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Frontiers in Global Women's Health 2023The World Health Organization (WHO) recommends treatment and management of gestational diabetes (GD) through lifestyle changes, including diet and exercise, and... (Review)
Review
INTRODUCTION
The World Health Organization (WHO) recommends treatment and management of gestational diabetes (GD) through lifestyle changes, including diet and exercise, and self-monitoring blood glucose (SMBG) to inform timely treatment decisions. To expand the evidence base of WHO's guideline on self-care interventions, we conducted a systematic review of SMBG among pregnant individuals with GD.
SETTING
Following PRISMA guidelines, we searched PubMed, CINAHL, LILACS, and EMBASE for publications through November 2020 comparing SMBG with clinic-based monitoring during antenatal care (ANC) globally.
PRIMARY AND SECONDARY OUTCOME MEASURES
We extracted data using standardized forms and summarized maternal and newborn findings using random effects meta-analysis in GRADE evidence tables. We also reviewed studies on values, preferences, and costs of SMBG.
RESULTS
We identified 6 studies examining SMBG compared to routine ANC care, 5 studies on values and preferences, and 1 study on costs. Nearly all were conducted in Europe and North America. Moderate-certainty evidence from 3 randomized controlled trials (RCTs) showed that SMBG as part of a package of interventions for GD treatment was associated with lower rates of preeclampsia, lower mean birthweight, fewer infants born large for gestational age, fewer infants with macrosomia, and lower rates of shoulder dystocia. There was no difference between groups in self-efficacy, preterm birth, C-section, mental health, stillbirth, or respiratory distress. No studies measured placenta previa, long-term complications, device-related issues, or social harms. Most end-users supported SMBG, motivated by health benefits, convenience, ease of use, and increased confidence. Health workers acknowledged SMBG's convenience but were wary of technical problems. One study found SMBG by pregnant individuals with insulin-dependent diabetes was associated with decreased costs for hospital admission and length of stay.
CONCLUSION
SMBG during pregnancy is feasible and acceptable, and when combined in a package of GD interventions, is generally associated with improved maternal and neonatal health outcomes. However, research from resource-limited settings is needed.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42021233862.
PubMed: 37293246
DOI: 10.3389/fgwh.2023.1006041 -
Sexual & Reproductive Healthcare :... Jun 2023To identify maternal factors associated with labor dystocia in low-risk nulliparous women. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To identify maternal factors associated with labor dystocia in low-risk nulliparous women.
METHODS
MEDLINE, Embase, ClinicalTrials.gov, Cochrane, and CINAHL were searched for intervention studies and observational studies published from January 2000 to January 2022. Low-risk was defined as nulliparous women with a singleton, cephalic birth in spontaneous labor at term. Labor dystocia was defined by national or international criteria or treatment. Countries were restricted to OECD members. Two authors independently screened 11,374 titles and abstracts, extracted data, and assessed risk of bias using the Newcastle-Ottawa Scale. Results were presented narratively and by meta-analysis when compatible.
RESULTS
Seven cohort studies were included. Overall, the certainty of the evidence was moderate. Three studies found that higher maternal age was associated with an increased frequency of labor dystocia (relative risk 1.68; 95% CI 1.43-1.98). Further three studies found that higher maternal BMI was associated with increased frequency of labor dystocia (relative risk 1.20; 95% CI 1.01-1.43). Maternal short stature, fear of childbirth, and high caffeine intake were also associated with an increased frequency of labor dystocia, while maternal physical activity was associated with a decreased frequency.
CONCLUSION
Maternal factors associated with an increased frequency of labor dystocia were mainly maternal age, physical characteristics, and fear of childbirth. Maternal physical activity was associated with a decreased frequency. Intervention studies targeting these maternal factors would need to be initiated before or early in pregnancy to test the causality of the identified factors and labor dystocia.
Topics: Pregnancy; Female; Humans; Cesarean Section; Dystocia; Maternal Age; Delivery, Obstetric; Risk Factors
PubMed: 37210774
DOI: 10.1016/j.srhc.2023.100855 -
BMC Pregnancy and Childbirth May 2023Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such...
BACKGROUND
Caesarean section (CS) is widely perceived as protective against obstetric brachial plexus injury (BPI), but few studies acknowledge the factors associated with such injury. The objectives of this study were therefore to aggregate cases of BPI after CS, and to illuminate risk factors for BPI.
