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European Journal of Obstetrics,... Apr 2018Despite decades of research, the concept of normality in labour in terms of its progression and duration is not universal or standardized. However, in clinical practice,... (Review)
Review
BACKGROUND
Despite decades of research, the concept of normality in labour in terms of its progression and duration is not universal or standardized. However, in clinical practice, it is important to define the boundaries that distinguish what is normal from what is abnormal to enable women and care providers have a shared understanding of what to expect and when labour interventions are justified.
OBJECTIVES
To synthesise available evidence on the duration of latent and active first stage and the second stage of spontaneous labour in women at low risk of complications with 'normal' perinatal outcomes.
SEARCH STRATEGY
PubMed, EMBASE, CINAHL, POPLINE, Global Health Library, and reference lists of eligible studies.
SELECTION CRITERIA
Observational studies and other study designs.
DATA COLLECTION AND ANALYSIS
Four authors extracted data on: maternal characteristics; labour interventions; duration of latent first stage, active first stage, and second stage of labour; and the definitions of onset of latent and active first stage, and second stage where reported. Heterogeneity in the included studies precluded meta-analysis and data were presented descriptively.
MAIN RESULTS
Thirty-seven studies reporting the duration of first and/or second stages of labour for 208,000 women met our inclusion criteria. Among nulliparous women, the median duration of active first stage (when the starting reference point was 4 cm) ranged from 3.7-5.9 h (95th percentiles: 14.5-16.7 h). With active phase starting from 5 cm, the median duration was from 3.8-4.3 h (95th percentiles: 11.3-12.7 h). The median duration of second stage ranged from 14 to 66 min (95th percentiles: 65-138 min) and from 6 to 12 min (95th percentiles: 58-76 min) in nulliparous and parous women, respectively. Sensitivity analyses excluding first and second stage interventions did not significantly impact on these findings CONCLUSIONS: The duration of spontaneous labour in women with good perinatal outcomes varies from one woman to another. Some women may experience labour for longer than previously thought, and still achieve a vaginal birth without adverse perinatal outcomes. Our findings question the rigid limits currently applied in clinical practice for the assessment of prolonged first or second stage that warrant obstetric intervention.
Topics: Delivery, Obstetric; Female; Humans; Labor Stage, First; Labor Stage, Second; Labor, Obstetric; Parity; Pregnancy; Pregnancy Outcome; Time Factors
PubMed: 29518643
DOI: 10.1016/j.ejogrb.2018.02.026 -
Lancet (London, England) Mar 2021Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes.
METHODS
We did a systematic review of randomised trials comparing vaginal progesterone, intramuscular 17-hydroxyprogesterone caproate (17-OHPC), or oral progesterone with control, or with each other, in asymptomatic women at risk of preterm birth. We identified published and unpublished trials that completed primary data collection before July 30, 2016, (12 months before data collection began), by searching MEDLINE, Embase, CINAHL, the Maternity and Infant Care Database, and relevant trial registers between inception and July 30, 2019. Trials of progestogen to prevent early miscarriage or immediately-threatened preterm birth were excluded. Individual participant data were requested from investigators of eligible trials. Outcomes included preterm birth, early preterm birth, and mid-trimester birth. Adverse neonatal sequelae associated with early births were assessed using a composite of serious neonatal complications, and individually. Adverse maternal outcomes were investigated as a composite and individually. Individual participant data were checked and risk of bias assessed independently by two researchers. Primary meta-analyses used one-stage generalised linear mixed models that incorporated random effects to allow for heterogeneity across trials. This meta-analysis is registered with PROSPERO, CRD42017068299.
