The IRELAnD study-investigating the role of early low-dose aspirin in diabetes mellitus: a double-blinded, placebo-controlled, randomized trial

BACKGROUND

Although aspirin therapy is being increasingly advocated with the intention of risk modification for a wide range of pregnancy complications, women with prepregnancy diabetes mellitus are commonly excluded from clinical trials.

OBJECTIVE

The primary aim of this study was to examine the effect of aspirin therapy on a composite measure of adverse perinatal outcome in pregnancies complicated by pregestational diabetes mellitus.

STUDY DESIGN

A double-blinded, placebo-controlled randomized trial was conducted at 6 university-affiliated perinatology centers. Women with type 1 diabetes mellitus or type 2 diabetes mellitus of at least 6 months' duration were randomly allocated to 150-mg daily aspirin or placebo from 11 to 14 weeks' gestation until 36 weeks. Established vascular complications of diabetes mellitus, including chronic hypertension or nephropathy, led to exclusion from the trial. The primary outcome was a composite measure of placental dysfunction (preeclampsia, fetal growth restriction, preterm birth <34 weeks' gestation, or perinatal mortality). The planned sample size was 566 participants to achieve a 35% reduction in the primary outcome, assuming 80% statistical power. Secondary end points included maternal and neonatal outcomes and determination of insulin requirements across gestation. Data were centrally managed using ClinInfo and analyzed using SAS 9.4. The 2 treatment groups were compared using t tests or chi-square tests, as required, and longitudinal data were compared using a repeated-measures analysis.

RESULTS

From February 2020 to September 2022, 191 patients were deemed eligible, 134 of whom were enrolled (67 randomized to aspirin and 67 to placebo) with a retrospective power of 64%. A total of 101 (80%) women had type 1 diabetes mellitus and 25 (20%) had type 2 diabetes mellitus. Reaching the target sample size was limited by the impact of the COVID-19 pandemic. Baseline characteristics were similar between the aspirin and placebo groups. Treatment compliance was very high and similar between groups (97% for aspirin, 94% for placebo). The risk of the composite measure of placental dysfunction did not differ between groups (25% aspirin vs 21% placebo; P=.796). Women in the aspirin group had significantly lower insulin requirements throughout pregnancy compared with the placebo group. Insulin requirements in the aspirin group increased on average from 0.7 units/kg at baseline to 1.1 units/kg by 36 weeks' gestation (an average 83% within-patient increase), and increased from 0.7 units/kg to 1.3 units/kg (a 181% within-patient increase) in the placebo group, over the same gestational period (P=.002). Serial hemoglobin A1c levels were lower in the aspirin group than in the placebo group, although this trend did not reach statistical significance.

CONCLUSION

In this multicenter, double-blinded, placebo-controlled randomized trial, aspirin did not reduce the risk of adverse perinatal outcome in pregnancies complicated by prepregnancy diabetes mellitus. Compared with the placebo group, aspirin-treated patients required significantly less insulin throughout pregnancy, indicating a beneficial effect of aspirin on glycemic control. Aspirin may exert a plausible placenta-mediated effect on pregestational diabetes mellitus that is not limited to its antithrombotic properties.

Is the older perineum a safer perineum? Risk factors for obstetric anal sphincter injury

INTRODUCTION

Obstetric anal sphincter injury (OASI) is the most common cause of anal incontinence. Identifying risk factors may facilitate change in labour and delivery practice, potentially reducing the risk. The objective of this study is to identify maternal, foetal and intrapartum risk factors for OASI in a regional hospital.

METHOD

We conducted a retrospective analysis of vaginal deliveries over a 10-year period (2008-2017). Anal sphincter injury was diagnosed by an experienced clinician and classified according to RCOG recommendations. A multiple logistic regression model was created using the presence of OASI as the dependent variable. Coefficients were adjusted for relevant maternal, foetal and intrapartum risk factors.