METHODS
Pubmed Central, EMBASE and MEDLINE databases were searched using free text: ("brachial plexus injury" or "brachial plexus injuries" or "brachial plexus palsy" or "brachial plexus palsies" or "Erb's palsy" or "Erb's palsies" or "brachial plexus birth injury" or "brachial plexus birth palsy") and ("caesarean" or "cesarean" or "Zavanelli" or "cesarian" or "caesarian" or "shoulder dystocia"). Studies with clinical details of BPI after CS were included. Studies were assessed using the National Institutes for Healthy Study Quality Assessment Tool for Case Series, Cohort and Case-Control Studies.
MAIN RESULTS
39 studies were eligible. 299 infants sustained BPI after CS. 53% of cases with BPI after CS had risk factors for likely challenging handling/manipulation of the fetus prior to delivery, in the presence of considerable maternal or fetal concerns, and/or in the presence of poor access due to obesity or adhesions.
CONCLUSIONS
In the presence of factors that would predispose to a challenging delivery, it is difficult to justify that BPI could occur due to in-utero, antepartum events alone. Surgeons should exercise care when operating on women with these risk factors.
Topics: Female; Pregnancy; Humans; Cesarean Section; Brachial Plexus; Brachial Plexus Neuropathies; Case-Control Studies; Risk Factors; Paralysis; Birth Injuries; Dystocia
PubMed: 37198580
DOI: 10.1186/s12884-023-05696-1 -
JAMA Network Open May 2023Elective induction of labor at 39 weeks of gestation is common. Thus, there is a need to assess maternal labor-related complications and neonatal outcomes associated... (Meta-Analysis)
Meta-Analysis
Comparison of Maternal Labor-Related Complications and Neonatal Outcomes Following Elective Induction of Labor at 39 Weeks of Gestation vs Expectant Management: A Systematic Review and Meta-analysis.
IMPORTANCE
Elective induction of labor at 39 weeks of gestation is common. Thus, there is a need to assess maternal labor-related complications and neonatal outcomes associated with elective induction of labor.
OBJECTIVE
To examine maternal labor-related complications and neonatal outcomes following elective induction of labor at 39 weeks compared with expectant management.
DATA SOURCES
A systematic review of the literature was conducted using the MEDLINE (Ovid), Embase (Ovid), Cochrane Central Library, World Health Organization, and ClinicalTrials.gov databases and registries to search for articles published between database inception and December 8, 2022.
STUDY SELECTION
This systematic review and meta-analysis included randomized clinical trials, cohort studies, and cross-sectional studies reporting perinatal outcomes following induction of labor at 39 weeks vs expectant management.
DATA EXTRACTION AND SYNTHESIS
Two reviewers independently assessed study eligibility, extracted data, and assessed studies for bias. Pooled odds ratios (ORs) and 95% CIs were calculated using a random-effects model. This study is reported per the Preferred Reporting Items for Systematic Reviews and Meta-analyses 2020 guideline, and the protocol was prospectively registered with PROSPERO.
MAIN OUTCOMES AND MEASURES
Maternal outcomes of interest included emergency cesarean section, perineal injury, postpartum hemorrhage, and operative vaginal birth. Neonatal outcomes of interest included admission to the neonatal intensive care unit, low 5-minute Apgar score (<7) after birth, macrosomia, and shoulder dystocia.
RESULTS
Of the 5827 records identified in the search, 14 studies were eligible for inclusion in this review. These studies reported outcomes for 1 625 899 women birthing a singleton pregnancy. Induction of labor at 39 weeks of gestation was associated with a 37% reduced likelihood of third- or fourth-degree perineal injury (OR, 0.63 [95% CI, 0.49-0.81]), in addition to reductions in operative vaginal birth (OR, 0.87 [95% CI, 0.79-0.97]), macrosomia (OR, 0.66 [95% CI, 0.48-0.91]), and low 5-minute Apgar score (OR, 0.62 [95% CI, 0.40-0.96]). Results were similar when confined to multiparous women only, with the addition of a substantial reduction in the likelihood of emergency cesarean section (OR, 0.61 [95% CI, 0.38-0.98]) and no difference in operative vaginal birth (OR, 1.01 [95% CI, 0.84-1.21]). However, among nulliparous women only, induction of labor was associated with an increased likelihood of shoulder dystocia (OR, 1.22 [95% CI, 1.02-1.46]) compared with expectant management.
