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Prenatal Diagnosis Dec 2021Prenatal myelomeningocele (MMC) repair has been shown to improve neurological outcomes. It has been suggested that decreases in the hysterotomy diameter during surgery...
BACKGROUND/OBJECTIVES
Prenatal myelomeningocele (MMC) repair has been shown to improve neurological outcomes. It has been suggested that decreases in the hysterotomy diameter during surgery can improve perinatal outcomes without altering neurologic outcomes. The objective of this study is to describe and compare the main maternal and fetal outcomes of fetuses undergoing open surgery for MMC repair, through the different modifications (standard-classical, mini-hysterotomy, and microneurosurgery).
DATA SOURCE
MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Ovid, SciELO, LILACS, PROSPERO.
RESULTS
From a total of 112 studies, seven case series were selected including 399 fetuses with open fetal surgery, five studies using the classical technique (n = 181), one with mini-hysterotomy (n = 176), and one with the microneurosurgery technique (n = 42). The mini-hysterotomy and microneurosurgery techniques presented a lower risk of preterm delivery (21.4% and 30%, respectively) compared to the classic technique (47.3%), premature rupture of membranes (78%, 62%, and 72.5 %, respectively), oligohydramnios (0% and 72.5%, respectively), dehiscence of hysterotomy, maintaining the same frequency of Chiari reversion (78%, 62%, and 72.5%, respectively), postnatal correction requirement (0%, 4.8%, and 5.8%, respectively), and lower frequency of requirement for a ventriculoperitoneal shunt placement (13.0%, 7.5%, and 29.1%, respectively).
CONCLUSION
The least invasive techniques (minihysterotomy-microneurosurgery) are possible and reproduceable, as they are associated with better maternal and perinatal outcomes.
Topics: Adult; Female; Fetal Therapies; Fetoscopy; Gestational Age; Humans; Pregnancy; Spinal Dysraphism; Ventriculoperitoneal Shunt
PubMed: 34676573
DOI: 10.1002/pd.6063 -
Current Opinion in Obstetrics &... Dec 2019To review literature about risk factors of neonatal hypoxic-ischemic encephalopathy (HIE). (Meta-Analysis)
Meta-Analysis
PURPOSE OF REVIEW
To review literature about risk factors of neonatal hypoxic-ischemic encephalopathy (HIE).
RECENT FINDINGS
Search in PubMed, MEDLINE, Embase, Clinicaltrials.gov and reference lists from 1999 to 2018.
INCLUSION CRITERIA
study population composed of neonates who manifested HIE within 28 days from delivery, data reported as proportional rate. Studies were excluded if they included preterm pregnancies, postnatal conditions leading to HIE and/or fetal malformations, focused on a single risk factor, were not in English language. PRISMA guidelines were followed. Interstudies heterogeneity was assessed and a random/fixed models were generated as appropriate. Comparison between neonates with HIE vs. controls was performed by calculating odds ratio-95% confidence interval (OR-95% CI). Differences were significant if 95% CI did not encompass 1. Twelve articles were included. Fetuses with growth restriction (OR: 2.87; 95% CI: 1.77-4.67), nonreassuring cardiotocography (OR: 6.38; 95% CI: 2.56-15.93), emergency cesarean section (OR: 3.69; 95% CI: 2.75-4.96), meconium (OR: 3.76; 95% CI: 2.58-5.46) and chorioamnionitis (OR: 3.46: 95% CI: 2.07-5.79) were at higher risk of developing HIE. Nulliparity, gestational diabetes, hypertension, oligohydramnios, polyhydramnios, male sex, induction of labor, labor augmentation, premature rupture of membrane, and vacuum delivery were not significantly different.
SUMMARY
Neonatal HIE has multifactorial origin and its cause is often undetermined and not preventable.PROSPERO (Registration number: CRD42018106563).
Topics: Cardiotocography; Cesarean Section; Chorioamnionitis; Female; Fetal Growth Retardation; Humans; Hypoxia-Ischemia, Brain; Infant, Newborn; Male; Meconium Aspiration Syndrome; Odds Ratio; Pregnancy; Risk Factors
PubMed: 31567446
DOI: 10.1097/GCO.0000000000000581 -
Mayo Clinic Proceedings. Innovations,... Aug 2020The aim of this study was to investigate the effect of serial amnioinfusion therapy (SAT) for pulmonary hypoplasia in lower urinary tract obstruction (LUTO) or...
