Aspirin Dosing on Preeclampsia Prevention Sydney Behling, B.S, MSN/CNL student Faculty: Dr. Claire Bode, DNP, RN, CRNP University of Maryland Baltimore, School of Nursing

BACKGROUND AND SIGNIFICANCE EVIDENCE SUMMARY

Preeclampsia affects 2-8% of all pregnancies Authors Level and Quality Sample Intervention Results worldwide and rates of preeclampsia in the United Gu et al. Level 2 Pregnant women 25, 50, or 75mg aspirin taken daily at night starting at 12 • Low dose aspirin does significantly decrease incidence of preeclampsia (at term) (2020) High quality with one or more weeks gestation and preterm preeclampsia (p=0.001) States has increased almost 25% from 1984 to 2004. high risk factors for • There is a negatively correlated dose dependent relationship on efficacy (r=-0.243) Since this increase over the past few decades, preeclampsia Control: Placebo pill taken daily at night starting at 12 weeks • The higher the dose, the greater the efficacy preeclampsia has become the #1 cause of N=1160 gestation Rolnik et al. Level 2 Pregnant adult 150mg aspirin taken daily at night starting between 11-13 • Aspirin significantly reduced incidence of preterm preeclampsia (N=13/798) maternal/infant mortality in the United States. (2017) High quality women carrying weeks gestation compared to placebo (N=35/822) (p=0.004) Preeclampsia diagnostic criteria has recently changed singleton pregnancy • The likelihood of developing preterm preeclampsia (<37 weeks) is 62% lower for who are high risk for Control: Placebo pill taken daily at night starting between the 150 mg aspirin group (RR=0.38; p=0.004) and is now defined by the American College of preeclampsia 11-13 weeks gestation • The likelihood of developing preeclampsia <34 weeks is 82% lower for the aspirin Obstetricians and Gynecologists (ACOG) as N=1776 group (RR=0.18; p=0.004) persistently high blood pressure, >140/90, that develops Roberge et al. Level 1 Pregnant adult 50-150mg aspirin taken daily starting between 7-36 weeks • Any dose makes a significant impact on all outcomes when initiated before 16 week (2017) High quality women who are at gestation, compared to when initiated after 16 weeks (p<0.001). in pregnancy usually after 20 week gestation and is risk for Placebo pill taken daily or no treatment starting between 7- • There is a dose-response effect on the outcomes (p=0.036); with higher doses there combined with protein in the urine >300mg/24 hours or preeclampsia 36 weeks is better efficacy in reducing risk of reported outcomes one of the following: decreased platelets, impaired liver 45 RCT, N=20,909 • Doses of 75mg (N=373) and 100mg (N=334) had statistically effective impacts on preeclampsia (p=0.001; p<0.001), severe preeclampsia (p=0.005; p=0.005), and or kidney function, fluid in the lungs, visual fetal growth restriction (p<0.001; p<0.001) disturbances, or seizures. The exact cause of Van Doorn et Level 1 Pregnant women at 50mg-150mg aspirin taken daily starting between 12-32 • Overall aspirin use at any dosage reduced the risk of all gestational age preeclampsia is unknown. The United States al. (2021) High quality risk for weeks gestation preeclampsia by 27% (RR=0.73, p<0.001) and preterm preeclampsia by 30% preeclampsia (RR=0.70, p=0.011) Preventative Services Task Force (USPSTF) recognizes 23 RCTs, N= 32,370 Placebo pill or no treatment starting between 12-32 weeks • For all gestational ages, aspirin dose <81mg reduced risk by 29% (RR=0.71, high risk individuals as those with a history of gestation p=0.003) and dose >82 mg by 25% (RR=0.75, p=0.009) • For preterm preeclampsia aspirin dose <81mg was not significant (p=0.107), but preeclampsia, multifetal pregnancy, chronic aspirin dose >82mg reduced incidence by 54% (RR=0.46, p<0.001) hypertension, diabetes type 1 or type 2, renal disease, Ayala et al. Level 2 Pregnant adult 100mg aspirin taken daily either upon awakening, 8 hours • Taking aspirin 8 hours after awakening or at bedtime showed a statistically or autoimmune disease. Medication can help physical (2013) High quality women less than 16 after awakening, or before bedtime starting before 16 weeks significant difference in the outcomes compared to upon awakening (p<0.001) weeks gestation at gestation • 100mg aspirin daily significantly reduce hazard ratio of adverse pregnancy and physiological symptoms, but the only true cure for high risk for outcomes as a whole by 65% (HR=0.35, p<0.001) preeclampsia is delivery. gestational Control: Placebo pill taken daily either upon awakening, 8 • There was a significant difference in the incidence of gestational hypertension hypertension hours after awakening, or before bedtime starting before 16 (p=0.002), preeclampsia (p=0.041), preterm delivery (p=0.008), and intrauterine weeks gestation fetal growth restriction (p=0.011)

OBJECTIVE IMPLICATIONS FOR NURSING PRACTICE AND CNL ROLE

Among childbearing women with increased EOPE risk, Due to the impact of preeclampsia on pregnancy, it is important to identify a specific optimal daily dose for aspirin to create the best efficacy in does a daily dose of acetylsalicylic acid between 75- prevention of preeclampsia at all gestational ages in women qualifying as high risk under the USPSTF’s criteria. With evidence gathered and 162 mg (81, 100, 121, 150, 162 mg) initiated before 16 reflecting on the data, a CNL can present a fresh perspective on topics of care overlooked by an interdisciplinary team such as aspirin dosing for weeks gestation until delivery effect incidence of pre- preeclampsia prevention. A commonality reported was a lack of clear dosing recommendations between organizations, countries, etc. It is eclampsia compared to no medication? acknowledged that any daily low dose aspirin use is better than “nothing” to reduce preeclampsia risk and commonly that higher doses yield higher efficacy. In the United States, aspirin is only manufactured in 81mg tablets and therefore, the USPSTF recommends daily aspirin at 81mg due to these limitations in pharmaceutical manufacturing. A CNL must advocate for greater access to a variety of aspirin doses in the nation.