FINDINGS
Initial searches identified 47 eligible trials. Individual participant data were available for 30 of these trials. An additional trial was later included in a targeted update. Data were therefore available from a total of 31 trials (11 644 women and 16185 offspring). Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0·78, 95% CI 0·68-0·90), 17-OHPC (five trials, 3053 women; 0·83, 0·68-1·01), and oral progesterone (two trials, 181 women; 0·60, 0·40-0·90). Results for other birth and neonatal outcomes were consistently favourable, but less certain. A possible increase in maternal complications was suggested, but this was uncertain. We identified no consistent evidence of treatment interaction with any participant characteristics examined, although analyses within subpopulations questioned efficacy in women who did not have a short cervix. Trials in multifetal pregnancies mostly included women without additional risk factors. For twins, vaginal progesterone did not reduce preterm birth before 34 weeks (eight trials, 2046 women: RR 1·01, 95% CI 0·84-1·20) nor did 17-OHPC for twins or triplets (eight trials, 2253 women: 1·04, 0·92-1·18). Preterm premature rupture of membranes was increased with 17-OHPC exposure in multifetal gestations (rupture <34 weeks RR 1·59, 95% CI 1·15-2·22), but we found no consistent evidence of benefit or harm for other outcomes with either vaginal progesterone or 17-OHPC.
INTERPRETATION
Vaginal progesterone and 17-OHPC both reduced birth before 34 weeks' gestation in high-risk singleton pregnancies. Given increased underlying risk, absolute risk reduction is greater for women with a short cervix, hence treatment might be most useful for these women. Evidence for oral progesterone is insufficient to support its use. Shared decision making with woman with high-risk singleton pregnancies should discuss an individual's risk, potential benefits, harms and practicalities of intervention. Treatment of unselected multifetal pregnancies with a progestogen is not supported by the evidence.
FUNDING
Patient-Centered Outcomes Research Institute.
Topics: 17-alpha-Hydroxyprogesterone; Administration, Intravaginal; Decision Making, Shared; Female; Humans; Infant, Newborn; Injections, Intramuscular; Pregnancy; Pregnancy Outcome; Pregnancy, High-Risk; Premature Birth; Progesterone; Randomized Controlled Trials as Topic; Risk Assessment
PubMed: 33773630
DOI: 10.1016/S0140-6736(21)00217-8 -
American Journal of Obstetrics &... Jan 2023The World Health Organization has recently declared a monkeypox outbreak as a public health emergency of global concern. The main aim of this systematic review was to... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
The World Health Organization has recently declared a monkeypox outbreak as a public health emergency of global concern. The main aim of this systematic review was to ascertain the maternal and perinatal outcomes of pregnancies complicated by monkeypox infection.
DATA SOURCES
The Medline, Embase, and Cochrane databases were searched on June 25, 2022 utilizing combinations of the relevant medical subject heading terms, key words, and word variants for "monkeypox" and "pregnancy."
STUDY ELIGIBILITY CRITERIA
The search and selection criteria were restricted to the English language.
METHODS
The outcomes observed were miscarriage; intrauterine, neonatal, and perinatal death; preterm birth, vertical transmission, and maternal symptoms. A metaanalysis of proportions was used to analyze the data.
RESULTS
Four studies were included. All the cases in the present systematic review presented with symptoms and signs of monkeypox infection. There was no case of maternal death. Miscarriage occurred in 39% of cases (95% confidence interval, 0-89.0), whereas intrauterine fetal death occurred in 23.0% (95% confidence interval, 0-74.0) of cases. The overall incidence of late fetal and perinatal loss was 77.0% (95% confidence interval, 26.0-100), whereas only 23% (95% confidence interval, 0-74.0) of the included fetuses survived to birth. The incidence of preterm birth before 37 weeks of gestation was 8.0% (95% confidence interval, 0-62.0). Vertical transmission occurred in 62.0% (95% confidence interval, 3.0-100) of cases. When stratifying the analysis according to gestational age at infection, fetal loss was found to occur in 67.0% (95% confidence interval, 9.0-99.0) of cases with first-trimester infection and in 82.0% (95% confidence interval, 17.0-100) of those with second-trimester infection.
CONCLUSION
Monkeypox infection in pregnancy is associated with a high risk of perinatal loss and vertical transmission. The preliminary results from this systematic review affected by a very small number of included cases highlight the need for thorough maternal and fetal surveillance in pregnancies complicated by monkeypox infection.
