Effect of esomeprazole on maternal serum soluble fms-like tyrosine kinase-1 and endoglin in patients with early-onset preeclampsia

Objective: This study evaluates the effect of esomeprazole on the maternal serum levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng) in patients with early-onset preeclampsia.Methods: A randomized, double-blind, placebo-controlled trial was carried out in a tertiary University hospital between March 2018, and September 2019 (Clinical Trials.Gov: NCT03213639). The study included women between 28 and 31+6 weeks gestational age who had been diagnosed as preeclampsia without severe features. They were randomly assigned in a 1:1 ratio into an esomeprazole group, which received esomeprazole 40 mg orally once a day, and a placebo group, which received one placebo tablet daily. Blood samples were obtained to assess levels of serum sFlt-1and sEng using ELISA testing. The primary outcome was the difference between the mean serum level of sFlt-1 and sEng at the start of treatment and at the termination of pregnancy in both groups.Results: Eighty-eight patients were randomly assigned into both groups (44 in each). No statistically significant difference was found in the levels of sFlt-1 between both groups at admission and termination of pregnancy. The number of days of treatment for the esomeprazole group was slightly longer than the placebo group (11.4±9.4 vs. 10.3±6.3 days, P=0.515). No statistically significant difference in the rate of maternal and fetal complications occurred between the two groups. No side effects from the study medications were reported.Conclusions: Esomeprazole, at the dosage used in this study did not effectively lower the serum levels of sFlt-1 and sEng in patients with early-onset preeclampsia. Furthermore, it did not prolong the duration of pregnancy, nor did it decrease maternal or fetal complications.

Sarah A. Shaffer, DO, MME

Sarah A. Shaffer, DO, MME. University of Iowa Hospitals and Clinics. Clinical Associate Professor of Obstetrics and Gynecology-General Obstetrics and Gynecology Department of Obstetrics and Gynecology Clerkship Director - Obstetrics & Gynecology. University of Iowa Carver College of Medicine, Iowa City, Iowa

COVID-19 related complete blood count changes among asymptomatic pregnant women

Objective: To evaluate complete blood count (CBC) changes that suggest coronavirus disease-2019 (COVID-19) among asymptomatic pregnant women attending routine antenatal care Methods: A cross-sectional study included 187 healthy pregnant women who were attending the antenatal care clinic of a tertiary University hospital between March and June 2020. After a thorough history and examinations, a venous blood sample was taken from each participant for complete and differential blood counts. Those who showed CBC findings suggestive of COVID-19 were further scheduled for a nasopharyngeal swab for detection of SARS-CoV-2 specific antigens through polymerase chain reaction (PCR). Results: We found 5.3% (n=10) of the study population showed CBC changes that are suggestive of COVID-19. When they were scheduled for nasopharyngeal swab for a PCR confirmatory test, 30% (n=3) of them were PCR positive (which represented 1.6% of the entire study population). The most frequently encountered COVID-19-suggestive change in peripheral blood leukocyte differential counts was leucopenia (100%), followed by decreased eosinophil count (50%), then neutropenia and lymphocytopenia (30%). Conclusions: Certain differential leucocyte count changes (leucopenia, neutropenia, lymphocytopenia and decreased eosinophil count) among asymptomatic pregnant women might be related to COVID-19 infection and may indicate a need for further testing.

The impact of adding fetal MRI to sonographically diagnosed intrauterine ventriculomegaly: a prospective cohort study

