Perinatal outcomes in women living with HIV-1 and receiving antiretroviral therapy-a systematic review and meta-analysis.

INTRODUCTION: Antiretroviral therapy-naïve pregnant women living with HIV are at an increased risk for adverse pregnancy outcomes. It remains controversial whether this risk persists with antiretroviral therapy. We conducted a systematic review and meta-analysis to evaluate whether pregnant women living with HIV and receiving antiretroviral therapy antenatally, are at an increased risk of adverse outcomes compared with HIV-negative controls. MATERIAL AND METHODS: We searched MEDLINE, Embase, International Pharmaceutical Abstracts, EBM Reviews, PubMed (non-MEDLINE records), EBSCO CINAHL Complete, Clarivate Web of Science, African Index Medicus, LILACS and Google Scholar for all observational studies comparing pregnant women living with HIV on antiretroviral therapy with HIV-negative controls from 1 January 1994 to 10 August 2021 with no language or geographic restrictions. Perinatal outcomes included preterm birth (PTB), low birthweight, small-for-gestational age and preeclampsia. Using a random-effects model we pooled raw data to generate odds ratio (OR) with 95% confidence intervals (CI) for each outcome. Sub-analyses for high and low resource countries and time of antiretroviral therapy initiation were performed. This systematic review and meta-analysis is registered with PROSPERO, number CRD42020182722. RESULTS: Of the 7900 citations identified, 27 were eligible for analysis (12 636 pregnant women living with HIV on antiretroviral therapy and 7 812 115 HIV-negative controls). ORs (95% CI) of PTB (1.88 [1.63-2.17]), small-for-gestational age (1.60 [1.18-2.17]) and low birthweight (2.15 [1.58-2.92]) were significantly higher in pregnant women living with HIV than in HIV-negative women, while the risk of preeclampsia (0.86 [0.57-1.30]) was comparable. The risk of PTB and low birthweight was higher in both high resource and low resource countries, while the risk of small-for-gestational age was higher only in the former. Preconceptional antiretroviral therapy was associated with a higher risk of PTB compared with antenatal initiation. CONCLUSIONS: Pregnant women living with HIV on antiretroviral therapy have an increased risk of PTB, low birthweight and small-for-gestational age in high resource countries, as well as PTB and low birthweight in low income countries compared with HIV-negative controls.

Fetal Meconium Peritonitis - Prenatal Findings and Postnatal Outcome: A Case Series, Systematic Review, and Meta-Analysis.

PURPOSE: To describe the postnatal outcome of fetal meconium peritonitis and identify prenatal predictors of neonatal surgery. METHODS: We retrospectively reviewed all fetuses with ultrasound findings suspicious for meconium peritonitis at a single center over a 10-year period. A systematic review and meta-analysis were then performed pooling our results with previous studies assessing prenatally diagnosed meconium peritonitis and postnatal outcome. Prenatal sonographic findings were analyzed to identify predictors for postnatal surgery. RESULTS: 34 cases suggestive of meconium peritonitis were diagnosed at our center. These were pooled with cases from 14 other studies yielding a total of 244 cases. Postnatal abdominal surgery was required in two thirds of case (66.5 %). The strongest predictor of neonatal surgery was meconium pseudocyst (OR [95 % CI] 6.75 [2.53-18.01]), followed by bowel dilation (OR [95 % CI] 4.17 [1.93-9.05]) and ascites (OR [95 % CI] 2.57 [1.07-5.24]). The most common cause of intestinal perforation and meconium peritonitis, found in 52.2 % of the cases, was small bowel atresia. Cystic fibrosis was diagnosed in 9.8 % of cases. Short-term neonatal outcomes were favorable, with a post-operative mortality rate of 8.1 % and a survival rate of 100 % in neonates not requiring surgery. CONCLUSION: Meconium pseudocysts, bowel dilation, and ascites are prenatal predictors of neonatal surgery in cases of meconium peritonitis. Fetuses with these findings should be delivered in centers with pediatric surgery services. Though the prognosis is favorable, cystic fibrosis complicates postnatal outcomes.

