How much physical activity is safe and healthy for pregnant women?

We will be discussing: Physical activity and the risk of preterm birth: a systematic review and meta-analysis of epidemiological studies by Aune and colleagues.

Wednesday 30th August 2017, 8pm BST

Scenario
The first patient on the afternoon clinic schedule is seeing you for her first
obstetric visit. She is a healthy nulliparous 37-year-old business
administrator. She asks whether her morning workout routine will increase the
risk of preterm delivery.

What recommendations do you make about time and intensity of exercise during
pregnancy?

Description of research

Participants: Pregnant women in prospective studies of physical activity in
pregnancy.
Outcomes: Preterm birth <37 weeks
Study Design: Systematic review and meta-analysis of 41 studies from Europe, North America, South America, Asia, Australia and New Zealand
Authors’ conclusion: Higher leisure-time physical activity in pregnancy is associated
with a 14% relative risk reduction in preterm birth <37 weeks of gestation compared to lower physical activity. The data does not definitively answer the question of “how much” exercise is enough, or too much, but the lowest observed risk for preterm
birth was at 2-4 hours of activity per week.

Discussion points

  • How do you counsel women on physical activity in pregnancy?
  • Do you give the same advice about exercise to women who are underweight? How about those who are overweight or obese?
  • What is the most important conclusion of this study, from a patient-counselling standpoint?
  • Some of the forest plots (e.g Figure 4e) suggest that RCTs and cohort studies give different answers to a clinical question. Is this common in women’s health research? Can you name prominent examples where observational data gave an “opposite” or “wrong” answer to an important clinical question?
  • Describe the difficulties in studying this topic. How could you design the “perfect study” to answer the question of “how much” physical activity is safe and healthy for pregnant women?

Suggested reading

1. Perales et al. Exercise during pregnancy. JAMA 2017;317(11):1113-4.
2. Magro-Malosso et al. Exercise during pregnancy and risk of preterm birth in overweight and obese women: a systematic review and meta-analysis of randomized controlled trials. Acta Obstet Gynecol Scand 2017; 96:263-273.

 

A pill or a patch for a hot flush?

We will be discussing: Vasomotor symptoms due to natural menopause; systematic review and network meta-analysis (NMA) of treatment effects from the NICE Menopause Guideline by Sarri and colleagues.

Wednesday 26th July 2017, 8pm BST

Scenario
A 52 year old woman presents to your clinic with hot flushes and night sweats coinciding with the menopause. She does not wish to have an operation. What treatments do you recommend?

Description of research

Participants: 8326 women participating in 47 randomised controlled trials of medications and therapies to control
Interventions:
1) Transdermal oestradiol and progesterone
2) Oral oestradiol and progesterone
3) Isofavones
4) Black cohosh
5) Chinese herbal medicine
6) Multibotanicals
7) Acupuncture
8) SSRIs
9) SNRIs
Comparison: Placebo and sham acupuncture
Outcomes: Odds ratios and means ratios of vasomotor symptoms (hot flushes and night sweats)
Study Design: Bayesian network meta-analysis (NMA)

Discussion points

  • What advice do you currently give women in the situation above?
  • In your experience, do women find pills or patches (a) more acceptable and (b) easier to use?
  • What is a network meta-analysis?
  • What does it mean for such an analysis to be Bayesian? How would you explain the methods used to another clinician?
  • There are many interventions in this analysis and many possible interactions. What problems does this present?
  • Would you change your recommendations to the women you treat as a result of this analysis?
  • Papers such as this use innovative statistical methods to answer real-life clinical questions. Consider your answers to questions 4 and 6. Is your answer to question 6 dependent on your answer to question 4? If so, how and why?

Suggested reading

Ades AE, Caldwell DM, Reken S, Welton NJ, Sutton AJ, Dias S. Evidence Synthesis for Decision Making 7. Med Decis Making. 3rd ed. SAGE PublicationsSage CA: Los Angeles, CA; 2013 Jun 26;33(5):679–91.