The 2015 Pregnancy Summit,London,UK

Abstract

The 2015 Pregnancy Summit was held over 3 days from 29 September to 1 October at Cineworld, The O2, London, UK. The event brings together a multidisciplinary faculty of international researchers and clinicians to discuss both scientific and clinical aspects of pregnancy-related issues in an informal setting. The goal of the meeting was to provide delegates with an update of recent advances in management of pregnancy-related conditions, to present research data and to discuss the current attitudes and practices in relevant topics. An extensive range of topics were discussed, from preeclampsia and treatment of hypertension, to the psychological impact of termination of pregnancy and feticide. This report will summarize a selection of the lectures presented.

Dianne Morrison-Beedy from the University of South Florida, USA, opened the conference by presenting the outcomes of the Health Improvement Project for Teens (HIP Teens) [1]. Adolescent girls are particularly vulnerable to unsafe sexual behavior, sexually transmissible diseases and unplanned pregnancy. HIP Teens is a randomized controlled trial evaluating the effectiveness of a community-based small group intervention program aimed at low-income girls aged 15–19 years in a mid-sized US city. The program delivered HIV prevention information, motivational strategies to change or modify certain behaviors, and exercises in assertiveness, negotiation and communication skills in order to facilitate sexual risk reduction. Intervention sessions utilized developmentally appropriate strategies such as games, activities, skits and role-playing. There was a significant decrease in the total number of sex partners and episodes of protected and unprotected vaginal sex and a significant increase in sexual abstinence in the intervention participants, as well as a 50% reduction in pregnancy rates, when compared with the control group. Sexual risk reduction interventions tailored to adolescent girls seem to be effective and continued development of these interventions are required to ensure they remain appealing, acceptable and feasible in this target group.

Hyperemesis gravidarum (HG) is a disorder of pregnancy characterized by severe nausea and vomiting with dehydration and weight loss. It has been attributed to high levels of beta HCG and estrogen, however, Phil Lowry from the University of Reading has proposed that HG is caused by placental endokinin [2]. Endokinin belongs to the same family of peptides as substance P, which is known to cause emesis and sialorrhea. Overflow of placental endokinin into the maternal circulation may contribute to HG. The beneficial effect of placental endokinin, in concert with placental C-reactive protein, is by clustering neurokinin 1 receptors (NK1Rs), thus improving local blood flow. This effect is antagonized by peripherally produced endokinin such as from the lung in smokers. Endokinin released from lung tissue may also downregulate the NK1Rs in the area postrema of the medulla oblongata which is involved in the vomiting reflex. These actions may explain the poor vascularization of the placenta and the lower incidence of hyperemesis in smokers, and suggest an area for development of targeted therapy for HG.

Preeclampsia is a multisystem disorder that is a major cause of perinatal morbidity and mortality. Its pathophysiology is complex, and involves abnormal placentation, resulting in poor uteroplacental perfusion, fetal growth restriction, and as the disease progresses, widespread endothelial dysfunction affecting all organ systems. A research team from Lund University, Sweden, headed by Stefan Hansson, is investigating the function of free HbF as a biomarker for preeclampsia and the role of alpha-1-microglobulin (A1M) as a therapy [3]. In vitro studies of freshly delivered placentas demonstrate that free HbF causes an increase in placental arterial pressure, increase in breakdown of collagen and damage to maternal endothelial cells. Thus, free HbF may have a future role in the prediction and diagnosis of preeclampsia. A1M is a reductase and a heme scavenger which prevents leakage from fetal to maternal circulation and repairs membrane and matrix damage caused by free HbF in the placenta. Studies on animal models demonstrate that free HbF leads to glomerular endotheliosis and renal damage, and A1M reduces this renal damage and improves creatinine levels [4–6]. Work is currently in progress on primate studies, with clinical studies planned for the next 2 years.

Previous studies have demonstrated the association between preeclampsia and increased cardiac output and systemic vascular resistance. These hemodynamic parameters can be measured with noninvasive impedance cardiography. David Chaffin from Marshall University in West Virginia, USA, discussed the measurement and monitoring of hemodynamics of pregnant women to guide the management of hypertension [7]. For example, using β-blockers in those with low cardiac output who are vasoconstricted may cause further problems, as would using vasodilators in pregnant women with high cardiac outputs. Data were presented showing decreased perinatal mortality, decreased rates of preeclampsia and no increase in fetal growth restriction in pregnant women who received antihypertensive therapy guided by hemodynamic information. It now seems that monitoring blood pressure alone is inadequate to effectively guide antihypertensive therapy in pregnancy.

