Surrogates face high risk of pregnancy and postpartum complications

Embargoed for release until 5:00 p.m. ET on Monday 23 September 2024  

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Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.       
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1. Surrogates face high risk of pregnancy and postpartum complications

Abstract: https://www.acpjournals.org/doi/10.7326/M24-0417  

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A large Canadian cohort study found that gestational carriers, or pregnancy surrogates, face a higher associated risk for severe maternal morbidity, hypertensive disorders of pregnancy, and postpartum hemorrhage compared with women who carry their own pregnancies with or without fertility assistance. According to the researchers, these findings suggest that a judicious selection of these carriers is warranted alongside the development of specific pregnancy care plans in this population. The study is published in Annals of Internal Medicine.

Researchers from McGill University studied more than 10 years of data from the Better Outcomes Registry & Network (BORN) Ontario database, which represents more than 99% of births in Ontario, to determine the risk for complications before, during, and after childbirth among gestational carriers. The study included 863,017 singleton births, 806 of which were from gestational carriers. The researchers found that the risk for severe maternal morbidity was 7.8% in gestational carriers, more than 3 times that of unassisted conception and nearly twice that of invitro fertilization (IVF) pregnancies. The three most common morbidities were severe postpartum hemorrhage, severe preeclampsia, and puerperal sepsis. The risk for severe neonatal morbidity was also slightly higher among gestational carriers compared to unassisted conception, with preterm birth more likely among gestational carriers.

The authors noted that gestational carriers were more likely to have given birth previously, reside in a lower-income area, and have higher rates of obesity and chronic hypertension. They also were more likely than the unassisted conception group to be older and nonsmokers, with some opposite trends when gestational carriers were compared with IVF recipients. However, after accounting for these factors, gestational carriers continued to have a higher risk for severe maternal morbidity and preterm birth. Further studies are needed to understand potential mechanisms.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with corresponding author Maria P. Velez, MD, PhD, FRCSC, please email Catriona McDonald at catriona.mcdonald@muhc.mcgill.ca and Misty Pratt at Misty.Pratt@ices.on.ca.

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2. ACP’s review of performance measures for pain finds measures for acute pain treatment lacking 

Paper says a quality measure for acute pain management is needed to reduce use of opioids

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00773  

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A review by the American College of Physicians (ACP) of performance measures designed to evaluate quality of care for those adults suffering from pain found three of six measures relevant to internal medicine physicians to be valid. Quality Indicators for Pain in Adults: A Review of Performance Measures by the American College of Physicians is published today in Annals of Internal Medicine. 

Pain is a debilitating symptom generally caused by injuries or various conditions. The goal of managing pain is to relieve or reduce suffering and improve patient functioning. Opioids are sometimes prescribed to manage severe pain, but opioids are associated with the possibility of opioid use disorders and fatal overdose. The Performance Measurement Committee (PMC) reviewed six performance measures for pain relevant to internal medicine physicians, of which three performance measures were considered valid. The three valid measures assess the overuse of imaging for low back pain and two performance measures that evaluate appropriate use of opioids.  In January 2020, ACP and AAFP developed the clinical guideline to provide clinical recommendations on nonpharmacologic and pharmacologic management of acute pain. 

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. To speak with someone from ACP, please email Andy Hachadorian at ahachadorian@acponline.org.    

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3. With careful human oversight, AI may enhance traditional methods of developing guideline questions

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00363

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A proof-of-concept study found that with careful human oversight, large language model (LLM) tools can be used to complement traditional methods of developing guideline questions. In their experiment, the researchers found that artificial intelligence (AI) seemed to be particularly useful in supporting the identification of additional patient needs and concerns, which are often not fully reflected in the medical literature or by experts involved in guideline panels. The study is published in Annals of Internal Medicine.

Recent advancements in LLM-based tools have enabled the development of new methods for generating guideline questions using real-world data. Researchers from Fraunhofer Institute for Translational Medicine and Pharmacology, Berlin, Germany sought to improve the ARIA (Allergic Rhinitis and its Impact on Asthma) 2024 guidelines for managing allergic rhinitis by using both input from a panel of experts and LLMs, or artificial intelligence (AI), to generate relevant questions. First, panel members proposed key questions, building on past guidelines and patient data. Then, two AI approaches were tested: one used Google Trends to search queries related to rhinitis and incorporated AI to determine if the search implicitly or explicitly conveyed questions, and the other used ChatGPT Open AI to directly generate new questions. The questions were then reviewed and voted on by experts to prioritize those most relevant to the guidelines. Of the nearly 4,000 search queries analyzed, the study authors identifying 37 questions, of which 22 had not been previously considered by guideline panel members, and 2 were prioritized. As for ChatGPT, the LLM generated 22 unique questions, 11 of which were new, with 4 being prioritized by the panel. Overall, 6 of the 39 final questions for the 2024 ARIA guidelines were novel contributions. These findings support the use of LLMs in the development of guideline questions.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org.  To speak with corresponding author Jean Bousquet, PhD, please email jean.bousquet@orange.fr.

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Also new in this issue: 

Characterizing the Ambulatory Safety-Net System To Improve Health Equity 

Ideas and Opinions 

Abstract: https://www.acpjournals.org/doi/10.7326/ANNALS-24-00607  

URL goes live when the embargo lifts