Birth outcomes in women with body mass index of 40 kg/m2 or greater stratified by planned and actual mode of birth: a systematic review and meta-analysis.

INTRODUCTION: Pregnant women with a body mass index (BMI) ≥40 kg/m2 are at an increased risk of requiring planned- and unplanned cesarean deliveries (CD). The aim of this systematic review is to compare outcomes in women with BMI ≥ 40 kg/m2 based on planned and actual mode of birth. MATERIAL AND METHODS: Five databases were searched for English and French-language publications until February 2019, and all studies reporting on delivery outcomes in women with BMI ≥ 40 kg/m2 , stratified by planned and actual mode of birth, were included. Risk-of-bias was assessed using the Newcastle-Ottawa Scale. Relative risks (RR) and 95% confidence intervals were calculated using random-effects meta-analysis. RESULTS: Ten observational studies were included. Anticipated vaginal birth vs planned CD (5 studies, n = 2216) was associated with higher risk for postpartum hemorrhage (13.0% vs 4.1%, P < .001, numbers needed to harm (NNH = 11), I2  = 0%) but lower risk for wound complications (7.6% vs 14.5%, P < .001, numbers needed to treat (NNT = 15), I2  = 58.3%). Planned trial of labor vs repeat CD (3 studies, n = 4144) was associated with higher risk for uterine dehiscence (0.94% vs 0.42%, P = .04, NNH = 200, I2  = 0%), endometritis (5.1% vs 2.2%, P < .001, NNH = 35, I2  = 0%), prolonged hospitalization (one study, 30.3% vs 26.0%, P = .003, NNH = 23), low five-minute Apgar scores (4.9% vs 1.7%, RR 2.95 (2.03, 4.28), NNH = 30, I2  = 0%) and birth trauma (1.1% vs 0.2%, P < .001, NNH = 111, I2  = 0%). Successful vaginal birth vs intrapartum CD (n = 3625) was associated with lower risk of postpartum hemorrhage (15.1% vs 70%, P < .001, NNT = 2, I2  = 0%), wound complications (one study, 0% vs 4.4%, P = .007, NNT = 23), prolonged hospitalization (one study, 1.9% vs 6.7%, 0.04, NNT = 21) and low five-minute Apgar scores (one study, 1.0% vs 5.6%, P = .03, NNT = 22), but more birth trauma (5.9% vs 0.6%, P = .005, NNH = 19, I2  = 0%). Compared groups had dissimilar demographic characteristics. Although studies scored 6-7/9 on risk-of-bias assessment, they were at high-risk for confounding by indication. CONCLUSIONS: Evidence from observational studies suggests clinical equipoise regarding the optimal mode of delivery in women with BMI ≥ 40 kg/m2 and no prior CD. This question is best answered by a randomized trial. Based on an unplanned subgroup analysis, for women with BMI ≥ 40 kg/m2 and prior CD, repeat CD may be associated with better clinical outcomes.

Does Time Spent on Active Surveillance Adversely Affect the Pathological and Oncologic Outcomes in Patients Undergoing Delayed Radical Prostatectomy?

