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BMJ (Clinical Research Ed.) Sep 2016To assess the association between maternal glucose concentrations and adverse perinatal outcomes in women without gestational or existing diabetes and to determine... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To assess the association between maternal glucose concentrations and adverse perinatal outcomes in women without gestational or existing diabetes and to determine whether clear thresholds for identifying women at risk of perinatal outcomes can be identified.
DESIGN
Systematic review and meta-analysis of prospective cohort studies and control arms of randomised trials.
DATA SOURCES
Databases including Medline and Embase were searched up to October 2014 and combined with individual participant data from two additional birth cohorts.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Studies including pregnant women with oral glucose tolerance (OGTT) or challenge (OGCT) test results, with data on at least one adverse perinatal outcome.
APPRAISAL AND DATA EXTRACTION
Glucose test results were extracted for OGCT (50 g) and OGTT (75 g and 100 g) at fasting and one and two hour post-load timings. Data were extracted on induction of labour; caesarean and instrumental delivery; pregnancy induced hypertension; pre-eclampsia; macrosomia; large for gestational age; preterm birth; birth injury; and neonatal hypoglycaemia. Risk of bias was assessed with a modified version of the critical appraisal skills programme and quality in prognostic studies tools.
RESULTS
25 reports from 23 published studies and two individual participant data cohorts were included, with up to 207 172 women (numbers varied by the test and outcome analysed in the meta-analyses). Overall most studies were judged as having a low risk of bias. There were positive linear associations with caesarean section, induction of labour, large for gestational age, macrosomia, and shoulder dystocia for all glucose exposures across the distribution of glucose concentrations. There was no clear evidence of a threshold effect. In general, associations were stronger for fasting concentration than for post-load concentration. For example, the odds ratios for large for gestational age per 1 mmol/L increase of fasting and two hour post-load glucose concentrations (after a 75 g OGTT) were 2.15 (95% confidence interval 1.60 to 2.91) and 1.20 (1.13 to 1.28), respectively. Heterogeneity was low between studies in all analyses.
CONCLUSIONS
This review and meta-analysis identified a large number of studies in various countries. There was a graded linear association between fasting and post-load glucose concentration across the whole glucose distribution and most adverse perinatal outcomes in women without pre-existing or gestational diabetes. The lack of a clear threshold at which risk increases means that decisions regarding thresholds for diagnosing gestational diabetes are somewhat arbitrary. Research should now investigate the clinical and cost-effectiveness of applying different glucose thresholds for diagnosis of gestational diabetes on perinatal and longer term outcomes.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO CRD42013004608.
Topics: Birth Weight; Diabetes, Gestational; Dystocia; Evidence-Based Medicine; Female; Fetal Macrosomia; Glucose Tolerance Test; Humans; Hyperglycemia; Infant, Newborn; Pregnancy; Pregnancy Outcome; Premature Birth; Randomized Controlled Trials as Topic; Risk Factors
PubMed: 27624087
DOI: 10.1136/bmj.i4694 -
Clinical Journal of the American... Nov 2010Studies of the impact of systemic lupus erythematosus (SLE) and its pregnancy complications have yielded conflicting results. Major limitations of these studies relate... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND OBJECTIVES
Studies of the impact of systemic lupus erythematosus (SLE) and its pregnancy complications have yielded conflicting results. Major limitations of these studies relate to their small numbers of patients and retrospective designs. The aim of this study was to perform a systematic literature review of pregnancy outcomes in women with SLE and a meta-analysis of the association of lupus nephritis with adverse pregnancy outcomes.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS
We searched electronic databases from 1980 to 2009 and reviewed papers with validity criteria. Random-effects analytical methods were used to evaluate pregnancy complications rates.