Preimplantation genetic testing for aneuploidy: A Canadian Fertility and Andrology Society Guideline.

The objective of this guideline from the Canadian Fertility and Andrology Society is to synthesize the evidence on preimplantation genetic testing for aneuploidies (PGT-A) using trophectoderm biopsy and 24-chromosome analysis and to provide clinical recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. To date, randomized controlled trials have been limited to good-prognosis patients who were able to generate two or more blastocysts for biopsy. In this specific population the GRADE analysis of PGT-A shows an increase in the implantation rate and ongoing pregnancy or delivery rate per transfer. Clearly, it is difficult to generalize from this subgroup of patients to the infertility population at large. As a result, the application of PGT-A should be individualized, and patient factors such as age and ability to generate embryos will influence decision-making. Comprehensive patient counselling and informed consent are imperative before undertaking PGT-A. Potential benefits must be weighed against the costs and limitations of the technology, including the risk of embryo damage, false positives, false negatives and the detection of embryonic mosaicism. Future research is required, especially with regard to the use of PGT-A in poorer prognosis patients, and with respect to reporting outcomes per cycle start and cumulatively per retrieval.

Barbed vs conventional suture at cesarean delivery: A systematic review and meta-analysis.

INTRODUCTION: Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis, and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared with conventional sutures in cesarean delivery. MATERIAL AND METHODS: MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomized controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/fascial/skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, and other morbidity including infection, re-operation or re-admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias, and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, whereas subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% CI were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859. RESULTS: The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk of bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time (MD 110.58 seconds, 95% CI 93.79-127.36 seconds), shorter total surgical time (MD 1.92 minutes, 95% CI 0.03-3.80 minutes), and a reduced need for additional hemostatic sutures (RR 0.39, 95% CI 0.28-0.54), with no difference in estimated blood loss (MD 46.17 mL, 95% CI 13.55 to -105.89 mL) or postoperative morbidity (RR 0.96, 95% CI 0.46-2.01). The level of evidence was deemed to be low to very low, based on inconsistency and imprecision of results. CONCLUSIONS: Barbed sutures may be a suitable alternative to conventional sutures for uterine closure because they reduce uterine repair time, total surgical time, and the need for additional hemostatic sutures, without an increase in blood loss or maternal morbidity.

Determining the optimal antibiotic regimen for chorioamnionitis: A systematic review and meta-analysis.

INTRODUCTION: To evaluate the effect of antibiotic regimens for chorioamnionitis on maternal and neonatal outcomes. MATERIAL AND METHODS: We conducted a systematic review, wherein we searched six bibliographic databases until June 2020 and included randomized clinical trials describing antibiotic regimens for treating chorioamnionitis. Risk of bias was assessed using the Cochrane Risk of Bias tool V2.0. Random-effects meta-analysis was performed and results were presented as risk ratio (RR) and mean differences (MD) with 95% CI. RESULTS: Fourteen trials at low-to-high risk of bias were included. Three trials (n = 244), comparing different intrapartum antibiotic regimens, showed no difference in outcomes except for lower composite maternal morbidity (endometritis, pneumonia, sepsis, blood transfusion, and ileus) with ampicillin/sulbactam vs ampicillin/gentamicin in one study (0/43 vs 6/49, P = .03). Three trials (n = 295) comparing different doses of intrapartum antibiotics showed no differences in maternal and neonatal outcomes, although one study showed a shorter duration of antibiotic treatment in the experimental arm (4 mg/kg gentamicin q24h + 1200 mg clindamycin q12h) vs conventional arm (1.33 mg/kg gentamicin + 800 mg clindamycin q8h) (48.0 ± 36 hours vs 55.2 ± 48 hours, P = .04). Four trials (n = 484) comparing postpartum antibiotics vs no antibiotics showed no difference in outcomes except for a shorter hospital stay (two studies, MD -7.90 hours, 95% CI -13.52 to -2.27 hours). Three trials (n = 447) comparing single vs multiple doses of postpartum antibiotics showed shorter hospital stay [MD -19.14 hours, 95% CI -29.88 to -8.41 hours), but no differences in treatment failure (RR 1.73, 95% CI 0.69-4.30) or total antibiotic dose (MD -9.24, 95% CI -19.49 to 1.01). One trial (n = 48) comparing intrapartum vs postpartum initiation of treatment found benefits to intrapartum (vs postpartum) initiation of antibiotics, in terms of postpartum maternal hospital stay (MD -24 hours, 95% CI -45.56 to -1.44 hours), neonatal hospital stay (MD -45.6 hours, -93.84 to -11.76 hours), and neonatal pneumonia or sepsis (RR 0.06, 95% CI 0.00-0.95). CONCLUSIONS: Upon diagnosis of chorioamnionitis, there is limited evidence to recommend the prompt initiation of intrapartum antibiotics, and to consider a single dose of postpartum antibiotics over multiple doses or no treatment. Well-designed trials using standard definitions of chorioamnionitis, outcome measures, and newer antibiotics are required to inform clinical practice with regard to the preferred antibiotic regimen, dose, and duration to optimize maternal and neonatal outcomes.

