Cardiovascular events following pregnancy complicated by pre-eclampsia with emphasis on comparison between early- and late-onset forms: systematic review and meta-analysis.

OBJECTIVE: To elucidate whether pre-eclampsia (PE) and the gestational age at onset of the disease (early- vs late-onset PE) have an impact on the risk of long-term maternal cardiovascular complications. METHODS: MEDLINE, EMBASE and Scopus databases were searched until 15 April 2020 for studies evaluating the incidence of cardiovascular events in women with a history of PE, utilizing combinations of the relevant MeSH terms, keywords and word variants for 'pre-eclampsia', 'cardiovascular disease' and 'outcome'. Inclusion criteria were cohort or case-control design, inclusion of women with a diagnosis of PE at the time of the first pregnancy, and sufficient data to compare each outcome in women with a history of PE vs women with previous normal pregnancy and/or in women with a history of early- vs late-onset PE. The primary outcome was a composite score of maternal cardiovascular morbidity and mortality, including cardiovascular death, major cardiovascular and cerebrovascular events, hypertension, need for antihypertensive therapy, Type-2 diabetes mellitus, dyslipidemia and metabolic syndrome. Secondary outcomes were the individual components of the primary outcome analyzed separately. Data were combined using a random-effects generic inverse variance approach. MOOSE guidelines and the PRISMA statement were followed. RESULTS: Seventy-three studies were included. Women with a history of PE, compared to those with previous normotensive pregnancy, had a higher risk of composite adverse cardiovascular outcome (odds ratio (OR), 2.05 (95% CI, 1.9-2.3)), cardiovascular death (OR, 2.18 (95% CI, 1.8-2.7)), major cardiovascular events (OR, 1.80 (95% CI, 1.6-2.0)), hypertension (OR, 3.93 (95% CI, 3.1-5.0)), need for antihypertensive medication (OR, 4.44 (95% CI, 2.4-8.2)), dyslipidemia (OR, 1.32 (95% CI, 1.3-1.4)), Type-2 diabetes (OR, 2.14 (95% CI, 1.5-3.0)), abnormal renal function (OR, 3.37 (95% CI, 2.3-5.0)) and metabolic syndrome (OR, 4.30 (95% CI, 2.6-7.1)). Importantly, the strength of the associations persisted when considering the interval (< 1, 1-10 or > 10 years) from PE to the occurrence of these outcomes. When stratifying the analysis according to gestational age at onset of PE, women with previous early-onset PE, compared to those with previous late-onset PE, were at higher risk of composite adverse cardiovascular outcome (OR, 1.75 (95% CI, 1.0-3.0)), major cardiovascular events (OR, 5.63 (95% CI, 1.5-21.4)), hypertension (OR, 1.48 (95% CI, 1.3-1.7)), dyslipidemia (OR, 1.51 (95% CI, 1.3-1.8)), abnormal renal function (OR, 1.52 (95% CI, 1.1-2.2)) and metabolic syndrome (OR, 1.66 (95% CI, 1.1-2.5). CONCLUSIONS: Both early- and late-onset PE represent risk factors for maternal adverse cardiovascular events later in life. Early-onset PE is associated with a higher burden of cardiovascular morbidity and mortality compared to late-onset PE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Counseling in maternal-fetal medicine: SARS-CoV-2 infection in pregnancy.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a zoonotic coronavirus that crossed species to infect humans, causing coronavirus disease 2019 (COVID-19). Despite a potentially higher risk of pregnant women acquiring SARS-CoV-2 infection compared with the non-pregnant population (particularly in some ethnic minorities), no additional specific recommendations to avoid exposure are needed in pregnancy. The most common clinical symptoms and laboratory signs of SARS-CoV-2 infection in pregnancy are fever, cough, lymphopenia and elevated C-reactive protein levels. Pregnancy is associated with a higher risk of severe SARS-CoV-2 infection compared with the non-pregnant population, including pneumonia, admission to the intensive care unit and death, even after adjusting for potential risk factors for severe outcomes. The risk of miscarriage does not appear to be increased in women with SARS-CoV-2 infection. Evidence with regards to preterm birth and perinatal mortality is conflicting, but these risks are generally higher only in symptomatic, hospitalized women. The risk of vertical transmission, defined as the transmission of SARS-CoV-2 from the mother to the fetus or the newborn, is generally low. Fetal invasive procedures are considered to be generally safe in pregnant women with SARS-CoV-2 infection, although the evidence is still limited. In pregnant women with COVID-19, use of steroids should not be avoided if clinically indicated; the preferred regimen is a 2-day course of dexamethasone followed by an 8-day course of methylprednisolone. Non-steroidal anti-inflammatory drugs may be used if there are no contraindications. Hospitalized pregnant women with severe COVID-19 should undergo thromboprophylaxis throughout the duration of hospitalization and at least until discharge, preferably with low molecular weight heparin. Hospitalized women who have recovered from a period of serious or critical illness with COVID-19 should be offered a fetal growth scan about 14 days after recovery from their illness. In asymptomatic or mildly symptomatic women who have tested positive for SARS-CoV-2 infection at full term (i.e. ≥ 39 weeks of gestation), induction of labor might be reasonable. To date, there is no clear consensus on the optimal timing of delivery for critically ill women. In women with no or few symptoms, management of labor should follow routine evidence-based guidelines. Regardless of COVID-19 status, mothers and their infants should remain together and breastfeeding, skin-to-skin contact, kangaroo mother care and rooming-in throughout the day and night should be practiced, while applying necessary infection prevention and control measures. Many pregnant women have already undergone vaccination, mostly in the USA where the first reports show no significant difference in pregnancy outcomes in pregnant women receiving SARS-CoV-2 vaccination during pregnancy compared with the background risk. Vaccine-generated antibodies were present in the umbilical cord blood and breast milk samples of pregnant and lactating women who received the mRNA COVID-19 vaccine. Based on the available limited data on the safety of the COVID-19 vaccine in pregnancy, it seems reasonable to offer the option of vaccination to pregnant women after accurate counseling on the potential risk of a severe course of the disease and the unknown risk of fetal exposure to the vaccine. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Weight discordance and perinatal mortality in monoamniotic twin pregnancy: analysis of MONOMONO, NorSTAMP and STORK multiple-pregnancy cohorts.