METHODS CONCLUSION CITATIONS

Ayala, D. E., Ucieda, R., & Hermida, R. C. (2013). Chronotherapy with low-dose aspirin for prevention of complications in pregnancy. “Aspirin AND preeclampsia” were searched on After thorough analysis of the evidence review, my recommendation Chronobiology International: The Journal of Biological and Medical Rhythm Research. 30(1-2), 260-279. https://doi.org/10.3109/07420528.2012.717455 for maximum efficacy is an aspirin dose of 100mg per day in high-risk Gu, W., Lin, J., Hou, Y. Y., Lin, N., Song, M. F., Zeng, W. J., Shang, J., & Huang, H. F. (2020). Effects of low-dose aspirin on the prevention of PubMed, MedLine, and CINAHL. Search results were preeclampsia and pregnancy outcomes: A randomized controlled trial from Shanghai, China. European Journal of Obstetrics & Gynecology and women initiated before 16 week gestation and taken daily at night. Reproductive Biology, 248, 156–163. https://doi.org/10.1016/j.ejogrb.2020.03.038 limited to publication date <10 years, and RCT or LeFevre, M. L. (2014). Low-dose aspirin use for the prevention of morbidity and mortality from preeclampsia: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine, 161(11), 819–826. https://doi.org/10.7326/M14-1884 meta-analysis, systematic review. 111 titles were Until the evidence is so extensively examined with effects so large that Preeclampsia Foundation. (2020). What is preeclampsia. Retrieved from https://www.preeclampsia.org/what-is-preeclampsia Roberge, S., Nicolaides, K., Demers, S., Hyett, J., Chaillet, N., & Bujold, E. (2017). The role of aspirin dose on the prevention of preeclampsia and screened for inclusion and irrelevant topics, a dose change is irrefutable on preeclampsia incidence, there is no fetal growth restriction: systematic review and meta-analysis. American Journal of Obstetrics and Gynecology, 216(2), 110–120. http://doi.org/10.1016/j.ajog.2016.09.076 alternative option in the United States other than to continue Rolnik, D. L., Wright, D., Poon, L. C., O’Gorman, N., Syngelaki, A., de Paco Matallana, C., Akolekar, R., Cicero, S., Janga, D., Singh, M., Molina, F. interventions, and outcomes were excluded. 39 S., Persico, N., Jani, J. C., Plasencia, W., Papaioannou, G., Tenenbaum-Gavish, K., Meiri, H., Gizurarson, S., Maclagan, K., & Nicolaides, K. H. recommending 81 mg per day for high-risk women due to availability. (2017). Aspirin versus placebo in pregnancies at high risk for preterm preeclampsia. New England Journal of Medicine, 377(7), 613–622. abstracts were screen for repeated criteria. 13 articles http://doi.org/10.1056/NEJMoa1704559 Van Doorn, R., Mukhtarova, N., Flyke, I. P., Lasarev, M., Kim, K. M., Hennekens, C. H., & Hoppe, K. K. (2021). Dose of aspirin to prevent preterm were reviewed and 6 of those studies were synthesized Special thanks to Dr. Claire Bode for the guidance and feedback preeclampsia in women with moderate or high-risk factors: A systematic review and meta-analysis. PLoS ONE, 16(3), e0247782. https://doi.org/10.1371/journal.pone.0247782 in the table of evidence. throughout this process. Clinical Implications of the Route of Postpartum Oxytocin Administration (Intravenous Infusion vs. Intramuscular Injection) on Preventing Postpartum Hemorrhage

Joy Okorafor, MDH , RDH , MSN-CNL Student Faculty: Kathleen McElroy, PhD, RN University of Maryland School of Nursing, Baltimore, Maryland

