Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 1.977
Filtrar
1.
Cochrane Database Syst Rev ; 9: CD012871, 2020 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-32970845

RESUMO

BACKGROUND: Preterm birth (PTB) remains the foremost global cause of perinatal morbidity and mortality. Thus, the prevention of spontaneous PTB still remains of critical importance. In an attempt to prevent PTB in singleton pregnancies, cervical cerclage, in combination with other treatments, has been advocated. This is because, cervical cerclage is an intervention that is commonly recommended in women with a short cervix at high risk of preterm birth but, despite this, many women still deliver prematurely, as the biological mechanism is incompletely understood. Additionally, previous Cochrane Reviews have been published on the effectiveness of cervical cerclage in singleton and multiple pregnancies, however, none has evaluated the effectiveness of using cervical cerclage in combination with other treatments. OBJECTIVES: To assess whether antibiotics administration, vaginal pessary, reinforcing or second cerclage placement, tocolytic, progesterone, or other interventions at the time of cervical cerclage placement prolong singleton gestation in women at high risk of pregnancy loss based on prior history and/or ultrasound finding of 'short cervix' and/or physical examination. History-indicated cerclage is defined as a cerclage placed usually between 12 and 15 weeks gestation based solely on poor prior obstetrical history, e.g. multiple second trimester losses due to painless dilatation. Ultrasound-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation for transvaginal ultrasound cervical length < 20 mm in a woman without cervical dilatation. Physical exam-indicated cerclage is defined as a cerclage placed usually between 16 and 23 weeks gestation because of cervical dilatation of one or more centimetres detected on physical (manual) examination. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (26 September 2019), and reference lists of retrieved studies. SELECTION CRITERIA: We included published, unpublished or ongoing randomised controlled trial (RCTs). Studies using a cluster-RCT design were also eligible for inclusion in this review but none were identified. We excluded quasi-RCTs (e.g. those randomised by date of birth or hospital number) and studies using a cross-over design. We also excluded studies that specified addition of the combination therapy after cervical cerclage because the woman subsequently became symptomatic. We included studies comparing cervical cerclage in combination with one, two or more interventions with cervical cerclage alone in singleton pregnancies. DATA COLLECTION AND ANALYSIS: Two review authors independently screened titles and abstracts of all retrieved articles, selected studies for inclusion, extracted data, assessed risk of bias, and evaluated the certainty of the evidence for this review's main outcomes. Data were checked for accuracy. Standard Cochrane review methods were used throughout. MAIN RESULTS: We identified two studies (involving a total of 73 women) comparing cervical cerclage alone to a different comparator. We also identified three ongoing studies (one investigating vaginal progesterone after cerclage, and two investigating cerclage plus pessary). One study (20 women), conducted in the UK, comparing cervical cerclage in combination with a tocolytic (salbutamol) with cervical cerclage alone in women with singleton pregnancy did not provide any useable data for this review. The other study (involving 53 women, with data from 50 women) took place in the USA and compared cervical cerclage in combination with a tocolytic (indomethacin) and antibiotics (cefazolin or clindamycin) versus cervical cerclage alone - this study did provide useable data for this review (and the study authors also provided additional data on request) but meta-analyses were not possible. This study was generally at a low risk of bias, apart from issues relating to blinding. We downgraded the certainty of evidence for serious risk of bias and imprecision (few participants, few events and wide 95% confidence intervals). Cervical cerclage in combination with an antibiotic and tocolytic versus cervical cerclage alone (one study, 50 women/babies) We are unclear about the effect of cervical cerclage in combination with antibiotics and a tocolytic compared with cervical cerclage alone on the risk of serious neonatal morbidity (RR 0.62, 95% CI 0.31 to 1.24; very low-certainty evidence); perinatal loss (data for miscarriage and stillbirth only - data not available for neonatal death) (RR 0.46, 95% CI 0.13 to 1.64; very low-certainty evidence) or preterm birth < 34 completed weeks of pregnancy (RR 0.78, 95% CI 0.44 to 1.40; very low-certainty evidence). There were no stillbirths (intrauterine death at 24 or more weeks). The trial authors did not report on the numbers of babies discharged home healthy (without obvious pathology) or on the risk of neonatal death. AUTHORS' CONCLUSIONS: Currently, there is insufficient evidence to evaluate the effect of combining a tocolytic (indomethacin) and antibiotics (cefazolin/clindamycin) with cervical cerclage compared with cervical cerclage alone for preventing spontaneous PTB in women with singleton pregnancies. Future studies should recruit sufficient numbers of women to provide meaningful results and should measure neonatal death and numbers of babies discharged home healthy, as well as other important outcomes listed in this review. We did not identify any studies looking at other treatments in combination with cervical cerclage. Future research needs to focus on the role of other interventions such as vaginal support pessary, reinforcing or second cervical cerclage placement, 17-alpha-hydroxyprogesterone caproate or dydrogesterone or vaginal micronised progesterone, omega-3 long chain polyunsaturated fatty acid supplementation and bed rest.