OBJECTIVES: The primary objective was to quantify the risk of perinatal mortality in non-anomalous monochorionic monoamniotic (MCMA) twin pregnancies complicated by birth-weight (BW) discordance. The secondary objectives were to investigate the effect of inpatient vs outpatient fetal monitoring on the risk of mortality in weight-discordant MCMA twin pregnancies, and to explore the predictive accuracy of BW discordance for perinatal mortality. METHODS: This analysis included data on 242 MCMA twin pregnancies (484 fetuses) from three major research collaboratives on twin pregnancy (MONOMONO, STORK and NorSTAMP). The primary outcomes were the risks of intrauterine (IUD), neonatal (NND) and perinatal (PND) death, according to weight discordance at birth from ≥ 10% to ≥ 30%. The secondary outcomes were the association of inpatient vs outpatient fetal monitoring with the risk of mortality in weight-discordant pregnancies, and the accuracy of BW discordance in predicting mortality. Logistic regression and receiver-operating-characteristics-curve analyses were used to analyze the data. RESULTS: The risk of IUD was significantly increased in MCMA twin pregnancies with BW discordance ≥ 10% (odds ratio (OR), 2.2; 95% CI, 1.1-4.4; P = 0.022) and increased up to an OR of 4.4 (95% CI, 1.3-14.4; P = 0.001) in those with BW discordance ≥ 30%. This association remained significant on multivariate logistic regression analysis for BW-discordance cut-offs ≥ 20%. However, weight discordance had low predictive accuracy for mortality, with areas under the receiver-operating-characteristics curve of 0.60 (95% CI, 0.46-0.73), 0.52 (95% CI, 0.33-0.72) and 0.57 (95% CI, 0.45-0.68) for IUD, NND and PND, respectively. There was no difference in the risk of overall IUD, single IUD, double IUD, NND or PND between pregnancies managed as an inpatient compared with those managed as an outpatient, for any BW-discordance cut-off. CONCLUSIONS: MCMA twin pregnancies with BW discordance are at increased risk of fetal death, signaling a need for increased levels of monitoring. Despite this, the predictive accuracy for mortality is low; thus, detection of BW discordance alone should not trigger intervention, such as iatrogenic delivery. The current data do not demonstrate an advantage of inpatient over outpatient management in these cases. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Effectiveness of seminal plasma in in vitro fertilisation treatment: a systematic review and meta-analysis.

BACKGROUND: With in vitro fertilization (IVF) techniques, only 20-25% of the transferred embryos lead to a pregnancy. OBJECTIVE: To evaluate the beneficial effects of seminal plasma (SP) or semen applied at the time of oocyte aspiration or embryo transfer. SEARCH STRATEGY: Electronic databases were searched from their inception up to August 2017. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) evaluating the effects of SP or semen in IVF treatment. Trials were considered if women were exposed to any kind of SP or semen (either SP/semen injection or sexual intercourse) around the time of oocyte pickup and embryo transfer. DATA COLLECTION AND ANALYSIS: The primary outcome was clinical pregnancy rate (CPR). MAIN RESULTS: Eight RCTs on women undergoing IVF (2128 in total) were included in the meta-analysis. Women randomized in the intervention group had a significantly higher CPR compared with controls (30.0 versus 25.1%; RR 1.20; 95% CI, 1.04-1.39). No significant differences were found in the secondary outcomes, including livebirth rate, biochemical pregnancy, miscarriage, multiple pregnancies, and birth weight. The subgroup analyses (four RCTs, 780 participants), including only those RCTs in which prepared undiluted SP was injected just after oocyte pickup, conformed with the overall analysis for the primary outcome (46.3 versus 37.2%; RR 1.23; 95% CI, 1.05-1.45). CONCLUSION: Because intravaginal or intracervical SP application around the time of oocyte pickup is associated with higher CPR, local application SP may be considered as a potential treatment to improve implantation. TWEETABLE ABSTRACT: SP at the time of oocyte pickup is associated with higher CPR.

Pituitary block with gonadotrophin-releasing hormone antagonist during intrauterine insemination cycles: a systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Several randomised controlled trials (RCTs) have investigated the usefulness of pituitary block with gonadotrophin-releasing hormone (GnRH) antagonists during intrauterine insemination (IUI) cycles, with conflicting results. OBJECTIVE: The aim of the present systematic review and meta-analysis of RCTs was to evaluate the effectiveness of GnRH antagonist administration as an intervention to improve the success of IUI cycles. SEARCH STRATEGY: Electronic databases (MEDLINE, Scopus, EMBASE, Sciencedirect) and clinical registers were searched from their inception until October 2017. SELECTION CRITERIA: Randomised controlled trials of infertile women undergoing one or more IUI stimulated cycles with GnRH antagonists compared with a control group. DATA COLLECTION AND ANALYSIS: The primary outcomes were ongoing pregnancy/live birth rate (OPR/LBR) and clinical pregnancy rate (CPR). Pooled results were expressed as odds ratio (OR) or mean differences with 95% confidence interval (95% CI). Sources of heterogeneity were investigated through sensitivity and subgroups analysis. The body of evidence was rated using GRADE methodology. Publication bias was assessed with funnel plot, Begg's and Egger's tests. MAIN RESULTS: Fifteen RCTs were included (3253 IUI cycles, 2345 participants). No differences in OPR/LBR (OR 1.14, 95% CI 0.82-1.57, P = 0.44) and CPR (OR 1.28, 95% CI 0.97-1.69, P = 0.08) were found. Sensitivity and subgroup analyses did not provide statistical changes in pooled results. The body of evidence was rated as low (GRADE 2/4). No publication bias was detected. CONCLUSION: Pituitary block with GnRH antagonists does not improve OPR/LBR and CPR in women undergoing IUI cycles. TWEETABLE ABSTRACT: Pituitary block with GnRH antagonists does not improve the success of IUI cycles.

