Effectiveness of progesterone, cerclage and pessary for preventing preterm birth in singleton pregnancies: a systematic review and network meta-analysis.

BACKGROUND: Preterm birth (PTB) is the leading cause of infant death, but it is unclear which intervention is best to prevent it. OBJECTIVES: To compare progesterone, cerclage and pessary, determine their relative effects and rank them. SEARCH STRATEGY: We searched Medline, EMBASE, CINAHL, Cochrane CENTRAL and Web of Science (to April 2016), without restrictions, and screened references of previous reviews. SELECTION CRITERIA: We included randomised trials of progesterone, cerclage or pessary for preventing PTB in women with singleton pregnancies at risk as defined by each study. DATA COLLECTION AND ANALYSIS: We extracted data by duplicate using a piloted form and performed Bayesian random-effects network meta-analyses and pairwise meta-analyses. We rated evidence quality using GRADE, ranked interventions using SUCRA and calculated numbers needed to treat (NNT). MAIN RESULTS: We included 36 trials (9425 women; 25 low risk of bias trials). Progesterone ranked first or second for most outcomes, reducing PTB < 34 weeks [odds ratio (OR) 0.44; 95% credible interval (CrI) 0.22-0.79; NNT 9; low quality], <37 weeks (OR 0.58; 95% CrI 0.41-0.79; NNT 9; moderate quality), and neonatal death (OR 0.50; 95% CrI 0.28-0.85; NNT 35; high quality), compared with control, in women overall at risk. We found similar results in the subgroup with previous PTB, but only a reduction of PTB < 34 weeks in women with a short cervix. Pessary showed inconsistent benefit and cerclage did not reduce PTB < 37 or <34 weeks. CONCLUSIONS: Progesterone was the best intervention for preventing PTB in singleton pregnancies at risk, reducing PTB < 34 weeks, <37 weeks, neonatal demise and other sequelae. TWEETABLE ABSTRACT: Progesterone was better than cerclage and pessary to prevent preterm birth, neonatal death and more in network meta-analysis.

Preterm birth prevention in twin pregnancies with progesterone, pessary, or cerclage: a systematic review and meta-analysis.

BACKGROUND: About half of twin pregnancies deliver preterm, and it is unclear whether any intervention reduces this risk. OBJECTIVES: To assess the evidence for the effectiveness of progesterone, cerclage, and pessary in twin pregnancies. SEARCH STRATEGY: We searched Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and ISI Web of Science, without language restrictions, up to 25 January 2016. SELECTION CRITERIA: Randomised controlled trials of progesterone, cerclage, or pessary for preventing preterm birth in women with twin pregnancies, without symptoms of threatened preterm labour. DATA COLLECTION AND ANALYSIS: Two independent reviewers extracted data using a piloted form. Study quality was appraised with the Cochrane Risk of Bias tool. We performed pairwise inverse variance random-effects meta-analyses. MAIN RESULTS: We included 23 trials (all but three were considered to have a low risk of bias) comprising 6626 women with twin pregnancies. None of the interventions significantly reduced the risk of preterm birth overall at <34 or <37 weeks of gestation, or neonatal death, our primary outcomes, compared to a control group. In women receiving vaginal progesterone, the relative risk (RR) of preterm birth <34 weeks of gestation was 0.82 (95% CI 0.64-1.05, seven studies, I2  36%), with a significant reduction in some key secondary outcomes, including very low birthweight (<1500 g, RR 0.71, 95% CI 0.52-0.98, four studies, I2  46%) and mechanical ventilation (RR 0.61, 95% CI 0.45-0.82, four studies, I2  22%). CONCLUSION: In twin gestations, although no overarching intervention was beneficial for the prevention of preterm birth and its sequelae, vaginal progesterone improved some important secondary outcomes. TWEETABLE ABSTRACT: Vaginal progesterone may be beneficial in twin pregnancies, but not 17-OHPC, cerclage, or pessary.

Does non-pharmacological therapy for antenatal depression reduce risks for the infant?

Depression during pregnancy has been associated with an increased risk of adverse outcomes for the infant such as preterm birth. These risks are not reduced with pharmacological treatment, but the effect of non-pharmacological therapies is unknown. We performed a systematic review to assess the risk of adverse perinatal outcomes in non-pharmacologically treated depressed women compared to non-depressed women. We found no studies that met our inclusion criteria, highlighting a critical need for research on this topic.