Assuntos
Cerclagem Cervical/métodos , Nascimento Prematuro/prevenção & controle , Albuterol/uso terapêutico , Analgésicos Opioides/uso terapêutico , Antibacterianos/uso terapêutico , Viés , Cefazolina/uso terapêutico , Clindamicina/uso terapêutico , Feminino , Humanos , Indometacina/uso terapêutico , Ópio/uso terapêutico , Gravidez , Nascimento Prematuro/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Natimorto/epidemiologia , Tocolíticos/uso terapêutico
2.
PLoS One ; 15(9): e0238938, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32936823

RESUMO

BACKGROUND: Despite having the high rate of stillbirth in most of the countries of South Asia, there is a lack of synthesized evidence based on factors associated with stillbirth. This study systematically synthesizes the evidence on factors associated with stillbirth in the four selected countries of South Asia. METHODS: This review was conducted using Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Studies that examined factors associated with stillbirth in South Asia were searched using five major electronic search databases including MEDLINE, CINAHL, Embase, PsycINFO, and Scopus, published between January 2000 and December 2019. In the meta-analysis, significant heterogeneity was detected among studies (I2 >50%), and hence a random effect model was used. RESULTS: A total of 20 studies met the inclusion criteria. The pooled rate of stillbirth from the studies in Bangladesh, India, Nepal, and Pakistan was 25.15 per 1000 births. Pregnancy complications, maternal health conditions, fetal complications, lack of antenatal care, and lower Socio Economic Status (SES) were the most common factors associated with stillbirth in countries of South Asia. CONCLUSION: This study confirmed that stillbirth in selected countries of South Asia remains high. To reduce stillbirth, a greater focus needs to be on timely management of preterm labor, maternal hypertension, and provision of financial support for quality antenatal and delivery care. The interventions should be targeted for women living in remote areas, who are less educated and those with low SES.


Assuntos
Complicações na Gravidez/epidemiologia , Cuidado Pré-Natal/estatística & dados numéricos , Natimorto/epidemiologia , Bangladesh/epidemiologia , Feminino , Humanos , Índia/epidemiologia , Recém-Nascido , Masculino , Saúde Materna , Nepal/epidemiologia , Estudos Observacionais como Assunto , Paquistão/epidemiologia , Gravidez , Medição de Risco
3.
Ann Ist Super Sanita ; 56(3): 378-389, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32959805

RESUMO

INTRODUCTION: The study was implemented to provide guidance to decision-makers and clinicians by describing hospital care offered to women who gave birth with confirmed SARS-CoV-2 infection. MATERIALS AND METHODS: National population-based prospective cohort study involving all women with confirmed SARS-CoV-2 infection who gave birth between February 25 and April 22, 2020 in any Italian hospital. RESULTS: The incidence rate of confirmed SARS-CoV-2 infection in women who gave birth was 2.1 per 1000 maternities at a national level and 6.9/1000 in the Lombardy Region. Overall one third of the women developed a pneumonia and 49.7% assumed at least one drug against SARS-CoV-2 infection. Caesarean rate was 32.9%, no mothers nor newborns died. Six percent of the infants tested positive for SARS-CoV-2 at birth. CONCLUSIONS: Clinical features and outcomes of COVID-19 in women who gave birth are similar to those described for the general population, most women developing mild to moderate illness.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Pandemias , Pneumonia Viral/epidemiologia , Complicações Infecciosas na Gravidez/epidemiologia , Corticosteroides/uso terapêutico , Adulto , Cesárea/estatística & dados numéricos , Infecções por Coronavirus/congênito , Infecções por Coronavirus/tratamento farmacológico , Infecções por Coronavirus/terapia , Infecções por Coronavirus/transmissão , Emigrantes e Imigrantes/estatística & dados numéricos , Feminino , Maturidade dos Órgãos Fetais/efeitos dos fármacos , Humanos , Incidência , Recém-Nascido , Transmissão Vertical de Doença Infecciosa/estatística & dados numéricos , Itália/epidemiologia , Pulmão/embriologia , Pneumonia Viral/congênito , Pneumonia Viral/terapia , Pneumonia Viral/transmissão , Gravidez , Complicações Infecciosas na Gravidez/virologia , Resultado da Gravidez , Nascimento Prematuro/epidemiologia , Utilização de Procedimentos e Técnicas , Estudos Prospectivos , Natimorto/epidemiologia
4.
5.
PLoS One ; 15(9): e0239630, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32970750

RESUMO

OBJECTIVE: Current data on the role of the umbilical cord in pregnancy complications are conflicting; estimates of the proportion of stillbirths due to cord problems range from 3.4 to 26.7%. A systematic review and meta-analysis were undertaken to determine which umbilical cord abnormalities are associated with stillbirth and related adverse pregnancy outcomes. METHODS: MEDLINE, EMBASE, CINAHL and Google Scholar were searched from 1960 to present day. Reference lists of included studies and grey literature were also searched. Cohort, cross-sectional, or case-control studies of singleton pregnancies after 20 weeks' gestation that reported the frequency of umbilical cord characteristics or cord abnormalities and their relationship to stillbirth or other adverse outcomes were included. Quality of included studies was assessed using NIH quality assessment tools. Analyses were performed in STATA. RESULTS: This review included 145 studies. Nuchal cords were present in 22% of births (95% CI 19, 25); multiple loops of cord were present in 4% (95% CI 3, 5) and true knots of the cord in 1% (95% CI 0, 1) of births. There was no evidence for an association between stillbirth and any nuchal cord (OR 1.11, 95% CI 0.62, 1.98). Comparing multiple loops of nuchal cord to single loops or no loop gave an OR of 2.36 (95% CI 0.99, 5.62). We were not able to look at the effect of tight or loose nuchal loops. The likelihood of stillbirth was significantly higher with a true cord knot (OR 4.65, 95% CI 2.09, 10.37). CONCLUSIONS: True umbilical cord knots are associated with increased risk of stillbirth; the incidence of stillbirth is higher with multiple nuchal loops compared to single nuchal cords. No studies reported the combined effects of multiple umbilical cord abnormalities. Our analyses suggest specific avenues for future research.