Background Summary and Conclusions

PICO Question: Among women with a Current research does not provide enough singleton pregnancy with vaginal delivery, does evidence to support a change in clinical IV oxytocin administration comparted to IM guidelines; however, it further reinforces oxytocin administration prevent PPH? that IV and IM oxytocin administration are equally effective at reducing PPH. . Maternal mortality: death from obstetric . The research supports the relative safety cause in pregnancy, childbirth or early of either route of administration. postpartum (42 days); identified as priority by Healthy People 2030. Evidence Summary . Research is needed in more diverse populations, given that women of . Postpartum hemorrhage ( PPH): blood loss 4 studies found no statistically significant difference Hispanic ethnicity and Asian/ Pacific ≥500ml in 1st 24 hours; accounts for 10.7% between the administration route and PPH. Islander race are more likely to maternal deaths in US; primarily due to experience PPH. uterine atony. . The largest study, which included +4,000 participants, and 2 hospitals, found a statistically . Recommended management in 3rd stage of significant reduction in PPH among those in the IV Implications for Nursing labor includes 10 IU oxytocin either infusion group compared to those in the IM intravenously (IV) or intramuscularly (IM); injection group (0.8% vs. 1.5% respectively, IM oxytocin injection is a cost -effective route of administration may impact p=0.023). intervention to reduce the risk of PPH in oxytocin’s effectiveness. . 1 study found no statistically significant difference places with limited resources and training. in PPH; however, they found a significant . Administering 10 IU of IV or IM oxytocin Methods reduction in severe PPH (blood loss of ≥ 1000 mL) postpartum provides the best quality of and the need for blood transfusions among those care and aligns with the Joint Literature review database search: PubMed in the IV oxytocin group (4.6% (IV) vs. 8.1% (IM), Com m ission’s (JC) updated practice . Keywords: Intravenous oxytocin vs. p=0.02, and 1.5%(IV) vs. 4.4%(IM), p=0.005, standards to reduce PPH. respectively). intramuscular oxytocin, postpartum . The clinical nurse leader is in the prime hemorrhage, postpartum blood loss, active . 3 studies evaluated safety concerns; none found a position to ensure accredited hospitals are management of the third stage of labor. statistically significant difference in side effects educated about the JC’s standards and . Exclusion criteria: Study did not address the between the two routes of administration. help integrate those standards into intervention of interest, was older than ten . All the studies failed to address differences in clinical practice. years, evaluated different uterotonic agents, race/ ethnicity within their sample, which was a or failed to address the outcome of interest. significant limitation. . Included: 5 randomized controlled trials References

. Bryant, A., Mhyre, J. M., Leffert, L. R., Hoban, R. A., Yakoob, M. Y., & Bateman, B. T. (2012). The association of maternal race and ethnicity and the risk of postpartum hemorrhage. Anesthesia and Analgesia, 115(5), 1127–113 6 . https://doi.org/10.1213/ANE.0b013e3182691e62 . Chou, D. (n.d.). Indicator Metadata Registry Details: Maternal Deaths. World Health Organization. https://www.who.int/data/gho/indicator- metadata-registry/ imr-details/4622 . The Joint Commission. (2019). Proactive prevention of maternal death from maternal hemorrhage. https://www.jointcommission.org/- /media/tjc/idev-imports/ blogs/ qs_51_maternal_hemorrhage_10_25_19_final2pdf.pdf For Pregnant Women, Does The Use Of Tranexamic Acid In Addition To Oxytocin Have A Greater Effect In Reducing The Risk Of Postpartum Hemorrhage Compared To The Use Of Oxytocin Only During Childbirth? Brigit Ngaleu, MSN Student Dr. Malissa da Graca, MS, RNC, FNP-C University of Maryland Baltimore, School of Nursing BACKGROUND & SIGNIFICANCE IMPLICATION FOR NURSING PRACTICE AND Postpartum hemorrhage (PPH) is defined as excessive bleeding after EVIDENCE SUMMARY ROLE OF CNL the delivery of a baby. For vaginal deliveries, any blood loss greater than  An important aspect of these studies was to find out if the use of tranexamic acid  Hassan et al., (2020) performed a double-blinded randomized control 500 ml or in cesarean sections, any blood loss greater than 1000 ml is has negative side effects on women. One article found that the women who received trial which showed a statistically significant difference between Group A considered postpartum hemorrhage. Postpartum hemorrhage is one of tranexamic acid had nausea and vomiting more frequently than those that had (oxytocin bolus and oxytocin infusion) and Group C (oxytocin bolus the most common maternal diseases leading to death. Uterine atony is oxytocin only, but the cases were not considered severe side effects. only) with a p-value = 0.017 and between Group B (oxytocin bolus and one of the most common causes of postpartum hemorrhage as it accounts  The other four articles did not find serious side effects such as thrombosis, kidney tranexamic acid infusion) and Group C with p-value = 0.032. No for about 70 to 80 percent of it. According to the CDC, the rates of or liver issues with those receiving tranexamic acid. statistical significance between Group A and Group B was found (p- postpartum hemorrhage have significantly increased from 4.3 in 1993 to  The need for uterotonic agents and blood transfusion were much lower in those value = 0.678). 21.2 in 2014 leading to an increased rate of blood transfusion, the risk receiving tranexamic acid in addition to oxytocin.  Mirghafourvand et al., (2015) conducted a randomized double-blind for shock, and respiratory and renal damage.  A lack of double-blinding, randomization, inadequate sample size and insufficient controlled trial, and results showed that the mean (SD) calculated total Current practice for postpartum hemorrhage includes the use of were present in few studies threatening the reliability and generalizability of the blood loss (P = 0.036) and measured blood loss from placental delivery uterotonic drugs such as Pitocin, misoprostol, methylergonovine, and studies. to 2 h postpartum (P < 0.001) was significantly lower in those that hemabate, compression techniques such as uterine massages, and  Further studies with women with a history of postpartum hemorrhage or other received tranexamic acid compared to those that didn’t. surgeries such as curettage and hysterectomy. An alternative-based thrombotic diseases should be evaluated to see if the use of tranexamic acid reduces  Saccone et al., (2019) conducted a meta-analysis of randomized control intervention that has been used to improve this clinical problem is the their chances of recurrent bleeding. trials which showed that women who received prophylactic tranexamic use of oxytocin in addition to tranexamic acid in women with low-risk  Larger sample sizes in the future would increase generalizability among a acid in addition to oxytocin after vaginal delivery had a significantly PPH. Tranexamic acid is an antifibrinolytic agent that blocks the binding population. lower incidence of postpartum hemorrhage and lower mean blood loss. of plasminogen to fibrin which leads to a reduction in bleeding.  The CNL in this intervention will utilize interdisciplinary collaboration and lateral  Sentilhes et al., (2018) performed a multi-centered, double-blinded integration to promote effective teamwork between different members of the randomized control trial, and women in the tranexamic acid group had a healthcare team through education meetings and sessions on the use of tranexamic lower rate of provider-assessed clinically significant postpartum acid and its possible side effects for the patients. hemorrhage than those in the placebo group (P=0.004; P=0.04) and  CNLs can also play a vital role in this change of practice by using evidence-based received additional uterotonic agents less often (P=0.006). practice and research to evaluate the benefits and safety of this new intervention.  Thavare et al., (2019) performed a prospective randomized observational study, and group A (tranexamic acid and oxytocin) total blood loss during the cesarean section was 476.49 ml while in group B (oxytocin only) it was 576.06 ml. Intraoperative blood loss in group A was 455.63 ml while in group B it was 536.53 ml. Post placental blood loss in group A was 411.59 ml while in group B was 485.08 ml.