Perinatal mortality, timing of delivery and prenatal management of monoamniotic twin pregnancy: systematic review and meta-analysis.

OBJECTIVE: To quantify the rate of perinatal mortality in monochorionic monoamniotic (MCMA) twin pregnancies, according to gestational age, and to ascertain the incidence of mortality in pregnancies managed as inpatients compared with those managed as outpatients. METHODS: MEDLINE, EMBASE and CINAHL databases were searched for studies on monoamniotic twin pregnancy. The primary outcomes explored were the incidence of intrauterine death (IUD), neonatal death (NND) and perinatal death (PND) in MCMA twins at different gestational-age windows (24-30, 31-32, 33-34, 35-36 and ≥ 37 weeks of gestation). The secondary outcomes were the incidence of IUD, NND and PND in MCMA twins according to the type of fetal monitoring (inpatient vs outpatient), and the incidence of delivery ahead of schedule. Random-effects model meta-analyses were used to analyze the data. RESULTS: Twenty-five studies (1628 non-anomalous twins reaching 24 weeks of gestation) were included. Single and double intrauterine deaths occurred in 2.5% (95% CI, 1.8-3.3%) and 3.8% (95% CI, 2.5-5.3%) of cases, respectively. IUD occurred in 4.3% (95% CI, 2.8-6.2%) of twins at 24-30 weeks, in 1.0% (95% CI, 0.6-1.7%) at 31-32 weeks and in 2.2% (95% CI, 0.9-3.9%) at 33-34 weeks of gestation, while there was no case of IUD, either single or double, from 35 weeks of gestation. In MCMA twin pregnancies managed mainly as inpatients, the incidence of IUD was 3.0% (95% CI, 1.4-5.2%), while the corresponding figure for those managed mainly as outpatients was 7.4% (95% CI, 4.4-11.1%). Finally, 37.8% (95% CI, 28.0-48.2%) of MCMA pregnancies were delivered before the scheduled time, due mainly to spontaneous preterm labor or abnormal cardiotocographic findings. CONCLUSIONS: MCMA twins are at high risk of perinatal loss during the third trimester of pregnancy, with the large majority of such losses occurring as apparently unexpected events. Inpatient management seems to be associated with a lower rate of mortality, although further studies are needed in order to establish the appropriate type and timing of prenatal assessment in these pregnancies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Contraceptive use and sexual function: a comparison of Italian female medical students and women attending family planning services.

Objectives: The aims of the study were to understand how education relates to contraceptive choice and how sexual function can vary in relation to the use of a contraceptive method.Methods: We surveyed female medical students and women attending a family planning service (FPS) in Italy. Participants completed an online questionnaire which asked for information on sociodemographics, lifestyle, sexuality and contraceptive use and also included items of the Female Sexual Function Index (FSFI).Results: The questionnaire was completed by 413 women (362 students and 51 women attending the FPS) between the ages of 18 and 30 years. FSFI scores revealed a lower risk of sexual dysfunction among women in the control group who did not use oral hormonal contraception. The differences in FSFI total scores between the two study groups, when subdivided by the primary contraceptive method used, was statistically significant (p < 0.005). Women using the vaginal ring had the lowest risk of sexual dysfunction, compared with all other women, and had a positive sexual function profile. In particular, the highest FSFI domain scores were lubrication, orgasm and satisfaction, also among the control group. Expensive contraception, such as long-acting reversible contraception, was not preferred by this young population, even though such methods are more contemporary and manageable. Compared with controls, students had lower compliance with contraception and a negative attitude towards voluntary termination of pregnancy.Conclusion: Despite their scientific knowledge, Italian female medical students were found to need sexual and contraceptive assistance. A woman's sexual function responds to her awareness of her body and varies in relation to how she is guided in her contraceptive choice. Contraceptive counselling is an excellent means to improve female sexuality.

Induction of labour for suspected macrosomia at term in non-diabetic women: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Several randomized controlled trials (RCTs) compared induction of labour with expectant management in non-diabetic women with suspected fetal macrosomia. OBJECTIVE: To evaluate the effects of labour induction for suspected fetal macrosomia. SEARCH STRATEGY: Literature search in electronic databases. SELECTION CRITERIA: We included all RCTs of suspected fetal macrosomia comparing labour induction with expectant management in term pregnancy. DATA COLLECTION AND ANALYSIS: The primary outcome was the incidence of caesarean delivery. MAIN RESULTS: Four RCTs, including 1190 non-diabetic women with suspected fetal macrosomia at term, were analysed. Pooled data did not show a significant difference in incidence of caesarean delivery [relative risk (RR) 0.91, 95% confidence interval (CI) 0.76-1.09], operative and spontaneous vaginal delivery, shoulder dystocia, intracranial haemorrhage, brachial plexus palsy, Apgar score <7 at 5 min, cord blood pH <7, and mean birth weight comparing women who received induction of labour with those who were managed expectantly. The induction group had a significantly lower time to delivery (mean difference -7.55 days, 95% CI -8.20 to -6.89), lower rate of birth weight ≥4000 g (RR 0.50, 95% CI 0.42-0.59) and ≥4500 g (RR 0.21, 95% CI 0.11-0.39), and lower incidence of fetal fractures (RR 0.17, 95% CI 0.03-0.79) compared with expectant management group. CONCLUSION: Induction of labour ≥38 weeks for suspected fetal macrosomia is associated with a significant decrease in fetal fractures, and therefore can be considered as a reasonable option. TWEETABLE ABSTRACT: #Induction of labour for #macrosomia improves neonatal outcome.

Cervical length screening for prevention of preterm birth in singleton pregnancy with threatened preterm labor: systematic review and meta-analysis of randomized controlled trials using individual patient-level data.