Assuntos
Cordão Nucal/epidemiologia , Natimorto/epidemiologia , Cordão Umbilical/anormalidades , Feminino , Humanos , Gravidez , Cordão Umbilical/patologia
6.
Zhonghua Fu Chan Ke Za Zhi ; 55(8): 510-515, 2020 Aug 25.
Artigo em Chinês | MEDLINE | ID: mdl-32854474

RESUMO

Objective: To analyze the perinatal outcomes of unicornuate uterus pregnancy. Methods: The clinical data of patients with unicornuate uterus pregnancy who delivered between January 2009 and December 2018 in Women's Hospital, School of Medicine, Zhejiang University, were reviewed retrospectively. Live birth was defined as the delivery of a baby after at least 28 weeks gestational age. Ninety-eight patients were diagnosed as unicornuate uterus, while 4 cases of stillbirth and 4 cases of twin pregnancy and 10 cases of incomplete data were excluded, and 80 patients with unicornuate uterus were included in the observation group. By matching the age, gestational age and delivery mode, 160 patients were randomly selected as the control group. The perinatal outcomes such as delivery mode, cesarean section indication sequence, postpartum hemorrhage, vaginal delivery time, newborn birth weight and Apgar score were analyzed retrospectively. Results: In the unicornuate uterus group, there were 10 cases of vaginal delivery and 70 cases of cesarean section, among which the primary indication of premature cesarean section and full-term cesarean section was abnormal fetal position, accounting for 7/18 and 50.0% (26/52), respectively. While in the control group, there were 20 cases of vagianl delivery and 140 cases of cesarean section, among which the main indications of premature cesarean section were placenta previa, intrahepatic cholestasis during pregnancy and scar uterus, accounting for 19.4% (7/36), and the primary indication of full-term cesarean section was abnormal fetal position, accounting for 23.1% (24/104). The postpartum hemorrhage of the vaginal delivery in the unicornuate uterus group and the control group was (319±161) and (261±152) ml, respectively, and the postpartum hemorrhage of the cesarean section delivery was (257±106) and (272±123) ml, respectively. There were no significant differences between the two groups statistically (all P>0.05). The time of the first stage of labor was (502±386) and (465±296) minutes in the unicornuate uterus group and the control group, and the time of the second stage was (74±73) and (47±30) minutes, respectively. There were no significant differences between the two groups statistically (all P>0.05). The neonatal birth weight in the unicornuate uterus group and the control group was (3 018±548) and (3 080±562) g, respectively, and there was no significant difference between the two groups statistically (P=0.42). According to preterm birth and different pre-pregnancy body mass index, the neonatal birth weight of the two groups were compared, and the differences were not statistically significant (all P>0.05). One-minute Apgar score of premature in the unicornuate uterus group and the control group were 10 (9.25-10) and 10 (10-10), 5-minute Apgar score were 10 (10-10) and 10 (10-10), respectively. One-minute Apgar score of full-term in the unicornuate uterus group and the control group were 10 (10-10) and 10 (10-10), 5-minute Apgar score were 10 (10-10) and 10 (10-10), respectively. There were no statistically significant differences between the two groups, respectively (all P>0.05). Conclusions: The patients with unicornuate uterus could give birth vaginally in the absence of other operation indications. The perinatal outcome of women with unicornuate uterus is similar to that of women with non-uterine abnormalities. It is found that the abnormal fetal position with unicornuate uterus is the main reason for cesarean section.


Assuntos
Cesárea , Trabalho de Parto , Resultado da Gravidez/epidemiologia , Útero/anormalidades , Adulto , Parto Obstétrico , Feminino , Humanos , Recém-Nascido , Assistência Perinatal , Gravidez , Estudos Retrospectivos , Natimorto/epidemiologia
7.
Lancet Glob Health ; 8(10): e1273-e1281, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32791117

RESUMO

BACKGROUND: The COVID-19 pandemic response is affecting maternal and neonatal health services all over the world. We aimed to assess the number of institutional births, their outcomes (institutional stillbirth and neonatal mortality rate), and quality of intrapartum care before and during the national COVID-19 lockdown in Nepal. METHODS: In this prospective observational study, we collected participant-level data for pregnant women enrolled in the SUSTAIN and REFINE studies between Jan 1 and May 30, 2020, from nine hospitals in Nepal. This period included 12·5 weeks before the national lockdown and 9·5 weeks during the lockdown. Women were eligible for inclusion if they had a gestational age of 22 weeks or more, a fetal heart sound at time of admission, and consented to inclusion. Women who had multiple births and their babies were excluded. We collected information on demographic and obstetric characteristics via extraction from case notes and health worker performance via direct observation by independent clinical researchers. We used regression analyses to assess changes in the number of institutional births, quality of care, and mortality before lockdown versus during lockdown. FINDINGS: Of 22 907 eligible women, 21 763 women were enrolled and 20 354 gave birth, and health worker performance was recorded for 10 543 births. From the beginning to the end of the study period, the mean weekly number of births decreased from 1261·1 births (SE 66·1) before lockdown to 651·4 births (49·9) during lockdown-a reduction of 52·4%. The institutional stillbirth rate increased from 14 per 1000 total births before lockdown to 21 per 1000 total births during lockdown (p=0·0002), and institutional neonatal mortality increased from 13 per 1000 livebirths to 40 per 1000 livebirths (p=0·0022). In terms of quality of care, intrapartum fetal heart rate monitoring decreased by 13·4% (-15·4 to -11·3; p<0·0001), and breastfeeding within 1 h of birth decreased by 3·5% (-4·6 to -2·6; p=0·0032). The immediate newborn care practice of placing the baby skin-to-skin with their mother increased by 13·2% (12·1 to 14·5; p<0·0001), and health workers' hand hygiene practices during childbirth increased by 12·9% (11·8 to 13·9) during lockdown (p<0·0001). INTERPRETATION: Institutional childbirth reduced by more than half during lockdown, with increases in institutional stillbirth rate and neonatal mortality, and decreases in quality of care. Some behaviours improved, notably hand hygiene and keeping the baby skin-to-skin with their mother. An urgent need exists to protect access to high quality intrapartum care and prevent excess deaths for the most vulnerable health system users during this pandemic period. FUNDING: Grand Challenges Canada.


