Preterm risk higher with art : Study

October 10, 2018 0 By CH Unnikrishnan

Jeetha D’Silva

Advances in reproductive technology have benefited many women, but it is only recently that the collateral risks involved in these procedures have come to light. A recent study conducted among 113 women in Mumbai found that the incidence of preterm births was alarmingly high in women who have conceived through Assisted Reproductive Technology (ART).

The study, conducted by the National Institute for Research in Reproductive Health (NIRRH) and the Indian Council of Medical Research (ICMR), found that 76.23% of such women had preterm deliveries. Pregnancy related complications like pre-eclampsia (15%), gestational diabetes (11%) and heterotopic pregnancy (3%) were also found to be significantly high in this cohort.

Dr Anushree Patil, scientist, NIRRH, and the lead author of the study said that the higher incidence of preterm births was mostly due to the increase in pregnancies among women over the age of 35 years and the fact that most ART procedures have higher order multiple births.

“The profile of most of the patients who come in for ART procedures puts them at high risk. The average age is above 37 and many of them have been treated for fibroids and/or diabetes and other conditions. In addition, some of them may have undergone previous surgeries because of which the risk of preterm deliveries is higher,” says Dr Ameet Patki, medical director, Fertility Associates, and the past secretary general of Indian Society for Assisted Reproduction (ISAR).

Of the 113 women who were part of the study, 51 women (45.1%) had antepartum haemorrhage. Out of these, 45 women (35.9%) had bleeding episodes during the 1st trimester, of which four sustained pregnancy losses. Ten women had bleeding episodes during the second trimester, five of which were terminated. All the women were given progesterone supplementation to support the pregnancy till 12 weeks of pregnancy. 18 women (15.9%) required the use of tocolytic agents to arrest or prevent preterm labor in the late second and early third trimester.

Multiple gestations were observed in 51 participants (45.1%) and singleton pregnancies in 62 participants (54.9%). The high incidence of multiple gestations can be correlated with the high incidence of preterm births observed in this study.

Higher in India

The World Health Organization reports that about 15 million babies – or around 10 percent – are born prematurely around the world every year. In India, the incidence is higher. According to the National Health Portal, preterm births account for about 13% of all births in India. Preterm births are a significant health problem. Complications due to preterm birth is the leading cause of mortality in neonates, accounting for almost 1 million deaths worldwide each year.

Besides, preterm babies that survive might require prolonged neonatal intensive care and are at a greater risk of severe impairment and morbidities such as cerebral palsy, sensory deficits, learning disabilities and respiratory illnesses. The cost associated with providing medical care and support to preterm babies could run into several lakhs, and could hence be well out of the reach of many people.

“When you talk to couples who wish to undergo ART, it is important to counsel them and inform them about the risks. Providing medical care for a baby that is born preterm could be financially draining as the cost could be between Rs 10,000 to Rs 15,000 a day,” said Dr Patki.

It is also important that these pregnancies are closely supervised. With ART clinics coming up in smaller cities and towns, more people now have access to these procedures, but these mofussil areas often do not have the infrastructure to care for babies that are born preterm. “We also need to create awareness. We now have a test – called the fibronectin test – which costs approximately Rs 4,000, through which we can ascertain the risk of preterm deliveries. Patients who show a higher risk can be identified and managed appropriately,” he added.

In addition, administering betamethasone as a prophylactic in the seventh month helps to accelerate lung maturity in the foetus so this can greatly reduce complications in babies that are born preterm. In case of the early onset of labour in high-risk cases in remote areas, medicines should be given as early as possible to slow down the process, and the patient should be transferred to a medical centre that is equipped with NICU facilities to provide optimum care for the neonate, Dr Patki added.

Lacking data

The findings of the Mumbai study, the first of its kind in India, are similar to those of such studies conducted in the West. However, as the researchers point out, there is lack of data in the Indian context, unlike in the West where such pregnancies are extensively documented. “The Centre for Disease Control in Atlanta has very detailed records of such pregnancies, which make it easier for researchers to study the data,” Dr Patil said, emphasising the need for setting up a robust surveillance system in India.

“With the growing use of ART, there is a strong need to develop a National ART surveillance system in India like the one in CDC Atlanta. Mechanisms need to be built into the reporting systems like the National ART Registry of India to get complete data on the pregnancy course and outcomes of ART conceptions,” the researchers stated in their study.

The researchers also called for the formulation of guidelines for ART procedures. With multi-foetal pregnancies being very common in assisted reproductive technologies, the risk of preterm deliveries is also subsequently higher. “In most ART procedures, multiple embryos are transferred. This often leads to multi-foetal pregnancies which could itself lead to preterm deliveries. Hence, there is a need to restrict the number of embryos that are transferred. This needs to be done at the policy level,”

Dr Patil said.