Can we safely recommend gestational weight gain below the 2009 guidelines in obese women? A systematic review and meta-analysis.

A systematic review was conducted to determine the risk of adverse pregnancy outcomes with gestational weight gain (GWG) below the 2009 Institute of Medicine guidelines compared with within the guidelines in obese women. MEDLINE, Embase, Cochrane Register, CINHAL and Web of Science were searched from 1 January 2009 to 31 July 2014. Quality was assessed using a modified Newcastle-Ottawa scale. Three primary outcomes were included: preterm birth, small for gestational age (SGA) and large for gestational age (LGA). Eighteen cohort studies were included. GWG below the guidelines had higher odds of preterm birth (adjusted odds ratio [AOR] 1.46; 95% confidence interval [CI] 1.07-2.00) and SGA (AOR 1.24; 95% CI 1.13-1.36) and lower odds of LGA (AOR 0.77; 95% CI 0.73-0.81) than GWG within the guidelines. Across the three obesity classes, the odds of SGA and LGA did not show any notable gradient and remained unexplored for preterm birth. Decreased odds were noted for macrosomia (AOR 0.64; 95% CI 0.54-0.77), gestational hypertension (AOR, 0.70; 95% CI 0.53-0.93), pre-eclampsia (AOR 0.90; 95% CI 0.82-0.99) and caesarean (AOR 0.87; 95% CI 0.82-0.92). GWG below the guidelines cannot be routinely recommended but might occasionally be individualized for certain women, with caution, taking into account other known risk factors.

How often are late preterm births the result of non-evidence based practices: analysis from a retrospective cohort study at two tertiary referral centres in a nationalised healthcare system.

OBJECTIVE: To determine the proportion, characteristics, and predictors of late preterm birth (LPTB) in relation to evidence-based (EB) and non-evidence based (NEB) indications. DESIGN: Retrospective cohort study. SETTING: Two Canadian tertiary referral centres. POPULATION: All live singleton LPTBs over 1 year from 2010 to 2011, excluding major congenital anomalies. METHODS: Indications for LPTB were classified a priori as EB (i.e. based on practice guidelines or on evidence from randomised controlled trials) or NEB. Data were abstracted from maternal antenatal and labour records. Univariate analyses were completed using Fischer's exact, Pearson's chi-square, or analysis of variance (anova) F-tests. Logistic regression included gestation at birth, delivery provider, previous stillbirth, previous caesarean section, corticosteroid administration, and previous preterm birth as predictors for NEB LPTB. MAIN OUTCOME MEASURES: The proportion, characteristics, and predictors of women with NEB versus EB LPTBs. RESULTS: Of 524 LPTBs, 25.2% (n = 132) were NEB. Logistic regression revealed that NEB LPTBs were less likely if patients were delivered by their own doctor or their doctor's practice partner (OR 0.53, 95% CI 0.34-0.83). However, NEB LPTBs were more likely in women who had experienced a previous stillbirth (OR 2.57, 95% CI 1.20-5.49). CONCLUSIONS: Approximately one-quarter of LPTBs are NEB. Further research is needed to see if a review of the indications for LPTB, and subsequent reduction in NEB LPTBs, translates into improved neonatal outcomes and cost savings.

Women's intentions to breastfeed: a population-based cohort study.