Assuntos
Infecções por Coronavirus/prevenção & controle , Parto Obstétrico , Mortalidade Infantil/tendências , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Natimorto/epidemiologia , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Lactente , Recém-Nascido , Nepal/epidemiologia , Pneumonia Viral/epidemiologia , Gravidez , Estudos Prospectivos
8.
Lancet Glob Health ; 8(8): e1061-e1070, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32710862

RESUMO

BACKGROUND: Although gains in newborn survival have been achieved in many low-income and middle-income countries, reductions in stillbirth and neonatal mortality have been slow. Prematurity complications are a major driver of stillbirth and neonatal mortality. We aimed to assess the effect of a quality improvement package for intrapartum and immediate newborn care on stillbirth and preterm neonatal survival in Kenya and Uganda, where evidence-based practices are often underutilised. METHODS: This unblinded cluster-randomised controlled trial was done in western Kenya and eastern Uganda at facilities that provide 24-h maternity care with at least 200 births per year. The study assessed outcomes of low-birthweight and preterm babies. Eligible facilities were pair-matched and randomly assigned (1:1) into either the intervention group or the control group. All facilities received maternity register data strengthening and a modified WHO Safe Childbirth Checklist; facilities in the intervention group additionally received provider mentoring using PRONTO simulation and team training as well as quality improvement collaboratives. Liveborn or fresh stillborn babies who weighed between 1000 g and 2500 g, or less than 3000 g with a recorded gestational age of less than 37 weeks, were included in the analysis. We abstracted data from maternity registers for maternal and birth outcomes. Follow-up was done by phone or in person to identify the status of the infant at 28 days. The primary outcome was fresh stillbirth and 28-day neonatal mortality. This trial is registered with ClinicalTrials.gov, NCT03112018. FINDINGS: Between Oct 1, 2016, and April 30, 2019, 20 facilities were randomly assigned to either the intervention group (n=10) or the control group (n=10). Among 5343 eligible babies in these facilities, we assessed outcomes of 2938 newborn and fresh stillborn babies (1447 in the intervention and 1491 in the control group). 347 (23%) of 1491 infants in the control group were stillborn or died in the neonatal period compared with 221 (15%) of 1447 infants in the intervention group at 28 days (odds ratio 0·66, 95% CI 0·54-0·81). No harm or adverse effects were found. INTERPRETATION: Fresh stillbirth and neonatal mortality among low-birthweight and preterm babies can be decreased using a package of interventions that reinforces evidence-based practices and invests in health system strengthening. FUNDING: Bill & Melinda Gates Foundation.


Assuntos
Mortalidade Infantil/tendências , Recém-Nascido de Baixo Peso , Recém-Nascido Prematuro , Serviços de Saúde Materno-Infantil/organização & administração , Melhoria de Qualidade/organização & administração , Natimorto/epidemiologia , Feminino , Humanos , Lactente , Recém-Nascido , Quênia/epidemiologia , Masculino , Gravidez , Uganda/epidemiologia
9.
Cochrane Database Syst Rev ; 7: CD004945, 2020 07 15.
Artigo em Inglês | MEDLINE | ID: mdl-32666584