PURPOSE: Pathological and oncologic outcomes of delayed radical prostatectomy following prostate cancer active surveillance are not well established. We determined the pathological and oncologic outcomes of favorable risk, Grade Group 1, prostate cancer managed with active surveillance and progressing to radical prostatectomy for clinically significant prostate cancer (Grade Group 2 or greater). MATERIALS AND METHODS: Between 1992 and 2015, 170 men with favorable risk prostate cancer underwent delayed radical prostatectomy for clinically significant prostate cancer (ASRP) at the Princess Margaret Cancer Centre. Pathological and oncologic outcomes of the ASRP cohort were compared with a matched cohort treated with up-front radical prostatectomy (405) immediately before surgery. Biochemical recurrence-free survival, overall survival and cancer specific survival were compared. We examined the association between delayed radical prostatectomy and adverse pathology at radical prostatectomy and biochemical recurrence using logistic and Cox regression analyses, respectively. RESULTS: Median time spent on active surveillance before radical prostatectomy was 31.0 months. At radical prostatectomy pT3 (extraprostatic extension, seminal vesicle invasion), positive surgical margin and pN1 rates were comparable between the 2 cohorts. Median followup after radical prostatectomy was 5.6 years. The 5-year biochemical recurrence-free survival rate in the ASRP cohort and up-front radical prostatectomy cohort were 85.8% and 82.4%, respectively (p=0.38). Overall survival and cancer specific survival were comparable between the 2 groups. Delayed radical prostatectomy was not associated with adverse pathological outcomes and biochemical recurrence on regression analyses. CONCLUSIONS: Curative intent radical prostatectomy after a period of active surveillance results in excellent pathological and oncologic outcomes at 5 years. A period of active surveillance does not result in inferior outcomes compared to patients with similar risk characteristics undergoing up-front radical prostatectomy.

Maternal body mass index and pregnancy outcomes: a systematic review and metaanalysis.

OBJECTIVE DATA: The purpose of this study was to determine the effect of body mass index category on pregnancy outcomes. STUDY: Five databases (Medline, Embase, PubMed, www.clinicaltrials.gov, and Cochrane) were searched from inception until February 2019 for English or French publications that reported on pregnancy outcomes in women with body mass index ≥30 kg/m2. Reference lists of included articles were searched, and authors were contacted for missing data where necessary. Because no randomized trials were identified, we included single-center and population-based cohort studies that stratified pregnancy outcomes under the following body mass index categories: underweight, standard weight, overweight, and obese classes I-III, based on the World Health Organization international classification system. STUDY APPRAISAL AND SYNTHESIS METHODS: Study quality was appraised with the use of the Newcastle-Ottawa Scale Quality Assessment Scale for cohort studies. Because significant heterogeneity was anticipated among studies, we used random-effects metaanalysis to arrive at pooled estimates and 95% confidence intervals for pregnancy outcomes in each body mass index category and relative risks in relation to women with a standard body mass index. RESULTS: We identified 10,258 studies, of which 13 studies with a low risk-of-bias that described 3,722,477 pregnancies that were included in the metaanalysis. Most adverse pregnancy outcomes increased steadily with increasing body mass index category. Compared with women with body mass index 18.5-24.9 kg/m2, women with body mass index >40 kg/m2 were at increased risk for gestational diabetes mellitus [17% vs 3.9%; relative risk, 4.6 [95% confidence interval, 3.6-5.9]), hypertensive disorders of pregnancy (15.9% vs 3.5%; relative risk, 4.6 [95% confidence interval, 3.4-6.0]), and cesarean delivery (47.7% vs 26.0%; relative risk, 1.86 [95% confidence interval, 1.75-1.97]). Babies were at increased risk for hypoglycemia (4.1% vs 1.4%; relative risk, 3.3 [95% confidence interval, 2.8-3.8]), macrosomia (12.9% vs 6.2%; relative risk, 2.6 [95% confidence interval, 1.4-4.7]), infection (2.8% vs 1.3%; relative risk, 2.3 [95% confidence interval, 1.6-3.3]), birth trauma (1.3% vs 0.9%; relative risk, 2.1 [95% confidence interval, 1.2-3.8]), respiratory distress (5.1% vs 2.7%; relative risk, 2.0 [95% confidence interval, 1.8-2.2]), death (1.4% vs 0.9%; relative risk, 1.8 [95% confidence interval, 1.2-2.9]), and neonatal intensive care unit admission (13.5% vs 9.5%; relative risk, 1.6 [95% confidence interval, 1.4-1.9]). CONCLUSION: There is a linear association between maternal body mass index and almost all adverse pregnancy outcomes. These risks, stratified by body mass index category as presented in this article, would facilitate counselling and encourage appropriate interventions to improve outcomes for mothers and babies.