RESULTS

During the study period, there were 23,887 vaginal deliveries. Of these births, 18,550 were spontaneous (77.66%), 3746 vacuum-assisted (15.68%), 1196 forceps (5.01%) and 395 sequential instrumental deliveries (1.65%). The overall rate of OASI was 1.76%, with an upward trend seen in nulliparous mothers. Significant factors that increased the risk of OASI were nulliparity, Asian ethnicity, delivery by forceps or sequential instruments, and shoulder dystocia. Vacuum delivery did not significantly increase risk.

CONCLUSION

Maternal age ≥ 35 years confers a protective effect after adjusting for parity, birth weight and mode of delivery. Given the context of an ageing reproductive population, additional research is required to investigate the impact of maternal age on anal sphincter injury.

Anal sphincter injury associated with shoulder dystocia

Objective: Shoulder dystocia is an obstetric emergency, occurring in 0.2-3% of vaginal deliveries. Research has mainly focused on the neonatal morbidity arising from shoulder dystocia, such as brachial plexus injury and hypoxic-ischemic encephalopathy. Maternal morbidity is thought to be increased with shoulder dystocia though is much less commonly reported. Obstetric anal sphincter injury remains the leading cause of fecal incontinence in women and shares several antenatal and intrapartum risk factors with shoulder dystocia. The aim of this study was to identify risk factors for sphincter injury associated with shoulder dystocia.Methods: This retrospective analysis included all cases of shoulder dystocia from 2008 to 2017 in a single unit in North-East Ireland. Maternal characteristics and delivery outcomes were analyzed. Two groups were compared, those with and without anal sphincter injury in our shoulder dystocia cohort and those with and without shoulder dystocia, regardless of sphincter injury. Univariate and multivariate logistic regression models were used to examine risk factors for sphincter injury.Results: There were 24,159 singleton cephalic vaginal deliveries over the study period, with 495 cases of shoulder dystocia, giving an incidence of 2.1% (495/24 159). The rate of anal sphincter injury in those with shoulder dystocia was 4.4% (22/495), with 7.6% (12/158) in nulliparas, and 3.0% (10/337) among multiparas. Women with sphincter damage were more likely to be nulliparous than those with an intact sphincter (54.5% [12/22] vs. 30.9% [146/473]; p = .036) and have an operative vaginal delivery (72.7% [16/22] vs. 39.1% [185/473]; p = .004). Episiotomy was more common in those with a sphincter injury (68.2% [15/22] vs. 37.0% [175/473]; p = .007). On univariate regression analysis, nulliparity (OR 2.69) and operative vaginal delivery (OR 4.15) were associated with sphincter injury. No risk factors were identified on multivariate regression analysis.Discussion: In our population, the risk of anal sphincter injury with shoulder dystocia is 4.4%. Risk factors include nulliparity and operative vaginal delivery. After controlling for other factors, these associations became nonsignificant. Further research into sphincter injury at shoulder dystocia is warranted.

Grieving after early pregnancy loss--a common reality

A miscarriage can be very traumatic for a couple and their immediate family. The aim of this study was to assess, using the Perinatal Grief Scale (PGS), whether the type of early pregnancy loss influences the severity of grief and whether the presence of living children influences the severity of grief. Over a period of 6 months in 2008, seventy five patients were recruited for the study, of which 7 (9.3%) had molar pregnancies, 20 (26.7%) had ectopic pregnancies, 43 (573%) had a miscarriage and 5 (6.7%) had recurrent miscarriages. In this study there was no significant difference in severity of grief, between women that had a miscarriage and ectopic pregnancy (p = 0.14) or, between women that had a miscarriage and a molar pregnancy (p = 0.85). Women who had experienced a ectopic pregnancy did not have a higher grief intensity than the women that had a molar pregnancy (p = 0.75). However, for women with a child, the grief intensity significantly increases with the number of miscarriages (p = 0.015). Women with no children with an ectopic pregnancy grieve significantly more than those with a child (p = 0.019). An appointment for the 'Miscarriage Clinic' should be offered to all of these women but special attention should be paid to those in the categories most at risk