Topics: Pregnancy; Female; Infant, Newborn; Humans; Premature Birth; Abortion, Spontaneous; Gestational Age; Stillbirth; Fetal Death
PubMed: 36096413
DOI: 10.1016/j.ajogmf.2022.100747 -
Environmental Research May 2017Season and vitamin D are indirect and direct correlates of ultraviolet (UV) radiation and are associated with pregnancy outcomes. Further to producing vitamin D, UV has... (Review)
Review
BACKGROUND
Season and vitamin D are indirect and direct correlates of ultraviolet (UV) radiation and are associated with pregnancy outcomes. Further to producing vitamin D, UV has positive effects on cardiovascular and immune health that may support a role for UV directly benefitting pregnancy.
OBJECTIVES
To investigate the effects of UV exposure on pregnancy; specifically fetal growth, preterm birth and hypertensive complications.
METHODS
We conducted a systematic review of Medline, EMBASE, DoPHER, Global Health, ProQuest Public Health, AustHealth Informit, SCOPUS and Google Scholar to identify 537 citations, 8 of which are included in this review. This review was registered on PROSPERO and a. narrative synthesis is presented following PRISMA guidance.
RESULTS
All studies were observational and assessed at high risk of bias. Higher first trimester UV was associated with and improved fetal growth and increased hypertension in pregnancy. Interpretation is limited by study design and quality. Meta-analysis was precluded by the variety of outcomes and methods.
DISCUSSION
The low number of studies and risk of bias limit the validity of any conclusions. Environmental health methodological issues are discussed with consideration given to design and analytical improvements to further address this reproductive environmental health question.
CONCLUSIONS
The evidence for UV having benefits for pregnancy hypertension and fetal growth is limited by the methodological approaches utilized. Future epidemiological efforts should focus on improving the methods of modeling and linking widely available environmental data to reproductive health outcomes.
Topics: Animals; Female; Humans; Pregnancy; Pregnancy Outcome; Ultraviolet Rays
PubMed: 28264782
DOI: 10.1016/j.envres.2017.02.026 -
Acta Obstetricia Et Gynecologica... Jul 2022The association between intrahepatic cholestasis of pregnancy (ICP) and maternal lipid metabolism remains unknown. This systematic review and meta-analysis aimed to... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
The association between intrahepatic cholestasis of pregnancy (ICP) and maternal lipid metabolism remains unknown. This systematic review and meta-analysis aimed to evaluate the association between ICP and maternal lipid metabolism.
MATERIAL AND METHODS
We systematically searched Medline, Embase and the Cochrane Library (up to December 11, 2021) to identify relevant studies that investigated ICP and maternal plasma lipid concentrations. The weighted mean difference (WMD) and 95% confidence intervals (CI) were calculated using random-effects models. A subgroup analysis was conducted to identify the potential sources of heterogeneity. Potential publication bias was tested using funnel plots and the Egger's and Begg's tests. This meta-analysis was registered with PROSPERO (CRD42021293783).
RESULTS
Eleven studies were included in this qualitative analysis. A random-effects meta-analysis of data from the final included nine studies (n = 786 participants) showed a significant association between ICP and maternal dyslipidemia, with elevated levels of triglycerides (WMD, 0.67 mmol/L; 95% CI 0.39-0.95; P < 0.001), total cholesterol (WMD, 1.08 mmol/L; 95% CI 0.58-1.58; P < 0.001), low-density lipoprotein cholesterol (WMD, 1.08 mmol/L; 95% CI 0.53-1.64; P < 0.001), and reduced high-density lipoprotein cholesterol level (WMD, -0.38 mmol/L; 95% CI -0.53 to -0.23; P < 0.001) vs normal pregnancies.
CONCLUSIONS
The present study's findings support an association between ICP and maternal dyslipidemia. ICP pregnancies have dysregulated lipid metabolism vs normal pregnancies.