Efraim Siegler, president of the Israeli Society of Colposcopy and Cervical and Vulvar Pathology, presented a study on the treatment of cervical high-grade squamous intraepithelial changes (HSIL, or CIN 2–3) with loop excision of the transformation zone (LLETZ) during pregnancy [8]. 5% of women with HSIL on a PAP smear have coexistent invasive cancer, and 20% of CIN 3 lesions progress to invasive cancer within 5 years. Three percent of cervical cancers occur in pregnant women. Current guidelines such as the ACOG Practice Bulletin recommend treatment of HSIL in pregnancy only if invasion is suspected. Dr Siegler and colleagues studied 81 women diagnosed with CIN 2–3 during pregnancy, 41 of whom were treated with LLETZ procedure during the first 16 weeks of pregnancy and the rest observed only. Cervical cancer was found in 7.3% of those treated with LLETZ procedure, and CIN 2–3 or adenocarcinoma-in situ in 84%. There were no observed major complications such as severe bleeding or premature labor. One case of early missed miscarriage at 10-weeks' gestation and one case of cervical suture insertion were reported. The study concluded that LLETZ procedure during the first trimester appears to be safe, and the benefits of diagnosing and treating cancer should be considered against the small risk of complications. However, the study numbers were small and further research in this area may be required to guide future practice.

Amir Azarpazhooh from the University of Toronto, Canada, presented an informative review of the evidence base linking oral health and adverse pregnancy outcomes [9]. Periodontal disease is a chronic inflammatory condition which can result from untreated gingivitis. It poses a significant public health problem and has been associated with adverse outcomes in pregnancy. Studies on periodontitis and preterm birth show conflicting findings, and the evidence for periodontitis and low birth weight show no difference in outcomes. With regards to periodontitis and preeclampsia, a meta-analysis showed an increase in odds ratio but closer analysis of the higher quality trials involved demonstrated no difference. In summary, there is heterogeneity between studies concerning measurement of periodontal disease and type of adverse pregnancy outcome, and a causal relationship has not been confirmed. Although there is currently insufficient evidence to support the provision of periodontal treatment during pregnancy purely to reduce adverse pregnancy outcomes, it remains important to counsel women regarding the significance of good oral health during pregnancy.

Termination of pregnancy for fetal abnormality (TOPFA) accounts for 2% of all TOPs in England and Wales. This number is increasing due to advances in prenatal diagnosis and the increase in maternal age. Caroline Lafarge from the University of West London (Brentford, UK) presented a qualitative paper exploring women's coping strategies and the relationship between these strategies and psychological adjustment [10]. A comprehensive discussion of perinatal grief, post-traumatic growth versus resilience, and the four structures of coping (support, acceptance, avoidance, and meaning attribution) was presented. Overall, it was found that support and the ability to reciprocate are essential to coping. Promotion of adaptive coping strategies such as acceptance and minimizing self-blame are key areas to assisting psychological adjustment to TOPFA.

Ronit Leichtentritt of Tel Aviv University, Israel, presented a moving narrative of Israeli parents' experience of feticide [11,12]. It was revealed that, although an uncommon occurrence in Israel, feticide is a procedure that is encouraged when a fetal abnormality is detected antenatally. However, there is no discourse on the subject. There is no Hebrew term for the procedure, and there are no funerals, mourning rituals or graves for deceased fetuses. Many parents felt unacknowledged and isolated in their grief and felt pressured to suppress their emotions. Guilt, shame and a need to justify their decision were pervasive themes in the accounts of several couples' reactions to having undergone the procedure. It was clear that counseling, support and follow-up of these couples are required.

Monique Andersson of Stellenbosch University (South Africa) discussed the feasibility of eliminating mother to child transmission (MTCT) of hepatitis B virus (HBV) in sub-Saharan Africa [13]. If successful, this can prevent a significant proportion of associated chronic liver disease, including cirrhosis and hepatocellular carcinoma. The risk of HBV MTCT is dependent on E antigen (HBeAg) positivity or HBV viral load. Up to 38% women with HBV in sub-Saharan Africa are HBeAg positive and at high risk of transmitting HBV to their babies. Existing treatment and prevention options include hepatitis B vaccine, hepatitis B immunoglobulin and antiviral medications. Hepatitis B vaccination has greater than 95% efficacy and WHO guidelines recommend vaccination of a newborn within 24 h of delivery. However, in sub-Saharan Africa, hepatitis B vaccination is given 4–6 weeks after delivery and the cost and logistics of immunoprophylaxis of the newborn are too prohibitive. For women with a high viral load, antiviral therapy from the second trimester can reduce the risk of HBV MTCT and there is growing experience with drugs such as tenofovir which are used extensively in HIV treatment. Eliminating HBV transmission is biologically feasible but requires improvement in public health infrastructure, funding, community education and awareness, and further research addressing the development of rapid diagnostic tests, which antiviral drug is best, the timing of commencement of therapy and long-term consequences to infants.

The Pregnancy Summit 2015 delivered 3 days of excellent presentations on a variety of pregnancy-related topics which stimulated much thought and discussion. Further details and conference abstracts are available from the event website [14]. The next Pregnancy and Childbirth Summit will be held on 13–15 September 2016.