The edition · Obstetrics & Gynaecology
A haemoglobin still below 10.5 g/dL at 20 weeks predicts stillbirth
A secondary analysis of an Indian trial in 4,252 women with moderate iron deficiency anaemia found stillbirth and early preterm birth risk rose progressively as the mid-pregnancy haemoglobin fell below 10.5 g/dL. Plus aspirin works whenever you start it, and PCOS has been renamed.
The edition in brief
The most directly usable finding today comes from an Indian trial cohort. This secondary analysis of a multicentre randomised trial comparing single-dose intravenous iron with oral iron for moderate iron deficiency anaemia — haemoglobin 7.0 to 9.9 g/dL at 14 to 17 weeks — followed 4,252 women. Each 1 g/dL rise in haemoglobin by 20 to 24 weeks was associated with a lower risk of stillbirth (relative risk 0.74, 95% CI 0.56 to 0.98). Modelling a non-linear relationship, the risk of stillbirth (p<0.0001) and of early preterm birth before 34 weeks (p=0.01) rose progressively as haemoglobin fell below 10.5 g/dL. The message is that the response to iron, not the starting value, is what predicts outcome. A post hoc analysis of the ASPIRIN trial in 11,908 women across Africa, Asia and Latin America found the effect of low-dose aspirin on preterm delivery was not modified by gestational age at initiation between 6 and 13 weeks, nor by adherence. For each 5% increase in adherence the treatment risk ratio was 1.01 (95% CI 0.99 to 1.04) for preterm delivery. ACOG has published a new clinical practice guideline on obstetric cerclage, using a modified GRADE framework. An individual participant data meta-analysis of 2,297 pregnancies found metformin did not prevent gestational diabetes (adjusted odds ratio 1.00) but was associated with longer gestation and fewer preterm births. And polycystic ovary syndrome has been formally renamed polyendocrine metabolic ovarian syndrome, with diagnostic criteria unchanged.
The haemoglobin at 20 to 24 weeks, not the one at booking, predicts stillbirth
Recheck haemoglobin at 20 to 24 weeks after treating anaemia in pregnancy, and treat a value still below 10.5 g/dL as a failure requiring escalation — stillbirth and early preterm risk climb progressively below that level.
Aspirin in pregnancy works whenever you start it and however imperfectly it is taken
Low-dose aspirin's benefit in pregnancy was not reduced by starting later within the 6 to 13 week window or by imperfect adherence — so start it whenever the woman books and continue it despite missed doses.
ACOG publishes a full clinical practice guideline on obstetric cerclage
No new drug regulatory action today; ACOG's new GRADE-based cerclage guideline covers indications, technique and alternatives, and is worth auditing your unit's practice against.
Metformin does not prevent gestational diabetes
Metformin did not prevent gestational diabetes across 2,297 pregnancies in seven trials — do not prescribe it for that purpose.
PCOS is now PMOS, and the point is the metabolic framing
Polycystic ovary syndrome is now polyendocrine metabolic ovarian syndrome, criteria unchanged — ask about it at booking and treat it as an obstetric risk modifier for gestational diabetes, hypertensive disorders and growth restriction.
Book the repeat haemoglobin at the same visit you treat the anaemia
Book the 20 to 24 week repeat haemoglobin at the same visit you start iron, and write down that a value below 10.5 g/dL means escalate.
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