Topics: Cholestasis, Intrahepatic; Cholesterol; Dyslipidemias; Female; Humans; Pregnancy; Pregnancy Complications
PubMed: 35599353
DOI: 10.1111/aogs.14380 -
PloS One 2021Prostaglandins are thought to be important mediators in the initiation of human labour, however the evidence supporting this is not entirely clear. Determining how, and...
Prostaglandins are thought to be important mediators in the initiation of human labour, however the evidence supporting this is not entirely clear. Determining how, and which, prostaglandins change during pregnancy and labour may provide insight into mechanisms governing labour initiation and the potential to predict timing of labour onset. The current study systematically searched the existing scientific literature to determine how biofluid levels of prostaglandins change throughout pregnancy before and during labour, and whether prostaglandins and/or their metabolites may be useful for prediction of labour. The databases EMBASE and MEDLINE were searched for English-language articles on prostaglandins measured in plasma, serum, amniotic fluid, or urine during pregnancy and/or spontaneous labour. Studies were assessed for quality and risk of bias and a qualitative summary of included studies was generated. Our review identified 83 studies published between 1968-2021 that met the inclusion criteria. As measured in amniotic fluid, levels of PGE2, along with PGF2α and its metabolite 13,14-dihydro-15-keto-PGF2α were reported higher in labour compared to non-labour. In blood, only 13,14-dihydro-15-keto-PGF2α was reported higher in labour. Additionally, PGF2α, PGF1α, and PGE2 were reported to increase in amniotic fluid as pregnancy progressed, though this pattern was not consistent in plasma. Overall, the evidence supporting changes in prostaglandin levels in these biofluids remains unclear. An important limitation is the lack of data on the complexity of the prostaglandin pathway outside of the PGE and PGF families. Future studies using new methodologies capable of co-assessing multiple prostaglandins and metabolites, in large, well-defined populations, will help provide more insight as to the identification of exactly which prostaglandins and/or metabolites consistently change with labour. Revisiting and revising our understanding of the prostaglandins may provide better targets for clinical monitoring of pregnancies. This study was supported by the Canadian Institutes of Health Research.
Topics: Amniotic Fluid; Body Fluids; Databases, Factual; Dinoprost; Female; Humans; Labor Onset; Labor, Obstetric; Oxytocics; Plasma; Pregnancy; Prostaglandins; Prostaglandins E; Prostaglandins F; Serum; Urine
PubMed: 34793529
DOI: 10.1371/journal.pone.0260115 -
Journal of Obstetrics and Gynaecology :... Dec 2024Vaginal bleeding during pregnancy has been recognised as a significant risk factor for adverse pregnancy outcomes. This study aimed to investigate the association... (Meta-Analysis)
Meta-Analysis Review
Vaginal bleeding during pregnancy has been recognised as a significant risk factor for adverse pregnancy outcomes. This study aimed to investigate the association between vaginal bleeding during the first trimester of pregnancy and clinical adverse effects using a systematic review and meta-analysis. Databases of Scopus, Web of Science, PubMed (including Medline), Cochrane Library and Science Direct were searched until June of 2023. Data analysis using statistical test fixed- and random-effects models in the meta-analysis, Cochran and meta-regression. The quality of the eligible studies was assessed by using the Newcastle-Ottawa Scale checklist (NOS). A total of 46 relevant studies, with a sample size of 1,554,141 were entered into the meta-analysis. Vaginal bleeding during the first trimester of pregnancy increases the risk of preterm birth (OR: 1.8, CI 95%: 1.6-2.0), low birth weight (LBW; OR: 2.0, CI 95%: 1.5-2.6), premature rupture of membranes (PROMs; OR: 2.3, CI 95%: 1.8-3.0), abortion (OR: 4.3, CI 95%: 2.0-9.0), stillbirth (OR: 2.5, CI 95%: 1.2-5.0), placental abruption (OR: 2.2, CI 95%: 1.4-3.3) and placenta previa (OR: 1.9, CI 95%: 1.5-2.4). Vaginal bleeding in the first trimester of pregnancy is associated with preterm birth, LBW, PROMs, miscarriage, stillbirth, placental abruption and placenta previa. Therefore, physicians or midwives need to be aware of the possibility of these consequences and manage them when they occur.
