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Reproductive Health Sep 2014There is increasingly a double burden of under-nutrition and obesity in women of reproductive age. Preconception underweight or overweight, short stature and... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
There is increasingly a double burden of under-nutrition and obesity in women of reproductive age. Preconception underweight or overweight, short stature and micronutrient deficiencies all contribute to excess maternal and fetal complications during pregnancy.
METHODS
A systematic review and meta-analysis of the evidence was conducted to ascertain the possible impact of preconception care for adolescents, women and couples of reproductive age on maternal, newborn and child health (MNCH) outcomes. A comprehensive strategy was used to search electronic reference libraries, and both observational and clinical controlled trials were included. Cross-referencing and a separate search strategy for each preconception risk and intervention ensured wider study capture.
RESULTS
Maternal pre-pregnancy weight is a significant factor in the preconception period with underweight contributing to a 32% higher risk of preterm birth, and obesity more than doubling the risk for preeclampsia, gestational diabetes. Overweight women are more likely to undergo a Cesarean delivery, and their newborns have higher chances of being born with a neural tube or congenital heart defect. Among nutrition-specific interventions, preconception folic acid supplementation has the strongest evidence of effect, preventing 69% of recurrent neural tube defects. Multiple micronutrient supplementation shows promise to reduce the rates of congenital anomalies and risk of preeclampsia. Although over 40% of women worldwide are anemic in the preconception period, only one study has shown a risk for low birth weight.
CONCLUSION
All women, but especially those who become pregnant in adolescence or have closely-spaced pregnancies (inter-pregnancy interval less than six months), require nutritional assessment and appropriate intervention in the preconception period with an emphasis on optimizing maternal body mass index and micronutrient reserves. Increasing coverage of nutrition-specific and nutrition-sensitive strategies (such as food fortification; integration of nutrition initiatives with other maternal and child health interventions; and community based platforms) is necessary among adolescent girls and women of reproductive age. The effectiveness of interventions will need to be simultaneously monitored, and form the basis for the development of improved delivery strategies and new nutritional interventions.
Topics: Body Weight; Congenital Abnormalities; Dietary Supplements; Female; Folic Acid; Humans; Infant, Newborn; Preconception Care; Pregnancy; Pregnancy Complications; Prenatal Nutritional Physiological Phenomena
PubMed: 25415364
DOI: 10.1186/1742-4755-11-S3-S3 -
Fertility and Sterility Jul 2022To investigate whether a significant association between vitamin D status and the risk of miscarriage or recurrent miscarriage (RM) exists. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To investigate whether a significant association between vitamin D status and the risk of miscarriage or recurrent miscarriage (RM) exists.
DESIGN
Systematic review and meta-analysis.
SETTING
Not applicable.
PATIENT(S)
Women with miscarriage and RM.
INTERVENTION(S)
We searched the Ovid MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central Register of Controlled Trials from database inception to May 2021. Randomized and observational studies investigating the association between maternal vitamin D status and miscarriage and/or vitamin D treatment and miscarriage were included.
MAIN OUTCOME MEASURE(S)
The primary outcome was miscarriage or RM, with vitamin D status used as the predictor of risk. Whether vitamin D treatment reduces the risk of miscarriage and RM was also assessed.
RESULT(S)
Of 902 studies identified, 10 (n = 7,663 women) were included: 4 randomized controlled trials (n = 666 women) and 6 observational studies (n = 6,997 women). Women diagnosed with vitamin D deficiency (<50 nmol/L) had an increased risk of miscarriage compared with women who were vitamin D replete (>75 nmol/L) (odds ratio, 1.94; 95% confidence interval, 1.25-3.02; 4 studies; n = 3,674; I = 18%). Combined analysis, including women who were vitamin D insufficient (50-75 nmol/L) and deficient (<50 nmol/L) compared with women who were replete (>75 nmol/L), found an association with miscarriage (odds ratio, 1.60; 95% confidence interval, 1.11-2.30; 6 studies; n = 6,338; I = 35%). Although 4 randomized controlled trials assessed the effect of vitamin D treatment on miscarriage, study heterogeneity, data quality, and reporting bias precluded direct comparison and meta-analysis. The overall study quality was "low" or "very low" using the Grading of Recommendations, Assessment, Development and Evaluations approach.