OBJECTIVE: Cervical length screening by transvaginal sonography (TVS) has been shown to be a good predictive test for spontaneous preterm birth (PTB) in symptomatic singleton pregnancy with threatened preterm labor (PTL). The aim of this review and meta-analysis of individual participant data was to evaluate the effect of knowledge of the TVS cervical length (CL) in preventing PTB in singleton pregnancies presenting with threatened PTL. METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register and the Cochrane Complementary Medicine Field's Trials Register (May 2016) and reference lists of retrieved studies. Selection criteria included randomized controlled trials of singleton gestations with threatened PTL randomized to management based mainly on CL screening (intervention group), or CL screening with no knowledge of results or no CL screening (control group). Participants included women with singleton gestations at 23 + 0 to 36 + 6 weeks with threatened PTL. We contacted corresponding authors of included trials to request access to the data and perform a meta-analysis of individual participant data. Data provided by the investigators were merged into a master database constructed specifically for the review. The primary outcome was PTB < 37 weeks. Summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% CI. RESULTS: Three trials including a total of 287 singleton gestations with threatened PTL between 24 + 0 and 35 + 6 weeks were included in the meta-analysis, of which 145 were randomized to CL screening with knowledge of results and 142 to no knowledge of CL. Compared with the control group, women who were randomized to the known CL group had a significantly lower rate of PTB < 37 weeks (22.1% vs 34.5%; RR, 0.64 (95% CI, 0.44-0.94); three trials; 287 participants) and a later gestational age at delivery (MD, 0.64 (95% CI, 0.03-1.25) weeks; MD, 4.48 (95% CI, 1.18-8.98) days; three trials; 287 participants). All other outcomes for which there were available data were similar in the two groups. CONCLUSIONS: There is a significant association between knowledge of TVS CL and lower incidence of PTB and later gestational age at delivery in symptomatic singleton gestations with threatened PTL. Given that in the meta-analysis we found a significant 36% reduction in the primary outcome, but other outcomes were mostly statistically similar, further study needs to be undertaken to understand better whether the predictive characteristics of CL screening by TVS can be translated into better clinical management and therefore better outcomes and under what circumstances. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. CRIBADO MEDIANTE LA LONGITUD CERVICAL PARA LA PREVENCIÓN DEL PARTO PRETÉRMINO EN EMBARAZOS CON FETO ÚNICO Y RIESGO DE PARTO PREMATURO: REVISIÓN SISTEMÁTICA Y METAANÁLISIS DE ENSAYOS CONTROLADOS ALEATORIZADOS HACIENDO USO DE LOS DATOS INDIVIDUALES DE LAS PACIENTES: RESUMEN OBJETIVO: El cribado mediante la longitud cervical obtenida con ecografía transvaginal (ETV) ha demostrado ser una buena prueba para la predicción del parto pretérmino espontáneo (PPTE) en embarazos con feto único sintomáticos debido a la amenaza de parto pretérmino (PPT). El objetivo de esta revisión y metaanálisis de los datos de participantes individuales fue evaluar el efecto de medir la longitud cervical (LC) mediante ETV con el fin de prevenir el parto prematuro en embarazos únicos con amenaza de PPT. MÉTODOS: Se realizaron búsquedas en los ficheros de ensayos de Cochrane Pregnancy and Childbirth Group y Complementary Medicine Field (mayo de 2016), y en las listas de referencias de los estudios encontrados. Los criterios de selección incluyeron ensayos controlados aleatorizados de embarazos con feto único y riesgo de PPT con aleatorización de la paciente basada principalmente en el cribado mediante la LC (grupo de intervención), el cribado mediante la LC sin conocimiento de los resultados, o sin cribado de LC (grupo de control). Las participantes fueron mujeres embarazadas con feto único desde las 23 + 0 hasta las 36 + 6 semanas y con riesgo de PPT. Se estableció contacto con los autores de los ensayos incluidos para solicitar el acceso a los datos y llevar a cabo un metaanálisis de los datos de las participantes individualmente. Los datos proporcionados por los investigadores se agregaron a una base de datos maestra creada específicamente para esta revisión. El resultado primario fue el PPTE < 37 semanas. Las medidas resumen se reportaron como riesgo relativo (RR) o como diferencia de medias (DM) con IC del 95%. RESULTADOS: En el metaanálisis se incluyeron tres ensayos con un total de 287 embarazos con feto único y riesgo de PPT entre 24 + 0 y 35 + 6 semanas, de los cuales 145 fueron asignados al azar a un cribado mediante la LC con conocimiento de los resultados y 142 a aquellos para los que se desconocía la LC. En comparación con el grupo control, las mujeres que fueron asignadas aleatoriamente al grupo en el que se conocía la LC tuvieron una tasa de parto prematuro a < 37 semanas significativamente menor (22,1% vs. 34,5%; RR 0,64 (IC 95%, 0,44-0,94); 3 ensayos; 287 participantes ) y una edad gestacional al momento del parto más tardía (DM 0,64 (IC 95%, 0.03-1.25) semanas; DM 4,48 (IC 95%, 1,18-8,98) días; 3 ensayos; 287 participantes). El resto de los resultados para los cuales había datos disponibles fueron similares en ambos grupos. CONCLUSIONES: Existe una asociación significativa entre el conocimiento de la LC obtenida mediante ETV y una menor incidencia de PPTE y edad gestacional más tardía en el momento del parto en embarazos con feto único sintomáticos debido al riesgo de parto pretérmino (PPT). Teniendo en cuenta que en el metaanálisis se encontró una reducción significativa del 36% en el resultado primario, pero que los otros resultados fueron estadísticamente similares en su mayoría, serán necesarios más estudios para entender mejor si las propiedades predictivas del cribado mediante la LC obtenida con ETV se pueden traducir en una mejor atención clínica y por lo tanto mejores resultados dependiendo de las circunstancias. :META: : ,(preterm labor,PTL),(transvaginal sonography,TVS)(spontaneous preterm birth,PTB)。metaPTL,TVS(cervical length,CL)PTB。 : CochraneCochrane(20165)。PTL,CL()CLCL()。23 + 036+6PTL。,,meta。。37PTB。(relative risk,RR)95%CI(mean difference,MD)。 : meta3,28724 + 035+6PTL,145CL,142CL。,CL37PTB[22.1%34.5%;RR,0.64(95% CI,0.44 ~ 0.94);3;287],[MD,0.64(95% CI,0.03 ~ 1.25);MD,4.48(95% CI,1.18 ~ 8.98);3;287]。2,。 : PTL,TVS CLPTB。meta36%,,,TVSCL,。.