Topics: Pregnancy; Infant, Newborn; Female; Humans; Stillbirth; Premature Birth; Abruptio Placentae; Placenta Previa; Placenta; Pregnancy Outcome; Abortion, Spontaneous; Uterine Hemorrhage
PubMed: 38305047
DOI: 10.1080/01443615.2023.2288224 -
Scandinavian Journal of Surgery : SJS :... Sep 2023Non-obstetric surgery is fairly common in pregnant women. We performed a systematic review to update data on non-obstetric surgery in pregnant women. The aim of this... (Review)
Review
BACKGROUND AND OBJECTIVE
Non-obstetric surgery is fairly common in pregnant women. We performed a systematic review to update data on non-obstetric surgery in pregnant women. The aim of this review was to evaluate the effects of non-obstetric surgery during pregnancy on pregnancy, fetal and maternal outcomes.
METHODS
A systematic literature search of MEDLINE and Scopus was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The search span was from January 2000 to November 2022. Thirty-six studies matched the inclusion criteria, and 24 publications were identified through reference mining; 60 studies were included in this review. Outcome measures were miscarriage, stillbirth, preterm birth, low birth weight, low Apgar score, and infant and maternal morbidity and mortality rates.
RESULTS
We obtained data for 80,205 women who underwent non-obstetric surgery and data for 16,655,486 women who did not undergo surgery during pregnancy. Prevalence of non-obstetric surgery was between 0.23% and 0.74% (median 0.37%). Appendectomy was the most common procedure with median prevalence of 0.10%. Near half (43%) of the procedures were performed during the second trimester, 32% during the first trimester, and 25% during the third trimester. Half of surgeries were scheduled, and half were emergent. Laparoscopic and open techniques were used equally for abdominal cavity. Women who underwent non-obstetric surgery during pregnancy had increased rate of stillbirth (odds ratio (OR) 2.0) and preterm birth (OR 2.1) compared to women without surgery. Surgery during pregnancy did not increase rate of miscarriage (OR 1.1), low 5 min Apgar scores (OR 1.1), the fetus being small for gestational age (OR 1.1) or congenital anomalies (OR 1.0).
CONCLUSIONS
The prevalence of non-obstetric surgery has decreased during last decades, but still two out of 1000 pregnant women have scheduled surgery during pregnancy. Surgery during pregnancy increases the risk of stillbirth, and preterm birth. For abdominal cavity surgery, both laparoscopic and open approaches are feasible.
Topics: Infant; Pregnancy; Infant, Newborn; Female; Humans; Pregnancy Outcome; Premature Birth; Stillbirth; Abortion, Spontaneous; Fetus
PubMed: 37329286
DOI: 10.1177/14574969231175569 -
British Journal of Clinical Pharmacology Sep 2022Calcineurin inhibitors (CNIs) are often used for solid organ transplantation recipients or patients with immune-mediated diseases. This systematic review and... (Meta-Analysis)
Meta-Analysis Review
AIMS
Calcineurin inhibitors (CNIs) are often used for solid organ transplantation recipients or patients with immune-mediated diseases. This systematic review and meta-analysis aims to understand how CNIs affect pregnancy and neonatal outcomes.
METHODS
Electronic databases were searched for observational studies assessing pregnancy and neonatal outcomes in CNI-treated patients. The pooled rate of each outcome was determined. Metaregression was conducted to identify contributing factors to the outcomes.