Serial Amnioinfusion as Regenerative Therapy for Pulmonary Hypoplasia in Fetuses With Intrauterine Renal Failure or Severe Renal Anomalies: Systematic Review and Future Perspectives.
The aim of this study was to investigate the effect of serial amnioinfusion therapy (SAT) for pulmonary hypoplasia in lower urinary tract obstruction (LUTO) or congenital renal anomalies (CRAs), introduce patient selection criteria, and present a case of SAT in bilateral renal agenesis. We conducted a search of the MEDLINE, EMBASE, Web of Science, and Scopus databases for articles published from database inception to November 10, 2017. Eight studies with 17 patients (7 LUTO, 8 CRA, and 2 LUTO + CRA) were included in the study. The median age of the mothers was 31 years (N=9; interquartile range [IQR], 29-33.5 years), the number of amnioinfusions was 7 (N=17; IQR, 4.5-21), gestational age at first amnioinfusion was 23 weeks and 4 days (N=17; IQR, 21-24.07), gestational age at delivery was 32 weeks and 2 days (N=17; IQR, 30 weeks to 35 weeks and 6.5 days), birthweight of newborns was 3.7 kg (N= 9; IQR, 2.7-3.7 kg), Apgar score at 1 minute was 2.5 (N=8; IQR, 1-6.5), and Apgar score at 5 minutes was 5.5 (N=8; IQR, 0-7.75). In conclusion, SAT may provide fetal pulmonary palliation by reducing the risk of newborn pulmonary compromise secondary to oligohydramnios. Multidisciplinary research efforts are required to further inform treatment and counseling guidelines. We propose a multidisciplinary approach to prenatal classification of fetuses with LUTO to inform patient selection.
PubMed: 32793867
DOI: 10.1016/j.mayocpiqo.2020.04.008 -
Health Technology Assessment... Feb 2021Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy....
BACKGROUND
Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy. Ultrasound scans thereafter are performed for clinical indications only.
OBJECTIVES
We sought to assess the case for offering universal late pregnancy ultrasound to all nulliparous women in the UK. The main questions addressed were the diagnostic effectiveness of universal late pregnancy ultrasound to predict adverse outcomes and the cost-effectiveness of either implementing universal ultrasound or conducting further research in this area.
DESIGN
We performed diagnostic test accuracy reviews of five ultrasonic measurements in late pregnancy. We conducted cost-effectiveness and value-of-information analyses of screening for fetal presentation, screening for small for gestational age fetuses and screening for large for gestational age fetuses. Finally, we conducted a survey and a focus group to determine the willingness of women to participate in a future randomised controlled trial.
DATA SOURCES
We searched MEDLINE, EMBASE and the Cochrane Library from inception to June 2019.
REVIEW METHODS
The protocol for the review was designed a priori and registered. Eligible studies were identified using keywords, with no restrictions for language or location. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Health economic modelling employed a decision tree analysed via Monte Carlo simulation. Health outcomes were from the fetal perspective and presented as quality-adjusted life-years. Costs were from the perspective of the public sector, defined as NHS England, and the costs of special educational needs. All costs and quality-adjusted life-years were discounted by 3.5% per annum and the reference case time horizon was 20 years.
RESULTS
Umbilical artery Doppler flow velocimetry, cerebroplacental ratio, severe oligohydramnios and borderline oligohydramnios were all either non-predictive or weakly predictive of the risk of neonatal morbidity (summary positive likelihood ratios between 1 and 2) and were all weakly predictive of the risk of delivering a small for gestational age infant (summary positive likelihood ratios between 2 and 4). Suspicion of fetal macrosomia is strongly predictive of the risk of delivering a large infant, but it is only weakly, albeit statistically significantly, predictive of the risk of shoulder dystocia. Very few studies blinded the result of the ultrasound scan and most studies were rated as being at a high risk of bias as a result of treatment paradox, ascertainment bias or iatrogenic harm. Health economic analysis indicated that universal ultrasound for fetal presentation only may be both clinically and economically justified on the basis of existing evidence. Universal ultrasound including fetal biometry was of borderline cost-effectiveness and was sensitive to assumptions. Value-of-information analysis indicated that the parameter that had the largest impact on decision uncertainty was the net difference in cost between an induced delivery and expectant management.