Objective: Intrauterine fetal ventriculomegaly (IVM) is one of the most commonly detected fetal anomalies. Prenatal diagnosis in IVM is considered a challenge with a significant impact on management. The current study aims to evaluate the added value of performing fetal MRI to sonographically diagnosed IVM. Methods: A prospective cohort study was conducted at a tertiary University Hospital in the period between January 2017 and March 2019. We included pregnant women with a single fetus sonographically diagnosed IVM (symmetrical or asymmetrical). First, a basic obstetric sonographic examination was done, followed by a detailed (2D/3D) fetal CNS anomaly scan for the detection of other associated anomalies. A fetal MRI brain scan was performed for all cases. Results: Sixty women were included in the study. Of the 60 fetuses with IVM, additional findings were seen on MRI in 14 cases (23%), and most of these findings were identified in fetuses with severe IVM (about 50%). No additional abnormalities were identified in fetuses of less than 24 weeks gestation. Callosal and septum pellucidum lesions (29%), along with posterior fossa abnormalities (28%) and cortical malformations (21%) accounted for the most common additional significant fetal MRI findings. Fetal MRI sensitivity, specificity, and positive and negative predictive values in correlation with those of prenatal ultrasound turned out to be notably higher, approaching nearly 100 %. Conclusions: Fetal MRI for sonographically diagnosed moderate or severe IVM is recommended to guide clinical management.

Thin endometrial lining during frozen embryo cycles: a case-control study of risk factors and natural history

Objective: To identify predictors of thin endometrial lining in the first frozen embryo transfer cycles and to characterize the natural history of this condition over subsequent cycles. Design: Retrospective case-control study Conclusions: This study shows that prognosis after a diagnosis of thin endometrial lining is favorable. Lower weight and thinner fresh cycle lining are predictors of thin endometrial lining in FET cycles. Most importantly, women with a diagnosis of thin endometrial lining have similar live birth rates as those with adequate endometrial lining, although their time to achieve live birth is slightly longer.

Upstream oncology: identifying social determinants of health in a gynecologic oncology population

Introduction: Social determinants of health (SDoH) are the factors that affect a patient’s health quality and outcomes and contribute to health disparities. Evidence suggests that clinical care contributes only 20% to patients’ health outcomes, while the remainder is under the influence of upstream factors. The upstream approach to healthcare aims to address SDoH before they contribute to less ideal outcomes downstream. Several SDoH may contribute to outcomes for cancer patients. This Upstream Gynecologic Oncology Initiative seeks to identify which SDoH affect a population of patients with gynecologic malignancies. Hypothesis: This study hypothesizes that women receiving care for gynecologic malignancies are affected by specific SDoH among the categories of housing, food, transportation, finances, health literacy and social support. This study aims to identify the frequency of these six social factors among the outpatient gynecologic oncology population at the University of Iowa. Methods: This needs assessment is the first phase in a quality improvement project assessing the SDoH affecting women with gynecologic cancers. Two hundred twenty-two patients receiving outpatient care for gynecologic malignancies completed an anonymous needs assessment survey. Validated survey questions regarding housing, food, transportation, finances, health literacy and social support were used to identify needs. Responses were considered positive if any degree of need was reported. Results: Responses demonstrated the most substantial need in the categories of social support (32%), health literacy (28%) and financial stability (24%). Less need was reported in the categories of food (11%), transportation (5%) and housing (4%). Fifty-seven percent of women reported at least one social need among the six categories screened. Conclusion: Upstream SDoH, most notably social support, health literacy and financial stability are identified to be present and likely contributing to health quality, outcomes, and disparities within this gynecologic oncology patient population. Overall, these findings support the idea that SDoH should be assessed for each unique patient population - and for each patient receiving care for gynecologic cancer. While social support was the most frequently reported SDoH, many patients already received adequate help at home; suggesting that meaningful efforts should next be directed at improving health literacy in the population. Appreciation and assessment of SDoH potential to impact care and management should be used to design a routine screening tool for the study population and organize resources to address or mitigate the identified needs.