REFERENCES  Mirghafourvand, M., Mohammad-Alizadeh, S., Abbasalizadeh, F., & Shirdel, M. (2015). The effaect of prophylactic intravenous tranexamic acid on blood loss after vaginal delivery in women at low risk of postpartum haemorrhage: a double-blind randomised controlled trial. Australian and METHODS AND LITERATURE SEARCH New Zealand Journal of Obstetrics and Gynaecology, 55(1), 53–58. https://doi.org/10.1111/ajo.12262  A literature review was performed to find primary and peer-reviewed  Saccone, G., Della Corte, L., D’Alessandro, P., Ardino, B., Carbone, L., Raffone, A., Guida, M., articles on this topic. Locci, M., Zullo, F., & Berghella, V. (2019). Prophylactic use of tranexamic acid after vaginal  Engines used for this topic were PubMed, google scholars, and delivery reduces the risk of primary postpartum hemorrhage. The Journal of Maternal-Fetal & SUMMARY & CONCLUSION Neonatal Medicine, 33(19), 3368–3376. https://doi.org/10.1080/14767058.2019.1571576 OneSearch. On these 3 databases, an advanced search with key  Sentilhes, L., Winer, N., Azria, E., Sénat, M.-V., Le Ray, C., Vardon, D., Perrotin, F., Desbrière, R.,  Findings from three articles indicated that the use of tranexamic acid in addition to terms such as "postpartum hemorrhage" AND "oxytocin" AND Fuchs, F., Kayem, G., Ducarme, G., Doret-Dion, M., Huissoud, C., Bohec, C., Deruelle, P., oxytocin compared to oxytocin only reduces the risk of postpartum hemorrhage. "Tranexamic Acid'' AND "randomized control trial” was performed. Darsonval, A., Chrétien, J.-M., Seco, A., Daniel, V., & Deneux-Tharaux, C. (2018). Tranexamic  The other two articles suggested that there was no significant difference between Acid for the Prevention of Blood Loss after Vaginal Delivery. New England Journal of Medicine,  On PubMed, 13 articles resulted, on google scholars, 50 articles 379(8), 731–742. https://doi.org/10.1056/nejmoa1800942 the use of tranexamic acid in addition to oxytocin versus oxytocin only. resulted, and on OneSearch, 29 articles were populated.  Thavare, M. G., & Patil, A. S. (2019). To Study the Effect of Intravenous Tranexamic Acid on  Few articles had limitations and gaps, but the overall research is a moderate level of  With each article, exclusion factors were no abstracts, older than Blood Loss During and After Caesarean Section. MVP Journal of Medical Sciences, 6(1), 93–99. certainty indicating that there is sufficient evidence to offer the intervention. https://doi.org/10.18311/mvpjms/2019/v6i1/18670 seven years, titles not related to the topic, and access to the full text.  It can be concluded that the use of tranexamic acid in addition to oxytocin is a good  Five of the best out of the 10 articles with sufficient data were used intervention to help reduce postpartum hemorrhage, morbidity, and mortality rate in for the summary of evidence tables. women with low-risk of postpartum hemorrhage. There’s an App for That: Using mHealth to Improve Glycemic Control in Gestational Diabetes Clio Chimento Katie McElroy, PhD, RN University of Maryland School of Nursing Background and Significance Summary and Conclusion Evidence Table Summary Gestational Diabetes Mellitus (GDM) • Mobile applications that assist with blood glucose monitoring and Level/ • Development of carbohydrate intolerance resulting in hyperglycemia Outcomes Study Design Intervention Grade of deliver education improve patient self-management of GDM during pregnancy (American College of Obstetricians and Gynecologists (Intervention vs. control) Evidence • Impact on glycemic control is small, but app use is associated with [ACOG], 2018). Prospective single-center Dnurse app used for SMBG improved adherence, fewer off-target values, and less need for • Lower HbA1C before delivery (4.7 vs. 5.3, p<0.001) • Can cause negative outcomes for mother and baby, including randomized controlled trial, n = and education, nurse Guo et al., • Better SMBG adherence (83.3% vs 70.4%, p <0.001) medication 124. available for guidance two 2B preeclampsia, macrosomia, neonatal hypoglycemia and • Fewer off-target glucose measurements (p<0.001) 2019 Control group n = 60, intervention hrs/day. Control group • No significant difference in neonatal or delivery outcomes hyperbilirubinemia, shoulder dystocia, and increased risk of Cesarean group n = 64. received standard care. section (ACOG, 2018). Future directions for research • No significant difference in change blood glucose over gestation. • Effect of apps with self-paced education vs. more direct clinician • Up to 70% of women with GDM will develop Type 2 Diabetes within 28 Prospective single-center GDm-Health app used for • Better SMBG adherence (3.8 readings/day vs. 2.63, p <0.001) Mackillop randomized controlled trial, n = SMBG. Text messages by involvement years after pregnancy (ACOG, 2018). • Less metformin use (44.6% vs. 55.9%, OR 0.63, 95% CI 0.36 – 1.1). 206. Control group n = 103, midwives for alerts and 2A et al., 2018 • Preterm birth (OR 0.36, 95% CI 0.12-1.01) less likely and C-section less • Prevalence of GDM in United States is 6-9% (CDC, 2018) intervention group n = 103. education. Control group • Larger studies powered to look at maternal and fetal health outcomes common (26.7% vs 46.1%, p = 0.05) received standard care. • Highest prevalence among Asian women (11.1%); disproportionately • 95% of app group would use again; 85% of control group would consider • Long term follow-up and effects in subsequent pregnancies using app affects women of color (Deputy et al., 2018). • Cost of incorporating mHealth • Lower mean blood glucose (105.1 mg/dL vs 112.6 mg/dL, p<0.001). • Risk factors: increasing age, family history of diabetes, Glucose Buddy app used Prospective single-center • Better adherence: 84±0.16% vs. 66%, p<0.001. • Using mHealth to extend time between office visits Miremberg for SMBG. Clinic sent overweight/obesity (ACOG, 2018). randomized controlled trial, n = • Fewer off-target measurements (p<0.001) education and alerts via 2B et al., 2018 126. Control group n = 65, • Less insulin use (13.3% vs. 30%, p = 0.044) email. Control group intervention group n = 61. • No significant difference in neonatal/delivery outcomes received standard care. Diagnosis and treatment • Intervention group all reported high to very high satisfaction with app

• Universal screen at 24 weeks with two-step oral glucose tolerance test • Lower mean fasting BG measurements (4.31 mmol/L vs. 5.31 mmol/L, p = 0.00) WeChat used to upload • Primary treatment is education, diet, and exercise with self monitoring Quasi-experimental study, n = • Lower mean 2-hr postprandial BG measurements (5.76 mmol/L vs. 6.94 SMBG, ketones, and Yang et al., 157. Experimental group n = 57; mmol/L, p = 0.00) of blood glucose (SMBG) at least 4 times per day HbA1C. Communication control group 1 (no app use) n = • Difference in 1-hr postprandial BG not significant. 3C 2018 with clinician via WeChat. • Add insulin or metformin if necessary for good control (ACOG, 2018). 50; control group 2 (no app use, • More women in control group 1 (GDM, no WeChat) experienced Both control groups Implications for Practice no GDM dx) n = 50 premature delivery (12% vs. 1.75%, p = 0.032). received standard care. • More women in the intervention group delivered by C-section (31.58% vs 14%, p = 0.032). • Recommendation for practice: Offer mHealth based on clinical judgement Why would mHealth help? and patient preference • Mobile apps are an easy way to log blood glucose measurements, meals, HABITS-GDM used for SMBG and education. Prospective single-center • Lower mean BG results (5.40 mmol/L vs. 5.54 mmol/L; p = 0.001). • Benefits to patient: Increased SMBG adherence and patient satisfaction, and exercise Yew et al., Control group received randomized controlled trial, n = • Fewer off-target fasting (17.9% vs 23.2%, p = 0.003) and 2-hr standard care. 2B reduced use of hypoglycemic medication 2021 340. Control group n = 164, postprandial measurements (19.9% vs. 29.4%, p <0.001) • mHealth can be used to deliver education and personal support Only study that did not intervention group n = 167. • No delivery or neonatal outcomes reached significance • Benefits to clinician: Real-time review of glycemic control, easy to provide (Tassone et al., 2020) to enhance success of lifestyle modification use clinician interaction via app. feedback to patient • In the future, mHealth use in GDM may help improve outcomes and reduce Methods disparities for women without easy access to prenatal care