RESULTS
Thirty-seven studies with 1842 patients and 2751 pregnancies were included. Maternal complications included lupus flare (25.6%), hypertension (16.3%), nephritis (16.1%), pre-eclampsia (7.6%), and eclampsia (0.8%). The induced abortion rate was 5.9%, and when excluded, fetal complications included spontaneous abortion (16.0%), stillbirth (3.6%), neonatal deaths (2.5%), and intrauterine growth retardation (12.7%). The unsuccessful pregnancy rate was 23.4%, and the premature birth rate was 39.4%. Meta-regression analysis showed statistically significant positive associations between premature birth rate and active nephritis and increased hypertension rates in subjects with active nephritis or a history of nephritis. History of nephritis was also associated with pre-eclampsia. Anti-phospholipid antibodies were associated with hypertension, premature birth, and an increased rate of induced abortion.
CONCLUSIONS
In patients with SLE, both lupus nephritis and anti-phospholipid antibodies increase the risks for maternal hypertension and premature births. The presented evidence further supports timing of pregnancy relative to SLE activity and multispecialty care of these patients.
Topics: Abortion, Induced; Abortion, Spontaneous; Antibodies, Antiphospholipid; Female; Fetal Death; Fetal Growth Retardation; Humans; Hypertension, Pregnancy-Induced; Live Birth; Lupus Erythematosus, Systemic; Lupus Nephritis; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Premature Birth; Risk Assessment; Risk Factors; Stillbirth
PubMed: 20688887
DOI: 10.2215/CJN.00240110 -
Journal of the American Heart... Oct 2020Background Nonpharmacologic interventions that modify lifestyle can lower blood pressure (BP) and have been assessed in numerous randomized controlled trials and... (Meta-Analysis)
Meta-Analysis
Background Nonpharmacologic interventions that modify lifestyle can lower blood pressure (BP) and have been assessed in numerous randomized controlled trials and pairwise meta-analyses. It is still unclear which intervention would be most efficacious. Methods and Results Bayesian network meta-analyses were performed to estimate the comparative effectiveness of different interventions for lowering BP. From 60 166 potentially relevant articles, 120 eligible articles (14 923 participants) with a median follow-up of 12 weeks, assessing 22 nonpharmacologic interventions, were included. According to the surface under the cumulative ranking probabilities and Grading of Recommendations Assessment, Development and Evaluation (GRADE) quality of evidence, for adults with prehypertension to established hypertension, high-quality evidence indicated that the Dietary Approach to Stop Hypertension (DASH) was superior to usual care and all other nonpharmacologic interventions in lowering systolic BP (weighted mean difference, 6.97 mm Hg; 95% credible interval, 4.50-9.47) and diastolic BP (weighted mean difference, 3.54 mm Hg; 95% credible interval, 1.80-5.28). Compared with usual care, moderate- to high-quality evidence indicated that aerobic exercise, isometric training, low-sodium and high-potassium salt, comprehensive lifestyle modification, breathing-control, and meditation could lower systolic BP and diastolic BP. For patients with hypertension, moderate- to high-quality evidence suggested that the interventions listed (except comprehensive lifestyle modification) were associated with greater systolic BP and diastolic BP reduction than usual care; salt restriction was also effective in lowering both systolic BP and diastolic BP. Among overweight and obese participants, low-calorie diet and low-calorie diet plus exercise could lower more BP than exercise. Conclusions DASH might be the most effective intervention in lowering BP for adults with prehypertension to established hypertension. Aerobic exercise, isometric training, low-sodium and high-potassium salt, comprehensive lifestyle modification, salt restriction, breathing-control, meditation and low-calorie diet also have obvious effects on BP reduction.