RESUMO

BACKGROUND: Risks of stillbirth or neonatal death increase as gestation continues beyond term (around 40 weeks' gestation). It is unclear whether a policy of labour induction can reduce these risks. This Cochrane Review is an update of a review that was originally published in 2006 and subsequently updated in 2012 and 2018. OBJECTIVES: To assess the effects of a policy of labour induction at or beyond 37 weeks' gestation compared with a policy of awaiting spontaneous labour indefinitely (or until a later gestational age, or until a maternal or fetal indication for induction of labour arises) on pregnancy outcomes for the infant and the mother. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (17 July 2019), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) conducted in pregnant women at or beyond 37 weeks, comparing a policy of labour induction with a policy of awaiting spontaneous onset of labour (expectant management). We also included trials published in abstract form only. Cluster-RCTs, quasi-RCTs and trials using a cross-over design were not eligible for inclusion in this review. We included pregnant women at or beyond 37 weeks' gestation. Since risk factors at this stage of pregnancy would normally require intervention, only trials including women at low risk for complications, as defined by trialists, were eligible. The trials of induction of labour in women with prelabour rupture of membranes at or beyond term were not considered in this review but are considered in a separate Cochrane Review. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion, assessed risk of bias and extracted data. Data were checked for accuracy. We assessed the certainty of evidence using the GRADE approach. MAIN RESULTS: In this updated review, we included 34 RCTs (reporting on over 21,000 women and infants) mostly conducted in high-income settings. The trials compared a policy to induce labour usually after 41 completed weeks of gestation (> 287 days) with waiting for labour to start and/or waiting for a period before inducing labour. The trials were generally at low to moderate risk of bias. Compared with a policy of expectant management, a policy of labour induction was associated with fewer (all-cause) perinatal deaths (risk ratio (RR) 0.31, 95% confidence interval (CI) 0.15 to 0.64; 22 trials, 18,795 infants; high-certainty evidence). There were four perinatal deaths in the labour induction policy group compared with 25 perinatal deaths in the expectant management group. The number needed to treat for an additional beneficial outcome (NNTB) with induction of labour, in order to prevent one perinatal death, was 544 (95% CI 441 to 1042). There were also fewer stillbirths in the induction group (RR 0.30, 95% CI 0.12 to 0.75; 22 trials, 18,795 infants; high-certainty evidence); two in the induction policy group and 16 in the expectant management group. For women in the policy of induction arms of trials, there were probably fewer caesarean sections compared with expectant management (RR 0.90, 95% CI 0.85 to 0.95; 31 trials, 21,030 women; moderate-certainty evidence); and probably little or no difference in operative vaginal births with induction (RR 1.03, 95% CI 0.96 to 1.10; 22 trials, 18,584 women; moderate-certainty evidence). Induction may make little or difference to perineal trauma (severe perineal tear: RR 1.04, 95% CI 0.85 to 1.26; 5 trials; 11,589 women; low-certainty evidence). Induction probably makes little or no difference to postpartum haemorrhage (RR 1.02, 95% CI 0.91 to 1.15, 9 trials; 12,609 women; moderate-certainty evidence), or breastfeeding at discharge (RR 1.00, 95% CI 0.96 to 1.04; 2 trials, 7487 women; moderate-certainty evidence). Very low certainty evidence means that we are uncertain about the effect of induction or expectant management on the length of maternal hospital stay (average mean difference (MD) -0.19 days, 95% CI -0.56 to 0.18; 7 trials; 4120 women; Tau² = 0.20; I² = 94%). Rates of neonatal intensive care unit (NICU) admission were lower (RR 0.88, 95% CI 0.80 to 0.96; 17 trials, 17,826 infants; high-certainty evidence), and probably fewer babies had Apgar scores less than seven at five minutes in the induction groups compared with expectant management (RR 0.73, 95% CI 0.56 to 0.96; 20 trials, 18,345 infants; moderate-certainty evidence). Induction or expectant management may make little or no difference for neonatal encephalopathy (RR 0.69, 95% CI 0.37 to 1.31; 2 trials, 8851 infants; low-certainty evidence, and probably makes little or no difference for neonatal trauma (RR 0.97, 95% CI 0.63 to 1.49; 5 trials, 13,106 infants; moderate-certainty evidence) for induction compared with expectant management. Neurodevelopment at childhood follow-up and postnatal depression were not reported by any trials. In subgroup analyses, no differences were seen for timing of induction (< 40 versus 40-41 versus > 41 weeks' gestation), by parity (primiparous versus multiparous) or state of cervix for any of the main outcomes (perinatal death, stillbirth, NICU admission, caesarean section, operative vaginal birth, or perineal trauma). AUTHORS' CONCLUSIONS: There is a clear reduction in perinatal death with a policy of labour induction at or beyond 37 weeks compared with expectant management, though absolute rates are small (0.4 versus 3 deaths per 1000). There were also lower caesarean rates without increasing rates of operative vaginal births and there were fewer NICU admissions with a policy of induction. Most of the important outcomes assessed using GRADE had high- or moderate-certainty ratings. While existing trials have not yet reported on childhood neurodevelopment, this is an important area for future research. The optimal timing of offering induction of labour to women at or beyond 37 weeks' gestation needs further investigation, as does further exploration of risk profiles of women and their values and preferences. Offering women tailored counselling may help them make an informed choice between induction of labour for pregnancies, particularly those continuing beyond 41 weeks - or waiting for labour to start and/or waiting before inducing labour.


Assuntos
Trabalho de Parto Induzido/efeitos adversos , Gravidez Prolongada , Conduta Expectante , Cesárea/estatística & dados numéricos , Feminino , Idade Gestacional , Humanos , Lactente , Mortalidade Infantil , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Morte Perinatal , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Risco , Natimorto/epidemiologia
10.
Cochrane Database Syst Rev ; 7: CD000493, 2020 07 27.
Artigo em Inglês | MEDLINE | ID: mdl-32716060

RESUMO

BACKGROUND: Intrahepatic cholestasis of pregnancy (ICP) is a liver disorder that can develop in pregnancy. It occurs when there is a build-up of bile acids in the maternal blood. It has been linked to adverse maternal and fetal/neonatal outcomes. As the pathophysiology is poorly understood, therapies have been largely empiric. As ICP is an uncommon condition (incidence less than 2% a year), many trials have been small. Synthesis, including recent larger trials, will provide more evidence to guide clinical practice. This review is an update of a review first published in 2001 and last updated in 2013. OBJECTIVES: To assess the effects of pharmacological interventions to treat women with intrahepatic cholestasis of pregnancy, on maternal, fetal and neonatal outcomes. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (13 December 2019), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials, including cluster-randomised trials and trials published in abstract form only, that compared any drug with placebo or no treatment, or two drug intervention strategies, for women with a clinical diagnosis of intrahepatic cholestasis of pregnancy. DATA COLLECTION AND ANALYSIS: The review authors independently assessed trials for eligibility and risks of bias. We independently extracted data and checked these for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included 26 trials involving 2007 women. They were mostly at unclear to high risk of bias. They assessed nine different pharmacological interventions, resulting in 14 different comparisons. We judged two placebo-controlled trials of ursodeoxycholic acid (UDCA) in 715 women to be at low risk of bias. The ten different pharmacological interventions were: agents believed to detoxify bile acids (UCDA) and S-adenosylmethionine (SAMe); agents used to bind bile acids in the intestine (activated charcoal, guar gum, cholestyramine); Chinese herbal medicines (yinchenghao decoction (YCHD), salvia, Yiganling and Danxioling pill (DXLP)), and agents aimed to reduce bile acid production (dexamethasone) Compared with placebo, UDCA probably results in a small improvement in pruritus score measured on a 100 mm visual analogue scale (VAS) (mean difference (MD) -7.64 points, 95% confidence interval (CI) -9.69 to -5.60 points; 2 trials, 715 women; GRADE moderate certainty), where a score of zero indicates no itch and a score of 100 indicates severe itching. The evidence for fetal distress and stillbirth were uncertain, due to serious limitations in study design and imprecision (risk ratio (RR) 0.70, 95% CI 0.35 to 1.40; 6 trials, 944 women; RR 0.33, 95% CI 0.08 to 1.37; 6 trials, 955 women; GRADE very low certainty). We found very few differences for the other comparisons included in this review. There is insufficient evidence to indicate if SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yinchenghao decoction, Danxioling and Yiganling, or Yiganling alone or in combination are effective in treating women with intrahepatic cholestasis of pregnancy. AUTHORS' CONCLUSIONS: When compared with placebo, UDCA administered to women with ICP probably shows a reduction in pruritus. However the size of the effect is small and for most pregnant women and clinicians, the reduction may fall below the minimum clinically worthwhile effect. The evidence was unclear for other adverse fetal outcomes, due to very low-certainty evidence. There is insufficient evidence to indicate that SAMe, guar gum, activated charcoal, dexamethasone, cholestyramine, YCHD, DXLP, Salvia, Yiganling alone or in combination are effective in treating women with cholestasis of pregnancy. There are no trials of the efficacy of topical emollients. Further high-quality trials of other interventions are needed in order to identify effective treatments for maternal itching and preventing adverse perinatal outcomes. It would also be helpful to identify those women who are mostly likely to respond to UDCA (for example, whether bile acid concentrations affect how women with ICP respond to treatment with UDCA).