Dienogest and the Risk of Endometriosis Recurrence Following Surgery: A Systematic Review and Meta-analysis.

STUDY OBJECTIVE: To determine whether dienogest therapy after endometriosis surgery reduces the risk of endometriosis recurrence compared with expectant management. DATA SOURCES: Ovid MEDLINE, Ovid EMBASE, PubMed, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, clinicaltrials.gov, and International Standard Randomized Controlled Trial Number Registry were searched from inception to March 2019 for observational and randomized controlled trials. METHODS OF STUDY SELECTION: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Medical Subject Heading terms and keywords such as "dienogest," "endometriosis," and "recurrence" were used to identify relevant studies. TABULATION, INTEGRATION, AND RESULTS: The search yielded 328 studies, 10 of which were eligible for inclusion, representing 1184 patients treated with dienogest and 846 expectantly managed controls. Among these studies, 9 looked exclusively at endometrioma recurrence, whereas 1 used reappearance of symptoms as evidence of disease recurrence. Data on both incidence of and time to recurrence of endometriosis were extracted. The incidence rate of endometriosis recurrence in patients treated with dienogest was 2 per 100 women over a mean follow-up of 29 months (95% confidence interval [CI], 1.43-3.11) versus 29 per 100 women managed expectantly over a mean follow-up of 36 months (95% CI, 25.66-31.74). The likelihood of recurrence was significantly reduced with postoperative dienogest (log odds -1.96, CI, -2.53 to -1.38, p <.001). CONCLUSION: Patients receiving dienogest after conservative surgery for endometriosis had significantly lower risk of postoperative disease recurrence than those who were expectantly managed.

Complications of cricothyroidotomy versus tracheostomy in emergency surgical airway management: a systematic review.

BACKGROUND: Airway guidelines recommend an emergency surgical airway as a potential life-saving treatment in a "Can't Intubate, Can't Oxygenate" (CICO) situation. Surgical airways can be achieved either through a cricothyroidotomy or tracheostomy. The current literature has limited data regarding complications of cricothyroidotomy and tracheostomy in an emergency situation. The objective of this systematic review is to analyze complications following cricothyroidotomy and tracheostomy in airway emergencies. METHODS: This synthesis of literature was exempt from ethics approval. Eight databases were searched from inception to October 2018, using a comprehensive search strategy. Studies were included if they were randomized controlled trials or observational studies reporting complications following emergency surgical airway. Complications were classified as minor (evolving to spontaneous remission or not requiring intervention or not persisting chronically), major (requiring intervention or persisting chronically), early (from the start of the procedure up to 7 days) and late (beyond 7 days of the procedure). RESULTS: We retrieved 2659 references from our search criteria. Following the removal of duplicates, title and abstract review, 33 articles were selected for full-text reading. Twenty-one articles were finally included in the systematic review. We found no differences in minor, major or early complications between the two techniques. However, late complications were significantly more frequent in the tracheostomy group [OR (95% CI) 0.21 (0.20-0.22), p < 0.0001]. CONCLUSIONS: Our results demonstrate that cricothyroidotomies performed in emergent situations resulted in fewer late complications than tracheostomies. This finding supports the recommendations from the latest Difficult Airway Society (DAS) guidelines regarding using cricothyroidotomy as the technique of choice for emergency surgical airway. However, emergency cricothyroidotomies should be converted to tracheostomies in a timely fashion as there is insufficient evidence to suggest that emergency cricothyrotomies are long term airways.