Clinical question: In pregnant women diagnosed with gestational diabetes, do mHealth applications designed for GDM affect glycemic control during Evidence Summary pregnancy compared to standard GDM care? • Measures of glycemic control (mean blood glucose, off-target values, HbA1C) improved in all studies Databases searched: PubMed, CINAHL, and Scopus except Mackillop et al. (2018) Acknowledgements Limiters: Past five years; English only • Less need for hypoglycemic medication in mHealth group (Mackillop et al., 2018; Miremberg et al., 2018) As my reader, Dr. Katie McElroy provided invaluable guidance and Expanders: Apply related words; apply equivalent subjects; all fields • Neonatal and maternal delivery outcomes extremely variable; no consistent effect between studies feedback on this project. Thank you Dr. McElroy! Search Terms: mHealth, mobile app*, telemedicine, gestational diabetes, • Major weakness: All studies except Yew et al. (2021) incorporated intensive clinician feedback as part of glycemic control mHealth use; this is a potential confounding effect Results: 538 returns, 144 retained for further screening, five selected for • All studies also used convenience samples and required tech literacy, limiting generalizability analysis Inclusion criteria: gestational diabetes, some form of mobile app use or telehealth, at least one outcome = glycemic control References Exclusion criteria: other forms of diabetes, mobile app development, COVID-19, pilot/feasibility studies American College of Obstetricians and Gynecologists (ACOG) (2018). ACOG practice bulletin 190: Gestational diabetes mellitus. Obstetrics and Gynecology, 131(2), e49-e64. Casagrande, S. S., Linder, B, & Cowie, C. C. (2018). Prevalence of gestational diabetes and subsequent Type 2 diabetes among U.S. women. Diabetes Research and Clinical Practice, 141, 200-208. https://doi.org/10.1016/j.diabres.2018.05.010 The Role of the CNL Centers for Disease Control (CDC). (2018, June 12). Diabetes during pregnancy. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/diabetes-during-pregnancy.htm Deputy, N. P., Kim, S. Y., Conrey, E. J., & Bullard, K. M. (2018). Prevalence and changes in preexisting diabetes and gestational diabetes among women who had a live birth — United Interdisciplinary Collaboration States, 2012–2016. MMWR Morbidity and Mortality Weekly Report 67, 1201–1207. https://doi.org/10.15585/mmwr.mm6743a2 [Dnurse app logo]. Dnurse. https://www.dnurse.com/v2/en/app. Accessed April 18, 2021 • Input from multiple specialties is crucial to creating an mHealth platform [GDm-Health logo]. Sensyne Health. https://www.sensynehealth.com/gdm-health-us. Accessed April 18, 2021 • CNL has the expertise to bridge between disciplines to create a user-friendly and medically useful app [Habits-GDM logo]. Habits Gestational Diabetes. https://apps.apple.com/us/app/habits-gestational-diabetes/id1174824112. Accessed April 18, 2021 King, C. R., & Gerard, S. O (Eds.). (2016). Clinical Nurse Leader: Certification review (2nd ed.). Springer.

Mackillop, L., Hirst, J. E., Bartlett, K. J., Birks, J. S., Clifton, L., Farmer, A. J., Gibson, O., Kenworthy, Y., Levy, J. C., Loerup, L., Rivero-Arias, O., Ming, W., Velardo, C., & Tarassenko, L. (2018). Comparing the efficacy of a mobile phone-based blood glucose management system with standard clinic care in women with gestational diabetes: Randomized controlled trial. JMIR mHealth uHealth, 6(3), e71. http://mhealth.jmir.org/2018/3/e71/.

Lateral Integration Martis, R., Brown, J., Alsweiler, J., Crawford, T. J., & Crowther, C. A. (2016). Different intensities of glycaemic control for women with gestational diabetes mellitus. Cochrane Database of Systematic Reviews, 4, Art. No.: CD011624. https://doi.org/10.1002/14651858.CD011624.pub2.

• mHealth apps are a means of coordination between clients, nurses, and providers Miremberg, H., Ben-Ari, T., Betzer, T., Raphaeli, H., Gasnier, R., Barda, G., Bar, J., & Weiner, E. (2018).The impact of a daily smartphone-based feedback system among women with gestational diabetes on compliance, glycemic control, satisfaction, and pregnancy outcome: a randomized controlled trial. American Journal of Obstetrics and Gynecology, 18(453), • Use of mHealth for GDM in studies facilitated management e1-7. https://doi.org/10.1016/j.ajog.2018.01.044. ([Untitled illustration of glucose measurement], 2021) ([Untitled illustration of Dnurse app screen], 2021) Tassone, C., Keshavjee, K., Paglialonga, A., Moreira, N., Pinto, J., & Quintana, Y. (2020). Evaluation of mobile apps for treatment of patients at risk of developing gestational diabetes. Health Informatics Journal, 26(3), 1983-1194. https://doi.org/10.1177/1460458219896639

United States Preventive Services Task Force (USPSTF). (2018, June). Grade definitions. https://www.uspreventiveservicestaskforce.org/uspstf/about-uspstf/methods-and- Patient Advocacy processes/grade-definitions [Untitled illustration of glucose measurement]. Glucose Buddy. https://www.glucosebuddy.com. Accessed April 18, 2021

• CNL has advanced understanding of the microsystem; knows which features are most needed [Untitled illustration of Dnurse app screen]. Dnurse. https://www.dnurse.com/v2/en/app. Accessed April 18, 2021.

World Health Organization (WHO). (2011). mHealth: New horizons for health through mobile technologies: second global survey on eHealth. • Platform allows direct response to clients, improving communication https://www.who.int/goe/publications/goe_mhealth_web.pdf ([HABITS-GDm logo], 2021) ([GDm-Health logo], 2021) ([Dnurse logo], 2021) Xie, W., Dai, P., Qin, Y., Wu, M., Yang, B., & Yu., X. (2020). Effectiveness of telemedicine for pregnant women with gestational diabetes mellitus: An updated meta-analysis of 32 randomized controlled trials with trial sequential analysis. BMC Pregnancy and Childbirth, 20(198), 1-14. https://doi.org/10.1186/s12884-020-02892-1 Low Molecular Weight Heparin Combined with Low Dose Aspirin to Prevent Recurrent Preeclampsia? TiEla Harris, CNL Candidate Faculty Reader, Claire Bode, DNP, MS, CRNP University of Maryland Baltimore, School of Nursing

