ACOG Recommends Delayed Umbilical Cord Clamping for All Healthy Infants - ACOG

http://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Delayed-Umbilical-Cord-Clamping-for-All-Healthy-Infants The American College of Obstetricians and Gynecologists (ACOG) have recently updated their guidelines surrounding delayed cord clamping in term infants based on the outcomes of systematic review and meta-analysis. They recommend that delayed cord clamping (clamping the cord 30-60 seconds after birth instead of immediately as is common practice) should be instituted in preterm infants (<37 weeks) to improve the transition of the fetal circulation to the neonatal circulation, increase red blood cell volume and decrease blood transfusion. It also reduces brain bleeding and severe intestinal disease (necrotising enterocolitis). They now also recommend that delayed clamping should occur in term infants (>37 weeks). This increases haemoglobin levels (which increases the ability for blood cells to carry oxygen) and reduces iron deficiency into the first several months of life in the baby. There is a small increase in early jaundice (a yellowing of the skin that is a result of high bilirubin. This is temporary if properly recognised and treated) in these babies. However, there are some circumstances where delayed clamping may not be appropriate: Mother - heavy bleeding, clinically unstable/critical, placenta praevia/accreta/increta Baby - Need for immediate resuscitation, placental abruption (early separation of the placenta from the uterus), umbilical cord tearing, very small baby due to a weakening placenta). The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) have not yet supported this practice.

Why we should be concerned with the rise and rise of early planned births

Is a 'Planned Birth' between 37 and 39 weeks bad for your child's brain? This was the question asked by South Australian investigators in a recent record-linkage study of over 150,000 births. They found that the earlier your baby is born by induction or planned caesarean, the higher the likelihood that they would have signs of developmental delay at 6 years old. The strongest indicator that the findings are true is that there is a trend from week to week from 32 weeks to 39 weeks, where the risk reduces as gestation increases, even after 37 weeks (currently considered to be 'term' and no longer a risky gestation for delivery). Also, this data is consistent with previous findings from other investigators. At face value, this makes sense, and it is likely that inducing or performing elective caesareans before 39 weeks for no medical indication is not a good idea. However, there are some issues with this study and the conclusions it draws. A major concern is that, while the investigators could adjust for several factors at the time of birth that otherwise might affect the outcome of developmental delay (eg. socioeconomic factors, marital status at birth etc), they crucially could not account for childhood factors (eg. education, parental support and social situation, childcare and even breastfeeding). It is possible that any of these factors may have contributed to the findings. This is the major difficulty with performing such long-term follow up using databases (as opposed to clinical trials). Another issue is that the authors could not adequately account for the reason why deliveries were planned earlier. The usual reasons that a baby might be delivered early include things like: a very small (poorly growing) baby, preeclampsia (a severe form of high blood pressure in pregnancy), poorly controlled gestational diabetes, abnormal blood flow to the baby, low level of fluid around the baby, early ruptured membranes. These are all factors that could potentially increase the likelihood of neurodevelopmental delay later in life, and could explain the findings over just the gestation itself. Finally, while the authors have told us the risk of early delivery and suggested that delivery should be delayed, they have not adequately addressed the risks of such a delay. For example, they have not presented data from their study participants on the rates of stillbirth and preeclampsia. This is very important to know, as delaying delivery might increase the risk of these very serious outcomes. In short, I agree that early planned delivery (37-39 weeks) for a non-medical reason (eg. you want to share Christmas with your new baby, your obstetrician is going on holiday) is not advisable, but we knew this already. In an otherwise medically well pregnancy, where an elective caesarean is planned (eg. as a repeat after previous caesareans), the caesarean should be performed as close to 40 weeks as possible. If induction of labour or early (37-39 weeks)caesarean is necessary for a medical reason, it should not be delayed because of this study. If you would like to know more about the other cautions associated with the findings of this study, please feel free to send me a message using the link above. http://theconversation.com/why-we-should-be-concerned-with-the-rise-and-rise-of-early-planned-births-68427 and the link to the actual abstract: https://www.ncbi.nlm.nih.gov/pubmed/27940704

Molecular Psychiatry - Gestational vitamin D deficiency and autism-related traits: the Generation R Study