Topics: Comparative Effectiveness Research; Diet Therapy; Diet, Sodium-Restricted; Exercise; Humans; Hypertension; Prehypertension; Risk Reduction Behavior
PubMed: 32975166
DOI: 10.1161/JAHA.120.016804 -
International Journal of Environmental... Mar 2021: Hypertension is among the most important risk factors for cardiovascular diseases, which are considered high mortality risk medical conditions. To date, several... (Meta-Analysis)
Meta-Analysis Review
: Hypertension is among the most important risk factors for cardiovascular diseases, which are considered high mortality risk medical conditions. To date, several studies have reported positive effects of mindfulness-based stress reduction (MBSR) interventions on physical and psychological well-being in other medical conditions, but no meta-analysis on MBSR programs for hypertension has been conducted. Objectives: The objective of this study was to determine the effectiveness of MBSR programs for hypertension. : A systematic review and meta-analysis of randomized controlled trials examining the effects of MBSR on systolic and diastolic blood pressure (BP), anxiety, depression, and perceived stress in people with hypertension or pre-hypertension was conducted. The PubMed/MEDLINE and PsycINFO databases were searched in November 2020 to identify relevant studies. : Six studies were included. The comparison of MBSR versus control conditions on diastolic BP was associated with a statistically significant mean effect size favoring MBSR over control conditions ( = -2.029; 95% confidence interval (CI): -3.676 to -0.383, = 0.016, = 6; 22 effect sizes overall), without evidence of heterogeneity ( = 0.000%). The comparison of MBSR versus control conditions on systolic BP was associated with a mean effect size which was statistically significant only at a marginal level ( = -3.894; 95% CI: -7.736-0.053, = 0.047, = 6; 22 effect sizes overall), without evidence of high heterogeneity ( = 20.772%). The higher the proportion of participants on antihypertensive medications was, the larger the effects of MBSR were on systolic BP ( = -0.750, = -2.73, = 0.003). : MBSR seems to be a promising intervention, particularly effective on the reduction of diastolic BP. More well-conducted trials are required.
Topics: Anxiety; Blood Pressure; Humans; Hypertension; Mindfulness; Stress, Psychological
PubMed: 33799828
DOI: 10.3390/ijerph18062882 -
Ultrasound in Obstetrics & Gynecology :... Jul 2019Primary studies and systematic reviews provide estimates of varying accuracy for different factors in the prediction of pre-eclampsia. The aim of this study was to...
OBJECTIVE
Primary studies and systematic reviews provide estimates of varying accuracy for different factors in the prediction of pre-eclampsia. The aim of this study was to review published systematic reviews to collate evidence on the ability of available tests to predict pre-eclampsia, to identify high-value avenues for future research and to minimize future research waste in this field.
METHODS
MEDLINE, EMBASE and The Cochrane Library including DARE (Database of Abstracts of Reviews of Effects) databases, from database inception to March 2017, and bibliographies of relevant articles were searched, without language restrictions, for systematic reviews and meta-analyses on the prediction of pre-eclampsia. The quality of the included reviews was assessed using the AMSTAR tool and a modified version of the QUIPS tool. We evaluated the comprehensiveness of search, sample size, tests and outcomes evaluated, data synthesis methods, predictive ability estimates, risk of bias related to the population studied, measurement of predictors and outcomes, study attrition and adjustment for confounding.
RESULTS
From 2444 citations identified, 126 reviews were included, reporting on over 90 predictors and 52 prediction models for pre-eclampsia. Around a third (n = 37 (29.4%)) of all reviews investigated solely biochemical markers for predicting pre-eclampsia, 31 (24.6%) investigated genetic associations with pre-eclampsia, 46 (36.5%) reported on clinical characteristics, four (3.2%) evaluated only ultrasound markers and six (4.8%) studied a combination of tests; two (1.6%) additional reviews evaluated primary studies investigating any screening test for pre-eclampsia. Reviews included between two and 265 primary studies, including up to 25 356 688 women in the largest review. Only approximately half (n = 67 (53.2%)) of the reviews assessed the quality of the included studies. There was a high risk of bias in many of the included reviews, particularly in relation to population representativeness and study attrition. Over 80% (n = 106 (84.1%)) summarized the findings using meta-analysis. Thirty-two (25.4%) studies lacked a formal statement on funding. The predictors with the best test performance were body mass index (BMI) > 35 kg/m , with a specificity of 92% (95% CI, 89-95%) and a sensitivity of 21% (95% CI, 12-31%); BMI > 25 kg/m , with a specificity of 73% (95% CI, 64-83%) and a sensitivity of 47% (95% CI, 33-61%); first-trimester uterine artery pulsatility index or resistance index > 90 centile (specificity 93% (95% CI, 90-96%) and sensitivity 26% (95% CI, 23-31%)); placental growth factor (specificity 89% (95% CI, 89-89%) and sensitivity 65% (95% CI, 63-67%)); and placental protein 13 (specificity 88% (95% CI, 87-89%) and sensitivity 37% (95% CI, 33-41%)). No single marker had a test performance suitable for routine clinical use. Models combining markers showed promise, but none had undergone external validation.