RESULTS
We analysed 98 studies with a total of 5355 pregnancies in 4450 CNI-treated patients. The pooled rates of live birth and spontaneous abortion were 82.1% (95% confidence interval [CI] 76.7-86.4%) and 11.7% (95% CI 8.7-15.5%), respectively. The rates of preterm delivery (33.2%, 95% CI 29.2-37.5%), low birth weight (35.8%, 95% CI 27.7-44.8%) and preeclampsia (13.5%, 95% CI 9.4-19.2%) were 3-4 times higher than the rates of general population. Nearly half of the CNI-treated patients required caesarean delivery (43.5%, 95% CI 36.9-50.3%). The rates of stillbirth, neonatal and maternal death were 4.2% (95% CI 2.8-6.2%), 2.9% (95% CI 1.8-4.8%) and 2.3% (95% CI 1.3-4.1%), respectively. Metaregression showed that preeclampsia was significantly associated with the risks of preterm delivery and low birth weight. Older maternal age, prepregnancy hypertension and cyclosporine use increased the risk of preeclampsia.
CONCLUSION
Given the higher mortalities in CNI-treated patients and their children than the general averages, their pregnancy is considered high risk. The risks of preterm delivery and low birth weight were primarily attributed to preeclampsia. Since prepregnancy hypertension increased its risk, an appropriate preconception blood pressure management may improve their outcomes.
Topics: Calcineurin Inhibitors; Child; Female; Humans; Hypertension; Infant, Newborn; Pre-Eclampsia; Pregnancy; Pregnancy Outcome; Premature Birth
PubMed: 35593302
DOI: 10.1111/bcp.15414 -
American Journal of Obstetrics and... Oct 2022This study aimed to systematically assess the impact of cardiomyopathy on maternal pregnancy outcomes. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to systematically assess the impact of cardiomyopathy on maternal pregnancy outcomes.
DATA SOURCES
PubMed, Ovid Embase, Ovid MEDLINE, Cochrane Library, and ClinicalTrials.gov were systematically searched from inception to April 24, 2022.
STUDY ELIGIBILITY CRITERIA
Observational cohort, case-control, and case-cohort studies in human populations were included if they reported predefined maternal outcomes for pregnant women with cardiomyopathy (any subtype) and for an appropriate control population (pregnant women with no known heart disease or pregnant women with noncardiomyopathy heart disease).
METHODS
Two reviewers independently assessed the articles for eligibility and risk of bias, and conflicts were resolved by a third reviewer. Data were extracted and synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-Analyses of Observational Studies in Epidemiology guidelines.
RESULTS
A total of 14 studies (n=57,539,306 pregnancies) were eligible for inclusion. Women with cardiomyopathy were more likely to deliver by cesarean delivery than women with no heart disease (odds ratio, 2.96; 95% confidence interval, 2.47-3.55; I=95%; P≤.00001) or women with noncardiomyopathy heart disease (odds ratio, 1.90; 95% confidence interval, 1.62-2.22; I=91%; P<.00001). Having cardiomyopathy conferred a greater risk for experiencing severe maternal adverse cardiovascular events during pregnancy when compared with not having any heart disease (odds ratio, 206.64; 95% confidence interval, 192.09-222.28; I=73%; P<.0001) or having noncardiomyopathy heart disease (odds ratio, 7.09; 95% confidence interval; 6.08-8.27; I=88%; P<.00001). In-hospital mortality was significantly higher among women with cardiomyopathy than among women with no heart disease (odds ratio, 126.67; 95% confidence interval, 43.01-373.07; I=87%; P<.00001) or among women with noncardiomyopathy heart disease (odds ratio, 4.30; 95% confidence interval, 3.42-5.40; I=0%; P<.00001).
CONCLUSION
Pregnant women with cardiomyopathy have increased risks for adverse maternal outcomes, including maternal death, when compared with both women with no heart disease and women with noncardiomyopathy heart disease. Our results highlight the importance of preconception risk assessments to allow for informed decision-making before pregnancy. Pregnancies affected by cardiomyopathy are high risk and should be managed by expert, multidisciplinary obstetrical and cardiology teams.
Topics: Cardiomyopathies; Cesarean Section; Female; Humans; Odds Ratio; Pregnancy; Pregnancy Complications; Pregnancy Outcome
PubMed: 35609641
DOI: 10.1016/j.ajog.2022.05.039