What to tell patients about exercise in pregnancy

- Erin Fredrickson, DO, MPH

If we had a magic pill to reduce rates of pregnancy complications and improve the health of pregnant patients, we would prescribe it faster than Allyson Felix can sprint 400 meters. Exercise during pregnancy isn’t a magic pill, but the potential benefits of engaging in purposeful physical activity during all stages of the reproductive journey far outweigh the perceived risks. Family physicians have a unique opportunity to assess health behaviors of patients before, during, and after pregnancy and provide guidance around lifestyle changes in the context of families and communities.

Before discussing the benefits and considerations for leisure-time physical activity in pregnancy, it is important to note that not every pregnant patient has the privileges of time or safety required to include exercise in their daily routine. The burden of societal inequity, systemic racism, misogyny, and climate change falls hardest on Black, brown, Indigenous, and people of color, especially during pregnancy. Acknowledging these barriers, we can encourage patients through individual relationships while advocating for policy changes to support our communities.

All adults, including pregnant patients without contraindications, are recommended to engage in 150 minutes per week of moderate intensity physical activity for optimal health. Exercise in pregnancy is associated with lower rates of prenatal complications, better fetal outcomes, and gentler labor experiences and postpartum recovery. Studies have found lower rates of gestational diabetes and large for gestational age infants, gestational hypertension, and preterm delivery among exercising pregnant patients compared to those who did not exercise. One study found that people with higher physical activity levels during pregnancy had a shorter duration of active labor. Another systematic review and meta-analysis of 17 trials found a reduction in cesarean birth rate of 16% in the exercise group. Exercise is well-known to improve mood regulation and is associated with fewer symptoms of postpartum depression. Considering the biomechanical changes of pregnancy, at least 60% of pregnant patients experience musculoskeletal pain, but greater self-reported overall fitness is associated with lower levels of bodily pain, lumbar/sciatic pain, and reduced pain disability in the second and third trimester.

How should we talk to patients about exercise during pregnancy? Previously inactive patients can begin exercising with gradual increases in frequency and duration over time. Anyone physically active prior to pregnancy can continue throughout pregnancy, but will likely need to modify activities to adapt to physiologic and biomechanical changes over time. With the right support in place, elite athletes can partner with their care teams and coaches to prioritize a healthy pregnancy and athletic longevity. Almost all types of aerobic exercise are safe (walking, jogging, swimming, cycling), but pregnant patients should avoid activities with higher risk of blunt abdominal trauma. Patients should be counseled to take breaks when needed, get enough to eat and drink, avoid extreme heat, and stop exercise immediately if vaginal bleeding or contractions occur. Most people should aim for intensity <80% of their maximum heart rate (or <15 “hard” on the rating of perceived exertion scale).

People with certain obstetric and medical conditions, particularly cardiovascular/respiratory complications, should be more cautious with exercise during pregnancy and the primary obstetric care team should have a low threshold to consult with maternal-fetal medicine.

AFP has been discussing exercise in pregnancy before it was cool (1998), and the American College of Obstetricians and Gynecologists updated their clinical guidance in 2020 with helpful tables for counseling. Our July issue includes a FPIN Clinical Inquiry on reducing risk of hypertensive disorders of pregnancy with exercise and an article on care of the active female with recommendations for exercise in pregnancy and the postpartum period in this Table (subscription required). Encouraging and facilitating exercise during pregnancy, particularly for those with societally imposed barriers, is an important component of working toward health equity for pregnant patients.

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Dr. Fredrickson is a third-year resident at the University of Washington Family Medicine Residency Program, Seattle and one of AFP's 2022 Resident Representatives.

Pharmacists can now prescribe Paxlovid

 - Jennifer Middleton, MD, MPH

The United States (US) Food and Drug Administration (FDA) recently modified its Emergency Use Authorization (EUA) for nirmatrelvir/ritonavir (Paxlovid) to "authorize state-licensed pharmacists to prescribe Paxlovid to eligible patients, with certain limitations to ensure appropriate patient assessment and prescribing." Although some physician organizations have previously expressed concern with expanding pharmacists' scope of practice, others argue that increased access to Paxlovid is necessary. 

Nirmatrelvir/ritonavir must be started within 5 days of symptom onset, and its EUA applies to outpatient adults at high risk for severe COVID-19 illness. It is effective at reducing the risk of hospitalization or death, with a number needed to treat (NNT) of 18 in unvaccinated persons, with early non-peer-reviewed data demonstrating efficacy in vaccinated persons as well. When first approved, supplies and access were limited, but now plenty of nirmatrelvir/ritonavir is available to meet demand, which has been increasing in the US as COVID-19 surges again. The challenge for many patients is access to a prescription within the short 5 day window; COVID-19 tests, especially home test kits, may not be positive on the first day or two of symptoms, and prescribing requires time to review medical records for underlying liver and kidney disease as well as medication lists for nirmatrelvir/ritonavir's many drug-drug interactions.

