2010 Aug; 32Suppl 3)S1.


7. Lumley J et al. Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2009 Jul 8; 3:CD001055. ([Ссылки доступны только зарегистрированным пользователям ])

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8. Weintrob N et al. Short- and long-range complications in offspring of diabetic mothers. J Diabetes Complications 1996 Sep/Oct; 10:294.

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9. Willhoite MB et al. The impact of preconception counseling on pregnancy outcomes: The experience of the Maine Diabetes in Pregnancy Program. Diabetes Care 1993 Feb; 16:450.

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10. Reid SM et al. Interventions for clinical and subclinical hypothyroidism in pregnancy. Cochrane Database Syst Rev 2010 Jul 7; 7:CD007752. ([Ссылки доступны только зарегистрированным пользователям ])

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11. Schwarz EB et al. Prescription of teratogenic medications in United States ambulatory practices. Am J Med 2005 Nov; 118:1240. ([Ссылки доступны только зарегистрированным пользователям ])

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12. Santucci AK et al. Women's perspectives on counseling about risks for medication-induced birth defects. Birth Defects Res A Clin Mol Teratol 2010 Jan; 88:64. ([Ссылки доступны только зарегистрированным пользователям ])

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Опубликованы рекомендации ACOG по профилактике тромбоэмболических осложнений у беременных.
Основные положения гайдлайна:

Compared with nonpregnant women, pregnant women have a 4-fold to 5-fold increased risk for thromboembolism. About 80% of thromboembolic events during pregnancy are venous, with pulmonary embolism and other VTE responsible for 1.1 deaths per 100,000 deliveries, or 9% of all maternal deaths in the United States.

The only specific Level A ACOG recommendation (based on good and consistent scientific evidence) is that compression ultrasonography of the proximal veins is the recommended initial diagnostic test when signs or symptoms suggest new onset deep vein thrombosis.

Level B ACOG recommendations and conclusions (based on limited or inconsistent scientific evidence) include the following:
•Heparin compounds are the preferred anticoagulants in pregnancy.
•To minimize postpartum bleeding complications, a reasonable strategy is to resume anticoagulation therapy no sooner than 4 to 6 hours after vaginal delivery, or 6 to 12 hours after cesarean delivery.
•Warfarin, low molecular weight heparin (LMWH), and unfractionated heparin are compatible with breast-feeding because they do not accumulate in breast milk and do not lead to anticoagulation in the infant.

Level C ACOG recommendations (based primarily on consensus and expert opinion) include the following:
•Women with a history of thrombosis who have not been thoroughly evaluated for possible underlying causes should receive testing for antiphospholipid antibodies, as well as for inherited thrombophilias.
•For women with acute thromboembolism during the current pregnancy, or for those at high risk for VTE, including women with mechanical heart valves, therapeutic anticoagulation is recommended.
•For women in whom restarting anticoagulation is planned after delivery, pneumatic compression devices should be left in place until the woman is ambulatory and anticoagulation therapy is resumed.
•In the last month of pregnancy, or sooner if delivery appears imminent, women receiving either therapeutic or prophylactic anticoagulation may be converted from LMWH to unfractionated heparin, which has a shorter half-life.
•Neuraxial blockade should be withheld for 10 to 12 hours after the last prophylactic dose of LMWH, or 24 hours after the last therapeutic dose of LMWH.
•For all women not already receiving thromboprophylaxis, placement of pneumatic compression devices before cesarean delivery is recommended. However, an emergency cesarean delivery should not be delayed for the placement of compression devices.
Cesarean delivery is an independent risk factor for thromboembolic events — it nearly doubles a woman's risk. "Fitting inflatable compression devices on a woman's legs before cesarean delivery is a safe, potentially cost-effective preventive intervention. Inflatable compression sleeves should be left in place until a woman is able to walk after delivery or — in women who had been on blood thinners during pregnancy — until anticoagulation medication is resumed."

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Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long-term health risks related to polycystic ovary syndrome. Fertil Steril. 2004;81:19–25

Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Fertil Steril. 2008;89:505–522

Consensus on women’s health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertility and Sterility. Volume 97, Issue 1 , Pages 28-38.e25, January 2012.

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