249 Laparoscopic Assisted Enterolithotomy: A Viable Option in The Management of Gallstone Ileus

Introduction

Gallstone ileus (GSI) is a rare cause of small bowel obstruction in patients over the age of 65 years. We report a case of GSI treated successfully with a laparoscopic assisted enterolithotomy.

Case report

A 75-year-old female presented with two days of abdominal distension and vomiting with a non-peritonitic abdomen on examination. A computerised tomography scan demonstrated small bowel obstruction due to an obstructing stone in the distal ileum. Three port laparoscopy and small bowel assessment confirmed a solitary enterolith (4cms) in the distal ileum with upstream dilated loops. An infra-umbilical 6 cm midline incision was made and the localised bowel loop was delivered. An enterotomy was made proximal to the point of obstruction, stone retrieved, and a single layer interrupted closure was performed. Ten weeks post-operatively, patient had a virtual follow-up consultation and is doing well.

Conclusions

GSI often presents in elderly patients with multiple co-morbidities. A laparotomy with enterolithotomy is the initial treatment of choice with biliary intervention as a second operation, if needed, at a later date. Clearly, a conventional exploratory laparotomy in this cohort of patients carries a high risk and therefore the use of less morbid and less invasive procedure like laparoscopy should be considered. Although a total laparoscopic approach would require advanced laparoscopic skills particularly due to dilated bowel loops limiting the intra-abdominal space for suturing, a laparoscopic assisted approach as described above should be considered as a reasonable option within the remits of an emergency general surgeon.

Can neutrophil-to-lymphocyte ratio be used as a predictor in acute appendicitis?

Background: To determine if neutrophil-to-lymphocyte ratio (NLR) can be used to diagnose appendicitis and distinguish complicated from uncomplicated appendicitis. The secondary aim was to determine if the appendix cut-off size on ultrasound matches that of existing literature. Methods: We retrospectively analyzed all cases that underwent appendectomy in Father Muller medical college and hospital from 2014 to 2019. The NLR, histopathology, and ultrasound reports for all patients were reviewed. Recommended cut-off values for NLR and appendicular size on ultrasound were determined using receiver operating characteristic analysis (ROC). Data was analyzed using SPSS version 25. Ethical approval was obtained for this study. Results: We included 1623 patients in this study. The patients’ median age was 24 years, with appendicitis being more common in males than females. NLR>2.4 was statistically associated with appendicitis with sensitivity of 70.1% and specificity of 43.2%. NLR>4.3 was statistically associated with complicated appendicitis with sensitivity of 72.25% and specificity of 54.09%. An appendicular diameter >6.1 mm was suggestive of appendicitis on abdominal ultrasound based on our analysis. Conclusions: NLR is a simple adjunct that can be used to diagnose appendicitis and identify complicated appendicitis.

COVID-19 pandemic and population-level pregnancy and neonatal outcomes: a living systematic review and meta-analysis

Introduction

Conflicting reports of increases and decreases in rates of preterm birth (PTB) and stillbirth in the general population during the COVID‐19 pandemic have surfaced. The objective of our study was to conduct a living systematic review and meta‐analyses of studies reporting pregnancy and neonatal outcomes by comparing the pandemic and pre‐pandemic periods.

Material and methods

We searched PubMed and Embase databases, reference lists of articles published up until 14 May 2021 and included English language studies that compared outcomes between the COVID‐19 pandemic time period and pre‐pandemic time periods. Risk of bias was assessed using the Newcastle–Ottawa scale. We conducted random‐effects meta‐analysis using the inverse variance method.

Results

Thirty‐seven studies with low‐to‐moderate risk of bias, reporting on 1 677 858 pregnancies during the pandemic period and 21 028 650 pregnancies during the pre‐pandemic period, were included. There was a significant reduction in unadjusted estimates of PTB (28 studies, unadjusted odds ratio [uaOR] 0.94, 95% confidence [CI] 0.91–0.98) but not in adjusted estimates (six studies, adjusted OR [aOR] 0.95, 95% CI 0.80–1.13). The reduction was noted in studies from single centers/health areas (uaOR 0.90, 95% CI 0.86–0.94) but not in regional/national studies (uaOR 0.99, 95% CI 0.95–1.03). There was reduction in spontaneous PTB (five studies, uaOR 0.89, 95% CI 0.82–0.98) and induced PTB (four studies, uaOR 0.90, 95% CI 0.81–1.00). There was no reduction in PTB when stratified by gestational age <34, <32 or <28 weeks. There was no difference in stillbirths between the pandemic and pre‐pandemic time periods (21 studies, uaOR 1.08, 95% CI 0.94–1.23; four studies, aOR 1.06, 95% CI 0.81–1.38). There was an increase in birthweight (six studies, mean difference 17 g, 95% CI 7–28 g) during the pandemic period. There was an increase in maternal mortality (four studies, uaOR 1.15, 95% CI 1.05–1.26), which was mostly influenced by one study from Mexico. There was significant publication bias for the outcome of PTB.

Conclusions

The COVID‐19 pandemic time period may be associated with a reduction in PTB; however, referral bias cannot be excluded. There was no difference in stillbirth between the pandemic and pre‐pandemic period.

Cardiac Risk Score to Predict Small-for-Gestational-Age Infants in Pregnant Women with Heart Disease

BACKGROUND

One of the most common fetal complications in pregnant women with cardiovascular disease is small for gestational age (SGA) which is associated with a higher risk of perinatal morbidity/mortality and poor long-term health outcomes. The objective of this study was to identify cardiac determinants/derive a risk score of clinically relevant SGA < 5^th percentile (SGA-5^th).

METHODS

A prospective cohort of 1812 pregnancies in women with heart disease was studied. SGA-5^th was the outcome of interest, defined as birth weight less than 5^th percentile for gestational age and sex. Multivariable logistic regression analysis identified predictors for SGA-5^th. Based on the regression coefficients a weighted risk score was created.

RESULTS

SGA-5^th complicated 10% of pregnancies, eleven predictors of SGA-5^th were identified and each was assigned a weighted score: maternal cyanosis (8), Fontan palliation (7), smoking (3), moderate or severe valvular regurgitation (3), beta-blocker use throughout pregnancy (4) or only in the 2^nd and 3^rd trimester (2), high baseline beta-blocker dose (4), BMI < 18.5 (3) or 18.5-24.9 (1), Asian/other ethnicity (2) and significant outflow tract obstruction (1). In the absence of identified risk factors, the risk of SGA-5^th was approximately 4%. Pregnancies with risk scores/SGA-5^th rate were as follows: 0/4%, 1/5%, 2/7%, 3/9%, 4/12%, 5/14%, 6/18%, 7/23%, 8/28% and ≥ 9/34%.

CONCLUSIONS

There are a number of cardiac predictors that are associated with increased risk of SGA-5^th. This is a prognostically important outcome and consideration should be given to routinely predicting and modifying the risk whenever possible.

Decision Analysis in SHared decision making for Thromboprophylaxis during Pregnancy (DASH-TOP): a sequential explanatory mixed methods pilot study protocol

INTRODUCTION

Decision analysis is a quantitative approach to decision making that could bridge the gap between decisions based solely on evidence and the unique values and preferences of individual patients, a feature especially important when existing evidence cannot support clear recommendations and there is a close balance between harms and benefits for the treatments options under consideration. Low molecular weight heparin (LMWH) for the prevention of venous thromboembolism (VTE) during pregnancy represents one such situation. The objective of this paper is to describe the rationale and methodology of a pilot study that will explore the application of decision analysis to a shared decision-making process involving prophylactic LMWH for pregnant women or those considering pregnancy who have experienced a VTE.

METHODS AND ANALYSIS

We will conduct an international, mixed methods, explanatory, sequential study, including quantitative data collection and analysis followed by qualitative data collection and analysis. In step I, we will ask women who are pregnant or considering pregnancy and have experienced VTE to participate in a shared decision-making intervention for prophylactic LMWH. The intervention consists of three components: a direct choice exercise, a values elicitation exercise and a personalised decision analysis. After administration of the intervention, we will ask women to make a treatment decision and measure decisional conflict, self-efficacy and satisfaction. In step II, which follows the analysis of quantitative data, we will use the results to inform the qualitative interview. Step III will be a qualitative descriptive study that explores participants' experiences and perceptions of the intervention. In step IV, we will integrate findings from the qualitative and quantitative analyses to obtain meta-inferences.