CONCLUSIONS
This review of reviews calls into question the need for further aggregate meta-analysis in this area given the large number of published reviews subject to the common limitations of primary predictive studies. Prospective, well-designed studies of predictive markers, preferably randomized intervention studies, and combined through individual-patient data meta-analysis are needed to develop and validate new prediction models to facilitate the prediction of pre-eclampsia and minimize further research waste in this field. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
Topics: Adult; Biomarkers; Body Mass Index; Female; Humans; Mass Screening; Meta-Analysis as Topic; Placenta Growth Factor; Pre-Eclampsia; Predictive Value of Tests; Pregnancy; Pregnancy Complications; Prospective Studies; Pulsatile Flow; Risk Factors; Sensitivity and Specificity; Ultrasonography; Uterine Artery
PubMed: 30267475
DOI: 10.1002/uog.20117 -
Nutrients Oct 2017Vitamin D supplementation effects with or without calcium in pregnancy for reducing risk of preeclampsia and gestational or pregnancy induced hypertension are... (Meta-Analysis)
Meta-Analysis Review
Vitamin D supplementation effects with or without calcium in pregnancy for reducing risk of preeclampsia and gestational or pregnancy induced hypertension are controversial. Literature was systematically searched in Medline, Scopus and Cochrane databases from inception to July 2017. Only randomized controlled trials (RCTs) in English were selected if they had any pair of interventions (calcium, vitamin D, both, or placebo). Systematic review with two-step network-meta-analysis was used to indirectly estimate supplementary effects. Twenty-seven RCTs with 28,000 women were eligible. A direct meta-analysis suggested that calcium, vitamin D, and calcium plus vitamin D could lower risk of preeclampsia when compared to placebo with the pooled risk ratios (RRs) of 0.54 (0.41, 0.70), 0.47 (0.24, 0.89) and 0.50 (0.32, 0.78), respectively. Results of network meta-analysis were similar with the corresponding RRs of 0.49 (0.35, 0.69), 0.43 (0.17, 1.11), and 0.57 (0.30, 1.10), respectively. None of the controls were significant. Efficacy of supplementation, which was ranked by surface under cumulative ranking probabilities, were: vitamin D (47.4%), calcium (31.6%) and calcium plus vitamin D (19.6%), respectively. Calcium supplementation may be used for prevention for preeclampsia. Vitamin D might also worked well but further large scale RCTs are warranted to confirm our findings.
Topics: Adolescent; Adult; Calcium; Dietary Supplements; Female; Humans; Pre-Eclampsia; Pregnancy; Randomized Controlled Trials as Topic; Risk Factors; Treatment Outcome; Vitamin D; Young Adult
PubMed: 29057843
DOI: 10.3390/nu9101141 -
Experimental Gerontology Jun 2023The chronic antihypertensive effect of resistance training (RT) has been widely recognized in mixed-aged populations. However, the specific effect of RT on blood... (Meta-Analysis)
Meta-Analysis Review
The chronic antihypertensive effect of resistance training (RT) has been widely recognized in mixed-aged populations. However, the specific effect of RT on blood pressure (BP) in older individuals (≥60 years) remains unknown. Therefore, this meta-analysis of randomized controlled trials explored the chronic effects of dynamic RT alone on BP in older people. The study followed the PRISMA statement, and the search was performed using MeSH terms "strength training", "blood pressure" and "aged" on MEDLINE (PubMed), SCOPUS, and Web of Science databases. From 1783 potential articles, 24 studies met all inclusion criteria resulting in 835 participants randomized into 26 RT interventions (n = 430) and 24 control groups (n = 405). Overall, BP reduction favoring RT was observed both in SBP (-6.88 [-10.02, -3.73] mmHg) and DBP (-3.37 [-4.71, -2.22] mmHg). Subgroup analysis revealed BP decreases in both participants with hypertension (SBP: -10.42 [-15.67, -5.17]; DBP: -3.99 [-5.76,-2.22] mmHg), and prehypertension (SBP: -4.87 [-7.76, -1.98]; DBP: -2.77 [-4.88, -0.66] mmHg). Improvement in BP was found in studies using traditional RT (free weights and machines) (SBP: -7.04 [-11.04, -3.05]; DBP: -2.60 [-3.72, -1.47] mmHg) and elastic band interventions (SBP: -2.79 [-3.72, -1.86]; DBP:-1.68 [-3.18, -0.18] mmHg). RT performed at moderate intensity (60-80 % 1RM) reduced SBP (-6.98, [-11.93, -2.03]mmHg) and DBP (-3.64 [-5.11, -2.18] mmHg). In conclusion, RT can reduce BP in older people at prehypertensive and hypertensive stage, with traditional RT performed with moderate loads leading to an effect estimate of approximately -7 mmHg for SBP and -4 mmHg for DBP.