Risk of Cesarean scar defect following single- vs double-layer uterine closure: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: There is a growing body of evidence that suggests that the surgical technique for uterine closure following Cesarean delivery influences the healing of the Cesarean scar, but there is still no consensus on the optimal technique. The aim of this systematic review and meta-analysis was to compare the effect of single- vs double-layer uterine closure on the risk of uterine scar defect. METHODS: MEDLINE, Scopus, ClinicalTrials.gov, PROSPERO, EMBASE and the Cochrane Central Register of Controlled Trials were searched from inception of each database until May 2016. All randomized controlled trials (RCTs) evaluating the effect of single- vs double-layer uterine closure following low transverse Cesarean section on the risk of uterine scar defect were included. The primary outcome was the incidence of uterine scar defects detected on ultrasound. Secondary outcomes were residual myometrial thickness evaluated by ultrasound and the incidence of uterine dehiscence and/or rupture in subsequent pregnancy. Summary measures were reported as relative risk (RR) or mean difference (MD), with 95% CIs. Quality of the evidence was assessed using the GRADE approach. RESULTS: Nine RCTs (3969 participants) were included in the meta-analysis. The overall risk of bias of the included trials was low. Statistical heterogeneity within the studies was low, with no inconsistency in the primary and secondary outcomes. Women who received single-layer uterine closure had a similar incidence of uterine scar defects as did women who received double-layer closure (25% vs 43%; RR, 0.77 (95% CI, 0.36-1.64); five trials; 350 participants; low quality of evidence). Compared with double-layer uterine closure, women who received single-layer closure had a significantly thinner residual myometrium on ultrasound (MD, -2.19 mm (95% CI, -2.80 to -1.57 mm); four trials; 374 participants; low quality of evidence). No difference was found in the incidence of uterine dehiscence (0.4% vs 0.2%; RR, 1.34 (95% CI, 0.24-4.82); three trials; 3421 participants; low quality of evidence) or uterine rupture (0.1% vs 0.1%; RR, 0.52 (95% CI, 0.05-5.53); one trial; 3234 participants; low quality of evidence) in a subsequent pregnancy. CONCLUSIONS: Single- and double-layer closure of the uterine incision following Cesarean delivery are associated with a similar incidence of Cesarean scar defects, as well as uterine dehiscence and rupture in a subsequent pregnancy. However, the quality level of summary estimates, as assessed by GRADE, was low, indicating that the true effect may be, or is even likely to be, substantially different from the estimate of the effect. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Vaginal progesterone vs intramuscular 17α-hydroxyprogesterone caproate for prevention of recurrent spontaneous preterm birth in singleton gestations: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Randomized controlled trials (RCTs) have recently compared intramuscular 17α-hydroxyprogesterone caproate (17-OHPC) with vaginal progesterone for reducing the risk of spontaneous preterm birth (SPTB) in singleton gestations with prior SPTB. The aim of this systematic review and meta-analysis was to evaluate the efficacy of vaginal progesterone compared with 17-OHPC in prevention of SPTB in singleton gestations with prior SPTB. METHODS: Searches of electronic databases were performed to identify all RCTs of asymptomatic singleton gestations with prior SPTB that were randomized to prophylactic treatment with either vaginal progesterone (intervention group) or intramuscular 17-OHPC (comparison group). No restrictions for language or geographic location were applied. The primary outcome was SPTB < 34 weeks. Secondary outcomes were SPTB < 37 weeks, < 32 weeks, < 28 weeks and < 24 weeks, maternal adverse drug reaction and neonatal outcomes. The summary measures were reported as relative risk (RR) with 95% CI. Risk of bias for each included study was assessed. RESULTS: Three RCTs (680 women) were included. The mean gestational age at randomization was about 16 weeks. Women were given progesterone until 36 weeks or delivery. Regarding vaginal progesterone, one study used 90 mg gel daily, one used 100 mg suppository daily and one used 200 mg suppository daily. All included RCTs used 250 mg intramuscular 17-OHPC weekly in the comparison group. Women who received vaginal progesterone had significantly lower rates of SPTB < 34 weeks (17.5% vs 25.0%; RR, 0.71 (95% CI, 0.53-0.95); low quality of evidence) and < 32 weeks (8.9% vs 14.5%; RR, 0.62 (95% CI, 0.40-0.94); low quality of evidence) compared with women who received 17-OHPC. There were no significant differences in the rates of SPTB < 37 weeks, < 28 weeks and < 24 weeks. The rate of women who reported adverse drug reactions was significantly lower in the vaginal progesterone group compared with the 17-OHPC group (7.1% vs 13.2%; RR, 0.53 (95% CI, 0.31-0.91); very low quality of evidence). Regarding neonatal outcomes, vaginal progesterone was associated with a lower rate of neonatal intensive care unit admission compared with 17-OHPC (18.7% vs 23.5%; RR, 0.63 (95% CI, 0.47-0.83); low quality of evidence). For the comparison of 17-OHPC vs vaginal progesterone, the quality of evidence was downgraded for all outcomes by at least one degree due to imprecision (the optimal information size was not reached) and by at least one degree due to indirectness (different interventions). CONCLUSIONS: Daily vaginal progesterone (either suppository or gel) started at about 16 weeks' gestation is a reasonable, if not better, alternative to weekly 17-OHPC injection for prevention of SPTB in women with singleton gestations and prior SPTB. However, the quality level of the summary estimates was low or very low as assessed by GRADE, indicating that the true effect may be, or is likely to be, substantially different from the estimate of the effect. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. COMPARACIÓN ENTRE LA PROGESTERONA VAGINAL Y EL 17Α-HIDROXIPROGESTERONA CAPROATO INTRAMUSCULAR PARA LA PREVENCIÓN DEL PARTO PRETÉRMINO ESPONTÁNEO RECURRENTE EN EMBARAZOS CON FETO ÚNICO: REVISIÓN SISTEMÁTICA Y METAANÁLISIS DE ENSAYOS CONTROLADOS ALEATORIOS: RESUMEN OBJETIVO: Recientemente se han realizado varios ensayos controlados aleatorios (ECA) que comparaban el caproato de 17α-hidroxiprogesterona (17-OHPC, por sus siglas en inglés) por vía intramuscular con la progesterona por vía vaginal para la reducción del riesgo de parto pretérmino espontáneo (PPTE) en embarazos con feto único de gestantes con historial de PPTE. El objetivo de esta revisión sistemática y metaanálisis fue evaluar la eficacia de la progesterona vaginal en comparación con la 17-OHPC en la prevención de embarazos con feto único de gestantes con historial de PPTE. MÉTODOS: Se realizaron búsquedas en bases de datos electrónicas para identificar todos los ECA con embarazos de feto único asintomáticos con historial de PPTE antes de ser asignados al azar a un tratamiento profiláctico, ya fuera con progesterona vaginal (grupo de intervención) o con 17-OHPC intramuscular (grupo de control). No se aplicaron restricciones respecto al idioma o la ubicación geográfica. El resultado primario fue PPTE < 34 semanas. Los resultados secundarios fueron PPTE <37 semanas, < 32 semanas, < 28 semanas y < 24 semanas, la reacción materna adversa al fármaco y los resultados neonatales. Las medidas del resumen se reportaron como riesgo relativo (RR) con IC del 95%. Para cada estudio incluido se evaluó el riesgo de sesgo. RESULTADOS: Se incluyeron tres ECA (680 mujeres). La media de la edad gestacional en el momento de la aleatorización fue de 16 semanas. A las mujeres se les administró progesterona hasta la semana 36 o hasta el parto. Con respecto a la progesterona vaginal, un estudio utilizó gel de 90 mg diariamente, otro utilizó un supositorio diario de 100 mg y el otro utilizó un supositorio diario de 200 mg. Todos los ECA incluidos en el grupo de comparación utilizaron 250 mg semanales de 17-OHPC por vía intramuscular. Las mujeres que recibieron progesterona vaginal tuvieron tasas significativamente más bajas de PPTE < 34 semanas (17,5% vs. 25,0%; RR 0,71 (IC 95%, 0,53-0,95); calidad de la evidencia baja) y < 32 semanas (8,9% vs. 14,5%; RR 0,62 (IC 95%, 0,40-0,94); calidad de evidencia baja), en comparación con las mujeres que recibieron 17-OHPC. No hubo diferencias significativas en las tasas de PPTE < 37 semanas, < 28 semanas y < 24 semanas. La tasa de mujeres que reportaron reacciones adversas a los medicamentos fue significativamente menor en el grupo de progesterona vaginal en comparación con el grupo de 17-OHPC (7,1% vs. 13,2%; RR 0,53 (IC 95%, 0,31-0,91); calidad de la evidencia muy baja). En cuanto a los resultados neonatales, la progesterona vaginal se asoció a una menor tasa de admisiones en la unidad neonatal de cuidados intensivos en comparación con la 17-OHPC (18,7% vs. 23,5%; RR 0,63 (IC 95%, 0,47-0,83); calidad de evidencia baja). Para la comparación del 17-OHPC con la progesterona vaginal se rebajó la calidad de las pruebas para todos los resultados en al menos un grado debido a imprecisiones (no se alcanzó el tamaño óptimo de la información) y en al menos un grado debido al carácter indirecto de los estudios (diferentes intervenciones). CONCLUSIONES: La progesterona vaginal administrada diariamente (ya fuera como supositorio o como gel) desde la semana 16 de gestación es una alternativa razonable, si no mejor, a una inyección semanal de 17-OHPC para la prevención de PPTE en mujeres con embarazos de feto único e historial de PPTE. Sin embargo, el nivel de calidad de las estimaciones del resumen fue bajo o muy bajo según lo evaluado por GRADE, lo que indica que el verdadero efecto puede ser, o es probable que sea, sustancialmente diferente de la estimación del efecto. 17Α-:META: : (randomized controlled trials,RCTs)(spontaneous preterm birth,SPTB)17α-(intramuscular 17α-hydroxyprogesterone caproate,17-OHPC)SPTB。metaSPTB17-OHPCSPTB。 : ,SPTBRCTs,RCTs()17-OHPC()。。34SPTB。37、32、2824SPTB,。(relative risk,RR)95%CI。。 : 3RCTs(680)。16。,36。,90 mg,100 mg,200 mg。,RCTs250 mg 17-OHPC。17-OHPC,34 [17.5%25.0%;RR,0.71(95% CI,0.53 ~ 0.95);]32[8.9%14.5%;RR,0.62(95% CI,0.40 ~ 0.94);]SPTB。37、2824SPTB。17-OHPC,[7.1%13.2%;RR,0.53(95% CI,0.31 ~ 0.91);]。,17-OHPC,[18.7%23.5%;RR,0.63(95% CI,0.47 ~ 0.83);]。17-OHPC,(),()。 : SPTBSPTB,16()17-OHPC,。,GRADE,,。.

