Antenatal magnesium sulfate for fetal neuroprotection: a critical appraisal and systematic review of clinical practice guidelines.

Background Magnesium sulfate is an accepted intervention for fetal neuroprotection. There are some perceived differences in the international recommendations on the use magnesium sulfate for fetal neuroprotection in preterm labor. Content This systematic review analyses the available clinical guidelines for the use of magnesium sulfate for fetal neuroprotection and compares the recommendations, and assesses the quality of guidelines. This provides the consensus, differences and explores the areas for future collaborative research. We searched databases of PUBMED, EMBASE, COCHRANE, Web of Science, LILACS; and included the national and the international clinical practice guidelines. We included seven guidelines out of 227 search results. We evaluated the methodological quality of guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE II) tool and systematically extracted guideline characters, recommendation and supporting evidence base. Summary Five guidelines were of high quality and two were of moderate quality. One guideline achieved more than an 80% score in all the domains of AGREE II tool. All guidelines recommend use of magnesium sulfate for fetal neuroprotection. However, there are differences in other recommendations such as upper gestational age, dose, duration, repeating treatment and use of additional tocolytics. Outlook Future guidelines should include recommendations on all aspects of magnesium sulfate therapy for fetal neuroprotection. Future research and international collaboration should focus on areas where there are no international consensual recommendations.

Expectant management of caesarean scar ectopic pregnancy: a systematic review.

AIM: The purpose of this review is to systematically review all the reported cases and case series of caesarean scar pregnancy (CSP) managed expectantly without any intervention in order to understand the outcomes of pregnancy which will guide clinicians and patients in making treatment choices. METHODS: An electronic search on PubMed, EMBASE and Cochrane databases and a manual search from references of the articles were performed. Studies were selected based on inclusion and exclusion criteria. Data were extracted for various outcomes of pregnancy and the quality of the reports was assessed using a modified Delphi technique. RESULTS: A total of 56 cases of CSP from 11 reports were included in the review, including 44 cases with foetal cardiac activity. Live births were achieved in 73% of cases with a quarter of them born before 34 weeks. Hysterectomy rates were 70%. In 12/44 (27%) of cases pregnancies were lost due to complications before 24 weeks. Most (67%) of the CSPs with no foetal cardiac activities resolved on expectant management and the remaining required intervention for bleeding. CONCLUSIONS: Caution should be exercised when choosing expectant management in cases of viable CSPs, and if chosen, the patient should be counselled adequately for possible outcomes including loss of pregnancy and hysterectomy. Expectant management is acceptable in CSPs with no foetal cardiac activity. There is a need for prospective research on this topic with adequate reporting on possible prognostic markers, as well as a need to improve on the techniques to prevent loss of fertility during delivery.

Electronic intrapartum fetal monitoring: a systematic review of international clinical practice guidelines.

BACKGROUND: Electronic fetal monitoring or fetal assessment using a cardiotocograph is currently the most commonly employed tool for intrapartum surveillance. Furthermore, there are numerous guidelines informing best practice worldwide. OBJECTIVE: This systematic review aimed to compare and appraise all available practice guidelines on intrapartum electronic fetal monitoring to describe the similarities and variations in recommendations. STUDY DESIGN: A systematic protocol was developed per Preferred Reporting Item for Systematic Review and Meta-Analysis Protocols. A total of 4 independent reviewers were involved with independent searches and quality assessment using the Appraisal of Guidelines for Research and Evaluation Instrument for guideline quality reporting. RESULTS: Overall, 7 international practice guidelines were included in this systematic review. Appraisal of Guidelines for Research and Evaluation Instrument showed higher scores for scope and purpose and for clarity of presentation; however, the overall assessment varied between 25% and 89%. When individual characteristics of electronic fetal monitoring or cardiotocograph were compared, all guidelines and guidance were essentially trying to describe the characters similarly, with critical differences described in the full article. CONCLUSION: In the context of globalization, a uniform approach for defining terminology, classifying characters and similar interpretation of results is needed for electronic fetal monitoring. Therefore, we should consider a unified, simple, logistically approved, and acceptable guideline, which is probably accepted worldwide.

Bacterial vaginosis in pregnancy - a storm in the cup of tea.

Human vaginal microbiota is dominated by Lactobacillus spp both in the non-pregnant and pregnant state. Bacterial vaginosis (BV) is an imbalance of vaginal microbiota caused by a reduction in the normal lactobacillary bacteria, and a heavy over-growth of mixed anaerobic bacteria. Various clinical (Amsel's Criteria), laboratory (Nugent's score) and molecular diagnostic method (quantitative PCR) are used for diagnosis. BV in pregnancy is associated with increased risk of preterm birth, low birth weight, chorioamnionitis and postpartum endometritis, apart from bothersome vaginal discharge. Antibiotic treatment with metronidazole or clindamycin are effective in eradicating bacterial vaginosis and safe to use in pregnancy. Treatment of bacterial vaginosis has not been shown to improve obstetric outcomes in women at low risk of preterm birth, but may reduce the risk of preterm birth and low birth weight in women at increased risk of preterm birth. Routine screening and treatment is not recommended in low risk women. Test for cure should be performed after treatment. Further research is required on other treatment modalities such as probiotic therapy and microbiota transplantation.

