The risk of pre-eclampsia at booking

Pre-eclampsia is a major cause of maternal and foetal mortality and morbidity. The incidence of pre-eclampsia is 2-10%, depending on the population studied and definitions of pre-eclampsia. With the exception of smoking the literature has not been systematically reviewed for factors that predict the relative risk of developing pre-eclampsia.

The recent National Institute for Clinical Excellence (NICE) guidelines on antenatal care have reduced the number of antenatal visits recommended for healthy woman at low risk. As the randomised controlled trials on which this recommendation was based were never powered to identify important outcomes such as mortality, and as the failure to identify and act on known risk factors at booking contributes to deaths from pre-eclampsia,  it is important to define risk at the beginning of pregnancy.

A systematic review of controlled studies published between 1966 and 2002 was carried out to clarify some of these issues. Unadjusted relative risks were calculated from published data. A number of controlled cohort studies showed that the risk of pre-eclampsia is increased in women with a previous history of pre-eclampsia (relative risk 7.19) and in those with antiphospholipids antibodies (RR=9.72), pre-existing diabetes (RR=3.56), multiple (twin) pregnancy (RR=2.93), nulliparity (RR=2.91), family history (RR=2.90), raised blood pressure at booking (1.38), raised body mass index before pregnancy (2.47) or at booking (1.55), or maternal age over 40 (1.96) for multiparous women. Individual studies show that risk is also increased with an interval of 10 years or more since a previous pregnancy, autoimmune disease, renal disease, and chronic hypertension.

These factors and the underlying evidence base can be used to assess risk at booking so that a suitable surveillance routine to detect pre-eclampsia can be planned for the rest of the pregnancy.

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Folic acid and neural tube defects

Primary prevention of certain serious birth defects is now feasible globally. The groundbreaking studies of Smithells and colleagues, confirmed by many other studies and randomised clinical trials by the early 1990s, showed that supplements containing folic acid, a B vitamin, when consumed from before conception, can reduce spina bifida and other neural tube defects by an estimated 80% or more.

Neural tube defects, which also include anencephaly, are severe and often lethal conditions that annually affect at least 300 000 newborns worldwide. Accumulating data indicate additional benefits of folic acid on other major birth defects.

A retrospective cohort study of births monitored by birth defect registries was explored to evaluate this further.  Thirteen birth defects registries monitoring rates of neural tube defects from 1988 to 1998 in Norway, Finland, Northern Netherlands, England and Wales, Ireland, France (Paris, Strasbourg, and Central East), Hungary, Italy (Emilia Romagna and Campania), Portugal, and Israel were examined.

Cases of neural tube defects were ascertained among liveborn infants, stillbirths, and pregnancy terminations (where legal). Policies and recommendations were ascertained by interview and literature review.

The incidence and trends in rates of neural tube defects before and after 1992 (the year of the first recommendations) and before and after the year of local recommendations (when applicable).

The study showed that the issuing of recommendations on folic acid was followed by no detectable improvement in the trends of incidence of neural tube defects.

They conclude that recommendations alone did not seem to influence trends in neural tube defects up to six years after the confirmation of the effectiveness of folic acid in clinical trials. New cases of neural tube defects preventable by folic acid continue to accumulate. A reasonable strategy would be to quickly integrate food fortification with fuller implementation of recommendations on supplements.

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NICE guidelines for the management of depression

Guidelines from the National Institute for Clinical Excellence (NICE) have been published on depression. Depression is a common condition, contributing 12% of the total burden of nonfatal global disease. Variations in its treatment within the NHS are striking and perplexing.

NICE was able to provide clear guidance on the treatment of moderate to severe depression—antidepressant medication is recommended and, after careful review, that this should be a selective serotonin reuptake inhibitor (SSRI). New guidance by the Committee on Safety of Medicines and the MHRA about prescribing SSRIs now respects concerns about hitherto unpublished risks of agitation and increased likelihood of suicide.

The guidelines endorse the conclusions of the technology appraisal by NICE of electroconvulsive therapy. This should continue to be used, but its use should be restricted to achieving rapid and short term improvement in disabling symptoms in individuals with a severe depressive illness after other treatment options have proved ineffective or when the condition is potentially life threatening.

The guidelines recommend the use of cognitive behaviour therapy or interpersonal therapy, which are as effective as antidepressant medications. The guidelines do not recommend the routine use of psychodynamic psychotherapies.

People with mild to moderate depression or the associated mixed anxiety and depressive disorders constitute most of those whose care might be influenced by these guidelines. The review concluded that firm evidence is lacking that these conditions are responsive to antidepressant medication or specific psychological treatments. These are mostly subthreshold disorders where identifying the presenting difficulty as a treatable pathology may be inappropriate. Until research has established who is likely to benefit from active treatment, practitioners will continue to be tempted to respond to requests for help by allowing such negotiations to result in a medical diagnosis.

Changes in social networks leave the vulnerable with limited access to informal emotional support. Professionals providing support are increasingly obliged to restrict interventions to those with evidence of effectiveness. On the whole these are limited to those evaluated from a medical perspective. As a result distress may be defined as depression by patients as a necessary means to access support and by doctors as a way of legitimising the provision of such support.

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