CONCLUSION(S)
Vitamin D deficiency and insufficiency are associated with miscarriage. Whether preconception treatment of vitamin D deficiency protects against pregnancy loss in women at risk of miscarriage remains unknown.
REGISTRATION NUMBER
CRD42021259899.
Topics: Abortion, Habitual; Female; Humans; Pregnancy; Vitamin D; Vitamin D Deficiency; Vitamins
PubMed: 35637024
DOI: 10.1016/j.fertnstert.2022.04.017 -
Annals of the Rheumatic Diseases Mar 2017Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS).
EULAR recommendations for women's health and the management of family planning, assisted reproduction, pregnancy and menopause in patients with systemic lupus erythematosus and/or antiphospholipid syndrome.
OBJECTIVES
Develop recommendations for women's health issues and family planning in systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS).
METHODS
Systematic review of evidence followed by modified Delphi method to compile questions, elicit expert opinions and reach consensus.
RESULTS
Family planning should be discussed as early as possible after diagnosis. Most women can have successful pregnancies and measures can be taken to reduce the risks of adverse maternal or fetal outcomes. Risk stratification includes disease activity, autoantibody profile, previous vascular and pregnancy morbidity, hypertension and the use of drugs (emphasis on benefits from hydroxychloroquine and antiplatelets/anticoagulants). Hormonal contraception and menopause replacement therapy can be used in patients with stable/inactive disease and low risk of thrombosis. Fertility preservation with gonadotropin-releasing hormone analogues should be considered prior to the use of alkylating agents. Assisted reproduction techniques can be safely used in patients with stable/inactive disease; patients with positive antiphospholipid antibodies/APS should receive anticoagulation and/or low-dose aspirin. Assessment of disease activity, renal function and serological markers is important for diagnosing disease flares and monitoring for obstetrical adverse outcomes. Fetal monitoring includes Doppler ultrasonography and fetal biometry, particularly in the third trimester, to screen for placental insufficiency and small for gestational age fetuses. Screening for gynaecological malignancies is similar to the general population, with increased vigilance for cervical premalignant lesions if exposed to immunosuppressive drugs. Human papillomavirus immunisation can be used in women with stable/inactive disease.
CONCLUSIONS
Recommendations for women's health issues in SLE and/or APS were developed using an evidence-based approach followed by expert consensus.
Topics: Antiphospholipid Syndrome; Contraceptives, Oral, Hormonal; Delphi Technique; Early Detection of Cancer; Estrogen Replacement Therapy; Family Planning Services; Female; Fertility Preservation; Fetal Monitoring; Genital Neoplasms, Female; Humans; Lupus Erythematosus, Systemic; Menopause; Preconception Care; Pregnancy; Pregnancy Complications; Reproductive Techniques, Assisted; Risk Assessment
PubMed: 27457513
DOI: 10.1136/annrheumdis-2016-209770 -
Nutrients May 2018Rising rates of gestational diabetes mellitus (GDM) and related complications have prompted calls to identify potentially modifiable risk factors that are associated... (Meta-Analysis)
Meta-Analysis Review
Rising rates of gestational diabetes mellitus (GDM) and related complications have prompted calls to identify potentially modifiable risk factors that are associated with gestational diabetes mellitus (GDM). We systematically reviewed the scientific literature for observational studies examining specific dietary and/or physical activity (PA) factors and risk of GDM. Our search included PubMed, Medline, CINAHL/EBSCO, Science Direct and EMBASE, and identified 1167 articles, of which 40 met our inclusion criteria (e.g., singleton pregnancy, reported diet or PA data during pre-pregnancy/early pregnancy and GDM as an outcome measure). Studies were assessed for quality using a modified Quality Criteria Checklist from American Dietetic Association. Of the final 40 studies, 72% obtained a positive quality rating and 28% were rated neutral. The final analysis incorporated data on 30,871 pregnant women. Dietary studies were categorised into either caffeine, carbohydrate, fat, protein, calcium, fast food and recognized dietary patterns. Diets such as Mediterranean Diet (MedDiet), Dietary Approaches to Stop Hypertension (DASH) diet and Alternate Healthy Eating Index diet (AHEI) were associated with 15–38% reduced relative risk of GDM. In contrast, frequent consumption of potato, meat/processed meats, and protein (% energy) derived from animal sources was associated with an increased risk of GDM. Compared to no PA, any pre-pregnancy or early pregnancy PA was associated with 30% and 21% reduced odds of GDM, respectively. Engaging in >90 min/week of leisure time PA before pregnancy was associated with 46% decreased odds of GDM. We conclude that diets resembling MedDiet/DASH diet as well as higher PA levels before or in early pregnancy were associated with lower risks or odds of GDM respectively. The systematic review was registered at PROSPERO (www.crd.york.ac.uk/PROSPERO) as CRD42016027795.