Postpartum Acute Colonic Pseudo-Obstruction (Ogilvie's Syndrome): A systematic review of case reports and case series.

INTRODUCTION: Ogilvie's Syndrome or Acute Colonic Pseudo-Obstruction (ACPO) is a rare condition characterized by massive dilatation of the colon in the absence of mechanical obstruction. About 10% of all reported cases are related to Obstetric and Gynaecological procedures, Caesarean section being the commonest associated factor. Acute intestinal dilatation, if not treated, may lead to perforation and faecal peritonitis with consequent high morbidity and mortality. MATERIALS AND METHODS: An electronic literature searches were performed in PubMed, EMBASE, Google scholar and hand searches for relevant references were included without any language restriction. All the records reported after year 2002 were included for the full review. We analyzed the quality of the reports and the data was further analyzed for their respective risk factors, clinical features, management methods, morbidity and mortality. RESULTS: The results from our searches included a total of 125 cases of postpartum ACPO. A total of 66 cases were reported in 37 publications after year 2002. Details of delivery were recorded in 13(19%), clinical manifestations in 49(69%), imaging results in 43(65%) and management described in 100% of the cases. Although 62(92%) cases were following caesarean section, no specific antepartum or intrapartum factors were associated with ACPO. The caesarean sections performed for indications of preeclampsia, multiple pregnancy, antepartum haemorrhage/placenta previa were more in this group of patients who developed ACPO compared to caesarean sections performed for same indication in general population of England and Wales. Abdominal distension and pain were the commonest symptoms, followed by vomiting. Fever was common in patients with perforation. Twenty eight (43%) patients had intestinal perforation or impending perforation, and 31(47%) patients required laparotomy. Conservative management was successful in 33(50%) patients. All patients with a caecal diameter of more than 12cm perforated compared to 3/17 with a diameter of less than 9cm. Most perforations were diagnosed between postoperative day 3 and day 5. Only one case of mortality has been recorded (1.5%). CONCLUSIONS: No specific risk factors could be identified for postpartum ACPO. A postpartum patient with abdominal distension and pain should have appropriate imaging to rule out colonic dilatation and/or perforation. Perforation may occur with a caecal diameter of less than 9cm but it is more likely if the diameter exceeded 12cm. The mortality risk appears to be low in the postpartum group compared to other patients with ACPO. There is a need for establishing national level databases to capture all the relevant data in a consistent manner, to understand this rare disease process.

Comparison of treatment effects between animal experiments and clinical trials: systematic review.

OBJECTIVE: To examine concordance between treatment effects in animal experiments and clinical trials. Study design Systematic review. DATA SOURCES: Medline, Embase, SIGLE, NTIS, Science Citation Index, CAB, BIOSIS. STUDY SELECTION: Animal studies for interventions with unambiguous evidence of a treatment effect (benefit or harm) in clinical trials: head injury, antifibrinolytics in haemorrhage, thrombolysis in acute ischaemic stroke, tirilazad in acute ischaemic stroke, antenatal corticosteroids to prevent neonatal respiratory distress syndrome, and bisphosphonates to treat osteoporosis. Review methods Data were extracted on study design, allocation concealment, number of randomised animals, type of model, intervention, and outcome. RESULTS: Corticosteroids did not show any benefit in clinical trials of treatment for head injury but did show a benefit in animal models (pooled odds ratio for adverse functional outcome 0.58, 95% confidence interval 0.41 to 0.83). Antifibrinolytics reduced bleeding in clinical trials but the data were inconclusive in animal models. Thrombolysis improved outcome in patients with ischaemic stroke. In animal models, tissue plasminogen activator reduced infarct volume by 24% (95% confidence interval 20% to 28%) and improved neurobehavioural scores by 23% (17% to 29%). Tirilazad was associated with a worse outcome in patients with ischaemic stroke. In animal models, tirilazad reduced infarct volume by 29% (21% to 37%) and improved neurobehavioural scores by 48% (29% to 67%). Antenatal corticosteroids reduced respiratory distress and mortality in neonates whereas in animal models respiratory distress was reduced but the effect on mortality was inconclusive (odds ratio 4.2, 95% confidence interval 0.85 to 20.9). Bisphosphonates increased bone mineral density in patients with osteoporosis. In animal models the bisphosphonate alendronate increased bone mineral density compared with placebo by 11.0% (95% confidence interval 9.2% to 12.9%) in the combined results for the hip region. The corresponding treatment effect in the lumbar spine was 8.5% (5.8% to 11.2%) and in the combined results for the forearms (baboons only) was 1.7% (-1.4% to 4.7%). CONCLUSIONS: Discordance between animal and human studies may be due to bias or to the failure of animal models to mimic clinical disease adequately.