Effect of dexamethasone on reducing pain and gastrointestinal symptoms associated with cesarean section: a systematic review and meta-analysis

Background: Dexamethasone has analgesic and antiemetic actions that have been documented in the literature. Therefore, we performed a systematic review and meta-analysis to investigate its overall effectiveness in reducing a variety of negative outcomes after cesarean section. Objectives: To investigate the efficacy and safety of dexamethasone for reducing pain associated with cesarean section, nausea, vomiting, pruritus, postoperative need for analgesia, postoperative antiemetic requests and headache. Methods: We searched PubMed, Cochrane CENTRAL, SCOPUS, and Web of Science for relevant clinical trials. We then performed a systematic review and meta-analysis, including only randomized, placebo-controlled clinical trials. Our main population target was women undergoing elective cesarean delivery. The intervention under consideration was dexamethasone administered both by intravenous (IV) or subcutaneous (SC) over a variety of doses. The comparator was a placebo. Our main outcomes included: (1) perceptions as indicated by pain scores, (2) occurrence of nausea and (3) occurrence of vomiting. Secondary outcomes included: (4) occurrence of pruritus, (5) need for postoperative analgesia, (6) need for postoperative antiemetic drugs and (7) occurrence of headache. We assessed the quality of included studies using the risk of bias tool described in Cochrane's handbook for systematic reviews of interventions. Results: We found that dexamethasone seemed to significantly reduce scores for pain at rest (p<0.001), as well as occurrence of nausea (p<0.001) and vomiting (p<0.001). The drug also showed significant reduction of negative symptoms in other secondary outcomes, including need for postoperative analgesia (p<0.001) and postoperative antiemetic drugs (p<0.001). However, the drug showed no significant effect in reducing headache and pruritus or in improving pain at movement scores. Conclusion: Dexamethasone appears to decrease perception of pain at rest and protects against nausea and vomiting. However, it does not seem effective against headaches or pruritus.

Quantitative blood loss: a validation study

Objective: To determine if quantitative blood loss would correlate to predicted blood loss based on change in blood concentration of hemoglobin. Conclusion: The correlation between calculated blood using modified Brecher’s formula showed poor overall correlation to quantitative blood loss. There was a higher correlation at blood loss greater than 1500 cc which is where estimated blood loss has been shown to be most poor. Possible reasons for this poor correlation include maternal factors influencing hemoglobin levels, gestational age, error in blood loss calculation, inaccuracy of Brecher’s formula in pregnancy.

Efficacy and safety of Elagolix in the treatment of endometriosis associated pain: a systematic review and network meta-analysis

Background: Endometriosis commonly presents with dysmenorrhea, non-menstrual pelvic pain, and infertility. Elagolix is an oral, short-acting, gonadotropin-releasing hormone antagonist acting through complete estrogen suppression. Objective: To evaluate the evidence from published randomized controlled trials (RCTs) about the efficacy and safety of Elagolix in the treatment of endometriosis associated pain. Search strategy: Electronic databases containing articles published between January 2000 and February 2020 were searched using the MeSH terms (Elagolix OR gonadotropin-releasing hormone antagonist OR GnRH antagonist OR antigonadotropin) AND (endometriosis) AND (pelvic pain). Selection criteria: All RCTs assessing the efficacy of Elagolix in the treatment of pain associated with endometriosis were considered for this network meta-analysis, where five studies were deemed eligible for this review. Data collection and analysis: The mean difference (MD) and confidence intervals (95% CI) for continuous outcomes including analgesic use, dysmenorrhea, non-menstrual pelvic pain, and quality of life were calculated. Main results: Elagolix 250 mg reduced dysmenorrhea significantly, as compared to placebo, (MD = -0.41, 95% CI [-0.7, -0.13]) at 12 weeks, while Elagolix 200 mg reduced dysmenorrhea significantly (MD= -1.2, 95% CI [-1.9, -0.57]) compared to placebo after 24 weeks of treatment. Conclusions: Elagolix 200 mg seems to be an effective drug with fewer side effects when used to reduce dysmenorrhea and non-menstrual pelvic pain after 24 weeks of treatment in patients with endometriosis.

The Challenge of Maternal Mortality

The Challenge of Maternal Mortality, University of Iowa Obstetrics and Gynecology Postgraduate Virtual Conference, November 20, 2020. Poster presentations.