Clinical Trial Strives To Provide Optimal Care During High-Risk Pregnancies With Smaller Than Normal Babies

Dr. Enrique Jacome

Researchers are conducting a clinical trial to help determine the best timing of delivery in preterm pregnancies complicated by poor fetal growth. Preliminary results from the trial, which are published early online in Ultrasound in Obstetrics & Gynecology, demonstrate better than expected health outcomes in this high-risk group of fetuses.

Doctors are faced with a dilemma when deciding about the timing of delivery of a baby who does not grow adequately as a fetus, a condition called fetal growth restriction. To deliver early potentially exposes the baby to risks associated with being born immature, but to deliver late risks allowing other serious problems to develop due to a lack of nourishment and oxygen in the womb.

Doctors usually decide on the timing of delivery for a small baby in a high-risk pregnancy based on what they feel might be best for the baby, but without a solid basis in scientific facts.

Researchers designed a study - called the Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE) - in an attempt to help determine the best timing of delivery in preterm pregnancies complicated by fetal growth restriction. The study compares three groups of patients. In one group, the timing of delivery was based on monitoring the baby's heart rate. In the other two groups, timing was based on changes in the Doppler ultrasound measurement of one of the baby's blood vessels. A standardized prenatal monitoring and delivery protocol was used for all women in the trial. Ultimately, the investigators hope to determine which monitoring practice is best for safeguarding development by measuring babies' neurological health at age two years.

In the meantime, the researchers now report early results from TRUFFLE performed in 20 European centers. The analysis includes 503 women who were pregnant for less than 32 weeks and whose babies were smaller than would be expected. The results revealed better health outcomes for the babies compared with recent reports: deaths were uncommon (8%), and most of the babies (70%) survived without severe health problems. Women withhypertension were at increased risk of having babies who died before or after birth or who had health issues.

"Although the effects of the different fetal monitoring practices on long-term neurodevelopment are not yet known, these management protocols would help effect a reduction in perinatal mortality and short term morbidity in pregnancies complicated by severe, early-onset fetal growth restriction," said lead investigator Chistoph Lees, MD of Queen Charlotte's & Chelsea Hospital, London. "This is the largest prospective study of outcomes in pregnancies complicated by severe, early-onset fetal growth restriction showing that, at least in part, a standardized antenatal management protocol was responsible for the improved neonatal outcomes," said co-author Basky Thilaganathan, MD, PhD, and Editor-in-Chief of Ultrasound in Obstetrics & Gynecology.

Dr. Lees noted that the two-year outcomes of the babies in the study will be available in 2014, which may provide clues about what management and monitoring strategy is best to optimize long term neurodevelopmental outcome.

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Report Finds Womb Cancer Risks Decrease With Exercise, Diet And Coffee

Dr. Enrique Jacome

A new report reveals that engaging in physical activity, eating healthfully and drinking coffee can all reduce risks of womb cancer, a disease that affects nearly 50,000 women in the US each year, according to the American Cancer Society.

Authors of the report, which was published by the American Institute for Cancer Research (AICR) and World Cancer Research Fund International, say that worldwide, endometrial cancer - cancer of the womb lining - is the sixth most common cancer in women.

However, in the US, regular physical activity (30 minutes a day) and keeping a healthy weight (BMI between 18.5 and 25) can potentially prevent nearly 60% of endometrial cancer cases, the report shows.

Though womb cancer is mostly diagnosed in women over 60, there is currently no reliable screening system to detect it in the general population.

Symptoms of the disease include abnormal vaginal bleeding or discharge, as well as pain in the lower abdomen during sex.

Keeping a lean body helps reduce risks, but the researchers found that the risks were even lower for women who have never used hormone therapy, according to Elisa V. Bandera, associate professor from Rutgers Cancer Institute of New Jersey and panel member for the Continuous Update Project (CUP).

Bandera also says that evidence from cohort studies suggests that length of sitting time may increases risks, but she notes that more evidence is needed in order to make a firm conclusion.

Bandera adds:

"While additional studies are needed, it is a safe bet that maintaining a healthy weight and engaging in regular physical activity will reduce endometrial cancer risk, as well as having many other health benefits."

Coffee and other dietary choices decrease risk

In addition to staying fit, the research showed that drinking coffee can also reduce womb cancer risks.

Elisa V. Bandera says that both caffeinated and decaffeinated coffee is associated with "an estimated 7% reduction in risk for every cup of coffee consumed, based on eight studies."

She says that while the findings are interesting, drinking excessive coffee can also have adverse side effects. For example, Medical News Today recently reported that four cups of coffee a day is linked to death risks.

On the other hand, other studies have shown that coffee intake is linked to lower suicide risks and lower stroke risks.

Bandera notes that "in terms of food choices, eating a diet high in vegetables and low in fat and refined sugars is going to, at a minimum, help with weight control, while probably also protecting against cancer in other ways."

The report concludes:

"The evidence that body fatness (which the Panel interprets to be reflected by body mass index (BMI), measures of abdominal girth and adult weight gain) is a cause of endometrial cancer is convincing. Glycaemic load is probably a cause of endometrial cancer, and physical activity and coffee both probably protect against this cancer."

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Study Shows Good Bacteria Arrive In Babies' Digestive Systems From Their Mother's Gut Via Breast Milk

Dr. Enrique Jacome

Scientists have discovered that important 'good' bacteria arrive in babies' digestive systems from their mother's gut via breast milk.

Although this does confirm that when it comes to early establishment of gut and immune health, 'breast is best', a greater understanding of how babies acquire a population of good bacteria can also help to develop formula milk that more closely mimics nature.

The study, published in Environmental Microbiology, which is a journal of the Society for Applied Microbiology (SfAM), was led by Professor Christophe Lacroix at the Institute for Food, Nutrition and Health, ETH-Zurich, Switzerland.

Professor Lacroix said "We are excited to find out that bacteria can actually travel from the mother's gut to her breast milk.

"A healthy community of bacteria in the gut of both mother and baby is really important for baby's gut health and immune system development."

The Zurich team found the same strains of Bifidobacterium breve and several types of Clostridium bacteria, which are important for colonic health, in breast milk, and maternal and/or neonatal faeces. Strains found in breast milk may be involved in establishing a critical nutritional balance in the baby's gut and may be important to prevent intestinal disorders.

Professor Lacroix continued "We're not sure of the route the bacteria take from gut to breast milk but, we have used culture, isolation, sequencing and fingerprinting methods to confirm that they are definitely the same strains."

Future research will hopefully complete the picture of how bacteria are transferred from mother to neonate. With a more thorough knowledge, we can decide which bacterial species will be most important as probiotics in formula. But until then, for neonates at least, the old adage is true, breast is best.

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Research Shows General Practitioners Undertreat Women With Atrial Fibrillation

Dr. Enrique Jacome

General practitioners (GPs) undertreat women with atrial fibrillation (AF), according to research presented at ESC Congress 2013 today by Dr Pierre Sabouret from France. The analysis of more than 15,000 patients showed that women were undertreated with antithrombotic medications compared to men regardless of their stroke risk and co-morbidities.

In France both the prevalence (600,000 to 1 million patients) and incidence (110,000 to 230,000 new cases per year) of AF are dramatically increasing.7 ESC AF guidelines recommend the CHA2DS2-VASc score to determine stroke risk and the need for anticoagulation to prevent stroke.8 Female gender is a specific risk and adds one point to the stroke risk score. However no antithrombotic treatment is required if the patient is female, <65 years old and has lone AF.

Dr Sabouret said: "To improve the cardiovascular prognosis of women with AF it's important to know if there are any gender differences in management. Many AF patients are treated by GPs so we studied their practise."

The current study investigated the management of AF patients by GPs in France with a focus on gender differences. The aim was to identify potential factors in the choice of prescription (vitamin K antagonist [VKA] alone, aspirin alone or no oral anticoagulants), particularly patient characteristics, disease characteristics, medical history and concomitant medications.

A total of 15,623 AF patients aged ≥18 years were identified from the Longitudinal Patient Database (LPD) during 1 July 2010 to 30 June 2011. The LPD (set up in 1994) contains information on medical history, comorbidities and concomitant medication in 1.6 million active patients from a representative sample of 1,200 active GPs in France. The multivariate analyses included 14,274 patients after excluding those on clopidogrel. Median age was 77 years old, 41.6% were women and 93.2% had a CHA2DS2-VASc score >1.

After excluding women ineligible for anticoagulation (CHA2DS2-VASc score of 1 and age <65 years) the researchers found that women were significantly less treated than men. Just 48.1% of women received VKA (vs 52.6% men) (p<0.0001) and 30.5% received no prevention at all (vs 25.4% men) (p<0.0001). More than 21% received only aspirin despite guideline recommendations that they should receive VKA.

Dr Sabouret said: "Women with AF receive less anticoagulation treatment than men despite the fact that they are at greater risk of stroke. The new CHA2DS2-VASc score should be used more stringently, especially in women, to optimise their treatment. Treatment of all women with AF should be reviewed to ensure they are receiving anticoagulation if appropriate according to the CHA2DS2-VASc score."

Age-stratified multivariate analysis* of VKA prescription in patients <75 years found women were half as likely to be treated as men (odds ratio [OR]=0.56, 95% confidence interval [CI]=0.48-0.65) (p<0.0001). In the >75 years subgroup women were 33% less likely to be treated than men (OR=0.67, 95% CI=0.60-0.75) (p<0.0001).

Dr Sabouret concluded: "Women with AF are undertreated compared with men regardless of their stroke risk and comorbidities. This study has revealed a significant gap between guidelines and practice and requires GPs and cardiologists to work together to optimise treatment for women."

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