Disclosures Can I do this while Im pregnant? I have nothing to - PowerPoint PPT Presentation

10/16/2015 Disclosures “Can I do this while I’m pregnant?” • I have nothing to disclose Searching for Evidence Behind Pregnancy Advice Robyn Lamar, MD, MPH Assistant Professor, Obstetrics & Gynecology at UCSF Objectives • Consider how we discuss risk related to lifestyle choices in pregnancy Communicating Risk in • Evaluate pregnancy related advice concerning: Pregnancy – seafood – sleep position – caffeine – alcohol 1

10/16/2015 Laundry list? Public Health Campaign Poster? Economics-style Risk-Benefit Analysis? Medical Ethics framework? A C O G C O M M IT T E E O PIN IO N Num ber 390 • D ecem ber 2007 Ethical Decision Making in Obstetrics and Gynecology* • Ethical principles: – Autonomy – Beneficence & nonmaleficence – Justice 2

10/16/2015 Communicating Risk in Pregnancy: Decision-making in pregnancy Common pitfalls • Pregnant women deserve care that is both 1 Falsely dichotomizing a range of risk into evidence-based and patient- centered. “low risk” and “high risk” exposures • We should avoid reinforcing distortions of risk 2 Letting any risk to the fetus trump • We can do this by: considerations related to the wellbeing of the – acknowledging the range of values that pregnant pregnant woman women bring to decisions 3 Emphasizing the risks of taking certain – Identifying a range of well-considered options actions, but ignoring the risks of avoiding and allowing women to make decisions in the those actions context of their own priorities and life circumstances Lyerly, A. D. et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 109, 979–84 (2007). Lyerly, A. D. et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 109, 979–84 (2007). Can I eat seafood? Case Examples Retrieved from: http://www.montereyfish.com/ 3

10/16/2015 Seafood: Official Advice Seafood in Pregnancy ACOG: “pregnant women . . . should eat at least Several issues to consider: • From nutrition standpoint: high protein, low 8 and up to 12 ounces per week of a variety of fish lower in mercury.” fat, high in DHA • From contamination standpoint: mercury levels, other pollutants • From food safety perspective: contamination risk if raw/undercooked? ACOG Practice Advisory: Seafood Consumption During Pregnancy Seafood: History Seafood: Early Evidence 2001 FDA Advisory 1990s: cohort studies published in • Don’t eat 4 fish high in mercury • Faroe islands – Shark • New Zealand – Tilefish Correlated increasing levels of mercury in – King mackerel mother’s hair & decrements in child’s language – swordfish skills, memory, motor speed, and visuospatial • Limit overall fish consumption to 12oz/week function 4

10/16/2015 Seafood: Early Evidence Seafood: Seychelles Cohort study – Unusual consumption patterns (Faroe islands: pilot whale meat/blubber; NZ shark) – Reanalysis looking at seafood consumption itself (not mercury level) did NOT show link Davidson P, Cory-Slechta D, Thurston S, et al. Fish consumption and prenatal methylmercury exposure: Cognitive and behavioral outcomes in the main cohort at 17 years from the Seychelles child development study. NeuroToxicology 2011;32(6):711717. Seafood: Systematic Review of Seafood: Seychelles Cohort study prenatal fish & neurodevelopment • High fish diet (12 servings/wk), no • 8 cohort studies identified – Published between 2000-2014 consumption of marine mammals/shark • Predictor variable: maternal hair mercury – Predictor variable: maternal seafood consumption – Evaluated offspring from age 3 days – 9 years • Outcome variables: neurocognitive & – Sample sizes ranged from 135 to over 25,000 behavioral testing done from age 6mo – 17yo • Findings • Results: as maternal mercury increases . . . – One study showed no association – 26 of 27 outcomes: no difference or better scores – 7 studies showed improved outcomes as maternal – 1 of 27 outcomes: Higher risk of referral to school seafood consumption increased counselor Davidson P, Cory-Slechta D, Thurston S, et al. Fish consumption and prenatal methylmercury exposure: Cognitive and behavioral Starling P, Charlton K, McMahon AT, Lucas C. Fish intake during pregnancy and foetal neurodevelopment--a systematic review of the outcomes in the main cohort at 17 years from the Seychelles child development study. NeuroToxicology 2011;32(6):711717. evidence. Nutrients 2015;7(3):2001–14. 5