The FDA encourages patients seeking nirmatrelvir/ritonavir after a positive COVID-19 test to first "consider seeking care from their regular health provider" or look for a Test-to-Treat location nearby. If seeking nirmatrelvir/ritonavir from a state-licensed pharmacist, patients should bring records of liver and kidney labwork that are less than 1 year old along with a comprehensive list of their medications and supplements.

Pharmacists' expertise can benefit patients and physicians. This 2021 FPM article reviews how in-office pharmacists can help with medication safety reviews, assist with tobacco cessation, and improve diabetes and hypertension control. "Interventions that involve pharmacists" increase medication adherence in patients with multiple chronic health conditions. Compared to physicians, pharmacists' management of warfarin results in improved INR readings and safety outcomes, and pharmacists can safely manage uncomplicated urinary tract infections (UTIs). The Choosing Wisely campaign urges us to "[not] continue medications at transitions of care without a pharmacist...performing a comprehensive medication review."

The AAFP recognizes these benefits of collaborative agreements with pharmacists, but it also warns about fragmentation of care when pharmacist prescribing is decoupled from a patient's primary care physician. Ensuring adequate communication with primary care offices when a pharmacist prescribes nirmatrelvir/ritonavir will be necessary to minimize the risk of this fragmentation. Looking beyond the COVID-19 pandemic, family physicians should think creatively about how to maximize collaboration opportunities with pharmacists, especially since, on average, patients access their community pharmacists much more frequently than their primary care physician. 

Advances in peanut allergy prevention and treatment

 - Kenny Lin, MD, MPH

People with severe peanut allergy are at risk of life-threatening anaphylaxis from unintentional ingestion of small amounts of peanuts. A recent new drug review in AFP discussed oral immunotherapy with peanut allergen powder, which increases tolerance for ingesting the amount of peanut protein in a single peanut by 63% but has important downsides: 1 in 10 patients need to use epinephrine after administration (compared to 1 in 20 in a placebo group); common short-term adverse effects include abdominal pain, throat irritation, and oral pruritus; and a price of approximately $3000 annually.

Although it was once believed that children should not consume peanuts early in life, a United Kingdom randomized trial in infants 4 to 11 months of age at high risk of developing peanut allergies (described in this Practice Guidelines summary) found that early consumption of peanuts reduced the risk of developing peanut allergy by age 5 years by 80% (absolute risk reduction=14%, NNT=7). This finding led the National Institute of Allergy and Infectious Diseases to recommend in 2017 that peanut-containing foods be introduced into the diet of infants with severe eczema, egg allergy, or both at 4 to 6 months of age. In 2021, a consensus document on the primary prevention of food allergy from three North American professional allergy societies recommended introducing peanut-containing products to all infants around 6 months of age, regardless of their risk of developing peanut allergy.

A similar change to infant feeding guidelines in Australia occurred in 2016, recommending that all infants be introduced to peanuts before age 12 months. A study in JAMA last week evaluated changes in feeding practices and the prevalence of peanut allergy across two population-based cross-sectional samples recruited in 2007-2011 and 2018-2019. Although infants in the later sample were much more likely to have consumed peanuts before 12 months than infants in the earlier sample (86% vs. 22%), overall there was no statistical difference in peanut allergy prevalence. Noting that East Asian ancestry is considered a risk factor for peanut allergy, the authors hypothesized that the increased representation of infants with parents from East Asia in the later sample may have contributed to finding no effect. Another possible explanation is that early introduction of peanut-containing foods does not significantly modify peanut allergy development in infants not at high risk.

In a previous paper on identifying and using clinical practice guidelines, Dr. David Slawson and I observed: "The ultimate test of a good guideline is whether or not it has been prospectively validated; that is, has its adoption been shown to improve patient-oriented outcomes in real-world settings?" Based on the JAMA study, infant feeding recommendations to prevent peanut allergies have not yet passed this test. On the other hand, an accompanying editorial argued that "given the potential for benefit and the low risk of harm, the [study results] should not dissuade clinicians from following current consensus guidance that recommends early peanut introduction for infants." The challenge of identifying children at increased risk for peanut allergy (as noted in the consensus document, definitions have varied across studies and guidelines) and the inherently artificial nature of previous guidance restricting what an infant would otherwise naturally eat make this a reasonable course of action in the face of imperfect evidence.

Contraception resources for physicians & patients

 - Jennifer Middleton, MD, MPH

Patients may be more interested in methods to prevent pregnancy after the United States (US) Supreme Court's recent decision to allow state legislatures to determine whether, and to what degree, to permit abortion. Nearly half of US states are banning, or plan to ban, most or all abortion services. Patients may also present with questions about accessing contraception, including emergency contraception, after some US retaliers instituted purchasing limits on over the counter (OTC) emergency contraception, fearing consumer stockpiling after the Supreme Court's decision. Contraception remains legal in the US, and family physicians have a range of options and resources to share with patients who desire pregnancy prevention.