OBJECTIVE: Given that intention to breastfeed is a strong predictor of breastfeeding initiation and duration, the objectives of this study were to estimate the population-based prevalence and the factors associated with the intention to breastfeed. DESIGN: Retrospective population-based cohort study. SETTING: All hospitals in Ontario, Canada (1 April 2009-31 March 2010). POPULATION: Women who gave birth to live, term, singletons/twins. METHODS: Patient, healthcare provider, and hospital factors that may be associated with intention to breastfeed were analysed using univariable and multivariable regression. MAIN OUTCOME MEASURES: Population-based prevalence of intention to breastfeed and its associated factors. RESULTS: The study included 92,364 women, of whom 78,806 (85.3%) intended to breastfeed. The odds of intending to breastfeed were higher amongst older women with no health problems and women who were cared for exclusively by midwives (adjusted OR 3.64, 95% CI 3.13-4.23). Being pregnant with twins (adjusted OR 0.73, 95% CI 0.57-0.94), not attending antenatal classes (adjusted OR 0.58, 95% CI 0.54-0.62), having previous term or preterm births (adjusted OR 0.79, 95% CI 0.78-0.81, and adjusted OR 0.87, 95% CI 0.82-0.93, respectively), and delivering in a level-1 hospital (adjusted OR 0.85, 95% CI 0.77-0.93) were associated with a lower intention to breastfeed. CONCLUSIONS: In this population-based study ~85% of women intended to breastfeed their babies. Key factors that are associated with the intention to breastfeed were identified, which can now be targeted for intervention programmes aimed at increasing the prevalence of breastfeeding and improving overall child and maternal health.

Long-term interferon-beta treatment for multiple sclerosis.

The aim of our study was to analyze the dropout rate in patients with relapsing-remitting multiple sclerosis (RRMS) under long-term treatment with the three commercially available interferon beta (IFNbeta) preparations. According to the drug taken, we divided 122 RRMS patients into 4 groups: Betaferon group, 56 patients taking INFbeta-1b (24 MIU weekly, subcutaneous injections); Avonex group, 38 patients taking IFNbeta-1a (6 MIU weekly, intramuscularly); Rebif group, 18 patients taking INFbeta-1b (18 MIU subcutaneously). Ten patients who shifted from Betaferon to Avonex were included in a fourth group. Dropouts were registered every trimester with the related cause. Data were evaluated using Kaplan-Meier survival analysis and log-rank test. During the observation period of five years, 48 patients (39.9%) dropped out: 48% of the patients in Betaferon group withdrew at a median of 758 days, 26% of the Avonex group at 356 days; 38% of the Rebif group at 421 days, and 40% of those who shifted from Betaferon to Avonex at 259 days. The differences between groups were not significant on survival analysis. Patients receiving higher dose treatment (Betaferon and Rebif groups) dropped out mainly for clinical adverse events; conversely, patients receiving lower dose therapy (Avonex group) dropped out most often for inefficacy. Patients who shifted to a lower dose treatment (fourth group) had a dropout rate similar to that of the initial treatment. Our data showed that one-third of the patients stopped the therapy, mostly for adverse events and then for inefficacy, while the remaining two-thirds were still on treatment without problems up to 5 years of follow-up. Compliance seems related to the dose of the drug, but further analysis is needed to confirm our data.

Chlamydia infection in street youth: Need for more aggressive screening programs.

OBJECTIVES: To determine, first, the sexual practices among street youth in the Ottawa-Carleton, Ontario region; second, the percentage of street youth who report previous sexually transmitted disease (STD) screening; and third, the rate of previous infection with Chlamydia trachomatis in this population. METHODS: This prospective street youth pilot study was cross-sectional in design. Street youth aged 15 to 20 years were recruited through a drop-in centre or shelter in Ottawa, Ontario between August and October 1993. Information on demographics, substance use, current sexual practices and STD screening and infection history were obtained through a structured face to face interview and a 75-item questionnaire. Past C trachomatis infection was determined by microimmunofluorescence assay with purified antigens of C trachomatis (serovars A to K), Chlamydia psittaci (avian strain 6BC) and Chlamydia pneumoniae (TW-183 strain). RESULTS: Ninety-eight per cent of the youth approached participated. Of the 100 street youth (61 males, mean age 17.8 years; 39 females, mean age 17.1 years), 94% were sexually active, with 21% of males and 26% of females having had four or more different sexual partners in the previous year. Only 27% of males and 8% of females reported consistent condom use with all partners all of the time. Thirty per cent of males and 50% of females reported previous STD testing. Of the 100 street youth, 22 (16 males and six females) had had previous C trachomatis infection by serotesting, but only three of 16 (19%) of these males and three of six (50%) of these females reported previous STD testing. None of the 22 recalled previous diagnosis or treatment for any STD. CONCLUSIONS: These street youth reported a high prevalence of risky sexual behaviour, and this supports the national STD guidelines for targeted screening in this population. The current screening guidelines for C trachomatis in this population do not reach the majority of street youth.