10/16/2015 Seafood: Current Consumption Seafood consumption in last week among 1000 Pregnant Women 4+ oz None 20% 20% The women in the highest consumption category aren’t 2 to 4oz less than 2 oz necessarily even eating 1 20% 40% serving a week! S Ostroff. (2014, June 10). Why We Want Pregnant Women and Children to Eat More Fish. Retrieved from http://blogs.fda.gov/fdavoice/index.php/tag/environmental-protection-agency-and-food-and-drug-administration-advice-about- eating-fish/ Communicating Risk in Pregnancy: Common pitfalls 1 Falsely dichotomizing a range of risk into “low risk” and “high risk” exposures 2 Letting any risk to the fetus trump considerations related to the wellbeing of the pregnant woman 3 Emphasizing the risks of taking certain actions, but ignoring the risks of avoiding those actions Lyerly, A. D. et al. Risks, values, and decision making surrounding pregnancy. Obstet Gynecol 109, 979–84 (2007). Retrieved from: https://www.washingtonpost.com/national/health-science/2012/04/03/gIQABd16sS_graphic.html 6

10/16/2015 Fish Oil: Evidence This looks complicated. Recent Meta-analysis looked at omega-3 Should I just take fish oil instead? supplementation during pregnancy & childhood neurodevelopment • 11 RCTs with 5,272 participants • No difference in cognitive, language, or motor development – Except for cognitive scores in subgroup of 2-5 year olds; but driven by 2 studies rated high risk for bias Gould J, Smithers L, Makrides M. The effect of maternal omega-3 (n-3) LCPUFA supplementation during pregnancy on early childhood cognitive and visual development: a systematic review and meta-analysis of randomized controlled trials. Am J Clin Nutr. 2013;97(3):531–44. doi:10.3945/ajcn.112.045781. Raw Seafood: Advice OK, I’ll eat fish. What about • ACOG says no • NHS says raw fish is fine, if frozen first sushi? – Deep freezing kills parasites (anasakis, tapeworm) – FDA requires freezing fish intended to be eaten raw • Seafood causes a tiny percent of food poisoning in the US • Raw shellfish is responsible for the vast majority of seafood-associated “food poisoning” – can be contaminated with vibrio cholera or norovirus “Seafood Choices: Balancing Benefits and Risks.” IOM report brief, Oct 2006. http://www.nhs.uk/chq/pages/is-it-safe-to-eat-sushi-during-pregnancy.aspx?categoryid=54 7

10/16/2015 Seafood: Summary Can I sleep on my back? • Eat seafood • Not too much, but not too little • Eat some types, but not others • Cook shellfish thoroughly • Enjoy fish if it’s been well frozen . . . Is it any wonder women give up? Sleep Position: The Official advice sleep position while pregnant Web Images Videos News Shopping More Search tools About 1,560,000 results (0.59 seconds) The best sleep position during pregnancy is “SOS” ( sleep on side). Even better is to sleep on your left side. Sleeping on your left side will increase the amount of blood and nutrients that reach the placenta and your baby. Keep your legs and knees bent, and put a pillow between your legs. Sleeping Positions During Pregnancy american pregnancy .org/ pregnancy .../ sleeping - positions - during-pregnancy / Feedback 8

10/16/2015 Sleep Position Sleep Position: Stacey et al • Theory: simple & compelling 2011 prospective case-control study in New Zealand • Cases: 155 singletons with 3 rd tri stillbirth – As uterus enlarges, supine position causes • Controls: 301 ongoing singleton pregnancies matched compression of vena cava, decreasing venous for GA • Results: OR for stillbirth return & cardiac output – Supine vs left: – Familiar practice for c/s & ACLS in pregnancy, and 2.54 – Nocturia once or less vs more: 2.28 to ameliorate fetal heart tracing changes – Daytime napping vs not: 2.04 • Evidence: limited • Absolute risks of stillbirth if go to sleep on: – Left 1.96/1000 – Back or right 3.93/1000 Sleep Position: Stacey et al Sleep Position & IUGR: Theories • Some things to consider about Stacey’s study: • So is supine sleep part of the “triple risk” that – Recall bias? increases stillbirth? • Controls were asked about last night’s sleep – 1: maternal risk factors (obesity, smoking, age) • Cases interviewed an average of 25 days after delivery – 2: fetal & placenta risk factors (IUGR) – Reverse causality? – 3: stressor (sleeping position?) • Before pregnancy, cases & controls equally likely to • Or is IUGR actually the real risk factor that sleep on their back, left, or right sides • “What would reduce normal progression toward the leads to both supine sleep & stillbirth? preference of a more lateral tilt, [and] reduce the need to go to the bathroom at night?” IUGR? Stacey T, Thompson JM, Mitchell EA, Ekeroma AJ, Zuccollo JM, McCowan LM. Association between maternal sleep practices and risk of late stillbirth: a case-control study. BMJ. 2011 Jun 14;342:d3403. Froen JF et al. “No need to worry about sleeping position in pregnancy—quite yet.” BMJ 2011;342;d3404 9