Topics: Diabetes, Gestational; Diet, Healthy; Diet, Mediterranean; Dietary Approaches To Stop Hypertension; Evidence-Based Medicine; Exercise; Female; Healthy Lifestyle; Humans; Maternal Nutritional Physiological Phenomena; Preconception Care; Pregnancy; Prenatal Nutritional Physiological Phenomena; Protective Factors
PubMed: 29849003
DOI: 10.3390/nu10060698 -
Annals of the Rheumatic Diseases May 2016A European League Against Rheumatism (EULAR) task force was established to define points to consider on use of antirheumatic drugs before pregnancy, and during pregnancy...
A European League Against Rheumatism (EULAR) task force was established to define points to consider on use of antirheumatic drugs before pregnancy, and during pregnancy and lactation. Based on a systematic literature review and pregnancy exposure data from several registries, statements on the compatibility of antirheumatic drugs during pregnancy and lactation were developed. The level of agreement among experts in regard to statements and propositions of use in clinical practice was established by Delphi voting. The task force defined 4 overarching principles and 11 points to consider for use of antirheumatic drugs during pregnancy and lactation. Compatibility with pregnancy and lactation was found for antimalarials, sulfasalazine, azathioprine, ciclosporin, tacrolimus, colchicine, intravenous immunoglobulin and glucocorticoids. Methotrexate, mycophenolate mofetil and cyclophosphamide require discontinuation before conception due to proven teratogenicity. Insufficient documentation in regard to fetal safety implies the discontinuation of leflunomide, tofacitinib as well as abatacept, rituximab, belimumab, tocilizumab, ustekinumab and anakinra before a planned pregnancy. Among biologics tumour necrosis factor inhibitors are best studied and appear reasonably safe with first and second trimester use. Restrictions in use apply for the few proven teratogenic drugs and the large proportion of medications for which insufficient safety data for the fetus/child are available. Effective drug treatment of active inflammatory rheumatic disease is possible with reasonable safety for the fetus/child during pregnancy and lactation. The dissemination of the data to health professionals and patients as well as their implementation into clinical practice may help to improve the management of pregnant and lactating patients with rheumatic disease.
Topics: Abnormalities, Drug-Induced; Antirheumatic Agents; Biological Products; Delphi Technique; Female; Humans; Infant, Newborn; Lactation; Maternal-Fetal Exchange; Preconception Care; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Prenatal Exposure Delayed Effects; Rheumatic Diseases
PubMed: 26888948
DOI: 10.1136/annrheumdis-2015-208840 -
Autoimmunity Reviews Oct 2021To identify and assess the magnitude of effect of pregnancy outcome predictors in women with antiphospholipid syndrome (APS) by means of systematic review and... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To identify and assess the magnitude of effect of pregnancy outcome predictors in women with antiphospholipid syndrome (APS) by means of systematic review and meta-analysis.
METHODS
PubMed and Embase were searched (13th June 2020) for studies reporting on pre-pregnancy risk factors of pregnancy outcomes in APS patients. Literature screening and data extraction were conducted by two reviewers independently, in a blinded standardized manner. Pooled univariate odds ratios (OR) were computed using a random effects model. Heterogeneity was assessed by I%.