Assuntos
Colestase/terapia , Complicações na Gravidez/terapia , Prurido/terapia , Carvão Vegetal/uso terapêutico , Colagogos e Coleréticos/uso terapêutico , Colestase/complicações , Resina de Colestiramina/uso terapêutico , Dexametasona/uso terapêutico , Medicamentos de Ervas Chinesas/uso terapêutico , Feminino , Sofrimento Fetal/epidemiologia , Galactanos/uso terapêutico , Glucocorticoides/uso terapêutico , Humanos , Mananas/uso terapêutico , Gomas Vegetais/uso terapêutico , Gravidez , Prurido/etiologia , Ensaios Clínicos Controlados Aleatórios como Assunto , S-Adenosilmetionina/uso terapêutico , Natimorto/epidemiologia , Ácido Ursodesoxicólico/uso terapêutico
11.
PLoS One ; 15(7): e0236020, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32687491

RESUMO

BACKGROUND: We investigated associations of area-level deprivation with obstetric and perinatal outcomes in a large population-based routine dataset. METHODS: We used the data of n = 827,105 deliveries who were born in hospitals between 2009 to 2016 in Bavaria, Germany. The Bavarian Index of Multiple Deprivation (BIMD) on district level was assigned to each mother by the zip code of her residential address. We calculated odds ratios (ORs) with 95% confidence intervals (CIs) for preterm deliveries, Caesarian sections (CS), stillbirths, small for gestational age (SGA) births and low 5-minute Apgar scores by BIMD quintiles with and without adjustment for potential confounders. RESULTS: We observed a significantly increased risk for preterm deliveries in mothers from the most deprived compared to the least deprived districts (e.g. OR [95% CI] for highest compared to lowest deprivation quintile: 1.06 [1.03, 1.09]) in adjusted analyses. Increased deprivation was also associated with higher SGA and secondary CS rates, but with lower proportions of stillbirths, primary CS and low Apgar scores. When one large clinic with an unusually high stillbirth rate was excluded, the association of BIMD with stillbirths was attenuated and almost disappeared. CONCLUSIONS: We found that area-level deprivation in Bavaria was positively associated with preterm and SGA births, confirming previous studies. In contrast, the finding of an inverse association between deprivation and both stillbirth rates and low Apgar score came somewhat surprising. However, we conclude that the stillbirths finding is spurious and reflects regional bias due to a clinic which seems to specialize in termination of pregnancies.


Assuntos
Mortalidade Infantil/tendências , Recém-Nascido Pequeno para a Idade Gestacional , Áreas de Pobreza , Nascimento Prematuro/epidemiologia , Fatores Socioeconômicos , Natimorto/epidemiologia , Adulto , Estudos Transversais , Feminino , Alemanha/epidemiologia , Humanos , Lactente , Recém-Nascido , Masculino , Gravidez , Fatores de Risco , Taxa de Sobrevida
14.
J Perinat Med ; 48(9): 857-866, 2020 Nov 26.
Artigo em Inglês | MEDLINE | ID: mdl-32692708

RESUMO

These guidelines follow the mission of the World Association of Perinatal Medicine, which brings together groups and individuals throughout the world with the goal of improving outcomes of maternal, fetal and neonatal (perinatal) patients. Guidelines for auditing, evaluation, and clinical care in perinatal medicine enable physicians diagnose, treat and follow-up of COVID-19-exposed pregnant women. These guidelines are based on quality evidence in the peer review literature as well as the experience of perinatal expert throughout the world. Physicians are advised to apply these guidelines to the local realities which they face. We plan to update these guidelines as new evidence become available.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Assistência Perinatal/métodos , Pneumonia Viral/complicações , Complicações Infecciosas na Gravidez/virologia , Antivirais/uso terapêutico , Aleitamento Materno , Técnicas de Laboratório Clínico/métodos , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Parto Obstétrico/métodos , Feminino , Humanos , Imunoglobulina G/sangue , Imunoglobulina M/sangue , Recém-Nascido , Transmissão Vertical de Doença Infecciosa/estatística & dados numéricos , Pandemias , Morte Perinatal , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Gravidez , Complicações Infecciosas na Gravidez/terapia , Reação em Cadeia da Polimerase Via Transcriptase Reversa , Natimorto/epidemiologia
15.
Ann Epidemiol ; 49: 8-12, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32648545