LIMITATIONS
The primary literature on the diagnostic effectiveness of ultrasound in late pregnancy is weak. Value-of-information analysis may have underestimated the uncertainty in the literature as it was focused on the internal validity of parameters, which is quantified, whereas the greatest uncertainty may be in the external validity to the research question, which is unquantified.
CONCLUSIONS
Universal screening for presentation at term may be justified on the basis of current knowledge. The current literature does not support universal ultrasonic screening for fetal growth disorders.
FUTURE WORK
We describe proof-of-principle randomised controlled trials that could better inform the case for screening using ultrasound in late pregnancy.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42017064093.
FUNDING
This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 25, No. 15. See the NIHR Journals Library website for further project information.
Topics: Cost-Benefit Analysis; Female; Gestational Age; Humans; Infant, Newborn; Mass Screening; Parity; Pregnancy; Randomized Controlled Trials as Topic; Ultrasonography
PubMed: 33656977
DOI: 10.3310/hta25150 -
JBI Database of Systematic Reviews and... Feb 2019The objective of this review was to identify, assess and synthesize the best available evidence on the effects of induction prior to post-term on the mother and fetus....
OBJECTIVE
The objective of this review was to identify, assess and synthesize the best available evidence on the effects of induction prior to post-term on the mother and fetus. Maternal and fetal outcomes after routine labor induction in low-risk pregnancies at 41+0 to 41+6 gestational weeks (prior to post-term) were compared to routine labor induction at 42+0 to 42+6 gestational weeks (post-term).
INTRODUCTION
Induction of labor when a pregnancy exceeds 14 days past the estimated due date has long been used as an intervention to prevent adverse fetal and maternal outcomes. Over the last decade, clinical procedures have changed in many countries towards earlier induction. A shift towards earlier inductions may lead to 15-20% more inductions. Given the fact that induction as an intervention can cause harm to both mother and child, it is essential to ensure that the benefits of the change in clinical practice outweigh the harms.
INCLUSION CRITERIA
This review included studies with participants with expected low-risk deliveries, where both fetus and mother were considered healthy at inclusion and with no known risks besides the potential risk of the ongoing pregnancy. Included studies evaluated induction at 41+1-6 gestational weeks compared to 42+1-6 gestational weeks. Randomized control trials (n = 2), quasi-experimental trials (n = 2), and cohort studies (n = 3) were included. The primary outcomes of interest were cesarean section, instrumental vaginal delivery, low Apgar score (≤ 7/5 min.), and low pH (< 7.10). Secondary outcomes included additional indicators of fetal or maternal wellbeing related to prolonged pregnancy or induction.
METHODS
The following information sources were searched for published and unpublished studies: PubMed, CINAHL, Embase, Scopus, Swemed+, POPLINE; Cochrane, TRIP; Current Controlled Trials; Web of Science, and, for gray literature: MedNar; Google Scholar, ProQuest Nursing & Allied Health Source, and guidelines from the Royal College of Obstetricians and Gynaecologists, and American College of Obstetricians and Gynecologists, according to the published protocol. In addition, OpenGrey and guidelines from the National Institute for Health and Care Excellence, World Health Organization, and Society of Obstetricians and Gynaecologists of Canada were sought. Included papers were assessed by all three reviewers independently using the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). The standardized data extraction tool from JBI SUMARI was used. Data were pooled in a statistical meta-analysis model using RevMan 5, when the criteria for meta-analysis were met. Non-pooled results were presented separately.
RESULTS
Induction at 41+0-6 gestational weeks compared to 42+0-6 gestational weeks was found to be associated with an increased risk of overall cesarean section (relative risk [RR] = 1.11, 95% confidence interval [CI] 1.09-1.14), cesarean section due to failure to progress (RR = 1.43, 95% CI 1.01-2.01), chorioamnionitis (RR = 1.13, 95% CI 1.05-1.21), labor dystocia (RR = 1.29, 95% CI 1.22-1.37), precipitate labor (RR = 2.75, 95% CI 1.45-5.2), uterine rupture (RR = 1.97, 95% CI 1.54-2.52), pH < 7.10 (RR = 1.9, 95% CI 1.48-2.43), and a decreased risk of oligohydramnios (RR = 0.4, 95% CI 0.24-0.67) and meconium stained amniotic fluid (RR = 0.82, 95% CI 0.75-0.91). Data lacked statistical power to draw conclusions on perinatal death. No differences were seen for postpartum hemorrhage, shoulder dystocia, meconium aspiration, 5-minute Apgar score < 7, or admission to neonatal intensive care unit. A policy of awaiting spontaneous onset of labor until 42+0-6 gestational weeks showed, that approximately 70% went into spontaneous labor.