ETHICS AND DISSEMINATION

Site-specific ethics boards have approved the study. All participants will provide informed consent. The research team will take an integrated approach to knowledge translation.

A novel "video-game" simulator for training fetoscopic laser coagulation of anastomoses in twin-to-twin transfusion syndrome

We have developed a high-fidelity interactive "video-game" simulator in order to teach fetoscopic laser ablation of placental anastomoses for twin-twin transfusion syndrome This simulator may be used by teachers in order to provide metrics-based simulator education to multiple trainees, in both hands-on and distanced learning settings WHAT IS ALREADY KNOWN ABOUT THIS TOPIC?: The use of simulation improves training of the fetoscopic laser techniques utilized in the treatment of twin-twin transfusion syndrome A number of mannequins have been developed to aid this education WHAT DOES THIS STUDY ADD?: Two new simulators are described for twin-twin transfusion syndrome training-silicone and digital The digital simulator is a novel digital video game virtual format This new format has enhanced interactivity and has the potential to enable distance learning.

Impact of Obesity on Outcomes of Pregnancy in Women With Heart Disease

BACKGROUND

Women with heart disease are at risk for complications during pregnancy. This study sought to examine the effect of maternal obesity on pregnancy complications in women with heart disease.

OBJECTIVES

The objective was to determine the incidence of adverse cardiac events (CE) in pregnant women with heart disease and obesity.

METHODS

Adverse CE during pregnancy were examined in a prospective cohort of women with heart disease. CE were a composite of the following: cardiac death/arrest, arrhythmias, heart failure, myocardial infarction, stroke, aortic dissection, and thromboembolic events. Pre-eclampsia and post-partum hemorrhage were also studied. Outcomes were examined according to body mass index (BMI). To identify additional predictors of CE, a baseline risk score (CARPREG [Canadian Cardiac Disease in Pregnancy Study] II score) for predicting cardiac complications was calculated for all pregnancies and included in a multivariable logistic regression model.

RESULTS

Of 790 pregnancies, 19% occurred in women with BMI ≥30 kg/m² (obesity), 25% in women with BMI 25 to 29.9 kg/m² (overweight), 53% in women with BMI 18.5 to 24.9 kg/m² (normal weight), and 3% in women with BMI <18.5 kg/m² (underweight). Women with obesity were at higher risk of CE when compared with women with normal weight (23% vs. 14%; p = 0.006). In a multivariable model, obesity (odds ratio: 1.7; 95% confidence interval: 1.0 to 2.7) and higher CARPREG II risk scores (odds ratio: 1.7; 95% confidence interval: 1.5 to 1.9) predicted CE. Pre-eclampsia was more frequent in women with obesity compared with those with normal weight (8% vs. 2%; p = 0.001).

CONCLUSIONS

Obesity increases the risk of maternal cardiovascular complications in pregnant women with heart disease. This modifiable risk factor should be addressed at the time of preconception counseling.

Patient- and Health-Care-Provider-Reported Outcomes to Consider in Research on Pregnancy-Associated Venous Thromboembolism

BACKGROUND

 Venous thromboembolism (VTE) in pregnancy can have numerous adverse impacts on patients and health care systems. Ongoing research aimed at improving maternal and fetal/neonatal outcomes is hampered by the lack of patient perspective in determining which outcomes are considered important to assess the effectiveness of interventions.

OBJECTIVES

 The objective of this study was to elicit outcomes from those who experienced or were at risk for pregnancy-associated VTE (health service users, HSUs) and health care providers (HCPs) involved in their care.

METHODS

 Canadian HSUs and HCPs were recruited using convenience and purposive sampling, respectively. Individual, semistructured interviews aimed specifically at eliciting pregnancy-related outcomes were conducted until data saturation was attained. Interviews were audio-recorded and transcribed verbatim. Written transcripts were de-identified and interpretatively analyzed in duplicate to obtain outcomes related to participant experiences. Outcomes were grouped based on a taxonomy developed for medical research and compared between and across interviews with patients and HCPs, and with those obtained through a systematic review of the published literature.

RESULTS AND CONCLUSION

 We interviewed 10 HSUs and eight HCPs and elicited 52 outcomes, 21 of which have not been reported in the literature. Although the majority of elicited outcomes were in the clinical/physiological core outcome area, both HSUs and HCPs highlighted the importance of outcomes related to functioning/life impact and general wellbeing of mother and baby. These outcomes representing the perspectives of HSUs and HCPs should be considered while conducting trials on pregnancy-associated VTE.

Barbed vs conventional suture at cesarean delivery: A systematic review and meta-analysis

INTRODUCTION

Barbed sutures are used in cesarean delivery with the intended benefits of better tissue approximation, hemostasis, and strength, as well as reduced operative time. A systematic review and meta-analysis was undertaken to assess the safety and efficacy of the use of barbed suture compared with conventional sutures in cesarean delivery.

MATERIAL AND METHODS

MEDLINE, EMBASE, PubMed, Scopus, Cochrane CENTRAL, and three clinical trial registries, were searched from inception to December 2019, without restriction by language or publication year. Randomized controlled trials comparing the use of barbed suture with conventional sutures in closure of any layer (uterine/fascial/skin) during cesarean delivery were included. The safety outcomes included estimated blood loss, pain, mortality, and other morbidity including infection, re-operation or re-admission. Effectiveness outcomes included closure time, need for additional suture and scar integrity. Study selection, data extraction, risk-of-bias, and quality assessment were independently performed by two authors. Primary analysis compared outcomes for all layers of surgical closure, whereas subgroup analysis was performed by individual layer. Pooled mean differences (MD) and risk ratios (RR) with 95% CI were calculated using a random effects model. Level of evidence was assessed using GRADE criteria. PROSPERO registration number: CRD42020168859.

RESULTS

The review included four trials (three comparing uterine closure and one comparing skin closure), at high risk of bias, representing 460 participants. Primary analysis showed no morbidity differences between two groups. The use of barbed suture for uterine closure was associated with shorter incision closure time (MD 110.58 seconds, 95% CI 93.79-127.36 seconds), shorter total surgical time (MD 1.92 minutes, 95% CI 0.03-3.80 minutes), and a reduced need for additional hemostatic sutures (RR 0.39, 95% CI 0.28-0.54), with no difference in estimated blood loss (MD 46.17 mL, 95% CI 13.55 to -105.89 mL) or postoperative morbidity (RR 0.96, 95% CI 0.46-2.01). The level of evidence was deemed to be low to very low, based on inconsistency and imprecision of results.

CONCLUSIONS

Barbed sutures may be a suitable alternative to conventional sutures for uterine closure because they reduce uterine repair time, total surgical time, and the need for additional hemostatic sutures, without an increase in blood loss or maternal morbidity.

Composite adverse outcomes in obstetric studies: a systematic review

BACKGROUND

Composite outcomes are increasingly being used in obstetric trials. The aim of this systematic review is to critically appraise the use of composite outcomes in obstetric RCTs with an intention of identifying limitations and providing potential solutions for future research.

METHODS

The study protocol was prospectively registered. Medline, Embase, Cochrane Databases and www.clinicaltrials.gov were searched for randomized controlled trials (RCTs) published in English between 1999 and 2019, using search terms related to pregnancy and composite outcomes.

STUDY ELIGIBILITY CRITERIA

RCTs involving an obstetric condition that reported on a composite outcome.

STUDY APPRAISAL AND SYNTHESIS METHODS

Screening and data extraction were performed in duplicate, and a descriptive synthesis and critical appraisal of composite obstetric outcomes, is presented.