RESULTS
The search yielded 3013 unique results; 27 records were included in this meta-analysis. Previous thrombosis was associated with a decreased live birth risk (OR 0.60, p < 0.01, I = 40%), increased neonatal mortality (OR 15.19, p < 0.01, I = 0%), an increased risk of antenatal or postpartum thrombosis (OR 6.26, p < 0.01, I = 0%) and an increased risk of delivering a small for gestational age neonate (SGA) (OR 2.60, p = 0.01, I = 0%). Patients with an APS laboratory category I (double or triple positivity) profile had a decreased live birth risk (OR 0.66, p < 0.01, I = 0%), an increased risk of SGA (OR 1.86, p = 0.01, I = 43%) and preterm birth (OR 1.35, p < 0.01, I = 49%). Triple positivity was associated with a decreased live birth risk (OR 0.33, p < 0.01, I = 68%), an increased risk of preeclampsia (OR 2.43, p = 0.02, I = 35%) and SGA (OR 2.47, p = 0.04, I = 61%). Patients with lupus anticoagulant positivity had an increased risk of preeclampsia (OR 2.10, p = 0.02, I = 48%), SGA (OR 1.78, p < 0.01, I = 0%) and preterm birth (OR 3.56, p = 0.01, I = 48%). Risk of bias assessment suggested considerable bias on study participation and statistical methods.
CONCLUSIONS
The results of this meta-analysis identified previous thrombosis, laboratory category I, triple positivity and lupus anticoagulant positivity as the most important predictors of adverse pregnancy outcomes. This up-to-date knowledge, can be used in preconception counseling and tailoring of obstetric care.
Topics: Antiphospholipid Syndrome; Female; Humans; Infant, Newborn; Lupus Coagulation Inhibitor; Pre-Eclampsia; Pregnancy; Pregnancy Outcome; Premature Birth
PubMed: 34280554
DOI: 10.1016/j.autrev.2021.102901 -
PLoS Medicine Aug 2019Women who undergo bariatric surgery prior to pregnancy are less likely to experience comorbidities associated with obesity such as gestational diabetes and hypertension.... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Women who undergo bariatric surgery prior to pregnancy are less likely to experience comorbidities associated with obesity such as gestational diabetes and hypertension. However, bariatric surgery, particularly malabsorptive procedures, can make patients susceptible to deficiencies in nutrients that are essential for healthy fetal development. The objective of this systematic review and meta-analysis is to investigate the association between pregnancy after bariatric surgery and adverse perinatal outcomes.
METHODS AND FINDINGS
Searches were conducted in Medline, Embase, PsycINFO, CINAHL, Scopus, and Google Scholar from inception to June 2019, supplemented by hand-searching reference lists, citations, and journals. Observational studies comparing perinatal outcomes post-bariatric surgery to pregnancies without prior bariatric surgery were included. Outcomes of interest were perinatal mortality, congenital anomalies, preterm birth, postterm birth, small and large for gestational age (SGA/LGA), and neonatal intensive care unit (NICU) admission. Pooled effect sizes were calculated using random-effects meta-analysis. Where data were available, results were subgrouped by type of bariatric surgery. We included 33 studies with 14,880 pregnancies post-bariatric surgery and 3,979,978 controls. Odds ratios (ORs) were increased after bariatric surgery (all types combined) for perinatal mortality (1.38, 95% confidence interval [CI] 1.03-1.85, p = 0.031), congenital anomalies (1.29, 95% CI 1.04-1.59, p = 0.019), preterm birth (1.57, 95% CI 1.38-1.79, p < 0.001), and NICU admission (1.41, 95% CI 1.25-1.59, p < 0.001). Postterm birth decreased after bariatric surgery (OR 0.46, 95% CI 0.35-0.60, p < 0.001). ORs for SGA increased (2.72, 95% CI 2.32-3.20, p < 0.001) and LGA decreased (0.24, 95% CI 0.14-0.41, p < 0.001) after gastric bypass but not after gastric banding. Babies born after bariatric surgery (all types combined) weighed over 200 g less than those born to mothers without prior bariatric surgery (weighted mean difference -242.42 g, 95% CI -307.43 to -177.40 g, p < 0.001). There was low heterogeneity for all outcomes (I2 < 40%) except LGA. Limitations of our study are that as a meta-analysis of existing studies, the results are limited by the quality of the included studies and available data, unmeasured confounders, and the small number of studies for some outcomes.
