Aspirin in pregnancy: a review of indications, timing, dosing and efficacy.

PURPOSE OF REVIEW: The aim of this study was to evaluate the recent literature examining the utility of low-dose daily aspirin (LDA) in the prevention of preeclampsia and other potential adverse perinatal sequelae. The evidence supporting various aspirin doses and timing of initiation of treatment for this purpose will be examined. The potential benefits of LDA therapy in pregnancy will be discussed weighing against any potential associated harm. RECENT FINDINGS: Findings from several recent meta-analyses of randomized controlled trials are consistent with prior studies in showing a reduction in risk for preeclampsia with LDA use in individuals at an increased risk for this complication. Some studies suggest aspirin at a dose greater than the current recommended 81 mg is associated with the highest reduction in preterm PE.Several studies have demonstrated a reduction in risk for preterm birth, small for gestational age (SGA) infant or intrauterine growth restriction (IUGR), and a reduction in the risk of perinatal mortality associated with aspirin use. The findings of reduced preterm birth (PTB) and IUGR were also demonstrated among low-risk patients.Identifying patients at risk was re-evaluated, with resulting changes to existing United States Preventive Services Task Force (USPSTF) guidelines. SUMMARY: This review of recent evidence suggests a decreased rate of preeclampsia at aspirin doses higher than the standardly used 81 mg when treatment is initiated prior to 16 weeks of gestation. Although LDA use seems promising for other outcomes such as preterm delivery and IUGR, further studies to strengthen recommendations are warranted.

Patient-selected goal attainment for pessary wearers: what is the clinical relevance?

OBJECTIVE: The purpose of this study was to evaluate whether patient determined goal achievement is associated with pessary continuation. STUDY DESIGN: Patients identified goals they wished to achieve from pessary use. Patients were asked whether they continued pessary use and if goals were met 6-12 months later. Goals were divided into 8 categories. Fisher exact test was used to evaluate categorical variables, t tests for continuous variables, and regression methods to calculate odds ratios (OR). RESULTS: Eighty women enrolled in the study. Sixty-four had follow-up data. Goals commonly listed were bladder (36%), activity (20%), general health (13%), and prolapse related (11%). Thirty-four women continued and 30 discontinued pessary use. Women who continued pessary use were more likely to meet 1 or 2 goals (OR 17.5, 21.1 and 95% CI 4.8-64.4, 5.7-78.9, respectively). CONCLUSION: Patient goals are variable and subjective. However, when assessed for achievement, they are associated with pessary continuation. Women who attain self-determined goals are likely to continue pessary use.

Pelvic floor symptom changes in pessary users.

OBJECTIVE: The objective of the study was to compare pelvic floor symptom changes in patients who continue vs discontinue pessary use, and determine whether changes predict pessary continuation. STUDY DESIGN: Women fitted with pessaries completed the Pelvic Floor Distress Inventory-20 (PFDI-20) before and after initiating pessary use. Scores were compared in women who continued vs discontinued pessaries. Analysis of covariance adjusted for baseline differences in scores. Logistic regression and receiver operating characteristic curves were used to find a score predicting pessary continuation. RESULTS: Sixty-four women had complete follow up data; at 6-12 months, 36 of 64 (56%) continued pessary use, and 28 of 64 (44%) discontinued use. The continuation group's final PFDI-20 total, bladder, and prolapse scale scores were better than the discontinuation group's. A 2-month prolapse score that fell to 50% of baseline best predicted pessary continuation. CONCLUSION: PFDI-20 scores improved most in women continuing pessary use. Pessaries effectively treated urinary symptoms, and most effectively treated prolapse symptoms. Prolapse score improvement best predicted continued pessary use.

Postpartum X-ray pelvimetry. Its use in calculating the fetal-pelvic index and predicting fetal-pelvic disproportion.

OBJECTIVE: To determine whether postpartum x-ray pelvimetry can be used to calculate the fetal-pelvic index (FPI) in future pregnancies. STUDY DESIGN: In stage I of the study, 10 gravid women, after 36 completed weeks' gestation, underwent x-ray pelvimetry before delivery. Pelvimetry was repeated within two days after delivery. Comparisons between antepartum and postpartum measurements were made using paired t tests and correlation coefficients. In stage II, 25 gravid women, after 36 completed weeks' gestation, underwent fetal ultrasound for biometry. X-ray pelvimetry was performed within two days after delivery. FPI was calculated for each pregnancy using antepartum fetal ultrasound and postpartum pelvimetry measurements. FPI calculations were correlated with the incidence of fetal-pelvic disproportion (FPD), as indicated by the requirement for cesarean section for arrest of active labor. Sensitivity, specificity and predictive value of FPI were assessed. RESULTS: In stage I, mean anteroposterior and transverse diameters of the pelvic inlet, midpelvis and pelvic outlet did not differ significantly. In stage II, the sensitivity of FPI for detecting FPD was 100%, specificity 95%, positive predictive value 80%, and negative predictive value 100%. CONCLUSION: Postpartum pelvimetry has the same association with FPD as antepartum pelvimetry. The strategy of using postpartum pelvimetry and antepartum fetal biometry to calculate FPI successfully identified 100% of the patients who ultimately required cesarean section for FPD, with a false positive rate of 5%. Pelvimetry performed postpartum in an index pregnancy may be used in future pregnancies, in combination with antepartum fetal ultrasound, to calculate FPI and predict the likelihood of FPD.

Ultrasonographic measurement of the abdominal circumference in fetuses with congenital diaphragmatic hernia.

OBJECTIVE: To determine whether ultrasonographic measurements of the abdominal circumference are smaller in fetuses with congenital diaphragmatic hernia and whether this is reflected as an underestimation of the estimated fetal weight. STUDY DESIGN: A retrospective review of 225 abdominal circumference measurements made between 24 and 41 weeks of gestation in 85 fetuses with congenital diaphragmatic hernia was performed. The individual and mean abdominal circumference value at each week of gestation versus gestational age was plotted and compared with normative data. Comparisons between abdominal circumference measurements and hernia variables were made with the chi(2) test. The Pearson correlation was used to examine the accuracy of ultrasonographic determination of the estimated fetal weight. RESULTS: The mean measurements of abdominal circumference were not found to differ significantly from normative data until term, although fetuses with liver herniation were less likely to have measurements more than 2 standard deviations below the mean. Calculation of estimated fetal weight was similar in accuracy to that in normal fetuses. CONCLUSION: Small abdominal circumference measurements should not be expected in fetuses with congenital diaphragmatic hernia. Abnormalities of the abdominal circumference or an abdominal circumference-dependent estimated fetal weight should not be attributed to the anatomic defect without considering other etiologies.