RESULTS

Of the 4170 results screened, we identified 156 RCTs, reporting on 181 composite outcomes. Of these, 158 composite outcomes related to general morbidity and mortality, either exclusively maternal (n=20), fetal-neonatal [perinatal] (n=116) or maternal and perinatal (n=22) were included in the final analysis. Obstetric composite outcomes included between two and 16 components. Components that comprised these composite outcomes were often dissimilar in terms of severity and frequency of occurrence, unlikely to have similar relative risk reductions and sometimes unrelated to the study's primary objective - important pre-requisites to consider while constructing composite outcomes. In addition, composite adverse obstetric outcomes often do not incorporate the perspectives of pregnant persons, embrace a holistic view of health or consider outcomes related to both members of the mother-fetus dyad.

CONCLUSIONS

Composite outcomes are being increasingly used as primary outcomes in obstetric RCTs, based on which study conclusions are drawn and clinical recommendations made. However, there is a lack of consistency with regard to what components should be included within a composite adverse obstetric outcome and how these components should be measured. The use of novel research methods such as concept mapping may be able to address some of the limitations with the development of composite adverse obstetric outcomes, to inform future research.

Pregnancy and COVID-19: pharmacologic considerations

In this review, we summarize evidence regarding the use of routine and investigational pharmacologic interventions for pregnant and lactating patients with coronavirus disease 2019 (COVID-19). Antenatal corticosteroids may be used routinely for fetal lung maturation between 24 and 34 weeks' gestation, but decisions in those with critical illness and those < 24 or > 34 weeks' gestation should be made on a case-by-case basis. Magnesium sulfate may be used for seizure prophylaxis and fetal neuroprotection, albeit cautiously in those with hypoxia and renal compromise. There are no contraindications to using low-dose aspirin to prevent placenta-mediated pregnancy complications when indicated. An algorithm for thromboprophylaxis in pregnant patients with COVID-19 is presented, which considers disease severity, timing of delivery in relation to disease onset, inpatient vs outpatient status, underlying comorbidities and contraindications to the use of anticoagulation. Nitrous oxide may be administered for labor analgesia while using appropriate personal protective equipment. Intravenous remifentanil patient-controlled analgesia should be used with caution in patients with respiratory depression. Liberal use of neuraxial labor analgesia may reduce the need for emergency general anesthesia which results in aerosolization. Short courses of non-steroidal anti-inflammatory drugs can be administered for postpartum analgesia, but opioids should be used with caution due to the risk of respiratory depression. For mechanically ventilated pregnant patients, neuromuscular blockade should be used for the shortest duration possible and reversal agents should be available on hand if delivery is imminent. To date, dexamethasone is the only proven and recommended experimental treatment for pregnant patients with COVID-19 who are mechanically ventilated or who require supplemental oxygen. Although hydroxycholoroquine, lopinavir/ritonavir and remdesivir may be used during pregnancy and lactation within the context of clinical trials, data from non-pregnant populations have not shown benefit. The role of monoclonal antibodies (tocilizumab), immunomodulators (tacrolimus), interferon, inhaled nitric oxide and convalescent plasma in pregnancy and lactation needs further evaluation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

A tool for assessing the comprehensiveness of outcome reporting within clinical trials in pregnancy

INTRODUCTION

Clinical trials provide fundamental evidence used to inform healthcare decisions at patient- and population levels and it is thus important that trials consider outcomes relevant to both patients and stakeholders. Although validated tools assessing other aspects of trial integrity exist, there is no tool for assessing the breadth and completeness of outcomes measured. Our objective was to develop a comprehensiveness of outcome reporting (COR) tool to assess this within trials in pregnancy.

MATERIAL AND METHODS

We developed a tool that aids in visualizing outcome reporting through the automatic generation of a heatmap, enabling assessment of the range of maternal and fetal/neonatal outcomes included in clinical trials. Outcome reporting and measurement of each study is compared to a context-specific, user-determined, ideal standard set of outcomes, created by initially considering all domains within five core outcome areas. These include mortality, morbidity, functioning/life-impact, resource-use, and adverse events, as identified by the most recent taxonomy for outcomes in medical research. We tested the tool's functionality using trials previously identified as studies on obesity in pregnant patients, and further compared the utility of the COR Tool against Cochrane's Risk of Bias 2.0 Tool using correlational analysis.

RESULTS

The pilot heatmap using clinical trials studying obesity in pregnancy (n = 15), illustrated a lack of comprehensiveness of reported outcomes in the majority of studies. Included trials were found to readily report physiological/clinical outcome but consistently neglected outcome areas related to functioning, delivery of care, resource-use, and adverse events. Outcome areas reported and measured were done so with largely varying degrees of quality. When the COR Tool was compared with Cochrane's RoB 2.0 Tool on a scatter plot, only a weak correlation was found (R = 0.2936, R²  = 0.0862) CONCLUSIONS: The COR Tool will promote transparency in clarifying what outcomes a trial's conclusions are based on, encourage trialists to consider outcomes related to all aspects of maternal and fetal/neonatal health, and support reviewers in appraising outcome reporting and measurement in the assessment of trial integrity. Used in tandem with RoB tools and core outcome sets, we hope the COR Tool will meaningfully contribute to improving maternal-infant health.

Determining the optimal antibiotic regimen for chorioamnionitis: A systematic review and meta-analysis

INTRODUCTION

To evaluate the effect of antibiotic regimens for chorioamnionitis on maternal and neonatal outcomes.

MATERIAL AND METHODS

We conducted a systematic review, wherein we searched six bibliographic databases until June 2020 and included randomized clinical trials describing antibiotic regimens for treating chorioamnionitis. Risk of bias was assessed using the Cochrane Risk of Bias tool V2.0. Random-effects meta-analysis was performed and results were presented as risk ratio (RR) and mean differences (MD) with 95% CI.

RESULTS

Fourteen trials at low-to-high risk of bias were included. Three trials (n = 244), comparing different intrapartum antibiotic regimens, showed no difference in outcomes except for lower composite maternal morbidity (endometritis, pneumonia, sepsis, blood transfusion, and ileus) with ampicillin/sulbactam vs ampicillin/gentamicin in one study (0/43 vs 6/49, P = .03). Three trials (n = 295) comparing different doses of intrapartum antibiotics showed no differences in maternal and neonatal outcomes, although one study showed a shorter duration of antibiotic treatment in the experimental arm (4 mg/kg gentamicin q24h + 1200 mg clindamycin q12h) vs conventional arm (1.33 mg/kg gentamicin + 800 mg clindamycin q8h) (48.0 ± 36 hours vs 55.2 ± 48 hours, P = .04). Four trials (n = 484) comparing postpartum antibiotics vs no antibiotics showed no difference in outcomes except for a shorter hospital stay (two studies, MD -7.90 hours, 95% CI -13.52 to -2.27 hours). Three trials (n = 447) comparing single vs multiple doses of postpartum antibiotics showed shorter hospital stay [MD -19.14 hours, 95% CI -29.88 to -8.41 hours), but no differences in treatment failure (RR 1.73, 95% CI 0.69-4.30) or total antibiotic dose (MD -9.24, 95% CI -19.49 to 1.01). One trial (n = 48) comparing intrapartum vs postpartum initiation of treatment found benefits to intrapartum (vs postpartum) initiation of antibiotics, in terms of postpartum maternal hospital stay (MD -24 hours, 95% CI -45.56 to -1.44 hours), neonatal hospital stay (MD -45.6 hours, -93.84 to -11.76 hours), and neonatal pneumonia or sepsis (RR 0.06, 95% CI 0.00-0.95).

CONCLUSIONS

Upon diagnosis of chorioamnionitis, there is limited evidence to recommend the prompt initiation of intrapartum antibiotics, and to consider a single dose of postpartum antibiotics over multiple doses or no treatment. Well-designed trials using standard definitions of chorioamnionitis, outcome measures, and newer antibiotics are required to inform clinical practice with regard to the preferred antibiotic regimen, dose, and duration to optimize maternal and neonatal outcomes.

Preventing Complications in Pregnant Women With Cardiac Disease

BACKGROUND

Pregnancy can lead to complications in women with heart disease, and these complications can be life threatening. Understanding serious complications and how they can be prevented is important.

OBJECTIVES

The primary objectives were to determine the incidence of serious cardiac events (SCEs) in pregnant women with heart disease, whether they were preventable, and their impact on fetal and neonatal outcomes. Serious obstetric events were also examined.

METHODS

A prospectively assembled cohort of 1,315 pregnancies in women with heart disease was studied. SCEs included cardiac death or arrest, ventricular arrhythmias, congestive heart failure or arrhythmias requiring admission to an intensive care unit, myocardial infarction, stroke, aortic dissection, valve thrombosis, endocarditis, and urgent cardiac intervention. The Harvard Medical Study criteria were used to adjudicate preventability.

RESULTS

Overall, 3.6% of pregnancies (47 of 1,315) were complicated by SCEs. The most frequent SCEs were cardiac death or arrest, heart failure, arrhythmias, and urgent interventions. Most SCEs (66%) occurred in the antepartum period. Almost one-half of SCEs (49%) were preventable; the majority of preventable SCEs (74%) were secondary to provider management factors. Adverse fetal and neonatal events were more common in pregnancies with SCEs compared with those without cardiac events (62% vs. 29%; p < 0.001). Serious obstetric events were less common (1.7%) and were primarily due to pre-eclampsia with severe features.

CONCLUSIONS

Pregnant women with heart disease are at risk for serious cardiac complications, and approximately one-half of all SCEs are preventable. Strategies to prevent serious cardiac complications in this high-risk cohort of women need to be developed.

The Moral Imperative to Include Pregnant Women in Clinical Trials of Interventions for COVID-19

Although the number of clinical trials for patients with COVID-19 is increasing, many exclude pregnant women as participants or do not address pregnancy. This commentary discuss why pregnancy women should be included in clinical trials of interventions for COVID-19.

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.

Pregnancy and Neuromyelitis Optica Spectrum Disorder - Reciprocal Effects and Practical Recommendations: A Systematic Review

Introduction: Neuromyelitis optica spectrum disorder (NMOSD) is an inflammatory disorder of the central nervous system characterized by severe, antibody-mediated astrocyte loss with secondary demyelination and axonal damage, predominantly targeting optic nerves and the spinal cord. Recent publications have alluded to increased disease activity during pregnancy, and adverse maternal and fetal outcomes in patients with NMOSD. Our objective was to systematically review published literature to help counsel and manage women with NMOSD contemplating pregnancy. Methods: We searched five databases including MEDLINE and EMBASE, for English-language publications describing pregnancies in women with NMOSD. Article selection, data extraction, and risk-of-bias assessment using Joanna Briggs' critical appraisal tool for case reports and case series, were performed in duplicate. Pooled incidences were calculated where possible, and a narrative summary was provided. Results: Of 2,118 identified titles, 22 case reports and seven case series, representing 595 pregnancies in 389 women, were included. The mean maternal age was 28.12 ± 5.19 years. At least 20% of cases were first diagnosed during pregnancy. There were no maternal deaths. Pooled estimates for clinical outcomes could not be obtained due to inadequate reporting. NMOSD-related disability and relapses increased considerably during pregnancy and especially in the immediate postpartum period. Although a high proportion of early pregnancy losses were reported, an association with disease activity or therapeutic interventions could not be established. Apart from one publication which reported an increased risk of preeclampsia, there was no increase in adverse obstetric outcomes including preterm birth, fetal growth restriction or congenital malformations. Initial attacks and relapses were successfully managed with oral or intravenous corticosteroids and immunosuppressants, and refractory cases with immunoglobulin, plasma exchange and immunoadsorption. Conclusion: Increased NMOSD-related disability and relapses during pregnancy the postpartum period may respond to aggressive management with corticosteroids and immunosuppressants such as azathioprine, which are safely administered during pregnancy and lactation. Emerging safety data on monoclonal antibodies during pregnancy, make these attractive options, while intravenous immunoglobulin, plasma exchange and immunoadsorption can be safely used to treat severe relapses. The complex interplay between NMOSD and pregnancy outcomes would be best understood through prospective analysis of data collected through an international registry. Disclosure: Dalia Rotstein has served as a consultant or speaker for Alexion and Roche. She has received research support from Roche Canada. Rohan D'Souza has served as a consultant and speaker for Ferring Canada Inc and Ferring Global Inc, on topics unrelated to this manuscript. The other authors have no relevant relationships to disclose.

Pregnancy Outcomes in Systemic Vasculitides

Purpose of Review

In recent years, improvements in the recognition of primary vasculitides and increased treatment options have led to greater survival rates and a better quality of life for patients. Therefore, pregnancy in women with vasculitis has become a more frequent consideration or event. Literature on pregnancy outcomes in this population has grown and allowed us, in this article, to review the effects of pregnancy on disease activity, as well as maternal and fetal outcomes for each type of vasculitides.

Recent Findings

Successful pregnancies in patients with vasculitides are possible, especially when conception is planned, and the disease is in remission. The risk of vasculitis flare is highly dependent on the type of vasculitis, but overall limited. The most frequent complication associated with large-vessel vasculitis (mainly Takayasu arteritis) is hypertension and preeclampsia. Preterm deliveries and intrauterine growth restriction occur more frequently with small- and medium-vessel vasculitis.

Summary

Pregnancies in patients with vasculitis should be considered high risk and followed by a multidisciplinary team with expertise in the field. Flares should be managed as in the non-pregnant population, while avoiding medications with unknown safety in pregnancy or known teratogens. Although commonly prescribed for the prevention of preeclampsia, there is limited evidence supporting the use of low-dose aspirin for pregnant women with vasculitis. Prospective registries or studies are needed, to better assess the value of aspirin, the place and long-term impact of new biologics and, to identify predictors of pregnancy outcomes other than disease status at conception.

A critical review of the pathophysiology of thrombotic complications and clinical practice recommendations for thromboprophylaxis in pregnant patients with COVID-19

Those who are infected with Severe Acute Respiratory Syndrome‐related CoronaVirus‐2 are theoretically at increased risk of venous thromboembolism during self‐isolation if they have reduced mobility or are dehydrated. Should patients develop coronavirus disease (COVID‐19) pneumonia requiring hospital admission for treatment of hypoxia, the risk for thromboembolic complications increases greatly. These thromboembolic events are the result of at least two distinct mechanisms – microvascular thrombosis in the pulmonary system (immunothrombosis) and hospital‐associated venous thromboembolism. Since pregnancy is a prothrombotic state, there is concern regarding the potentially increased risk of thrombotic complications among pregnant women with COVID‐19. To date, however, pregnant women do not appear to have a substantially increased risk of thrombotic complications related to COVID‐19. Nevertheless, several organizations have vigilantly issued pregnancy‐specific guidelines for thromboprophylaxis in COVID‐19. Discrepancies between these guidelines reflect the altruistic wish to protect patients and lack of high‐quality evidence available to inform clinical practice. Low molecular weight heparin (LMWH) is the drug of choice for thromboprophylaxis in pregnant women with COVID‐19. However, its utility in non‐pregnant patients is only established against venous thromboembolism, as LMWH may have little or no effect on immunothrombosis. Decisions about initiation and duration of prophylactic anticoagulation in the context of pregnancy and COVID‐19 must take into consideration disease severity, outpatient vs inpatient status, temporal relation between disease occurrence and timing of childbirth, and the underlying prothrombotic risk conferred by additional comorbidities. There is currently no evidence to recommend the use of intermediate or therapeutic doses of LMWH in thromboprophylaxis, which may increase bleeding risk without reducing thrombotic risk in pregnant patients with COVID‐19. Likewise, there is no evidence to comment on the role of low‐dose aspirin in thromboprophylaxis or of anti‐cytokine and antiviral agents in preventing immunothrombosis. These unanswered questions are being studied within the context of clinical trials.