RESUMO

PURPOSE: We use data from California, where 13% of US births occur, to address two questions arising from efforts in the first decade of this century to avoid stillbirths before 25 6/7 weeks of gestation (i.e., in the periviable period). First, did stillbirths decline in the first decade of this century? Second, if stillbirths did decline, did periviable live births increase simultaneously? Answering these questions is important given that periviable infants represent less than 1% of live births but account for roughly 40% of infant mortality and 20% of hospital-based obstetric costs in the United States. METHODS: We constructed 240 monthly conception cohorts, starting with that conceived in January 1991, from 9,880,536 singleton pregnancies that reached the 20 0/7 week of gestation. We used time-series design and Box-Jenkins methods that address confounding by autocorrelation, including secular trends and seasonality to answer our questions. RESULTS: We detected a downward shift in stillbirths in April 2007 that coincided with an upward shift in periviable live births. CONCLUSIONS: Our findings imply that, since 2007, fewer Californians than expected from history and from the size of conception cohorts reaching 20 0/7 weeks of gestation have had to contend with the sequelae of stillbirths, but more than expected likely have had to contend with those of periviable births.


Assuntos
Nascimento Vivo/epidemiologia , Natimorto/epidemiologia , Adulto , California/epidemiologia , Estudos de Coortes , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Gravidez , Segundo Trimestre da Gravidez , Estados Unidos/epidemiologia
16.
PLoS One ; 15(6): e0234728, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32555631

RESUMO

BACKGROUND: The impact of antenatal depression on pregnancy outcomes has been well investigated in developed countries, but few studies have been conducted in low-income countries. As depression is significantly affected by socio-economic and cultural factors, it would be difficult to generalize evidence from high-income countries to low-income countries. We conducted a community-based cohort study to estimate the incidence of adverse birth outcomes and the direct and indirect pathways via which depression and other psychosocial risk factors may impact such birth outcomes within Gondar town, Ethiopia. METHODS: The study followed 916 pregnant women who were screened for antenatal depression using the Edinburgh Postnatal Depression Scale (EPDS). We also assessed the incidence of preterm births, Low Birth Weight (LBW) and stillbirths. Modified Poisson regression was used to estimate the relative risk of predictors on adverse birth outcomes and a Generalized Structural Equation Model (GSEM) was used to estimate the direct and indirect effect of antenatal depression and other psychological risk factors on adverse birth outcomes. RESULTS: The cumulative incidence of stillbirth, LBW and preterm was 1.90%, 5.25%, and 16.42%, respectively. The risk of preterm birth was 1.61, 1.46, 1.49, and 1.77 times higher among participants who identified as Muslim, reported being fearful of delivery, were government employee's, and who had no antenatal care services, respectively. Partner support moderated the association between depression, preterm birth, and LBW. Depression had no direct effect on birth outcomes but indirectly affected preterm birth via partner support. Religion had both direct and indirect effects on preterm birth, while occupation and fear of delivery had direct effects. The risk of LBW was 9.44 and 2.19 times higher among preterm births and those who had exposure to tobacco, respectively. Stress coping was indirectly associated, and preterm birth and tobacco exposure were directly associated with LBW. The risk of stillbirth was 3.22 times higher in women with antenatal depression and 73% lower in women with higher coping abilities. CONCLUSIONS: There was a high incidence of all adverse birth outcomes in Gondar Town. Depression and psychosocial risk factors had important indirect negative effects on risk, while partner support provided a positive indirect effect on the incidence of adverse birth outcomes. Interventions that focus on increasing partner engagement and participation in antenatal support may help reduce adverse birth outcomes by enhancing maternal resilience.


Assuntos
Depressão/epidemiologia , Complicações na Gravidez/epidemiologia , Resultado da Gravidez , Características de Residência , Adolescente , Adulto , Estudos de Coortes , Etiópia/epidemiologia , Feminino , Humanos , Recém-Nascido de Baixo Peso , Masculino , Gravidez , Resultado da Gravidez/psicologia , Nascimento Prematuro/epidemiologia , Natimorto/epidemiologia , Adulto Jovem
18.
PLoS One ; 15(6): e0235113, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32574213

RESUMO

OBJECTIVES: Timely delivery of fetal growth restriction (FGR) is important in reducing stillbirth. However, targeted earlier delivery of FGR preferentially removes smaller babies from later gestations, thereby right-shifting the distribution of birthweights at term. This artificially increases the birthweight cutoffs defining the lower centiles and redefines normally grown babies as small by population-based birthweight centiles. Our objective was to compare updated Australian national population-based birthweight centile charts over time with the prescriptive INTERGROWTH-21st standard. METHODS: A retrospective descriptive study of all singleton births ≥34 weeks' gestation in Victoria, Australia in five two-year epochs: 1983-84, 1993-94, 2003-04, 2013-14, and 2016-17. The birthweight cutoffs defining the 3rd and 10th centile from three Australian national population-based birthweight centile charts, for births in 1991-1994, in 1998-2007, and 2004-2013 respectively, were applied to each epoch to calculate the proportion of babies with birthweight <3rd and <10th centile. The same analysis was done using the INTERGROWTH-21st birthweight standard. To assess change over gestation, proportions were also calculated at preterm, early term and late term gestations. RESULTS: From 1983-84 to 2016-17, the proportion of babies with birthweight <3rd fell across all birthweight centile charts, from 3.1% to 1.7% using the oldest Australian chart, from 3.9% to 1.9% using the second oldest Australian chart, from 4.3% to 2.2% using the most recent Australian chart, and from 2.0% to 0.9% using the INTERGROWTH-21st standard. A similar effect was evident for the <10th centile. The effect was most obvious at term gestations. Updating the Australian population birthweight chart progressively right-shifted the birthweight distribution, changing the definition of small over time. The birthweight distribution of INTERGROWTH-21st was left-shifted compared to the Australian charts. CONCLUSIONS: Locally-derived population-based birthweight centiles are better for clinical audit of care but should not be updated. Prescriptive birthweight standards are less useful in defining 'small' due to their significant left-shift.