This 2021 AFP article on "Initiating Hormonal Contraception" provides an overview of contraceptive pills, patches, injections, implants, and intrauterine devices (IUDs). Patients may initiate contraception at any point in their menstral cycle, and this Choosing Wisely recommendation reminds us that a pelvic examination is not necessary to prescribe contraceptive pills. The article also provides several useful algorithms for the "quick start" of pills, patches, injections, implants, and IUDs. Another AFP article, "Evidence-Based Contraception: Common Questions and Answers," was recently published online ahead of print and provides guidance on emergency contraception, fertility awareness methods, safety precautions in persons with migraine with aura, duration of long-acting reversible contraception (LARC), subcutaneous depot medroxyprogesterone acetate, and considerations for transgender and gender-diverse people. There's an AFP By Topic on Family Planning and Contraception with additional content including patient education handouts. 

Family physicians can also discuss contraception for families in between pregnancies to optimize outcomes for parents and infants. Breastfeeding (lactational amenorrhea method or "LAM") can prevent pregnancy, but only with "exclusive, frequent" breastfeeding in the first 6 months after birth. Persons desiring to prevent pregnancy after birth who are not breastfeeding frequently or exclusively, or who desire additional contraception in addition to LAM, have several safe options to choose from. Increasing intrapartum intervals to a minimum of 18 months is one of the aims of the March of Dimes' IMPLICIT project to reduce the prevalence of low birth weight infants. 

The US Centers for Disease Control and Prevention (CDC) has a "Contraceptive Guidance for Health Care Providers" website that includes a link to their US Medical Eligibility Criteria for Contraceptive Use (US MER) and US Selected Practice Recommendations for Contraceptive Use (US SPR) app. The app allows for convenient access to recommendations related to underlying medical conditions as well as "selected practice recommendations" regarding use and management of contraceptive methods.

For persons desiring irreversible contraception, family physicians can provide counseling regarding vasectomy and tubal ligation. Vasectomies are performed far less frequently than tubal ligations in the US despite the procedure's relative simplicity, safety, and inexpensive cost. The American Urological Association's Vasectomy Guideline (2015) describes optimal patient selection and post-procedure counseling, including recommended timing of postvasectomy semen analyses. Approximately 13% of vasectomies in the US are performed by family physicians, and the procedure can be learned in residency or following residency with a local mentor or skills course.

Lastly, the American Journal of Public Health just released a supplement to their June 2022 issue on "Reshaping Contraceptive Access Efforts By Centering Equity, Justice, and Autonomy." The issue "focuses on how contraceptive access policy is shaped, how policy is translated into practice, and how a focus on equity, justice, and autonomy has reshaped the field's approach to contraceptive access efforts." It's a resource to consider sharing with leaders in your healthcare system, state medical societies, and local and state government. The supplement includes descriptions of initiatives that successfully decreased adolescent pregnancy rates, used telehealth to "bridge gaps in contraceptive care deepened by COVID-19," and can promote health equity by "scaling up evidence-based practices in contraceptive access initiatives."

Sexually transmitted infections: trends and updated guidelines

 - Kenny Lin, MD, MPH

An outbreak of meningococcal disease in Florida and the continuing spread of monkeypox predominantly among men who have sex with men has called attention to the role of sexual networks in facilitating outbreaks of rare diseases. The Centers for Disease Control and Prevention (CDC) released new guidance on monkeypox that advises people to be aware of the transmission risk posed by contact with genital rashes or sores at raves, parties, clubs, and festivals. Although neither meningococcal disease nor monkeypox are thought to be directly transmitted though sex, both appear to spread more easily between close personal contacts.

Unfortunately, common sexually transmitted infections (STIs) are also on the rise in the U.S. According to the CDC's 2020 Sexually Transmitted Disease Surveillance Report released earlier this year, reported cases of gonorrhea and syphilis increased from 2019 to 2020 by 10% and 7%, respectively, while an alarming 2,148 cases of congenital syphilis occurred. Although reported chlamydia cases decreased by 13%, the CDC believes that this is most likely an artifact caused by disruptions in screening from the COVID-19 pandemic, since chlamydia is often asymptomatic. Similarly, an analysis published in last week's Morbidity and Mortality Weekly Report found that HIV testing declined by up to 50% in high-risk populations from 2019 to 2020, leading to a 17% decrease in new diagnoses that probably reflects diagnostic delays rather than a true decline in HIV incidence.