Development of a core outcome set for studies on prevention and management of pregnancy-associated venous thromboembolism (COSPVenTE): a study protocol

INTRODUCTION

Pregnancy and post partum are times of heightened risk for the development of venous thromboembolism (VTE), which in turn is one of the leading causes of maternal mortality and long-term morbidity. The current research aimed at improving health guidelines for women with pregnancy-associated VTE is limited by inconsistency in outcome reporting preventing comparison across studies, and lack of input from patients with respect to outcomes they propose are most important to measure. A suggested solution is the development of a core outcome set (COS) that defines the minimum criteria for outcome reporting in clinical trials and prospective studies. COSs function to facilitate data harmonisation and increase homogeneity in outcome reporting while incorporating the voice of women in this population in the planning of research to inform their ongoing care.

METHODS AND ANALYSIS

The development of a COS for studies on pregnancy-associated VTE will comprise five steps. First, a systematic review of the published literature will identify currently reported outcomes, their definitions and measurements if applicable. This will be followed by in-person interviews with patients, clinicians, researchers, hospital administrators and policy-makers to identify outcomes they consider important. Third, the long list of outcomes obtained from steps I and II will be condensed through online Delphi surveys involving an international group of relevant stakeholders including patients. This will be followed by a face-to-face consensus meeting with representatives of all stakeholder groups to arrive at a consensus on the final COS. Lastly, to determine how the identified core outcomes should be measured, another literature review and Delphi process will be carried out as necessary.

ETHICS AND DISSEMINATION

This study has been approved by the Mount Sinai Hospital Research Ethics Board (REB 18-0314-E). Study results will be published in open-access journals and presented at obstetrics, maternal-fetal medicine and haematology conferences. All progress will be documented on the international prospective register of systematic reviews (PROSPERO) and Core Outcome Measures in Effectiveness Trials databases.

PROSPERO REGISTRATION NUMBER

CRD42019111479.

Core outcome set for studies on pregnant women with vasa previa (COVasP): a study protocol

INTRODUCTION

Vasa previa is a condition where fetal blood vessels run unprotected in the membranes, outside the umbilical cord, and cross the internal opening of the cervix. During rupture of membranes, these vessels can rupture and put the baby at serious risk of severe blood loss and death. Numerous studies are being conducted to improve diagnostic modalities and establish clear management plans to improve pregnancy outcomes. However, the lack of a standardised set of outcomes for studies on vasa previa makes it difficult to compare study findings and draw meaningful conclusions. Through this project, we will be developing a core outcome set for studies on pregnant women with vasa previa (COVasP).

METHODS AND ANALYSIS

The development of COVasP will involve five steps. The first will be a systematic review, in which we will generate a long list of outcomes based on published studies in pregnancies complicated with vasa previa. The second will involve in-depth interviews with current and former patients, their family members and healthcare providers who care for these patients. This will be followed by a two-round Delphi survey, which will aim to narrow down the long list of outcomes into those considered important by four groups of 'stakeholders': (1) patients, family members and patient advocates/representatives, (2) healthcare providers, (3) researchers, epidemiologists and methodologists and (4) other stakeholders directly or indirectly involved in the management of these pregnancies such as administrators, guideline developers and policymakers. The fourth step will involve a face-to-face consensus meeting using a nominal group approach to establish a finalised core outcome set. The final step will involve measuring and defining the identified outcomes using a combination of systematic reviews and Delphi surveys.

ETHICS AND DISSEMINATION

This study as well as consent forms for stakeholder participation have received approval from the Mount Sinai Hospital Research Ethics Board (REB number 18-0173-E) on 05 September 2018 and the Human Research Ethics Committee at The University of Technology Sydney, Australia on 30 July 2019 (UTS HREC reference number ETH19-3718). All progress will be documented on the international prospective register of systematic reviews and Core Outcome Measures in Effectiveness Trials databases. REGISTRATION DETAILS: http://www.comet-initiative.org/studies/details/1117.

Adverse outcome of acute splenic sequestration crisis in pregnancy

Background

Acute splenic sequestration crisis, characterized by abrupt fall in hemoglobin, splenomegaly, hypovolemia, and often thrombocytopenia, occurs infrequently in adults with sickle cell disease and extremely rarely during pregnancy.

Case

A 25-year-old woman with HbSC presented at 33 weeks' gestation with vaso-occlusive pain. Sudden worsening of abdominal pain and non-reassuring fetal surveillance on day 3 of admission led to emergent delivery. Acute splenic sequestration crisis was the diagnosis of exclusion based on clinical presentation and intra-operative hemoglobin of 37 g/L. Five- and 10-minute Apgar scores were 4. Neonatal brain magnetic resonance imaging revealed significant diffuse white matter abnormalities.

Conclusion

Acute splenic sequestration crisis in pregnancy must be considered in the differential diagnosis for this patient population as it can evolve rapidly and lead to maternal and fetal compromise.

Inpatient versus outpatient induction of labour: a systematic review and meta-analysis

Background

As the number of indications for labour induction continue to increase, the focus has shifted to performing these procedures in an outpatient setting. This study aims to systematically review published data from randomized controlled trials that compare outpatient with inpatient labour induction, to ascertain the role of outpatient labour induction for low-risk pregnancies.

Methods

We conducted a systematic review wherein we searched MEDLINE, EMBASE, Biosis Previews®, and International Pharmaceutical Abstracts from inception to January 2020 to identify randomized controlled trials that reported on maternal, fetal and resource-related outcomes following outpatient versus inpatient labour induction. Pooled incidences and mean differences were calculated using random-effects meta-analysis. Risk-of-bias was assessed using the Cochrane Risk of Bias tool. Subgroup analysis was conducted based on the method of induction.

Results

Of the 588 records identified, 12 publications, representing nine independent randomized controlled trials conducted in Australia, Europe and North America, were included. These reported on 2615 cases of labour induction (1320 outpatients versus 1295 inpatients). Overall, apart from a higher number of suspicious fetal heart rate tracings [RR = 1.43 (1.10, 1.86)] and a shorter mean length of hospital stay [MD = 282.48 min (160.23, 404.73) shorter] in the outpatient group, there were no differences in delivery method, adverse outcomes or resource-use between the two arms. On subgroup analysis, when comparing the use of balloon catheters in both arms, those induced as outpatients had fewer caesarean deliveries [RR = 0.52 (0.30, 0.90)], a shorter admission-to-delivery interval [MD = 370.86 min (19.19, 722.54) shorter], and a shorter induction to delivery interval [MD = 330.42 min (120.13, 540.71) shorter].

Conclusion

Outpatient labour induction in resource-rich settings is at least as effective and safe, in carefully selected patient populations, when compared with inpatient labour induction. Whether outpatient labour induction results in lower rates of caesarean deliveries needs to be explored further.

Trial registration

This systematic review was prospectively registered in Prospero (CRD42019118049).

Placental histopathology in sickle cell disease: A descriptive and hypothesis-generating study

INTRODUCTION

Abnormal placental development is a unifying factor amongst many adverse pregnancy outcomes (APOs) in Sickle Cell Disease (SCD). Our aim was to describe placental histopathologic findings in women with SCD and their relationship with APOs, and to explore the association between antenatal sonographic findings and placental pathology.

METHODS

Retrospective single-centre case series of all pregnant women with SCD (January 2000-December 2017), pregnancy beyond 20 weeks' gestation, and available placenta histopathology. APOs included intrauterine fetal death, early neonatal death, preterm birth, small for gestational age, and hypertensive disorders of pregnancy. Review of images for mid-pregnancy ultrasound and one proximal to delivery was completed, blinded to clinical outcomes and histopathology results. Gross and histopathologic findings were reviewed and characterized per published classification.

RESULTS

Of 72 placentas, abnormalities were present in 69%, with Maternal Vascular Malperfusion (MVM) noted in 40%. APOs were encountered in 61% overall and in 79% of those with MVM. Neither SCD genotype nor severe maternal anemia had an influence on histopathologic placental features. Presence of high-resistance uterine artery waveforms at mid-trimester ultrasound was strongly associated with APOs and with abnormal findings on placental histopathology, most notably MVM. MVM was strongly associated with small for gestational age infants, preterm birth, and stillbirth.