CONCLUSIONS
In our systematic review of observational studies, we found that bariatric surgery, especially gastric bypass, prior to pregnancy was associated with increased risk of some adverse perinatal outcomes. This suggests that women who have undergone bariatric surgery may benefit from specific preconception and pregnancy nutritional support and increased monitoring of fetal growth and development. Future studies should explore whether restrictive surgery results in better perinatal outcomes, compared to malabsorptive surgery, without compromising maternal outcomes. If so, these may be the preferred surgery for women of reproductive age.
TRIAL REGISTRATION
PROSPERO CRD42017051537.
Topics: Bariatric Surgery; Birth Weight; Female; Gestational Age; Humans; Infant; Infant, Newborn; Intensive Care Units, Neonatal; Perinatal Mortality; Pregnancy; Pregnancy Outcome
PubMed: 31386658
DOI: 10.1371/journal.pmed.1002866 -
The Cochrane Database of Systematic... Apr 2021Infertility is a prevalent problem that has significant consequences for individuals, families, and the community. Modifiable lifestyle factors may affect the chance of... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Infertility is a prevalent problem that has significant consequences for individuals, families, and the community. Modifiable lifestyle factors may affect the chance of people with infertility having a baby. However, no guideline is available about what preconception advice should be offered. It is important to determine what preconception advice should be given to people with infertility and to evaluate whether this advice helps them make positive behavioural changes to improve their lifestyle and their chances of conceiving.
OBJECTIVES
To assess the safety and effectiveness of preconception lifestyle advice on fertility outcomes and lifestyle behavioural changes for people with infertility.
SEARCH METHODS
We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, CENTRAL, MEDLINE, Embase, PsycINFO, AMED, CINAHL, trial registers, Google Scholar, and Epistemonikos in January 2021; we checked references and contacted field experts to identify additional studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs), randomised cross-over studies, and cluster-randomised studies that compared at least one form of preconception lifestyle advice with routine care or attention control for people with infertility.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures recommended by Cochrane. Primary effectiveness outcomes were live birth and ongoing pregnancy. Primary safety outcomes were adverse events and miscarriage. Secondary outcomes included reported behavioural changes in lifestyle, birth weight, gestational age, clinical pregnancy, time to pregnancy, quality of life, and male factor infertility outcomes. We assessed the overall quality of evidence using GRADE criteria.
MAIN RESULTS
We included in the review seven RCTs involving 2130 participants. Only one RCT included male partners. Three studies compared preconception lifestyle advice on a combination of topics with routine care or attention control. Four studies compared preconception lifestyle advice on one topic (weight, alcohol intake, or smoking) with routine care for women with infertility and specific lifestyle characteristics. The evidence was of low to very low-quality. The main limitations of the included studies were serious risk of bias due to lack of blinding, serious imprecision, and poor reporting of outcome measures. Preconception lifestyle advice on a combination of topics versus routine care or attention control Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.79 to 1.10; 1 RCT, 626 participants), but the quality of evidence was low. No studies reported on adverse events or miscarriage. Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice on a combination of topics affects lifestyle behavioural changes: body mass index (BMI) (mean difference (MD) -1.06 kg/m², 95% CI -2.33 to 0.21; 1 RCT, 180 participants), vegetable intake (MD 12.50 grams/d, 95% CI -8.43 to 33.43; 1 RCT, 264 participants), alcohol abstinence in men (RR 1.08, 95% CI 0.74 to 1.58; 1 RCT, 210 participants), or smoking cessation in men (RR 1.01, 95% CI 0.91 to 1.12; 1 RCT, 212 participants). Preconception lifestyle advice on a combination of topics may result in little to no difference in the number of women with adequate folic acid supplement use (RR 0.98, 95% CI 0.95 to 1.01; 2 RCTs, 850 participants; I² = 4%), alcohol abstinence (RR 1.07, 95% CI 0.99 to 1.17; 1 RCT, 607 participants), and smoking cessation (RR 1.01, 95% CI 0.98 to 1.04; 1 RCT, 606 participants), on low quality evidence. No studies reported on other behavioural changes. Preconception lifestyle advice on weight versus routine care Studies on preconception lifestyle advice on weight were identified only in women with infertility and obesity. Compared to routine care, we are uncertain whether preconception lifestyle advice on weight affects the number of live births (RR 0.94, 95% CI 0.62 to 1.43; 2 RCTs, 707 participants; I² = 68%; very low-quality evidence), adverse events including gestational diabetes (RR 0.78, 95% CI 0.48 to 1.26; 1 RCT, 317 participants; very low-quality evidence), hypertension (RR 1.07, 95% CI 0.66 to 1.75; 1 RCT, 317 participants; very low-quality evidence), or miscarriage (RR 1.50, 95% CI 0.95 to 2.37; 1 RCT, 577 participants; very low-quality evidence). Regarding lifestyle behavioural changes for women with infertility and obesity, preconception lifestyle advice on weight may slightly reduce BMI (MD -1.30 kg/m², 95% CI -1.58 to -1.02; 1 RCT, 574 participants; low-quality evidence). Due to very low-quality evidence, we are uncertain whether preconception lifestyle advice affects the percentage of weight loss, vegetable and fruit intake, alcohol abstinence, or physical activity. No studies reported on other behavioural changes. Preconception lifestyle advice on alcohol intake versus routine care Studies on preconception lifestyle advice on alcohol intake were identified only in at-risk drinking women with infertility. We are uncertain whether preconception lifestyle advice on alcohol intake affects the number of live births (RR 1.15, 95% CI 0.53 to 2.50; 1 RCT, 37 participants; very low-quality evidence) or miscarriages (RR 1.31, 95% CI 0.21 to 8.34; 1 RCT, 37 participants; very low-quality evidence). One study reported on behavioural changes for alcohol consumption but not as defined in the review methods. No studies reported on adverse events or other behavioural changes. Preconception lifestyle advice on smoking versus routine care Studies on preconception lifestyle advice on smoking were identified only in smoking women with infertility. No studies reported on live birth, ongoing pregnancy, adverse events, or miscarriage. One study reported on behavioural changes for smoking but not as defined in the review methods.
AUTHORS' CONCLUSIONS
Low-quality evidence suggests that preconception lifestyle advice on a combination of topics may result in little to no difference in the number of live births. Evidence was insufficient to allow conclusions on the effects of preconception lifestyle advice on adverse events and miscarriage and on safety, as no studies were found that looked at these outcomes, or the studies were of very low quality. This review does not provide clear guidance for clinical practice in this area. However, it does highlight the need for high-quality RCTs to investigate preconception lifestyle advice on a combination of topics and to assess relevant effectiveness and safety outcomes in men and women with infertility.
Topics: Alcohol Drinking; Bias; Caffeine; Central Nervous System Stimulants; Counseling; Diet, Healthy; Exercise; Female; Folic Acid; Humans; Infertility; Infertility, Female; Life Style; Live Birth; Male; Preconception Care; Randomized Controlled Trials as Topic; Sex Factors; Smoking Cessation; Vitamin B Complex; Weight Loss
PubMed: 33914901
DOI: 10.1002/14651858.CD008189.pub3 -
The Cochrane Database of Systematic... Sep 2015Central venous catheters (CVCs) play a vital role in the management of acute and chronic illness. Dressings and securement devices must ensure CVCs do not dislodge or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Central venous catheters (CVCs) play a vital role in the management of acute and chronic illness. Dressings and securement devices must ensure CVCs do not dislodge or fall out, provide a barrier protection from microbial colonisation and infection, and be comfortable for the patient. There is a large range of dressing and securement products available for clinicians to use.
