RESUMO
OBJECTIVE: The aim of this systematic review and meta-analysis was to assess whether earlier discharge from hospital after cesarean delivery (CD) affects the rate of maternal readmission. DATA SOURCE: The research was conducted using PubMed, Embase, Web of Sciences, Scopus, ClinicalTrials.gov and the Cochrane Central Register of Controlled Trials as electronic databases, from the inception of each database to August 2023 with RCT as publication type. No restrictions for language or geographic location were applied. STUDY ELIGIBILITY CRITERIA: Selection criteria included only RCTs comparing the effect of earlier vs later hospital discharge after CD. STUDY APPRAISAL AND SYNTHESIS METHODS: The primary outcome was the rate of maternal readmission. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95% confidence intervals (CI) using the random effects model of Mentel-Haenszel. I-squared (Higgins I2) greater than 0% was used to identify heterogeneity. "Earlier" and "later" hospital discharge was first considered according to each study's definition and then a subgroup analysis was performed including only studies defining as "earlier" a discharge within 24-28 hours and "later" a discharge at 48 hours after CD. The study was registered on PROSPERO (CRD 42024529885). RESULTS: Seven RCTs including 4,267 individuals, of which 2,125 (49.8%) randomized in the early discharge and 2,142 (50.2%) in the late discharge group were included. There was no difference between the two groups in the rate of maternal readmission (3.6% vs 3.4%, RR 1.10; 95% CI 0.80-1.52). There was no significant difference in both maternal complications diagnosed within 6 weeks after CD and neonatal complications. Early discharge after CD was associated with improved psychological wellbeing and was cost-effective. The subgroup analysis of the primary outcomes only in high-quality studies showed similar results: no difference in the rate of maternal readmission was observed (3.8% vs 3.2%, RR 1.20; 95% CI 0.63-2.30) between the two groups. When focusing only on studies comparing 24-28-hour vs 48-hour hospital discharge, the rate of maternal readmission did not differ between the two groups, while the rates of neonatal readmission and neonatal jaundice were significantly higher in the earlier discharge group. CONCLUSIONS: There is no increase in the rate of maternal readmission following early hospital discharge at 24-28 hours as opposed to later hospital discharge after a CD. The rates of neonatal readmission and neonatal jaundice were significantly higher in the earlier discharge group. Patients undergoing uncomplicated CDs might be discharged from the hospital at 24-28 hours postpartum, as long as close neonatal outpatient follow-up is done in 1-2 days; if this is unfeasible, discharge at 48 hours seems to be safe and effective for both mother and baby. Early discharge after CD was associated with improved psychological wellbeing and was cost-effective.
RESUMO
OBJECTIVE: This was a systematic review and meta-analysis comparing maternal and neonatal outcomes of patients screened with the 1-step or 2-step screening method for gestational diabetes mellitus. DATA SOURCES: PubMed, Scopus, Cochrane, ClinicalTrials.gov, and LILACS were searched from inception up to September 2022. STUDY ELIGIBILITY CRITERIA: Only randomized controlled trials were included. Studies that had overlapping populations were excluded (International Prospective Register of Systematic Review registration number: CRD42022358903). METHODS: Risk ratios were computed with 95% confidence intervals by 2 authors. Unpublished data were requested. Large for gestational age was the primary outcome. RESULTS: The search yielded 394 citations. Moreover, 7 randomized controlled trials met the inclusion criteria. A total of 54,650 participants were screened for gestational diabetes mellitus by either the 1-step screening method (n=27,163) or the 2-step screening method (n=27,487). For large for gestational age, there was no significant difference found between the groups (risk ratio, 0.99; 95% confidence interval, 0.93-1.05; I2=0%). Newborns of patients who underwent 1-step screening had higher rates of neonatal hypoglycemia (risk ratio, 1.24; 95% confidence interval, 1.14-1.34; I2=0%) and neonatal intensive care unit admissions (risk ratio, 1.13; 95% confidence interval, 1.04-1.21; I2=0%) than newborns of patients who underwent 2-step screening. Patients in the 1-step screening method group were more likely to be diagnosed with gestational diabetes mellitus (risk ratio, 1.73; 95% confidence interval, 1.44-2.09; I2=80%) than patients in the 2-step screening method group. In addition, among trials that tested all patients before randomization and excluded patients with pregestational diabetes mellitus, newborns were more likely to have macrosomia (risk ratio, 1.27; 95% confidence interval, 1.21-1.34; I2=0%). Overall risk of bias assessment was of low concern. CONCLUSION: Large for gestational age did not differ between patients screened using the 1-step screening method and those screened using the 2-step screening method. However, patients randomized to the 1-step screening method had higher rates of neonatal hypoglycemia and neonatal intensive care unit admission and maternal gestational diabetes mellitus diagnosis than the patients randomized to the 2-step screening method.