DISCUSSION

MVM is the predominant lesion in placentas of women with SCD and is strongly associated with APOs. Mid-trimester ultrasound can identify a subset of women at risk. Future research into advanced imaging modalities to aid in antenatal diagnosis alongside investigations of potentially beneficial therapies is needed.

Variations in reported outcomes in studies on vasa previa: a systematic review

OBJECTIVE

To evaluate reported outcomes of published studies on the diagnosis and management of vasa previa in pregnancy.

MATERIALS AND METHODS

Databases such as MEDLINE, Embase, Cochrane, PubMed, and ClinicalTrials.gov were searched up to March 2018 for all published studies on vasa previa using combinations of the following medical subject headings and key words: vasa previa, placenta previa, low-lying placenta, succenturiate lobe or placenta, bilobed or bilobate placenta, and velamentous insertion. All original human research that described maternal, obstetric, placental, fetal or neonatal outcomes relating to pregnancies with vasa previa were included for analysis. Title and abstract screening and data extraction was conducted independently and in duplicate by 2 reviewers for all studies until total agreement for eligibility was achieved. Data extraction was also conducted in duplicate in approximately 50% of studies reviewed.

RESULTS

A total of 160 published studies (1004 pregnancies) were included. There was a wide range of reported outcomes, many of which were sparingly reported. The most commonly reported maternal outcomes included mode of delivery, presence of antepartum hemorrhage, time of diagnosis, and rupture of membranes. The presence of known risk factors for vasa previa such as a low-lying placenta, succenturiate or bilobed placenta, and (velamentous) cord insertion was incorrectly reported as "outcomes" in many studies. The most commonly reported fetal/neonatal outcomes included fetal heart rate, gestational age at delivery, birthweight, Apgar score, presence of neonatal anemia, cord blood gas measurements, need for blood transfusion, and death. Of note, only 3 studies reported outcomes related to life impact, maternal social and emotional functioning, perceived delivery of care, or resource utilization.

CONCLUSION

Despite the profound effect the diagnosis of vasa previa has on pregnant women, families, and healthcare systems, studies on vasa previa seldom report outcomes related to life impact and resource utilization. There is a need for the development of a core outcome set-a minimum standard set of outcomes deemed important by pregnant women and other stakeholders involved in their care-to standardize outcome reporting in future studies on vasa previa.

Vasa previa and associated risk factors: a systematic review and meta-analysis

OBJECTIVE

To systematically review published literature and calculate the prevalence of vasa previa and its known risk factors.

MATERIALS AND METHODS

MEDLINE, Embase, the Cochrane Library, PubMed (non-MEDLINE and in process), and www.clinicaltrials.gov were searched from inception to March 2018 using indexing terms "vasa previa," "placenta previa," "low lying placenta," "succenturiate lobe," "bilobate placenta," "bilobed placenta," and "velamentous insertion." All original research studies reporting on 5 or more pregnancies with vasa previa were included. The search was limited to studies on human data and those published in the English language. Two reviewers independently screened titles and abstracts, completed data extraction, and assessed reporting quality using the Study Quality Assessment Tool for Case Series Studies of the National Heart, Lung, and Blood Institute. Disagreements were discussed and resolved at each step of the process.

RESULTS

We included 21 studies that reported 428 pregnancies with vasa previa of 1,027,918 deliveries (0.46 cases of vasa previa per 1000 deliveries). These studies fared well on risk of bias assessment using the Study Quality Assessment Tool for Case Series Studies of the National Heart, Lung, and Blood Institute. The prevalence and 95% confidence intervals of known risk factors for vasa previa included a low-lying placenta (61.5%, 53.0%-70.0%), velamentous cord insertion (52.2%, 39.6%-64.7%), bilobed or succenturiate lobed placenta (33.3%, 20.9%-45.7%), use of in vitro fertilization (26.4%, 16.0%-36.8%), and multiple gestation (8.92%, 5.33%-12.5%).

CONCLUSION

Vasa previa affects 0.46 cases per 1000 pregnancies. Given the high prevalence of prenatally detectable risk factors in affected pregnancies, the cost-effectiveness of screening strategies for vasa previa either in isolation, using a risk factor-based approach, or universally, in tandem with cervical-length screening using transvaginal ultrasound, should be revisited.

Development of a Core Outcome Set for Studies on Cardiac Disease in Pregnancy (COSCarP): a study protocol

Background

Clinical studies looking at interventions to optimize pregnancy and long-term outcomes for women with cardiac disease and their babies are inconsistent in their reporting of clinical outcomes, making it difficult to compare results across studies and draw meaningful conclusions. The development of a core outcome set (COS)—a standardized, minimum set of outcomes that must be collected and reported in all studies—is a practical solution to this problem.

Methods/design

We will follow a five-step process in developing a COS for studies on pregnant women with cardiac disease. First, a systematic literature review will identify all reported outcomes (including patient-reported outcomes) and definitions. Second, semi-structured interviews with stakeholders involved in the care of pregnant women with cardiac disease will determine their perspective and add new outcomes that they consider important. Third, an international electronic Delphi survey will narrow outcomes obtained through the first two steps, in an attempt to arrive at a consensus. Fourth, a face-to-face consensus meeting will deliberate to finalize the COS. Finally, measurement tools and definitions for included outcomes will be determined through a series of literature reviews and Delphi surveys.

Discussion

This protocol provides an overview of the steps involved in the development of a COS that must be reported in studies involving pregnant women with cardiac disease, in an attempt to harmonize outcome reporting and ensure the validity of study results that will not only inform clinical practice and future research but also encourage the development of COS in other areas of medicine.

COMET core outcome set registration

http://www.cometinitiative.org/studies/details/834

Pregnancy outcomes in women with significant valve disease: a systematic review and meta-analysis

OBJECTIVE

To perform a systematic review and meta-analysis of maternal/fetal outcomes in pregnant women with moderate/severe native valvular heart disease (VHD) from medium/higher Human Development Index (HDI) countries.

METHODS

OvidSP platform databases were searched (1985-January 2019) to identify studies reporting pregnancy outcomes in women with moderate/severe VHD. The primary maternal outcome was maternal mortality. The primary fetal/neonatal outcome was stillbirth and neonatal death. Pooled incidences and 95% confidence intervals (CI) of maternal/fetal outcomes could only be calculated from studies involving mitral stenosis (MS) or aortic stenosis (AS).

RESULTS

Twelve studies on 646 pregnancies were included. Pregnant women with severe MS had mortality rates of 3% (95% CI, 0% to 6%), pulmonary oedema 37% (23%-51%) and new/recurrent arrhythmias 16% (1%-25%). Their stillbirth, neonatal death and preterm birth rates were 4% (1%-7%), 2% (0%-4%), and 18% (7%-29%), respectively. Women with moderate MS had mortality rates of 1%(0%-2%), pulmonary oedema 18% (2%-33%), new/recurrent arrhythmias 5% (1%-9%), stillbirth 2% (1%-4%) and preterm birth 10%(2%-17%).Pregnant women with severe AS had a risk of mortality of 2% (0%-5%), pulmonary oedema 9% (2%-15%), and new/recurrent arrhythmias 4% (0%-7%). Their stillbirth, neonatal death and preterm birth rates were 2% (0%-5%), 3% (0%-6%) and 14%(4%-24%), respectively. No maternal/neonatal deaths were reported in moderate AS, however women experienced pulmonary oedema (8%; 0%-20%), new/recurrent arrhythmias (2%; 0%-5%), and preterm birth (13%; 6%-20%).

CONCLUSIONS

Women with moderate/severe MS and AS are at risk for adverse maternal and fetal/neonatal outcomes. They should receive preconception counseling and pregnancy care by teams with pregnancy and heart disease experience.