OBJECTIVES
To compare the available dressing and securement devices for CVCs, in terms of catheter-related bloodstream infection (BSI), catheter colonisation, entry- and exit-site infection, skin colonisation, skin irritation, failed catheter securement, dressing condition and mortality.
SEARCH METHODS
In June 2015 we searched: The Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL); The Database of Abstracts of Reviews of Effects (DARE); NHS Economic Evaluation Database (NHSEED); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; six clinical trial registries and reference lists of identified trials. There were no restrictions based on language or date of publication or study setting.
SELECTION CRITERIA
We included randomised controlled trials that evaluated the effects of dressing and securement devices for CVCs. All types of CVCs were included, i.e. short- and long-term CVCs, tunnelled and non-tunnelled, port-a-caths, haemodialysis catheters, and peripherally-inserted central catheters (PICCs).
DATA COLLECTION AND ANALYSIS
We used standard Cochrane Collaboration methods including independent review of titles and abstracts for relevance, data extraction, and risk of bias assessment of the included studies by two review authors. Results are expressed using risk ratio (RR) for categorical data with 95% confidence intervals (CIs). For outcomes best presented as a rate-per-time-period, rate ratios and standard errors have been used. We performed multiple treatment meta-analyses to rank the effectiveness of each intervention for each outcome.
MAIN RESULTS
We included 22 studies involving 7436 participants comparing nine different types of securement device or dressing. All included studies were at unclear or high risk of performance bias due to the different appearances of the dressings and securement devices. The extent of blinding of outcome assessment was unclear in most studies. The quality of evidence varied between different comparisons and outcomes. We mainly downgraded the quality of evidence for imprecision, indirectness, risk of bias and inconsistency.It is unclear whether there is a difference in the rate of catheter-related BSI between securement with gauze and tape and standard polyurethane (SPU) (RR 0.64, 95% CI 0.26 to 1.63, low quality evidence), or between chlorhexidine gluconate-impregnated (CGI) dressings and SPU (RR 0.65, 95% CI 0.40 to 1.05, moderate quality evidence). There is high quality evidence that medication-impregnated dressings reduce the incidence of catheter-related BSI relative to all other dressing types (RR 0.60, 95% CI 0.39 to 0.93).There is moderate quality evidence that CGI dressings reduce the frequency of catheter-related BSI per 1000 patient days compared with SPU dressings (RR 0.51, 95% CI 0.33 to 0.78).There is moderate quality evidence that catheter tip colonisation is reduced with CGI dressings compared with SPU dressings (RR 0.58, 95% CI 0.47 to 0.73), but the relative effects of gauze and tape and SPU are unclear (RR 0.95, 95% CI 0.51 to 1.77, very low quality evidence). It is unclear if there is a difference in rates of skin irritation or damage when CGI dressings are compared with SPU dressings (moderate quality evidence) (RR 11.17, 95% CI 0.84 to 149.48).A multiple treatment meta-analysis found sutureless securement devices as likely to be the most effective at reducing the incidence of catheter-related BSI (low quality evidence), with CGI dressings ranked second (low quality evidence).
AUTHORS' CONCLUSIONS
Medication-impregnated dressing products reduce the incidence of catheter-related BSI relative to all other dressing types. There is some evidence that CGI dressings, relative to SPU dressings, reduce catheter-related BSI for the outcomes of frequency of infection per 1000 patient days, risk of catheter tip colonisation and possibly risk of catheter-related BSI. A multiple treatment meta-analysis found that sutureless securement devices are likely to be the most effective at reducing catheter-related BSI though this is low quality evidence. Most studies were conducted in intensive care unit (ICU) settings. More, high quality research is needed regarding the relative effects of dressing and securement products for CVCs. Future research may adjust the estimates of effect for the products included in this review and is needed to assess the effectiveness of new products.