BACKGROUND AND SIGNIFICANCE IMPLICATIONS AND ROLE OF THE CNL Preeclampsia (PE) is a hypertensive disorder that accounts for one LDA remains the most consistent and cost-effective option in the of the top ten leading causes of pregnancy related deaths in the prevention of recurrent PE. Additional evidence focusing on women United States. In the incidence of preeclampsia, maternal and fetal at high risk for recurrent PE is warranted to consider the use of health are jeopardized. A prior history of PE is the most predicting LMWH for the prevention of recurrent PE. risk factor for the recurrence of PE in a subsequent pregnancy. U.S. . The CNL can take on the roles of patient advocacy, risk Preventive Services Task Force recommends low-dose aspirin reduction, and disease prevention with an aim to reduce the (LDA) for the prevention of PE in women at high risk for risk of recurrent preeclampsia in women with a previous developing PE. LMWH has been suggested as a preventive history of preeclampsia. The CNL will perform a chart medication for recurrent PE. PICO: In pregnant women with a review for expectant mothers at an increased risk and history of preeclampsia, does LMWH combined with low dose educate, advocate, and empower patients to make the best aspirin prevent the recurrence of preeclampsia compared to low decision regarding LDA and recurrent preeclampsia. dose aspirin alone? . As a team leader, the CNL will embark the role of lateral EVIDENCE SUMMARY integrator with the intent to explore other potential . Placenta mediated complications were used to measure interventions to prevent recurrent PE. Utilizing lateral primary composite outcomes due to extensive overlap of integration, the CNL will recruit members aside from nursing to construct a collaborative team dedicated to physiological mechanisms. METHODS AND LITERATURE PROFILE improving maternal and fetal outcomes associated with . Findings were conflicted between studies. Three studies . PubMed database was utilized to perform the literature search recurrent PE. reported no significant differences in the recurrence of with a Research Librarian PE comparing LMWH + LDA to LDA alone. Five . Initial keywords and Mesh terms searched were: “Pre- studies observed a significant reduction of the recurrence eclampsia/prevention and control”[Mesh] and “low molecular of PE in groups receiving LMWH + LDA compared to CONCLUSIONS weight heparin” and “aspirin” and “placenta mediated LDA alone or no treatment. Prior history of the development of PE increases the risk for maternal complications” that revealed 36 articles and fetal morbidity and mortality. The prevention of recurrent . In one study, LMWH was ineffective in reducing . preeclampsia in women with a previous history is vital to improving Articles must have been published between 2011 and 2021, elevated concentrations of maternal serum biomarkers written in English, and focused on women with a history of maternal and neonatal outcomes. Findings do not suggest the use of associated with the development of PE preeclampsia. Systematic reviews were used to locate two LMWH + LDA for the prevention of recurrent PE due to inconsistent . selected studies There was a significant reduction in the incidence of PE evidence regarding improvements to maternal fetal safety and quality in women with a history of early onset or severe PE who . Ultimately eight articles were selected from the 36 results of care. Therefore LMWH + LDA is not recommended to prevent received LMWH + LDA compared to LDA alone. utilizing PubMed database. Three Randomized Controlled recurrent PE in women with a history of PE. LDA alone should be LMWH also demonstrated improved fetal and neonatal Trials and five Systematic Reviews with Meta-Analyses initiated in the first trimester for the prevention of recurrent PE in outcomes. this population. References available on request. Physical Activity In Alleviating Postpartum Depression Jocelyn Wagner, BSN, MSN/CNL student Background & Significance University of Maryland, School of Nursing

• As mental health is slowly being seen as a priority, it is still estimated that roughly 1 out of every 7 women develop Table of Evidence postpartum depression (PPD). • PPD is most commonly developed within the first six weeks after Authors Purpose Sample Intervention Results birth. Poyatos-León et al., The purpose of this meta-analysis was to All peer reviewed controlled trials Intervention: Physical activity ranging from low, Data from all the trials showed exercise interventions reduced • Roughly 20 percent of the deaths in women postpartum are (2017) determine how effective physical activity that included women currently moderate, or moderate high intensity (stretching & postpartum symptoms (effect size: 0.41; 95% CI 0.28-0.54), after suicides and is the second overall cause of death within the first interventions are in preventing and experiencing a non-complicated breathing exercises, walking program, subgroup analysis was performed effect size was 0.67 (95% CI year postpartum. managing PPD symptoms during pregnancy of a single fetus or cardiovascular only and mix with strength 0.44-0.90) for mothers with PPD at baseline and 0.29( (95% CI • Firstline therapy is antidepressants (often SSRI) in combination pregnancy and postnatally. postnatal women with a newborn as exercises, Pilates, yoga and homebased programs), 0.14-0.45) for mothers who didn’t. Exercise both during pregnancy with cognitive behavioral therapy. Next in line is Transcranial young as 6 weeks to 18 months, with sessions were from once a week up to 5 days a and the postnatal period are an effective safe tactic in reducing and Magnetic stimulation and eventually electroconvulsive therapy if both women with depressive week. Three studies individualized the avoiding symptoms of postpartum depression. the previously mentioned therapies fail. Antidepressants carry risk symptoms and some without. intervention. The interventions lasted as little as with breastfeeding and there is limited access to cognitive- one month to up to a year. Control group: prenatal behavioral therapy while exercise has limited risk and is more care and usual care for PPD. feasible.