Obesity in Pregnancy - Patient-Reported Outcomes in Qualitative Research: A Systematic Review

The purpose of this study was to determine the clinical and non-clinical outcomes that pregnant women with obesity value as pertaining to their health and that of their babies. In this systematic review of the qualitative literature, a search of four databases was conducted for studies using qualitative methods in pregnant women with obesity. From the included studies, the review synthesized relevant themes representing the voiced concerns and perceived benefits of and barriers to the uptake of interventions, to yield patient-reported outcomes (PROs). PROs were categorized into domains according to the published taxonomy of outcomes in medical research. Of the 89 identified studies, 27 were included, none of which were primarily intended to elicit PROs. A total of 256 PROs and 7 distinct themes were identified. Only 13% of PROs represented physiological or clinical outcomes, whereas 21% represented the core area of emotional functioning or well-being, and 15% represented the area of delivery of care. The most frequently voiced concern was inadequate health care provider support (60%), and women considered intervention-specific challenges to be the greatest barriers to the uptake of interventions (34%). This study synthesized the qualitative evidence of concerns that pregnant women with obesity have regarding their pregnancy and postpartum care, as well as specific barriers they perceive to the uptake of interventions. In addition, this study revealed that clinical outcomes, which are most often reported in clinical trials, comprise only a minority of outcomes considered important by these women. A core outcome set that adequately incorporates PROs is required to inform the conduct of future trials in pregnant women with obesity.

Variation in outcome reporting in studies on obesity in pregnancy-A systematic review

Although considerable research is being conducted with a view to improve outcomes for pregnant women with obesity and their babies, much of this research is compromised by the quality of outcome reporting. Our aim is to determine how outcomes have been reported and measured in obesity in pregnancy studies, as a first step towards developing a core outcome set to standardize outcome reporting in future trials. We conducted a systematic review of clinical trials and systematic reviews on obesity in pregnancy in accordance with the Preferred Reporting in Systematic Reviews and Meta-analyses guidelines. We searched Medline, Embase, controlled register of trials, World Health Organization International Clinical Trials Registry, www.clinicaltrials.gov and Google Scholar, for relevant studies and extracted study characteristics, outcome reporting and measurement. Reporting quality was assessed using previously published criteria. Outcomes were grouped using a published taxonomy and variations in outcome reporting and measurement were descriptively presented. Seventy included studies yielded a total of 135 outcomes. Foetal/neonatal outcomes were not reported in 53.3% of studies where an intervention could have implications to both, mother and baby. Reported outcomes were mostly physiological/clinical (74.8%), with very limited representation of outcomes related to mortality/survival (5.2%), life impact (7.4%), adverse events (5.9%) and resource utilization (6.7%).

Pregnancy outcomes in women with cardiothoracic transplants: A Systematic review and meta-analysis

Increasing numbers of women with thoracic transplants are planning and continuing pregnancies. However, pregnancy outcomes and risks to the mother and baby have not been systematically assessed. MEDLINE, EMBASE, and Cochrane Central were searched from their inception to January 2018, to identify studies reporting outcomes on 3 or more pregnancies following thoracic transplants. Pooled incidences were calculated using a random-effect meta-analysis. Risk-of-bias was assessed using the Joanna Briggs Checklist for case series. Subgroup analysis was conducted based on the organ transplanted. Of the 3,658 records identified, 12 studies were included that reported on 385 pregnancies in 272 thoracic transplant recipients. Maternal complications included mortality (pooled incidence 0.5% [95% confidence intervals 0, 1.1%] during pregnancy and 15.4% [10.4, 20.3%] during follow-up, which ranged between 3 and 7 years), graft rejection (7.4% [4.2, 10.5%]), hypertensive disorders of pregnancy [26.6% [13.7, 39.6%]), and cesarean deliveries (41.4% [33.4, 48.7%]). Maternal mortality was more common in recipients of lung vs heart transplants (41.4% [23.4, 59.3] vs 10.8% [5.9, 15.8]), respectively. Although 78.4% (69.8, 86.9%) of the pregnancies resulted in live births, 51.2% (31, 71.3%) were born preterm and neonatal deaths occurred in 3.4% (1.3, 5.6%). Congenital anomalies affected 4.3% (1.8, 6.8%) of the newborns. Although few maternal deaths occurred during pregnancy, in keeping with median survival data, delayed mortality for thoracic transplant recipients remains high. Despite the high numbers of live births, these pregnancies continue to be at risk for hypertensive disorders, graft rejection, preterm birth, and neonatal mortality. Prospectively gathered data from international registries should supplement these findings to better inform clinical counseling and practice.

Should an Early Anatomy Ultrasound Scan Be Offered Routinely to Obese Pregnant Women?

OBJECTIVE

The primary objective of this study was to determine whether an early anatomic scan (EAS), either on its own or in combination with the routine transabdominal scan (R-TAS), would improve overall completion rates of the fetal anatomic survey in the obese pregnant woman. The study's secondary objectives were to compare patients' and sonographers' satisfaction with EAS versus R-TAS.

METHODS

A prospective observational study was carried out over a 2.5-year period including consecutive pregnant women with a pre-pregnancy BMI ≥30 kg/m² who consented at a dating ultrasound appointment to undergo EAS at 15 ± 1 GA in addition to the second trimester R-TAS. Anatomic structures were categorized as normal, not well seen, or abnormal by using the institutional 26-item anatomic standardized reporting template. Examination completion and study duration were recorded. Neonatal follow-up was performed to evaluate for any missed diagnoses. Patients' and sonographers' satisfaction questionnaires were completed.

RESULTS

A total of 120 pregnant women completed the study. Visualization of all anatomic components was complete in 14% at EAS and in 61% at R-TAS (combined completion rate, 90%). Mean scan time was 30.4 minutes at EAS and 51 minutes at R-TAS. No missed diagnoses of structural anomalies were identified at neonatal follow-up. EAS and R-TAS differed in terms of sonographers' reports of difficult or suboptimal scans (9% vs. 58%), well-seen anatomy (85% vs. 78%), and good visibility (44% vs. 12%). Most sonographers expressed a preference for performing EAS in future pregnancies, rather than the R-TAS (96% vs. 6%). Although patients reported greater satisfaction with EAS (93% vs. 74%), for reasons that could not be determined, they expressed a preference for R-TAS in a subsequent pregnancy (23% vs. 63%).

CONCLUSION

Performing EAS along with R-TAS improves completion rates for anatomic evaluation in the obese gravida and is associated with greater patient and sonographer satisfaction.

P6312Pregnancy outcomes in women with cardiothoracic transplants: a systematic review and meta-analysis

Background

Increasing numbers of women with heart-lung transplants (HLT) are now planning and continuing with pregnancies. The risks of pregnancies in these women have not been systematically assessed.

Methods

A search strategy was designed for MEDLINE, EMBASE, and Cochrane Central from inception to January 2018 to identify studies reporting outcomes in three or more pregnancies following HLT. Pooled incidence of maternal outcomes and fetal and neonatal outcomes were calculated using random-effects meta-analysis and reported per 100 pregnancies with 95% confidence intervals (CI). Risk-of-bias was determined using the Joanna Briggs Checklist for Case Series. Subgroup analysis was conducted based on transplanted organ.

Results

A total of 3658 records were identified, 172 full texts reviewed, and 12 studies included. The included studies reported on 385 pregnancies in 272 transplant recipients. Maternal complications included mortality during pregnancy [0.5% (0, 1.1%)], mortality during the specified follow-up period [15.4% (10,4, 20.3%)], graft rejection during pregnancy [7.4% (4.2, 10.5%)], preeclampsia [12.3% (7.2%, 17.5%)], gestational diabetes [6.4% (2.6, 10.1%)], and caesarean deliveries [41.4% (33.4, 48.7%)]. As many as 78.4% (69.8, 86.9%) pregnancies resulted in live births. Of the remainder, 13.6% (6.3, 20.9%) resulted in miscarriages (fetal loss under 20 weeks of gestation), 2% (0.3, 3.7%) resulted in stillbirths (fetal loss after 20 weeks of gestation), and 6.8% (4.3, 9.3%) in pregnancy terminations for various reasons. Of those born live, 3.4% (1.3, 5.6%) succumbed in the neonatal period. Over half the pregnancies [51.2% (31, 71.3%)] resulted in preterm deliveries (<37 weeks of gestation). There were subgroup-specific variations in the prevalence of complications. For example, lung transplant recipients were less likely than heart transplant recipients to have pregnancies complicated by preeclampsia [8.3% (3.0, 13.6%) vs. 17.8% (10.8, 24.8%)] suffer maternal mortality during the follow up period [41.4% (23.4, 59.3%) vs. 10.8% (5.9, 15.8%)]. Studies had a moderate risk-of-bias.