CONCLUSIONS AND RELEVANCE
In this study, induction of labor at 39 weeks was associated with improved maternal labor-related and neonatal outcomes. However, among nulliparous women, induction of labor was associated with shoulder dystocia. These results suggest that elective induction of labor at 39 weeks may be safe and beneficial for some women; however, potential risks should be discussed with nulliparous women.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Cesarean Section; Fetal Macrosomia; Cross-Sectional Studies; Shoulder Dystocia; Labor, Induced; Labor, Obstetric; Obstetric Labor Complications; Infant, Newborn, Diseases
PubMed: 37171818
DOI: 10.1001/jamanetworkopen.2023.13162 -
American Journal of Obstetrics and... May 2023The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced...
The past 20 years witnessed an invigoration of research on labor progression and a change of thinking regarding normal labor. New evidence is emerging, and more advanced statistical methods are applied to labor progression analyses. Given the wide variations in the onset of active labor and the pattern of labor progression, there is an emerging consensus that the definition of abnormal labor may not be related to an idealized or average labor curve. Alternative approaches to guide labor management have been proposed; for example, using an upper limit of a distribution of labor duration to define abnormally slow labor. Nonetheless, the methods of labor assessment are still primitive and subject to error; more objective measures and more advanced instruments are needed to identify the onset of active labor, monitor labor progression, and define when labor duration is associated with maternal/child risk. Cervical dilation alone may be insufficient to define active labor, and incorporating more physical and biochemical measures may improve accuracy of diagnosing active labor onset and progression. Because the association between duration of labor and perinatal outcomes is rather complex and influenced by various underlying and iatrogenic conditions, future research must carefully explore how to integrate statistical cut-points with clinical outcomes to reach a practical definition of labor abnormalities. Finally, research regarding the complex labor process may benefit from new approaches, such as machine learning technologies and artificial intelligence to improve the predictability of successful vaginal delivery with normal perinatal outcomes.
Topics: Child; Female; Humans; Pregnancy; Artificial Intelligence; Delivery, Obstetric; Dystocia; Labor Stage, First; Labor, Obstetric
PubMed: 37164489
DOI: 10.1016/j.ajog.2022.11.1299 -
The Cochrane Database of Systematic... Mar 2023Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section.... (Review)
Review
BACKGROUND
Women with a suspected large-for-dates fetus or a fetus with suspected macrosomia (birthweight greater than 4000 g) are at risk of operative birth or caesarean section. The baby is also at increased risk of shoulder dystocia and trauma, in particular fractures and brachial plexus injury. Induction of labour may reduce these risks by decreasing the birthweight, but may also lead to longer labours and an increased risk of caesarean section.
OBJECTIVES
To assess the effects of a policy of labour induction at or shortly before term (37 to 40 weeks) for suspected fetal macrosomia on the way of giving birth and maternal or perinatal morbidity.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 January 2016), contacted trial authors and searched reference lists of retrieved studies.
SELECTION CRITERIA
Randomised trials of induction of labour for suspected fetal macrosomia.
DATA COLLECTION AND ANALYSIS
Review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We contacted study authors for additional information. For key outcomes the quality of the evidence was assessed using the GRADE approach.
MAIN RESULTS
We included four trials, involving 1190 women. It was not possible to blind women and staff to the intervention, but for other 'Risk of bias' domains these studies were assessed as being at low or unclear risk of bias. Compared to expectant management, there was no clear effect of induction of labour for suspected macrosomia on the risk of caesarean section (risk ratio (RR) 0.91, 95% confidence interval (CI) 0.76 to 1.09; 1190 women; four trials, moderate-quality evidence) or instrumental delivery (RR 0.86, 95% CI 0.65 to 1.13; 1190 women; four trials, low-quality evidence). Shoulder dystocia (RR 0.60, 95% CI 0.37 to 0.98; 1190 women; four trials, moderate-quality evidence), and fracture (any) (RR 0.20, 95% CI 0.05 to 0.79; 1190 women; four studies, high-quality evidence) were reduced in the induction of labour group. There were no clear differences between groups for brachial plexus injury (two events were reported in the control group in one trial, low-quality evidence). There was no strong evidence of any difference between groups for measures of neonatal asphyxia; low five-minute infant Apgar scores (less than seven) or low arterial cord blood pH (RR 1.51, 95% CI 0.25 to 9.02; 858 infants; two trials, low-quality evidence; and, RR 1.01, 95% CI 0.46 to 2.22; 818 infants; one trial, moderate-quality evidence, respectively). Mean birthweight was lower in the induction group, but there was considerable heterogeneity between studies for this outcome (mean difference (MD) -178.03 g, 95% CI -315.26 to -40.81; 1190 infants; four studies; I = 89%). For outcomes assessed using GRADE, we based our downgrading decisions on high risk of bias from lack of blinding and imprecision of effect estimates.