In this context, the May issue of AFP summarized important updates from the CDC's 2021 STI Treatment Guidelines. In a review article, Drs. Jessica Dalby and Bradley Stoner discussed several preventive strategies including hepatitis and human papillomavirus vaccinations, HIV preexposure prophylaxis (PrEP), and expedited partner therapy. The guidelines also emphasize antibiotic stewardship by distinguishing persons with a true IgE-mediated penicillin allergy from those who can safety receive ceftriaxone and penicillins through clinical tools such as the PEN-FAST rule. A Practice Guidelines piece highlighted more key practice points: doxycycline is preferred over azithromycin for most chlamydial infections, intramuscular ceftriaxone 500 mg (or 1 gram in patients weighing 150 kg or more) is now the standard therapy for gonorrhea, and women with trichomonas should received a 7-day course of metronidazole 500 mg twice daily rather than a single 2 gram dose.

More information for clinicians and patients on sexually transmitted infections, including techniques and tips for taking a sexual history,  is available in the AFP By Topic collection on STIs and separate collections on HIV/AIDS and Hepatitis (and Other Liver Diseases).

COVID-19 vaccines arrive for under 5s

 - Jennifer Middleton, MD, MPH

This past Friday, the United States (US) Food and Drug Administration (FDA) issued updates to its COVID vaccine recommendations, extending the Pfizer COVID-19 vaccine's Emergency Use Authorization to include children aged 6 months to 4 years while also extending the Moderna COVID-19 vaccine from ages 6 months to 17 years. The next day, the US Centers for Disease Control and Prevention (CDC) authorized both vaccines for their respective age groups. Since US states have been able to preorder vaccines in the past few weeks, many locales may be ready to vaccinate children aged 6 months and older as early as this week.

The Pfizer vaccine for ages 6 months through 4 years has had a rather bumpy road to approval. The first two doses of vaccine, which were all older children and adults required to demonstrate an immune response, did not elicit a sufficient immune response in this younger age group, necessitating the addition of a 3rd dose in the series. While the 3rd dose did elicit an immune response "comparable" to that of young adults, the number of cases among enrolled children was too low to permit rigorous analysis regarding the vaccine's effectiveness against infection or hospitalization. Pfizer has touted an 80% effectiveness rate for preventing COVID-19 infection after 3 doses, "[b]ut that 80 percent estimate was based on only 10 cases in a subset of 1,678 trial participants."

Moderna's vaccine has previously only been available for adults aged 18 and older, and the FDA  approved all three of its proposed new age groups on June 17: children aged 6 months to 5 years, children aged 6-11 years, and children and teens aged 12-17 years. For these groups:

• "Among participants 6 through 23 months of age...the vaccine was 50.6% effective in preventing COVID-19. Among participants 2 through 5 years of age...the vaccine was 36.8% effective in preventing COVID-19."
• Immune response was comparable in children aged 6-11 years to young adults, but there were not enough COVID-19 cases in this cohort to determine vaccine efficacy against infection and hospitalization.
• "[A]mong participants 12 through 17 years of age, the vaccine was 93.3% effective in preventing COVID-19."

All of these trials were conducted before omicron became the dominant COVID-19 strain, though the FDA and CDC are still encouraging parents to obtain the vaccine for their children, even if they previously had COVID-19 infection. All of these vaccine products are safe, and any level of protection against COVID-19 infection is better than none. Over 400 children under the age of 5 have died in the US from COVID-19 since the pandemic began, and Multisystem Inflammatory Syndrome in Children (MIS-C) afflicts 1 in every 3000-4000 children who get symptomatic COVID-19. Vaccination should help decrease COVID-19 outbreaks in schools and daycare centers, which have disrupted countless families' schedules over the past 2+ years.

Vaccine uptake is predicted to be low in the under-5-years age group, though, with a recent survey showing that only 18% of parents are planning to vaccinate their eligible children immediately with another 38% who are less certain and adopting a "wait and see" approach. The US state of Florida only ordered its vaccine supply for this age group late on Friday after initial statements from its governor regarding his opposition to the vaccine. Despite conflicting messages from government leaders and widespread parental concerns, family physicians can still help parents make well-informed vaccination decisions. Sharing information about COVID-19 infection's risks to children may help combat misinformation regarding a perceived "low" risk in this age group, and the US Federal Emergency Management Agency (FEMA) has a Coronavirus Rumor Control website that fact checks several common myths. This 2021 Lown Right Care article reviews "Helping Ambivalent Patients Make Healthy Decisions about COVID-19" using motivational interviewing. A recent Curbside Consultation discussed navigating when two parents disagree about vaccinating their child. Lastly, this 2016 AFP editorial provides evidence-based "Strategies for Addressing and Overcoming Vaccine Hesitancy" that ends by reminding us that "patients' ambivalence is your friend because it means that they have not closed their minds to vaccines."