Cerclage for sonographic short cervix in singleton gestations without prior spontaneous preterm birth: systematic review and meta-analysis of randomized controlled trials using individual patient-level data.

OBJECTIVE: The aim of this systematic review and meta-analysis was to quantify the efficacy of cervical cerclage in preventing preterm birth (PTB) in asymptomatic singleton pregnancies with a short mid-trimester cervical length (CL) on transvaginal sonography (TVS) and without prior spontaneous PTB. METHODS: Electronic databases were searched from inception of each database until February 2017. No language restrictions were applied. All randomized controlled trials (RCTs) of asymptomatic singleton pregnancies without prior spontaneous PTB, found to have short CL < 25 mm on mid-trimester TVS and then randomized to management with either cerclage or no cerclage, were included. Corresponding authors of all the included trials were contacted to obtain access to the data and perform a meta-analysis of individual patient-level data. Data provided by the investigators were merged into a master database constructed specifically for the review. Primary outcome was PTB < 35 weeks. Summary measures were reported as relative risk (RR) with 95% CI. The quality of the evidence was assessed using the GRADE approach. RESULTS: Five RCTs, including 419 asymptomatic singleton gestations with TVS-CL < 25 mm and without prior spontaneous PTB, were analyzed. In women who were randomized to the cerclage group compared with those in the control group, no statistically significant differences were found in PTB < 35 (21.9% vs 27.7%; RR, 0.88 (95% CI 0.63-1.23); I2 = 0%; five studies, 419 participants), < 34, < 32, < 28 and < 24 weeks, gestational age at delivery, preterm prelabor rupture of membranes (PPROM) and neonatal outcomes. In women who received cerclage compared with those who did not, planned subgroup analyses revealed a significantly lower rate of PTB < 35 weeks in women with TVS-CL < 10 mm (39.5% vs 58.0%; RR, 0.68 (95% CI, 0.47-0.98); I2 = 0%; five studies; 126 participants) and in women who received tocolytics (17.5% vs 32.7%; RR, 0.54 (95% CI, 0.31-0.93); I2 = 0%; four studies; 169 participants) or antibiotics (18.3% vs 31.5%; RR, 0.58 (95% CI, 0.33-0.98); I2 = 0%; three studies; 163 participants) as additional therapy to cerclage. The quality of evidence was downgraded two levels because of serious imprecision and indirectness, and therefore was judged as low. CONCLUSIONS: In singleton gestations without prior spontaneous PTB but with TVS-CL < 25 mm in the second trimester, cerclage does not seem to prevent preterm delivery or improve neonatal outcome. However, in these pregnancies, cerclage seems to be efficacious at lower CLs, such as < 10 mm, and when tocolytics or antibiotics are used as additional therapy, requiring further studies in these subgroups. Given the low quality of evidence, further well-designed RCTs are needed to confirm the findings of this study. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Identification, characterization and target gene analysis of testicular microRNAs in the oriental fruit fly Bactrocera dorsalis.

MicroRNAs (miRNAs) are small noncoding RNAs that regulate various diverse biological processes including insect spermatogenesis. The oriental fruit fly, Bactrocera dorsalis, is one of the most destructive horticultural pests in East Asia and the Pacific region. Although developmental miRNA profiles of B. dorsalis have enriched our knowledge, specific testicular miRNAs in this dipteran species are unexplored. In this study, we identified miRNAs from B. dorsalis testes by deep sequencing, which provided an overview of miRNA expression during spermatogenesis. Small RNA libraries were constructed from the testes of fully mature (FM), immature (IM) and middle-aged (MA) adult flies of B. dorsalis. Small RNA sequencing and data analysis revealed 172 known and 78 novel miRNAs amongst these libraries. Pairwise comparisons of libraries led to the identification of 24, 15 and 14 differentially expressed miRNAs in FM vs. IM, FM vs. MA and IM vs. MA insects, respectively. Using a bioinformatic approach, we predicted 124 target genes against the 13 most differentially expressed miRNAs. Furthermore, the expression patterns of six randomly selected miRNAs (from the 13 most differentially expressed miRNAs) and their putative target genes (from the 124 predicted target genes) were analysed in the testis of B. dorsalis by quantitative real-time PCR, which showed that out of six, four tested miRNAs-mRNAs had an inverse expression pattern and are probably co-regulated. This study is the first comparative profile of the miRNA transcriptome in three developmental stages of the testis, and provides a useful resource for further studies on the role of miRNAs in spermatogenesis in B. dorsalis.

Transvaginal ultrasound cervical length for prediction of spontaneous labour at term: a systematic review and meta-analysis.

BACKGROUND: The possibility to predict the delivery date is a question frequently raised by pregnant women. However, a clinician has currently little to predict when a woman at term will deliver. OBJECTIVE: To evaluate the predictive accuracy of transvaginal ultrasound (TVU) cervical length (CL) for spontaneous onset of labour in singleton gestation enrolled at term by a meta-analysis. SEARCH STRATEGY: We performed a literature search in electronic databases. SELECTION CRITERIA: We included only studies assessing the accuracy of TVU CL in prediction of spontaneous onset of labour in singleton gestations with vertex presentation who were enrolled at term. DATA COLLECTION AND ANALYSIS: The primary outcome was the accuracy of CL for prediction of spontaneous labour within 7 days. Pooled sensitivities and specificities were calculated. MAIN RESULTS: Five studies including 735 singleton gestations were included. For the prediction of spontaneous labour within 7 days for CL <30 mm the pooled sensitivity was 64% and pooled specificity was 60%. The higher the CL, the better the sensitivity; the lower the CL, the better the specificity. A woman with a singleton gestation at term and a TVU CL of 30 mm has a <50% chance of delivering within 7 days, while one with a TVU CL of 10 mm has an over 85% chance of delivery within 7 days. CONCLUSIONS: TVU CL at term has moderate value in predicting the onset of spontaneous labour. A woman with a TVU CL of 10 mm or less has a high chance of delivering within a week. TWEETABLE ABSTRACT: Cervical length at term has moderate value in predicting the onset of spontaneous labour.

Selective serotonin reuptake inhibitor (SSRI) use during pregnancy and risk of preterm birth: a systematic review and meta-analysis.