AUTHORS' CONCLUSIONS
Induction of labour for suspected fetal macrosomia has not been shown to alter the risk of brachial plexus injury, but the power of the included studies to show a difference for such a rare event is limited. Also antenatal estimates of fetal weight are often inaccurate so many women may be worried unnecessarily, and many inductions may not be needed. Nevertheless, induction of labour for suspected fetal macrosomia results in a lower mean birthweight, and fewer birth fractures and shoulder dystocia. The observation of increased use of phototherapy in the largest trial, should also be kept in mind. Findings from trials included in the review suggest that to prevent one fracture it would be necessary to induce labour in 60 women. Since induction of labour does not appear to alter the rate of caesarean delivery or instrumental delivery, it is likely to be popular with many women. In settings where obstetricians can be reasonably confident about their scan assessment of fetal weight, the advantages and disadvantages of induction at or near term for fetuses suspected of being macrosomic should be discussed with parents. Although some parents and doctors may feel the evidence already justifies induction, others may justifiably disagree. Further trials of induction shortly before term for suspected fetal macrosomia are needed. Such trials should concentrate on refining the optimum gestation of induction, and improving the accuracy of the diagnosis of macrosomia.
Topics: Infant; Infant, Newborn; Pregnancy; Female; Humans; Cesarean Section; Fetal Macrosomia; Birth Weight; Shoulder Dystocia; Fetal Weight; Labor, Induced
PubMed: 36884238
DOI: 10.1002/14651858.CD000938.pub3 -
PloS One 2023Neonatal near miss is a condition of newborn infant characterized by severe morbidity (near miss), but survived these conditions within the first 27 days of life. It is... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Neonatal near miss is a condition of newborn infant characterized by severe morbidity (near miss), but survived these conditions within the first 27 days of life. It is considered as the first step to design management strategies that can contribute in reducing long term complication and mortality. The aim of this study was to assess prevalence and determinants of neonatal near miss in Ethiopia.
METHODS
The protocol of this systematic review and meta-analysis was registered at the Prospero with a registration number of (PROSPERO 2020: CRD42020206235). International online databases such as PubMed, CINAHL, Google scholar, Global Health, Directory of open Access journal and African Index Medicus were used to search articles. Data extraction was undertaken with Microsoft Excel and STATA11 was used to conduct the Meta-Analysis. Random effect model analysis was considered when there was evidence of heterogeneity between the studies.
RESULTS
The overall pooled prevalence of neonatal near miss was 35.51% (95%CI: 20.32-50.70, I2 = 97.0%, p = 0.000). Primiparity (OR = 2.52, 95%CI: 1.62, 3.42), referral linkage (OR = 3.92, 95%CI: 2.73, 5.12), premature rupture of membrane (OR = 5.05, 95%CI: 2.03, 8.08), Obstructed labor (OR = 4.27, 95%CI: 1.62, 6.91) and maternal medical complications during pregnancy (OR = 7.10, 95%CI: 1.23, 12.98) had shown significant statistical association with neonatal near miss.
CONCLUSION
The prevalence of neonatal near miss in Ethiopia is evidenced to be high. Primiparity, referral linkage, premature rupture of membrane, obstructed labor and maternal medical complications during pregnancy were found to be determinant factors of neonatal near miss.
Topics: Infant; Pregnancy; Infant, Newborn; Female; Humans; Prevalence; Ethiopia; Near Miss, Healthcare; Parity; Morbidity; Dystocia
PubMed: 36809252
DOI: 10.1371/journal.pone.0278741 -
International Journal of Gynaecology... Aug 2023To assess the prevalence of intrauterine anomalies, primarily intrauterine adhesions (IUAd), after conservative surgical treatment of severe postpartum hemorrhage with... (Review)
Review
OBJECTIVE
To assess the prevalence of intrauterine anomalies, primarily intrauterine adhesions (IUAd), after conservative surgical treatment of severe postpartum hemorrhage with uterine atony (SPPH-UA) and determine patient eligibility for hysteroscopy.
METHODS
PubMed and the Cochrane Library were searched by combining keywords "postpartum hemorrhage", "uterine atony", and "hysteroscopy" to perform a literature review. Articles in French and English with more than five cases of hysteroscopy following SPPH-UA were selected. All cases that had hysteroscopy after conservative surgical treatment of SPPH-UA were collected. A blinded statistical analysis revealed IUAd risk factors.