CONCLUSIONS
Induction prior to post-term was associated with few beneficial outcomes and several adverse outcomes. This draws attention to possible iatrogenic effects affecting large numbers of low-risk women in contemporary maternity care. According to the World Health Organization, expected benefits from a medical intervention must outweigh potential harms. Hence, our results do not support the widespread use of routine induction prior to post-term (41+0-6 gestational weeks).
Topics: Adult; Apgar Score; Case-Control Studies; Cesarean Section; Chorioamnionitis; Delivery, Obstetric; Dystocia; Female; Fetus; Gestational Age; Humans; Infant, Newborn; Labor, Induced; Labor, Obstetric; Maternal Health Services; Meconium Aspiration Syndrome; Middle Aged; Oligohydramnios; Perinatal Death; Pregnancy; Pregnancy Outcome; Uterine Rupture
PubMed: 30299344
DOI: 10.11124/JBISRIR-2017-003587 -
European Journal of Clinical... Oct 2019Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended in the 3rd trimester of pregnancy due to known fetal adverse effects in an advanced gestational age....
PURPOSE
Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended in the 3rd trimester of pregnancy due to known fetal adverse effects in an advanced gestational age. This investigation was performed to assess whether there is a significant risk of NSAIDs being used as an analgesic or antipyretic medication in the 2nd trimester.
METHODS
A systematic search for publications reporting 2nd trimester NSAID exposure was performed in MEDLINE. The search focused on case descriptions reporting defined adverse effects including prenatal ductus arteriosus constriction, oligohydramnios, neonatal renal failure, and primary pulmonary hypertension. Original articles published until February 2018 were considered for evaluation.
RESULTS
Out of 681 identified publications, 26 included relevant information on the defined adverse effects. Among these publications, premature labor was the major reason for 2nd trimester indomethacin treatment while other clinical indications and other NSAIDs were underrepresented. Narrowing or closure of the ductus arteriosus in the 2nd trimester was described in 33 fetuses. Only eight publications reported adverse effects after less than 7-day exposure during the 2nd trimester.
CONCLUSIONS
Based on these results, short-term use of NSAIDs as analgesics or antipyretics in the 2nd trimester does not appear to pose a substantial risk for fetal adverse effects. Long-term use in the late 2nd trimester, however, should always be monitored.
Topics: Anti-Inflammatory Agents, Non-Steroidal; Female; Fetus; Humans; Maternal-Fetal Exchange; Pregnancy; Pregnancy Trimester, Second; Risk Assessment
PubMed: 31273431
DOI: 10.1007/s00228-019-02712-2 -
Journal of Clinical Epidemiology Jan 2024To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions.
OBJECTIVES
To evaluate the strength of the evidence for, and the extent of, overdiagnosis in noncancer conditions.
STUDY DESIGN AND SETTING
We systematically searched for studies investigating overdiagnosis in noncancer conditions. Using the 'Fair Umpire' framework to assess the evidence that cases diagnosed by one diagnostic strategy but not by another may be overdiagnosed, two reviewers independently identified whether a Fair Umpire-a disease-specific clinical outcome, a test result or risk factor that can determine whether an additional case does or does not have disease-was present. Disease-specific clinical outcomes provide the strongest evidence for overdiagnosis, follow-up or concurrent tests provide weaker evidence, and risk factors provide only weak evidence. Studies without a Fair Umpire provide the weakest evidence of overdiagnosis.
RESULTS
Of 132 studies, 47 (36%) did not include a Fair Umpire to adjudicate additional diagnoses. When present, the most common Umpire was a single test or risk factor (32% of studies), with disease-specific clinical outcome Umpires used in only 21% of studies. Estimates of overdiagnosis included 43-45% of screen-detected acute abdominal aneurysms, 54% of cases of acute kidney injury, and 77% of cases of oligohydramnios in pregnancy.
CONCLUSION
Much of the current evidence for overdiagnosis in noncancer conditions is weak. Application of the framework can guide development of robust studies to detect and estimate overdiagnosis in noncancer conditions, ultimately informing evidence-based policies to reduce it.
Topics: Female; Pregnancy; Humans; Medical Overuse; Overdiagnosis; Risk Factors
PubMed: 37952702
DOI: 10.1016/j.jclinepi.2023.11.005