BACKGROUND: Depression is a prevalent condition in pregnancy affecting about 10% of women. Maternal depression has been associated with an increase in preterm births (PTB), low birthweight and fetal growth restriction, and postnatal complications. Available treatments for depressive disorders are psychotherapeutic interventions and antidepressant medications including selective serotonin inhibitors (SSRIs). SSRI use during pregnancy has been associated with several fetal and neonatal complications; so far, however, the risk of PTB in women using SSRIs during pregnancy is still a subject of debate. OBJECTIVE: To evaluate the risk of preterm birth (PTB) in cases of exposure to SSRIs during pregnancy. SEARCH STRATEGY: Electronic databases (MEDLINE, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, EMBASE and the Cochrane Central Register of Controlled Trials) were searched from their inception until May 2015 with the use of a combination of the following text words 'depression', 'pregnancy', 'exposure', 'antidepressant', 'SSRI', 'selective serotonin reuptake inhibitor', 'preterm birth', 'small for gestational age' and 'prematurity'. SELECTION CRITERIA: We included studies evaluating the effect of SSRIs exposure in utero and pregnancy outcomes. All cohort and case-control studies were eligible to be included if they reported the incidence of PTB after any exposure to SSRIs and had a comparison group of unexposed pregnant women. Studies without a control group were excluded. DATA COLLECTION AND ANALYSIS: The primary outcome was the incidence of PTB <37 weeks. Subgroup analysis of studies in which controls were defined as women with depression but without SSRI exposure during pregnancy were planned. MAIN RESULTS: Eight studies (1 237 669 women) were included: 93 982 in the exposure group and 1 143 687 in the control group. After adjusting for confounders, the incidence of PTB was significantly higher in the group of women treated with SSRIs compared with controls (i.e. both women with depression but without SSRI exposure and women without depression) (adjusted OR (aOR) 1.24, 95% CI 1.09-1.41). In the subgroup analysis of studies in which controls were defined as women with depression but without SSRI exposure during pregnancy, an increased risk of PTB (6.8 versus 5.8%; OR 1.17, 95% CI 1.10-1.25) in the SSRI group was found compared with controls (i.e. depressed women treated with psychotherapy alone). CONCLUSIONS: Women who received SSRIs during pregnancy had a significantly higher risk of developing PTB compared with controls. This higher risk remained significant even when comparing depressed women on SSRI with women not on SSRI. TWEETABLE ABSTRACT: Selective serotonin reuptake inhibitors may be associated with preterm birth.

Omega-3 supplementation during pregnancy to prevent recurrent intrauterine growth restriction: systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To evaluate the efficacy of omega-3 supplementation during pregnancy in preventing intrauterine growth restriction (IUGR) in women with apparently uncomplicated singleton pregnancy and previous IUGR pregnancy. METHODS: For this systematic review, the research protocol was designed a priori. Searches were performed in electronic databases for studies published from inception of each database to December 2014. A combination of search terms was used including 'fish oil', 'long chain polyunsaturated fatty acids', 'intrauterine growth restriction', 'small for gestational age' and 'omega-3'. We included all randomized controlled trials (RCTs) of women with an uncomplicated singleton pregnancy and a prior IUGR pregnancy who were randomized to receive prophylactic treatment with omega-3 supplementation or either placebo or no treatment (control). Trials that included women with multiple gestations and those with only biochemical outcomes available were excluded. Pooled estimates were based on relative risk (RR) with 95% CI. Primary outcome was incidence of IUGR as defined in the RCTs. RESULTS: Three RCTs including 575 women with uncomplicated singleton pregnancy with prior IUGR were analyzed. Women who received omega-3 supplementation during pregnancy had the same incidence of IUGR, defined as estimated fetal weight < 5(th) or < 3(rd) centiles, as had controls (22.8% vs 20.2%, respectively; RR, 1.13 (95% CI, 0.83-1.54)). Compared to controls, women who received omega-3 supplementation delivered later (mean difference, 1.4 (95% CI, 1.28-1.63) weeks), had a longer latency (mean difference, 2 (95% CI, 1.73-2.08) weeks), had a similar incidence of perinatal death (2.1% vs 3.3%, respectively; RR, 0.60 (95% CI, 0.15-2.42)) and similar birth weight (mean difference, 50 g (95% CI, -26 to 246 g)). CONCLUSIONS: Omega-3 supplementation during pregnancy does not prevent recurrence of IUGR in women with uncomplicated singleton pregnancy and a previous IUGR pregnancy.

Cavernous haemangioma and mid trimester pregnancy loss leading to severe haemorrhage and hysterectomy: a case report and review of literature.

Background: Cavernous haemangiomas are benign vascular tumours that are known to occasionally involve the female genital tract, including the uterus. They are often underdiagnosed during pregnancy, although they can also lead to severe postpartum or antepartum haemorrhage. Objectives: Describe our case of an uncommon second-trimester pregnancy loss in a woman with a diffuse cavernous haemangioma of the uterus and cervix and review the wider literature. Methods: The review was conducted using MEDLINE, Scopus and PubMed electronic databases from beginning of the database to May 2023, using the following keywords: arteriovenous malformation; cavernous haemangioma/hemangioma; uterine neoplasms; pregnancy complications; abnormal vaginal bleeding. Main outcome measures: Description of the characteristics of cavernous haemangioma during pregnancy as well as diagnostic criteria and treatment options. Results: Twenty publications were included in the review, which included English-language case reports over a period from 1959 to 2022. No pathognomonic symptoms for cavernous haemangioma of the uterus in a pregnant woman were noted. Complications including massive secondary postpartum haemorrhage, haemoperitoneum, and severe thrombocytopenia with anaemia after delivery were reported. Conclusions: Diagnosis and management during pregnancy can be challenging and requires considerable attention, with a multidisciplinary approach including gynaecologists, radiologists, and pathologists to avoid major complications. What is new?: An additional case of diffuse cavernous haemangioma of the uterus and cervix is described, that adds to the little existing literature.