Association of Noninvasive Oxygenation Strategies With All-Cause Mortality in Adults With Acute Hypoxemic Respiratory Failure: A Systematic Review and Meta-analysis.

Importance: Treatment with noninvasive oxygenation strategies such as noninvasive ventilation and high-flow nasal oxygen may be more effective than standard oxygen therapy alone in patients with acute hypoxemic respiratory failure. Objective: To compare the association of noninvasive oxygenation strategies with mortality and endotracheal intubation in adults with acute hypoxemic respiratory failure. Data Sources: The following bibliographic databases were searched from inception until April 2020: MEDLINE, Embase, PubMed, Cochrane Central Register of Controlled Trials, CINAHL, Web of Science, and LILACS. No limits were applied to language, publication year, sex, or race. Study Selection: Randomized clinical trials enrolling adult participants with acute hypoxemic respiratory failure comparing high-flow nasal oxygen, face mask noninvasive ventilation, helmet noninvasive ventilation, or standard oxygen therapy. Data Extraction and Synthesis: Two reviewers independently extracted individual study data and evaluated studies for risk of bias using the Cochrane Risk of Bias tool. Network meta-analyses using a bayesian framework to derive risk ratios (RRs) and risk differences along with 95% credible intervals (CrIs) were conducted. GRADE methodology was used to rate the certainty in findings. Main Outcomes and Measures: The primary outcome was all-cause mortality up to 90 days. A secondary outcome was endotracheal intubation up to 30 days. Results: Twenty-five randomized clinical trials (3804 participants) were included. Compared with standard oxygen, treatment with helmet noninvasive ventilation (RR, 0.40 [95% CrI, 0.24-0.63]; absolute risk difference, -0.19 [95% CrI, -0.37 to -0.09]; low certainty) and face mask noninvasive ventilation (RR, 0.83 [95% CrI, 0.68-0.99]; absolute risk difference, -0.06 [95% CrI, -0.15 to -0.01]; moderate certainty) were associated with a lower risk of mortality (21 studies [3370 patients]). Helmet noninvasive ventilation (RR, 0.26 [95% CrI, 0.14-0.46]; absolute risk difference, -0.32 [95% CrI, -0.60 to -0.16]; low certainty), face mask noninvasive ventilation (RR, 0.76 [95% CrI, 0.62-0.90]; absolute risk difference, -0.12 [95% CrI, -0.25 to -0.05]; moderate certainty) and high-flow nasal oxygen (RR, 0.76 [95% CrI, 0.55-0.99]; absolute risk difference, -0.11 [95% CrI, -0.27 to -0.01]; moderate certainty) were associated with lower risk of endotracheal intubation (25 studies [3804 patients]). The risk of bias due to lack of blinding for intubation was deemed high. Conclusions and Relevance: In this network meta-analysis of trials of adult patients with acute hypoxemic respiratory failure, treatment with noninvasive oxygenation strategies compared with standard oxygen therapy was associated with lower risk of death. Further research is needed to better understand the relative benefits of each strategy.

Efficacy and safety of dexmedetomidine for analgesia and sedation in neonates: a systematic review.

Opioids and benzodiazepines have historically been employed for pain relief; however, they are associated with detrimental long-term neurodevelopmental consequences. Dexmedetomidine, a highly selective alpha-2-adrenoreceptor agonist, has piqued interest as a viable alternative for neonates, owing to its potential analgesic and neuroprotective attributes. We conducted a systematic review to assess the efficacy and safety of dexmedetomidine utilization in neonates. We conducted a comprehensive search of Ovid, MEDLINE, EMBASE, PubMed, Cochrane, and CINAHL, spanning from January 2010 to September 2022. Our review encompassed six studies involving 252 neonates. Overall, dexmedetomidine may be effective in achieving sedation and analgesia. Furthermore, it may reduce the need for adjunctive sedation or analgesia, shorten the time to extubation, decrease the duration of mechanical ventilation, and accelerate the attainment of full enteral feeds. Notably, no significant adverse effects associated with dexmedetomidine were reported. Nevertheless, additional well-designed studies to establish both the efficacy and safety of dexmedetomidine in neonatal care are needed.

Myasthenia gravis in pregnancy: Systematic review and case series.

Background: Myasthenia gravis is an autoimmune disease which can impact pregnancy. Methods: Six databases were systematically searched for studies with at least five subjects reporting pregnancy outcomes for women with myasthenia gravis in pregnancy. Assessment of bias was performed for all included studies. Forty-eight cases from our own centre were also included in the analysis. Results: In total, 32 publications met inclusion criteria for systematic review, for a total of 33 unique data sets including 48 cases from our institution. Outcome data was available for 824 pregnancies. Spontaneous vaginal delivery occurred in 56.3% of pregnancies. Overall risk of myasthenia gravis exacerbation was 33.8% with a 6.4% risk of myasthenic crisis in pregnancy and 8.2% postpartum. The incidence risk of transient neonatal myasthenia gravis was 13.0%. Conclusions: The current systematic review provides the best estimates of risk currently available to aid in counselling women with myasthenia gravis in pregnancy.

Noninvasive oxygenation strategies in adult patients with acute respiratory failure: a protocol for a systematic review and network meta-analysis.

BACKGROUND: Acute hypoxemic respiratory failure is one of the leading causes of intensive care unit admission and is associated with high mortality. Noninvasive oxygenation strategies such as high-flow nasal cannula, standard oxygen therapy, and noninvasive ventilation (delivered by either face mask or helmet interface) are widely available interventions applied in these patients. It remains unclear which of these interventions are more effective in decreasing rates of invasive mechanical ventilation and mortality. The primary objective of this network meta-analysis is to summarize the evidence and compare the effect of noninvasive oxygenation strategies on mortality and need for invasive mechanical ventilation in patients with acute hypoxemic respiratory failure. METHODS: We will search key databases for randomized controlled trials assessing the effect of noninvasive oxygenation strategies in adult patients with acute hypoxemic respiratory failure. We will exclude studies in which the primary focus is either acute exacerbations of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. The primary outcome will be all-cause mortality (longest available up to 90 days). The secondary outcomes will be receipt of invasive mechanical ventilation (longest available up to 30 days). We will assess the risk of bias for each of the outcomes using the Cochrane Risk of Bias Tool. Bayesian network meta-analyses will be conducted to obtain pooled estimates of head-to-head comparisons. We will report pairwise and network meta-analysis treatment effect estimates as risk ratios and 95% credible intervals. Subgroup analyses will be conducted examining key populations including immunocompromised hosts. Sensitivity analyses will be conducted by excluding those studies with high risk of bias and different etiologies of acute respiratory failure. We will assess certainty in effect estimates using GRADE methodology. DISCUSSION: This study will help to guide clinical decision-making when caring for adult patients with acute hypoxemic respiratory failure and improve our understanding of the limitations of the available literature assessing noninvasive oxygenation strategies in acute hypoxemic respiratory failure. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019121755.