Topics: Bandages; Catheter-Related Infections; Catheterization, Central Venous; Central Venous Catheters; Chlorhexidine; Humans; Randomized Controlled Trials as Topic
PubMed: 26358142
DOI: 10.1002/14651858.CD010367.pub2 -
The Cochrane Database of Systematic... Dec 2015It has been reported that neural tube defects (NTD) can be prevented with periconceptional folic acid supplementation. The effects of different doses, forms and schemes... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It has been reported that neural tube defects (NTD) can be prevented with periconceptional folic acid supplementation. The effects of different doses, forms and schemes of folate supplementation for the prevention of other birth defects and maternal and infant outcomes are unclear.
OBJECTIVES
This review aims to examine whether periconceptional folate supplementation reduces the risk of neural tube and other congenital anomalies (including cleft palate) without causing adverse outcomes in mothers or babies. This is an update of a previously published Cochrane review on this topic.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2015). Additionally, we searched the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (31 August 2015) and contacted relevant organisations to identify ongoing and unpublished studies.
SELECTION CRITERIA
We included all randomised or quasi-randomised trials evaluating the effect of periconceptional folate supplementation alone, or in combination with other vitamins and minerals, in women independent of age and parity.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies, checked data entry for accuracy and assessed the risk of bias of the included studies. We assessed the quality of the body of evidence using the GRADE approach.
MAIN RESULTS
Five trials involving 7391 women (2033 with a history of a pregnancy affected by a NTD and 5358 with no history of NTDs) were included. Four comparisons were made: 1) supplementation with any folate versus no intervention, placebo or other micronutrients without folate (five trials); 2) supplementation with folic acid alone versus no treatment or placebo (one trial); 3) supplementation with folate plus other micronutrients versus other micronutrients without folate (four trials); and 4) supplementation with folate plus other micronutrients versus the same other micronutrients without folate (two trials). The risk of bias of the trials was variable. Only one trial was considered to be at low risk of bias. The remaining studies lacked clarity regarding the randomisation method or whether the allocation to the intervention was concealed. All the participants were blinded to the intervention, though blinding was unclear for outcome assessors in the five trials.The results of the first comparison involving 6708 births with information on NTDs and other infant outcomes, show a protective effect of daily folic acid supplementation (alone or in combination with other vitamins and minerals) in preventing NTDs compared with no interventions/placebo or vitamins and minerals without folic acid (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.17 to 0.58); five studies; 6708 births; high quality evidence). Only one study assessed the incidence of NTDs and showed no evidence of an effect (RR 0.07, 95% CI 0.00 to 1.32; 4862 births) although no events were found in the group that received folic acid. Folic acid had a significant protective effect for reoccurrence (RR 0.34, 95% CI 0.18 to 0.64); four studies; 1846 births). Subgroup analyses suggest that the positive effect of folic acid on NTD incidence and recurrence is not affected by the explored daily folic acid dosage (400 µg (0.4 mg) or higher) or whether folic acid is given alone or with other vitamins and minerals. These results are consistent across all four review comparisons.There is no evidence of any preventive or negative effects on cleft palate (RR 0.73, 95% CI 0.05 to 10.89; three studies; 5612 births; low quality evidence), cleft lip ((RR 0.79, 95% CI 0.14 to 4.36; three studies; 5612 births; low quality evidence), congenital cardiovascular defects (RR 0.57, 95% CI 0.24 to 1.33; three studies; 5612 births; low quality evidence), miscarriages (RR 1.10, 95% CI 0.94 to 1.28; five studies; 7391 pregnancies; moderate quality evidence) or any other birth defects (RR 0.94, 95% CI 0.53 to 1.66; three studies; 5612 births; low quality evidence). There were no included trials assessing the effects of this intervention on neonatal death, maternal blood folate or anaemia at term.
AUTHORS' CONCLUSIONS
Folic acid, alone or in combination with vitamins and minerals, prevents NTDs, but does not have a clear effect on other birth defects.
Topics: Dietary Supplements; Female; Folic Acid; Humans; Infant; Neural Tube Defects; Preconception Care; Pregnancy; Randomized Controlled Trials as Topic; Vitamin B Complex
PubMed: 26662928
DOI: 10.1002/14651858.CD007950.pub3