Assuntos
Peso ao Nascer/fisiologia , Retardo do Crescimento Fetal/epidemiologia , Recém-Nascido Pequeno para a Idade Gestacional/fisiologia , Natimorto/epidemiologia , Feminino , Desenvolvimento Fetal/fisiologia , Idade Gestacional , Humanos , Lactente , Mortalidade Infantil/tendências , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional/crescimento & desenvolvimento , Masculino , Vigilância da População/métodos , Gravidez , Estudos Retrospectivos , Vitória/epidemiologia
19.
JAMA Netw Open ; 3(6): e208243, 2020 06 01.
Artigo em Inglês | MEDLINE | ID: mdl-32556259

RESUMO

Importance: Knowledge of whether serious adverse pregnancy outcomes are associated with increasingly widespread effects of climate change in the US would be crucial for the obstetrical medical community and for women and families across the country. Objective: To investigate prenatal exposure to fine particulate matter (PM2.5), ozone, and heat, and the association of these factors with preterm birth, low birth weight, and stillbirth. Evidence Review: This systematic review involved a comprehensive search for primary literature in Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, PubMed, ClinicalTrials.gov website, and MEDLINE. Qualifying primary research studies included human participants in US populations that were published in English between January 1, 2007, and April 30, 2019. Included articles analyzed the associations between air pollutants or heat and obstetrical outcomes. Comparative observational cohort studies and cross-sectional studies with comparators were included, without minimum sample size. Additional articles found through reference review were also considered. Articles analyzing other obstetrical outcomes, non-US populations, and reviews were excluded. Two reviewers independently determined study eligibility. The Arskey and O'Malley scoping review framework was used. Data extraction was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Findings: Of the 1851 articles identified, 68 met the inclusion criteria. Overall, 32 798 152 births were analyzed, with a mean (SD) of 565 485 (783 278) births per study. A total of 57 studies (48 of 58 [84%] on air pollutants; 9 of 10 [90%] on heat) showed a significant association of air pollutant and heat exposure with birth outcomes. Positive associations were found across all US geographic regions. Exposure to PM2.5 or ozone was associated with increased risk of preterm birth in 19 of 24 studies (79%) and low birth weight in 25 of 29 studies (86%). The subpopulations at highest risk were persons with asthma and minority groups, especially black mothers. Accurate comparisons of risk were limited by differences in study design, exposure measurement, population demographics, and seasonality. Conclusions and Relevance: This review suggests that increasingly common environmental exposures exacerbated by climate change are significantly associated with serious adverse pregnancy outcomes across the US.


Assuntos
Poluição do Ar/estatística & dados numéricos , Temperatura Alta , Recém-Nascido de Baixo Peso , Nascimento Prematuro/epidemiologia , Natimorto/epidemiologia , Feminino , Humanos , Exposição Materna/estatística & dados numéricos , Estudos Observacionais como Assunto , Gravidez , Estados Unidos
20.
BMJ ; 369: m1007, 2020 04 29.
Artigo em Inglês | MEDLINE | ID: mdl-32349968

RESUMO

OBJECTIVE: To explore conditions and outcomes of a first delivery at term that might predict later preterm birth. DESIGN: Population based, prospective register based study. SETTING: Medical Birth Registry of Norway, 1999-2015. PARTICIPANTS: 302 192 women giving birth (live or stillbirth) to a second singleton child between 1999 and 2015. MAIN OUTCOME MEASURES: Main outcome was the relative risk of preterm delivery (<37 gestational weeks) in the birth after a term first birth with pregnancy complications: pre-eclampsia, placental abruption, stillbirth, neonatal death, and small for gestational age. RESULTS: Women with any of the five complications at term showed a substantially increased risk of preterm delivery in the next pregnancy. The absolute risks for preterm delivery in a second pregnancy were 3.1% with none of the five term complications (8202/265 043), 6.1% after term pre-eclampsia (688/11 225), 7.3% after term placental abruption (41/562), 13.1% after term stillbirth (72/551), 10.0% after term neonatal death (22/219), and 6.7% after term small for gestational age (463/6939). The unadjusted relative risk for preterm birth after term pre-eclampsia was 2.0 (95% confidence interval 1.8 to 2.1), after term placental abruption was 2.3 (1.7 to 3.1), after term stillbirth was 4.2 (3.4 to 5.2), after term neonatal death was 3.2 (2.2 to 4.8), and after term small for gestational age was 2.2 (2.0 to 2.4). On average, the risk of preterm birth was increased 2.0-fold (1.9-fold to 2.1-fold) with one term complication in the first pregnancy, and 3.5-fold (2.9-fold to 4.2-fold) with two or more complications. The associations persisted after excluding recurrence of the specific complication in the second pregnancy. These links between term complications and preterm delivery were also seen in the reverse direction: preterm birth in the first pregnancy predicted complications in second pregnancies delivered at term. CONCLUSIONS: Pre-eclampsia, placental abruption, stillbirth, neonatal death, or small for gestational age experienced in a first term pregnancy are associated with a substantially increased risk of subsequent preterm delivery. Term complications seem to share important underlying causes with preterm delivery that persist from pregnancy to pregnancy, perhaps related to a mother's predisposition to disorders of placental function.


Assuntos
Descolamento Prematuro da Placenta/epidemiologia , Morte Perinatal , Pré-Eclâmpsia/epidemiologia , Nascimento Prematuro/epidemiologia , Natimorto/epidemiologia , Nascimento a Termo , Adulto , Feminino , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Noruega/epidemiologia , Gravidez , Estudos Prospectivos , Sistema de Registros , Fatores de Risco , Adulto Jovem
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA