Postpartum care – what's new?

Pharmacokinetics of Hydroxychloroquine in Pregnancies with Rheumatic Diseases

BACKGROUND

Hydroxychloroquine is an oral drug prescribed to pregnant women with rheumatic disease to reduce disease activity and prevent flares. Physiologic changes during pregnancy may substantially alter drug pharmacokinetics. However, the effect of pregnancy on hydroxychloroquine disposition and the potential need for dose adjustment remains virtually unknown.

METHODS

We performed a population-pharmacokinetic analysis using samples from the Duke Autoimmunity in Pregnancy Registry from 2013 to 2016. We measured hydroxychloroquine concentration using high-performance liquid chromatography/tandem mass spectrometry and analyzed data using non-linear mixed-effect modeling. We calculated differences between pregnancy and postpartum empirical Bayesian estimates using paired t tests. We computed steady-state concentration profiles for hydroxychloroquine during pregnancy and postpartum using individual clinical data and empirical Bayesian estimates developed from the final pharmacokinetic model.

RESULTS

We obtained 145 serum samples from 50 patients, 25 of whom had paired pregnancy and postpartum specimens. Five subjects had average concentrations (pregnancy and postpartum) < 100 ng/mL, consistent with medication non-adherence, and were excluded. The population estimated apparent volume of distribution was 1850 L/70 kg and estimated apparent clearance was 51 L/h. Compared with postpartum, median apparent volume of distribution increased significantly during pregnancy (p < 0.001), whereas apparent clearance and 24-h area under the curve did not change.

CONCLUSIONS

We developed a one-compartment population-pharmacokinetic model for hydroxychloroquine in pregnant women with rheumatic disease. Estimates for serum CL were within the expected range for plasma in non-pregnant adults. Because CL and 24-h area under the curve did not change during pregnancy compared with postpartum, our modeling in this small cohort does not support adjusting hydroxychloroquine dose during pregnancy.

Education for contraceptive use by women after childbirth

BACKGROUND

Contraceptive education is generally a standard component of postpartum care, although the effectiveness is seldom examined. The assumptions that form the basis of such programs include postpartum women being motivated to use contraception and that they will not return to a health provider for family planning advice. Women may wish to discuss contraception both prenatally and after hospital discharge. Nonetheless, two-thirds of postpartum women have unmet needs for contraception. In the USA, many adolescents have repeat pregnancies within a year of giving birth.

OBJECTIVES

Assess the effectiveness of educational interventions for postpartum women on contraceptive use

SEARCH METHODS

We searched for trials through June 2015 in PubMed, CENTRAL, CINAHL, POPLINE, and Web of Science. For current trials, we searched ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE and PsycInfo. We also examined reference lists of relevant articles. For earlier versions, we contacted investigators to locate additional reports.

SELECTION CRITERIA

We considered randomized controlled trials (RCTs) that examined postpartum education about contraceptive use, whether delivered to individuals or to groups of women. Studies that randomized clusters rather than individuals were eligible if the investigators accounted for the clustering in the analysis. The intervention must have started within one month after delivery.

DATA COLLECTION AND ANALYSIS

We assessed titles and abstracts identified during the literature searches. The data were abstracted and entered into Review Manager. Studies were examined for methodological quality. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI) was calculated. Where data were sFor continuous variables, we computed the mean difference (MD) with 95% CI. Due to varied interventions and outcome measures, we did not conduct meta-analysis.

MAIN RESULTS

Twelve trials met our eligibility criteria, included the three added in this update. The studies included a total of 4145 women. Eight trials were conducted in the USA; the others were from Australia, Nepal, Pakistan, and Syria. Four studies provided one session before hospital discharge; three had structured counseling of varying intensity and one involved informal counseling. Of eight interventions with than one contact, five focused on adolescents. Three of the five involved home visiting, one provided multiple clinic services, and one had in-person contact and phone follow-up. Of the remaining three for women of varying ages, two involved home visits and one provided phone follow-up.Our sensitivity analysis included six trials with evidence of moderate or high quality. In a study with adolescents, the group with home-based mentoring had fewer second births within two years compared to the control group (OR 0.41, 95% CI 0.17 to 1.00). The other five interventions had no effect. Of trials with lower quality evidence, two showed some effectiveness. In Nepal, women with an educational session immediately postpartum were more likely to use contraception at six months than those with a later or no session (OR 1.62, 95% CI 1.06 to 2.50). In an Australian study, teenagers in a structured home-visiting program were more likely to have effective contraception use at six months than those with standard home visits (OR 3.24; 95% CI 1.35 to 7.79).

AUTHORS' CONCLUSIONS

We focused our results summary on trials with moderate or high quality evidence. Overall, the overall quality of evidence in this review was moderate to low and the evidence of effectiveness was mostly low quality. The interventions could be improved by strengthening the program design and implementation. Some studies did not report program training for providers, adherence to the intervention protocol, or measurement of participants' knowledge and skills. Many trials did not have an objective outcome measure, i.e., pregnancy test or structured questionnaire for contraceptive use. Valid and reliable outcome measures are needed to obtain meaningful results. Still, given the associated costs and logistics, some programs would not be feasible in many settings.

Education for contraceptive use by women after childbirth

BACKGROUND

Providing contraceptive education is now considered a standard component of postpartum care. The effectiveness is seldom examined. Questions have been raised about the assumptions on which such programs are based, e.g., that postpartum women are motivated to use contraception and that they will not return to a health center for family planning advice. Surveys indicate that women may wish to discuss contraception both prenatally and after hospital discharge. Nonetheless, two-thirds of postpartum women may have unmet needs for contraception. In the USA, many adolescents become pregnant again within a year a giving birth.

OBJECTIVES

Assess the effects of educational interventions for postpartum mothers about contraceptive use

SEARCH METHODS

In May 2012, we searched the computerized databases of MEDLINE, CENTRAL, CINAHL, PsycINFO, and POPLINE. We also searched for current trials via ClinicalTrials.gov and ICTRP. Previous searches also included EMBASE. In addition, we examined reference lists of relevant articles, and contacted subject experts to locate additional reports.

SELECTION CRITERIA

Randomized controlled trials were considered if they evaluated the effectiveness of postpartum education about contraceptive use. The intervention must have started postpartum and have occurred within one month of delivery.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts identified during the literature searches with no language limitations. The data were abstracted and entered into RevMan. Studies were examined for methodological quality. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% confidence interval (CI) was calculated. For continuous variables, we computed the mean difference (MD) with 95% CI. Due to varied study designs, we did not conduct meta-analysis.

MAIN RESULTS

Ten trials met the inclusion criteria. Of four trials that provided one or two counseling sessions, two showed some evidence of effectiveness. In a study from Nepal, women with an immediate postpartum and a session three months later were more likely to use contraception at six months than those with only the later session (OR 1.62; 95% CI 1.06 to 2.50). However, most comparisons did not show evidence of effectiveness. In a trial conducted in Pakistan, women in the counseling group were more likely than those without counseling to use contraception at 8 to 12 weeks postpartum (OR 19.56; 95% CI 11.65 to 32.83). The assessments were short-term. The remaining two studies were from the USA; one did not provided sufficient data and one had too small a sample to detect differences.Six trials provided multifaceted programs with many contacts. Three showed evidence of effectiveness. Of those, two USA studies focused on adolescents. Adolescents in a home-visiting program were less likely to have a second birth in two years compared to adolescents who received usual care (OR 0.41; 95% CI 0.17 to 1.00). In the other trial, adolescents receiving enhanced well-baby care were less likely to have a repeat pregnancy by 18 months compared to those with usual well-baby care (OR 0.35; 95% CI 0.17 to 0.70). In an Australian study, teenagers in a structured home-visiting program were more likely to use contraception at six months than those who had standard home visits (OR 3.24; 95% CI 1.35 to 7.79). The trials without evidence of effectiveness included two for adolescents in the USA (computer-assisted motivational interviewing and cell phone counseling) and a home-visiting program for women in Syria.

AUTHORS' CONCLUSIONS

The overall quality of evidence was moderate. Half of these postpartum interventions led to fewer repeat pregnancies or births or more contraceptive use. However, the evidence of intervention effectiveness was of low to moderate quality. Trials with evidence of effectiveness included two that provided one or two sessions and three that had multiple contacts. The former had limitations, such as self-reported outcomes and showing no effect for many comparisons. The interventions with multiple sessions were promising but would have to be adapted for other locations and then retested. Researchers and health care providers will have to determine which intervention might be appropriate for their setting and level of resources.

Postpartum education for contraception: a systematic review

Contraceptive education is generally considered a standard component of postpartum care, but the effectiveness is seldom examined. Two-thirds of postpartum women may have unmet needs for contraception, and many adolescents become pregnant again within a year of giving birth. Women may prefer to discuss contraception prenatally or after hospital discharge. The objective of this systematic review was to assess the effects of educational interventions for postpartum mothers about contraceptive use. We searched computerized databases for randomized controlled trials that evaluated the effectiveness of postpartum contraceptive education. The intervention must have started within 1 month after delivery. The Mantel-Haenszel odds ratio was calculated with 95% confidence interval for the dichotomous outcomes. Eight trials met the inclusion criteria. Of 4 short-term interventions, 1 did not have sufficient data and 1 was statistically underpowered. The remaining 2 showed a positive effect on contraceptive use. Of 4 multifaceted programs, 2 showed fewer pregnancies or births among adolescents in the experimental group that had enhanced services, and 1 structured home-visiting program showed more contraceptive use. The effective interventions were conducted in Australia, Nepal, Pakistan, and the United States. Postpartum education about contraception led to more contraception use and fewer unplanned pregnancies. Short-term interventions were limited by self-reported outcomes or showing no effect for many comparisons. The longer-term programs were promising and not necessarily more costly than usual care. Health care providers can determine if 1 of these interventions suits their setting and level of resources.

TARGET AUDIENCE

Obstetricians & Gynecologist, Family Physicians.

LEARNING OBJECTIVES

After completing this educational activity, the participant should be better able to assess the importance of assessing delivery methods when examining intervention quality, evaluate the evidence from randomized trials on the effectiveness of postpartum education, and employ why additional research on postpartum education is needed for improving clinical practice.

Education for contraceptive use by women after childbirth

BACKGROUND

Providing contraceptive education is now considered a standard component of postpartum care. The effectiveness is seldom examined. Questions have been raised about the assumptions on which such programs are based, e.g., that postpartum women are motivated to use contraception and that they will not return to a health center for family planning advice. Surveys indicate that women may wish to discuss contraception prenatally and after hospital discharge. Nonetheless, two-thirds of postpartum women may have unmet needs for contraception. In particular, many adolescents become pregnant again within a year a giving birth.

OBJECTIVES

Assess the effects of educational interventions for postpartum mothers about contraceptive use

SEARCH STRATEGY

We searched the computerized databases of MEDLINE, CENTRAL, EMBASE, CINAHL, PsycINFO, and POPLINE. We also searched for current trials via ClinicalTrials.gov and ICTRP. In addition, we examined reference lists of relevant articles, and contacted subject experts to locate additional reports.

SELECTION CRITERIA

Randomized controlled trials were considered if they evaluated the effectiveness of postpartum education about contraceptive use. The intervention must have started postpartum and have occurred within one month of delivery.

DATA COLLECTION AND ANALYSIS

We assessed for inclusion all titles and abstracts identified during the literature searches with no language limitations. The data were abstracted and entered into RevMan. Studies were examined for methodological quality. For dichotomous outcomes, the Mantel-Haenszel odds ratio (OR) with 95% CI was calculated using a fixed-effect model.

MAIN RESULTS

Eight trials met the inclusion criteria. Of four trials with short-term interventions in the immediate postpartum period, one did not have sufficient data and one was statistically underpowered. The remaining two showed a positive effect on contraceptive use. However, most comparisons did not show an effect in one study and the other had short-term assessments. Of four multifaceted programs with multiple contacts, two showed fewer pregnancies or births among adolescents in the experimental group that had enhanced services, and a structured home-visiting program showed more contraceptive use. The effective interventions were conducted in Australia, Nepal, Pakistan, and the USA.

AUTHORS' CONCLUSIONS

Postpartum education about contraception led to more contraception use and fewer unplanned pregnancies. Both short-term and multiple-contact interventions had effects. The former were limited by self-reported outcomes or showing no effect for many comparisons. The longer-term interventions were promising and not necessarily more costly than usual care. Health care providers can determine if one of these interventions suits their setting and level of resources.