Topics: Humans; Aged; Prehypertension; Resistance Training; Hypertension; Blood Pressure; Antihypertensive Agents
PubMed: 37121334
DOI: 10.1016/j.exger.2023.112193 -
International Journal of Stroke :... Feb 2021Coronavirus disease 2019 (COVID-19) has become a global pandemic, affecting millions of people. However, the relationship between COVID-19 and acute cerebrovascular... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Coronavirus disease 2019 (COVID-19) has become a global pandemic, affecting millions of people. However, the relationship between COVID-19 and acute cerebrovascular diseases is unclear.
AIMS
We aimed to characterize the incidence, risk factors, clinical-radiological manifestations, and outcome of COVID-19-associated stroke.
METHODS
Three medical databases were systematically reviewed for published articles on acute cerebrovascular diseases in COVID-19 (December 2019-September 2020). The review protocol was previously registered (PROSPERO ID = CRD42020185476). Data were extracted from articles reporting ≥5 stroke cases in COVID-19. We complied with the PRISMA guidelines and used the Newcastle-Ottawa Scale to assess data quality. Data were pooled using a random-effect model.
SUMMARY OF REVIEW
Of 2277 initially identified articles, 61 (2.7%) were entered in the meta-analysis. Out of 108,571 patients with COVID-19, acute CVD occurred in 1.4% (95%CI: 1.0-1.9). The most common manifestation was acute ischemic stroke (87.4%); intracerebral hemorrhage was less common (11.6%). Patients with COVID-19 developing acute cerebrovascular diseases, compared to those who did not, were older (pooled median difference = 4.8 years; 95%CI: 1.7-22.4), more likely to have hypertension (OR = 7.35; 95%CI: 1.94-27.87), diabetes mellitus (OR = 5.56; 95%CI: 3.34-9.24), coronary artery disease (OR = 3.12; 95%CI: 1.61-6.02), and severe infection (OR = 5.10; 95%CI: 2.72-9.54). Compared to individuals who experienced a stroke without the infection, patients with COVID-19 and stroke were younger (pooled median difference = -6.0 years; 95%CI: -12.3 to -1.4), had higher NIHSS (pooled median difference = 5; 95%CI: 3-9), higher frequency of large vessel occlusion (OR = 2.73; 95%CI: 1.63-4.57), and higher in-hospital mortality rate (OR = 5.21; 95%CI: 3.43-7.90).
CONCLUSIONS
Acute cerebrovascular diseases are not uncommon in patients with COVID-19, especially in those whom are severely infected and have pre-existing vascular risk factors. The pattern of large vessel occlusion and multi-territory infarcts suggests that cerebral thrombosis and/or thromboembolism could be possible causative pathways for the disease.