RESULTS
In all, 83% of patients agreed to hysteroscopy and 38% of 71 cases had an IUAd. Age was not a risk factor (P = 0.950). Other factors included multiparity (odds ratio [OR] 1.93, P = 0.039), cesarean delivery (OR 3.58, P = 0.584) and postpartum infection (OR 3.33, P = 0.04). Risk was at 57% after uterine padding with multiple transfixing square stitches (Cho-technique) (P = 0.001), 6% after non-transfixing uterine folding brace suture (B-Lynch technique) when used alone, 29% after uterine artery embolization and after internal iliac artery ligation (OR 0.98, P = 0.645); uterine vascular ligation (OR 0.69, P = 0.253) and more than two procedures (OR 0.69, P = 2.53). Disparity between authors was observed (P = 0.015) and concerned only the surgical techniques used.
CONCLUSION
A classification is proposed for deciding post-SPPH hysteroscopy. Further studies are required to determine appropriateness.
Topics: Pregnancy; Female; Humans; Suture Techniques; Postpartum Hemorrhage; Uterus; Uterine Inertia; Uterine Diseases; Postpartum Period
PubMed: 36710527
DOI: 10.1002/ijgo.14704 -
BJOG : An International Journal of... Jul 2023There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There is conflicting evidence regarding the safety of Kielland's rotational forceps delivery (KRFD) in comparison with other modes of delivery for the management of persistent fetal malposition in the second stage of labour.
OBJECTIVES
To derive estimates of risks of maternal and neonatal complications following KRFD, compared with rotational ventouse delivery (RVD), non-rotational forceps delivery (NRFD) or a second-stage caesarean section (CS), from a systematic review and meta-analysis of the literature.
SEARCH STRATEGY
Standard search methodology, as recommended by the Cochrane Handbook for Systematic Reviews of Interventions.
SELECTION CRITERIA
Case series, prospective or retrospective cohort studies and population-based studies.
DATA COLLECTION AND ANALYSIS
A meta-analysis using a random-effects model was used to derive weighted pooled estimates of maternal and neonatal complications.
MAIN RESULTS
Thirteen studies were included. For postpartum haemorrhage there was no significant difference between Kielland's and ventouse delivery; the rate was lower in Kielland's delivery compared with non-rotational forceps (RR 0.79, 95% CI 0.65-0.95) and second-stage CS (RR 0.45, 95% CI 0.36-0.58). There were no differences in the rates of anal sphincter injuries or admission to neonatal intensive care. Rates of shoulder dystocia were higher with Kielland's delivery compared with ventouse delivery (RR 1.79, 95% CI 1.08-2.98), but rates of neonatal birth trauma were lower (RR 0.49, 95% CI 0.26-0.91). There were no differences seen in the rates of 5-min APGAR score < 7 between Kielland's delivery and other instrumental births, but they were lower when compared with second-stage CS (RR 0.47, 95% CI 0.23-0.97).
CONCLUSIONS
Kielland's rotational forceps delivery is a safe option for the management of fetal malposition in the second stage of labour.
Topics: Infant, Newborn; Pregnancy; Humans; Female; Extraction, Obstetrical; Obstetrical Forceps; Cesarean Section; Retrospective Studies; Prospective Studies; Obstetric Labor Complications; Infant, Newborn, Diseases
PubMed: 36694989
DOI: 10.1111/1471-0528.17402 -
Diagnostics (Basel, Switzerland) Nov 2022Asynclitism, the most feared malposition of the fetal head during labor, still represents to date an unresolved field of interest, remaining one of the most common... (Review)
Review
Asynclitism, the most feared malposition of the fetal head during labor, still represents to date an unresolved field of interest, remaining one of the most common causes of prolonged or obstructed labor, dystocia, assisted delivery, and cesarean section. Traditionally asynclitism is diagnosed by vaginal examination, which is, however, burdened by a high grade of bias. On the contrary, the recent scientific evidence highly suggests the use of intrapartum ultrasonography, which would be more accurate and reliable when compared to the vaginal examination for malposition assessment. The early detection and characterization of asynclitism by intrapartum ultrasound would become a valid tool for intrapartum evaluation. In this way, it will be possible for physicians to opt for the safest way of delivery according to an accurate definition of the fetal head position and station, avoiding unnecessary operative procedures and medication while improving fetal and maternal outcomes. This review re-evaluated the literature of the last 30 years on asynclitism, focusing on the progressive imposition of ultrasound as an intrapartum diagnostic tool. All the evidence emerging from the literature is presented and evaluated from our point of view, describing the most employed technique and considering the future implication of the progressive worldwide consolidation of asynclitism and ultrasound.
PubMed: 36553005
DOI: 10.3390/diagnostics12122998