Published in a high impact journal, this large retrospective cohort study (looking back at data that has been previously collected about vitamin D deficiency and then seeing how it affects the outcome (autistic traits)) has found a link between vitamin D deficiency in pregnancy and autism related traits, which naturally has gained significant media attention. Before you get too concerned, the authors quite correctly conclude that, while this has found an association, this does not imply causality, and because of the design of this study, it is impossible to definitively state that 'vitamin D deficiency in pregnancy causes autism'. It does (correctly) suggest that further randomised trials should are now justified. This study assessed two time points of vitamin D levels (at 20 weeks gestation and from cord blood at delivery) and followed children up to the age of 6. Firstly, the definition of vitamin D deficiency was a level <25. This is a very low level, and while 16%of their population was at this level, we probably see it less frequently (anecdotally). Some data was incomplete, and statistical modelling was performed to account for this. There was no reporting of vitamin D supplementation in their cohort, as it is probable that at least some patients had treatment during their pregnancy. For this reason, we still do not know whether supplementation of vitamin D in deficient mothers would prevent these autistic traits. Importantly, the authors could not account for other factors that could have caused autistic traits in this cohort, and 6 years is a long time for follow up! During this time, children may have been exposed to different peer situations, medical conditions (eg. thyroid dysfunction), schooling and education, parental role models, care and socioeconomic situations that could not be adjusted for in the analysis. There was also no adjustment for other antenatal factors like alcohol and drugs, though they did adjust for smoking (where possible). They could not determine when the vitamin D deficiency was an issue, as it may have been childhood deficiency rather than antenatal deficiency that caused the traits, as it is probable that antenatal deficiency would be a risk factor for childhood deficiency. Finally, vitamin D deficiency itself may not be the issue, but it may be something that causes vitamin D deficiency that is the true causative factor (eg. poor diet, lack of exercise, sedentary lifestyle). In a retrospective study, it is difficult to distinguish between these related factors. However, vitamin D supplementation is simple and easy and affordable. We are already supplementing patients in Australia with vitamin D for low levels, and this study supports this practice. In short, until more high quality research is performed, I will be recommending vitamin D supplementation to all deficient patients, but not necessarily because of this study or the presumed link with autistic traits. http://www.nature.com/mp/journal/vaop/ncurrent/full/mp2016213a.html

Seasonality of gestational diabetes mellitus: a South Australian population study -- Verburg et al. 4 (1) -- BMJ Open Diabetes Research & Care

In this large retrospective study from South Australia including over 60,000 women, the authors have concluded that the season that you conceive in can effect your risk of gestational diabetes (GDM). The authors show that your risk of GDM increases if you conceive in the winter months. They speculate that this may be because of seasonal reductions in vitamin D, physical activity and nutrient intake during the winter months (which have also been associated with GDM). It is important to recognise that the risk of GDM when conception occurred in January was 6.60% and when conceived in July was 5.41%. This represents an actual difference of only 1.19%. This difference is probably not clinically significant! So rest assured that you can still safely conceive in winter! http://drc.bmj.com/content/4/1/e000286.full

Treating Hyperemesis Gravidarum and Nausea and Vomiting in Pregnancy

While nothing exceptionally new, this article does support us treating pregnancy associated nausea and vomiting on a 'symptom severity' basis, with simple options such as ginger and vitamin B6 being sufficient for mild symptoms, without resorting to stronger medications unless necessary. Ondansetron is not recommended as a first line treatment and the benefit of intravenous corticosteroids for severe symptoms is still uncertain. http://jamanetwork.com/journals/jama/article-abstract/2565294

Non-steroidal anti-inflammatory drugs (NSAIDs) review

This was raised by a rheumatological colleague recently - it should be noted that the TGA review of non-steroidal anti inflammatory drugs - NSAIDs (medications like ibuprofen and naproxen) was prompted by identification of inconsistencies in drug labelling in Australia, and not by any new data. NSAIDs (with the exception of aspirin) should not be used in pregnancy as they are associated with higher miscarriage rates in early pregnancy and early closure of an essential blood vessel near the baby's heart in late pregnancy. https://www.tga.gov.au/alert/non-steroidal-anti-inflammatory-drugs-nsaids-review

Dr Shavi Fernando - Specialist Obstetrician and Gynaecologist

Dr Shavi Fernando - Obstetrician Gynaecologist

Official Website is now online www.drshavifernando.com

Dr Shavi Fernando - Specialist Obstetrician and Gynaecologist's cover photo

Currently consulting (seeing patients) at: - Monash Obstetrics, 15 Murray St Clayton VIC 3168 - Mother and Baby Centre, Cabrini Hospital Malvern VIC 3144 Currently delivering and operating at: - Cabrini Hospital, Malvern - Jessie MacPherson Hospital, Clayton - Waverley Private Hospital, Mount Waverley

Website coming soon!