Topics: Brain Ischemia; COVID-19; Humans; Observational Studies as Topic; Risk Factors; Stroke
PubMed: 33103610
DOI: 10.1177/1747493020972922 -
Frontiers in Nutrition 2021The modified Dietary Approaches to Stop Hypertension (DASH) diet was a potentially effective treatment for pre-hypertensive and hypertensive patients. The evidence for...
The modified Dietary Approaches to Stop Hypertension (DASH) diet was a potentially effective treatment for pre-hypertensive and hypertensive patients. The evidence for the effect of the modified DASH diet on blood pressure reduction was inconsistent. The study was designed to assess the effects of the modified DASH diet on blood pressure (BP) in hypertensive and pre-hypertensive adults. We searched Medline, Embase, CENTRAL, CNKI, VIP, Wanfang Data, SINOMED, Google Scholar, the World Health Organization's International Clinical Trials Registry Platform, and Clinicaltrials.gov from inception to July 1st, 2021. Randomized controlled trials (RCTs) assessing the effects of the modified DASH diet on systolic and diastolic BP, cardiovascular risk factors (body weight, body mass index, waist circumference, fasting glucose, blood lipids), cardiovascular events, and all-cause mortality were included. Statistical analysis was performed using Stata software. Risk of bias was assessed with the Cochrane tool and quality of evidence with GRADE. A total of 10 RCTs were included. Compared with control diet, the modified DASH diet could reduce mean systolic (-3.26 mmHg; 95% confidence interval -5.58, -0.94 mmHg; = 0.006) and diastolic (-2.07 mmHg; 95% confidence interval -3.68, -0.46 mmHg; = 0.01) BP. Compared with the controlling diet, the modified DASH diet could reduce systolic BP to a greater extent in trials with a mean baseline BP ≥ 140/90 mmHg compared with <140/90 mmHg. Diastolic BP reduction was greater when the mean body mass index was ≥30 kg/m2 than <30 kg/m. Diastolic BP reduction was more marked in trials with a follow-up time of >8 weeks compared with ≤8 weeks. The modified DASH diet could affect mean waist circumference (difference: 1.57 cm; 95% confidence interval -2.98, -0.15) and triglyceride concentration (difference: 1.04 mol/L; 95% confidence interval -1.47, -0.60). The modified DASH diet can reduce BP, waist circumference, and triglyceride concentration in hypertension patients. A higher baseline BP is associated with more marked systolic and diastolic BP reduction. PROSPERO registration number: CRD42020190860.
PubMed: 34557511
DOI: 10.3389/fnut.2021.725020 -
The Cochrane Database of Systematic... Nov 2017Gestational diabetes mellitus (GDM) is associated with a wide range of adverse health consequences for women and their infants in the short and long term. With an... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Gestational diabetes mellitus (GDM) is associated with a wide range of adverse health consequences for women and their infants in the short and long term. With an increasing prevalence of GDM worldwide, there is an urgent need to assess strategies for GDM prevention, such as combined diet and exercise interventions. This is an update of a Cochrane review that was first published in 2015.
OBJECTIVES
To assess the effects of diet interventions in combination with exercise interventions for pregnant women for preventing GDM, and associated adverse health consequences for the mother and her infant/child.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 November 2016) and reference lists of retrieved studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) and cluster-RCTs, comparing combined diet and exercise interventions with no intervention (i.e. standard care), that reported on GDM diagnosis as an outcome. Quasi-RCTs were excluded. Cross-over trials were not eligible for inclusion. We planned to include RCTs comparing two or more different diet/exercise interventions, however none were identified.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed study eligibility, extracted data, assessed the risk of bias of the included trials and assessed quality of evidence for selected maternal and infant/child outcomes using the GRADE approach. We checked data for accuracy.