Pritchett et al., The goal of this systematic review and Peer Reviewed Randomized Intervention: Each intervention consisted of The aerobic exercise intervention reduced depressive symptoms Purpose (2017) meta-analysis is to examine the use of Controlled Trials that utilized adult increasing aerobic exercise; only exercise, among all of the studies (SMD is -0.44; in a 95% confidence aerobic exercise compared against usual postpartum women who had possible exercise along with co-interventions, group interval= -0.75 to -0.12, n=1307) (SMD was -1.54 EPDS units The intention of this review was to investigate in adult postpartum care as an intervention on effects on PPD depression, scored 10 or more on the exercise and exercise counseling which lasted half within a 95% confidence interval= -2.97 to -0.12 with n=652). women, if the addition of physical activity to antidepressant symptoms in women up to 1 year EPDS scale, or were diagnosed using an hour and occurred 3-5 times each week. The Postpartum women diagnosed with depression or without had medications and therapy would result in a decline in the prevalence postpartum. ICD-10 or DSM-IV or BDI. length of the intervention was as short as 4 weeks reduced depressive symptoms due to exercise interventions (both of postpartum depression up to a year postpartum. or as long as six months. group, participation chosen or in combination with other Control: Standard of care, with a range of support interventions). interventions such as phone support (counseling), Methods in person counseling or consultation, educational material provided in written form. • A search was conducted using the databases PubMed and CINAHL. • Boolean phrases utilized: (“postpartum depression” AND McCurdy et al., The purpose of this meta-analysis is to RCTs that included adult postpartum Intervention: Exercise ranging from light to After the intervention was applied depressive symptoms were lower “exercise”) OR (“postpartum depression” AND “physical (2017) investigate the impact exercise has on women who scored 10 or greater on moderate intensity, with the frequency ranging in the exercise groups among all trials (-0.34, 95% CI -0.50 to 0.19) activity”). depressive symptoms in the postpartum the EPDS scale or 12 or more on the from once to five times a week lasting 30-60 I2 = 37%. The treatment trials had a moderate effect (SMD -0.48, • Articles were included from the years 2017-2020 and were RCTs period, and the prevalence of symptoms. Hamilton Depression rating scale or minutes. The intervention was implemented 95% CI -0.73 to -0.22, I2 = 42%) and a small effect among the or metanalysis. who were diagnosed through a between 6 weeks and a year. prevention trials (SMD -0.22, 95% CI -0.36 to -0.08, I2 = 2%). • After applying inclusion and exclusion criteria 5 articles were structured clinical interview. Control: Inactive women receiving standard of Postpartum women experience a reduction in mild to moderate PPD used. care (the process that a clinician would follow to symptoms and strengthen the chance that their mild to moderate prevent or treat depression). depression will resolve when using light to moderate intensity Summary and aerobic exercise.

Conclusion Carter et al., (2019) The purpose of this meta-analysis is to Randomized controlled trials with 10 Intervention: Most studies used A significant effect of moderate size was found for exercise determine the effect exercise and physical trials that included postpartum aerobic/strengthening/muscle stretching exercises, reducing depressive symptoms (SMD =-0.64, 95% CI = -0.96, - • Each study assessed the effect of physical activity interventions activity- based interventions have both the women who had increased while 4 used motivational and coaching health 0.33, p <0.001). Concluding exercise has a small to moderate effect on postpartum women (18 years or older) on preventing and prevention and treatment of depressive depressive symptoms or were at risk promotion with no exercise, and six had a mixed in the reduction of depression symptoms on post-natal women. treating PPD consistently determining it to have a significant symptoms among postnatal women up to for PPD due to a history of approach. The intervention lasted for up to 12 positive effect in comparison to standard of care and can be used 52 weeks in the postpartum period. depression and two included women weeks for 76% of the studies (4 studies had the as an alternative and adjunct therapeutic tactic in both treating with PPD intervention last longer), lasting about 30-90 min and preventing depressive symptoms among women up to a year per session at a moderate intensity occurring a postpartum range of 1-4 times a week. • Due to the discrepancies in measurement of postpartum Control: Usual care, non-intervention and active depression it is difficult to determine the exact mechanism of how controls. physical activity is improving the PPD symptoms. • There were no harmful effects reported from the studies and there Özkan et al., (2020) The objective of this RCT is to determine Postpartum women ages 20-35 with Intervention: Participants received an There was a statistically significant difference in EPDS scores 4 were additional physical health benefits along with mental health the effect an exercise program has on EPDS scores greater than 13 informational booklet on exercises and the weeks post intervention (z= -6.501, P=0001) among the benefits such as increased confidence, body image and overall decreasing the severity of PPD. benefits. Mild-moderate exercise performed intervention group (7.29 ± 1.67) and the control group (12.54 ± mood. Weeks 1 &2, 5/7 days for minimum of 30 minutes 2.65). The 4-week exercise program is significantly effective in • A more in depth look into the multiple positive consequences of and then moderate-severe intensity Weeks 3 &4. reducing the severity of depression symptoms experienced by using this intervention for postpartum depression may encourage Control: Standard of care postpartum women. a broader acceptance and application into standard of practice.

Acknowledgements Implications for Nursing and CNL Role References I would like to thank Debra Scrandis, PhD, FNP-BC, FPMHNP-BC for taking on the role of my reader and assisting me through this • Interventions should focus less on coaching/motivational aspects but more on the exercise-oriented elements which generate an increase in significant outcomes. process. • The frequency and intensity of the exercise interventions needs to be further evaluated in order to determine its more specific effect. • Future studies should look at tailoring the interventions more specifically to the individual patients needs as well as the effect of combining the exercise intervention with educational interventions. • Due to the similar adherence levels between the exercise interventions compared to pharmacological treatment, the intervention is very feasible. • CNL’s can look into reducing potential barriers by assisting and educating the women in developing strategies to be successful in the exercise regimen when they are not supervised providing continuity of care as they transition from the hospital to home. • A CNL can help enable a more effective and individualized care by coordinating with interdisciplinary teams such as a physical therapist as well as with the fitness instructors.