MAIN RESULTS
In this update, we included 23 RCTs (involving 8918 women and 8709 infants) that compared combined diet and exercise interventions with no intervention (standard care). The studies varied in the diet and exercise programs evaluated and health outcomes reported. None reported receiving funding from a drug manufacturer or agency with interests in the results. Overall risk of bias was judged to be unclear due to the lack of methodological detail reported. Most studies were undertaken in high-income countries.For our primary review outcomes, there was a possible reduced risk of GDM in the diet and exercise intervention group compared with the standard care group (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.71 to 1.01; 6633 women; 19 RCTs; Tau² = 0.05; I² = 42%; P = 0.07; moderate-quality evidence). There was also a possible reduced risk of caesarean section (RR 0.95, 95% CI 0.88 to 1.02; 6089 women; 14 RCTs; moderate-quality evidence). No clear differences were seen between groups for pre-eclampsia (RR 0.98, 95% CI 0.79 to 1.22; 5366 participants; 8 RCTs; low-quality evidence), pregnancy-induced hypertension and/or hypertension (average RR 0.78, 95% CI 0.47 to 1.27; 3073 participants; 6 RCTs; Tau² = 0.19; I² = 62%; very low-quality evidence), perinatal mortality (RR 0.82, 95% CI 0.42 to 1.63; 3757 participants; 2 RCTs; low-quality evidence) or large-for-gestational age (RR 0.93, 95% CI 0.81 to 1.07; 5353 participants; 11 RCTs; low-quality evidence). No data were reported for infant mortality or morbidity composite.Subgroup analyses (based on trial design, maternal body mass index (BMI) and ethnicity) revealed no clear differential treatment effects. We were unable to assess the impact of maternal age, parity and specific features of the diet and exercise interventions. Findings from sensitivity analyses (based on RCT quality) generally supported those observed in the main analyses. We were not able to perform subgroup analyses based on maternal age, parity or nature of the exercise/dietary interventions due to the paucity of information/data on these characteristics and the inability to meaningfully group intervention characteristics.For most of the secondary review outcomes assessed using GRADE, there were no clear differences between groups, including for perineal trauma (RR 1.27, 95% CI 0.78 to 2.05; 2733 participants; 2 RCTs; moderate-quality evidence), neonatal hypoglycaemia (average RR 1.42, 95% CI 0.67 to 2.98; 3653 participants; 2 RCTs; Tau² = 0.23; I² = 77%; low quality evidence); and childhood adiposity (BMI z score) (MD 0.05, 95% CI -0.29 to 0.40; 794 participants; 2 RCTs; Tau² = 0.04; I² = 59%; low-quality evidence). However, there was evidence of less gestational weight gain in the diet and exercise intervention group compared with the control group (mean difference (MD) -0.89 kg, 95% CI -1.39 to -0.40; 5052 women; 16 RCTs; Tau² = 0.37; I² = 43%;moderate-quality evidence). No data were reported for maternal postnatal depression or type 2 diabetes; childhood/adulthood type 2 diabetes, or neurosensory disability.
AUTHORS' CONCLUSIONS
Moderate-quality evidence suggests reduced risks of GDM and caesarean section with combined diet and exercise interventions during pregnancy as well as reductions in gestational weight gain, compared with standard care. There were no clear differences in hypertensive disorders of pregnancy, perinatal mortality, large-for-gestational age, perineal trauma, neonatal hypoglycaemia, and childhood adiposity (moderate- tovery low-quality evidence).Using GRADE methodology, the evidence was assessed as moderate to very low quality. Downgrading decisions were predominantly due to design limitations (risk of bias), and imprecision (uncertain effect estimates, and at times, small sample sizes and low event rates), however two outcomes (pregnancy-induced hypertension/hypertension and neonatal hypoglycaemia), were also downgraded for unexplained inconsistency (statistical heterogeneity).Due to the variability of the diet and exercise components tested in the included studies, the evidence in this review has limited ability to inform practice. Future studies could describe the interventions used in more detail, if and how these influenced behaviour change and ideally be standardised between studies. Studies could also consider using existing core outcome sets to facilitate more standardised reporting.
Topics: Cesarean Section; Combined Modality Therapy; Diabetes, Gestational; Diet; Exercise; Female; Humans; Hypertension; Infant, Newborn; Perinatal Mortality; Perineum; Pregnancy; Pregnancy Complications, Cardiovascular; Randomized Controlled Trials as Topic
PubMed: 29129039
DOI: 10.1002/14651858.CD010443.pub3