Conclusions

Although large proportions of pregnancies in women with HLT result in live births and few maternal deaths occur during pregnancy, these women are at increased risk for preeclampsia, preterm birth, perinatal mortality and maternal mortality following childbirth. Subgroup-specific variations should be taken into account while counselling HLT recipients contemplating pregnancies.

Acknowledgement/Funding

None

Pregnancy outcomes in women with primary systemic vasculitis: a retrospective study

BACKGROUND/AIMS

Pregnancies in women with systemic vasculitis constitute high-risk pregnancies, and outcomes vary based on the size of the affected blood vessels. Currently, there is limited data describing pregnancy outcomes in these women. The aim of this paper is to evaluate pregnancy outcomes in women with large, medium, or small vessel vasculitis to aid preconceptional counseling and inform antepartum and intrapartum care.

METHODS

We included all women with large-, medium-, or small-vessel vasculitis and documented pregnancies attending high-risk pregnancy clinics at Mount Sinai Hospital, Toronto, Canada between 2001 and 2016. Pregnancy characteristics and outcomes were reported as proportions. Maternal, fetal/neonatal, and obstetric outcomes, stratified by type of vasculitis, were the main outcomes measured.

RESULTS

We identified 60 pregnancies in 50 women with systemic vasculitis. These included large-vessel (n = 10), medium-vessel (n = 5), small-vessel [n = 30, of which 16 were AntiNeutrophil Cytoplasmic Autoantibody (ANCA)-associated and 14 were immune-complex mediated], central nervous system (n = 3), and retinal (n = 2). Although vasculitis flares occurred with large-vessel (3/12), small-vessel (13/36), and retinal (2/3) vasculitis, only one was severe and involved hemoptysis requiring blood transfusion in a woman with ANCA-associated vasculitis. Preeclampsia complicated two pregnancies each with large- (25%) and small- (6%) vessel vasculitis. Intrauterine growth restriction (IUGR) only occurred with small-vessel vasculitis (10, 29.4%). Although seven (26.4%) viable pregnancies resulted in preterm birth, the mean gestational age was over 35 weeks.

CONCLUSION

Although women with systemic vasculitis can have successful pregnancies, they are at increased risk for late preterm birth. In addition, those with small-vessel vasculitis are at increased risk for IUGR and vasculitis flares.

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.

Predicting Intrauterine Transfusion Interval and Perinatal Outcomes in Alloimmunized Pregnancies: Time-to-Event Survival Analysis

BACKGROUND

The risk factors determining the frequency of intrauterine transfusions (IUTs) for severely affected red blood cell alloimmunized singleton pregnancies are not well known.

OBJECTIVE

To assess factors associated with IUT frequency and adverse pregnancy outcomes in transfused pregnancies.

METHODS

Retrospective cohort analysis of 246 consecutive cases between 1991 and 2014. Time-to-event survival analysis for repeated events was used to evaluate risk of subsequent IUT. Multivariable logistic regression assessed odds of a composite adverse pregnancy outcome (intrauterine fetal death, termination of pregnancy, neonatal death, preterm birth <34 weeks' gestation).

RESULTS

Full information was available on232 cases (94.3%) and 716 IUTs. Fetal hydrops was associated with increased frequency (hazard ratio [HR] 1.29 [95% CIs 1.15-1.47, p < 0.001]) while higher fetal hemoglobin (Hb) pre-IUT (HR) 0.99 (95% CI 0.99-1.00, p = 0.021) and post-IUT (HR 0.99 [95% CI 0.99-1.00] p = 0.042), and higher transfused blood volume (HR 0.98 [95% CI 0.97-0.99] p < 0.001) were associated with reduced IUT frequency. Adverse pregnancy outcomes were more likely with lower gestational age (GA) at initial IUT. Antibody type was not associated with IUT frequency or adverse pregnancy outcomes.

CONCLUSIONS

Hydrops is associated with increased IUT frequency while lower GA at initial IUT is associated with higher adverse pregnancy outcomes in alloimmunized pregnancies.Higher transfused blood volumes, pre- and post-IUT Hb are associated with lower IUT frequency.

Clinical decision analysis and model-based economic evaluation studies in perinatology: A systematic review

INTRODUCTION

Perinatology, the study of two individuals that constitute the mother-fetus dyad, poses unique challenges to the conduct of clinical decision analysis (CDA) and economic evaluation (EE) studies. Our objective was systematically to review CDA and model-based EE studies in pregnant women to better understand how these studies have been conducted and reported in perinatology.

MATERIAL AND METHODS

MEDLINE, Embase, Scopus, Web of Science and clinicaltrials.gov were searched as of October 2018. The indexing terms "pregnancy", "decision trees", "Markov models" and "economic models" were used. The search was limited to human data and the English language. Two reviewers independently screened titles and abstracts. Data extraction and assessment of reporting quality were performed in duplicate for 10% of studies and reached 100% agreement. The remainder was carried out by a single reviewer. The study protocol was registered with PROSPERO (CRD 42016047206).

RESULTS

Seventy-seven studies met eligibility criteria and fulfilled between 40% and 91% of relevant attributes on the checklist for critical appraisal of CDA models. There was considerable variation in study reporting. A total of 53% of studies included maternal and offspring outcomes, 14% described using weighted means, meta-analyses or health administrative databases to estimate probabilities and 13% considered outcomes over the lifetime of mother and offspring. Patient preferences (utilities) were used in 47% of the studies. Of these, 10% were elicited from healthcare providers alone and not from pregnant women or the public. Of the EE studies, 25% described a societal analytic perspective. Where relevant, 42% described discounting for costs and benefits, and 30% reported using probabilistic and deterministic sensitivity analyses.

CONCLUSIONS

Despite long-term implications of perinatal decisions to mother and offspring, CDA and model-based EE studies in perinatology frequently do not consider lifetime horizons and patient-preferences for outcomes related to mother and offspring. They also often fail to adhere to guidelines regarding conduct and reporting.

Prediction models for determining the success of labor induction: A systematic review

INTRODUCTION

The purpose of this study was to systematically identify and compare clinical models using universally accessible clinical and demographic factors that were derived and/or validated to predict the success of labor induction with a view to making recommendations for practice.

MATERIAL AND METHODS

MEDLINE, Embase, www.clinicaltrials.gov, and PubMed (for non-MEDLINE and studies in-progress) were searched from inception to November 2017. Only studies that derived and/or validated clinical prediction models using variables obtained through antenatal history and digital cervical examination were included. Two reviewers independently screened titles and abstracts and extracted data from eligible studies into a standardized form. Extracted data included: participant characteristics, sample size, variables considered and included, endpoint definitions, study design and model performance. The Prediction Study Risk of Bias Assessment Tool (PROBAST) was used to appraise included studies. In view of clinical and methodologic heterogeneity between studies, only descriptive analysis was possible. The protocol was registered with the PROSPERO International prospective register of systematic reviews [CRD42017081548].

RESULTS

The search identified 16 studies describing 14 prediction models derived between 1966 and 2018. Models varied and demonstrated major limitations with regard to methodology, scope and performance. Of the derived models, six were internally validated and three were externally validated. Performance was most commonly measured using the area under the receiver operator characteristic curve, which ranged from 0.68 to 0.79, 0.67 to 0.77 and 0.61 to 0.73 for derived, internally validated and externally validated models, respectively. The risk-of-bias of included studies ranged from some studies fulfilling only 36% and some others fulfilling 86% of eligible PROBAST items.

CONCLUSIONS

No published model can be recommended for use at the bedside to determine the success of vaginal birth after labor induction. Based on the limitations of included models, a list of recommendations for improving model performance and utilization is provided, as well as measures for encouraging appropriate use of prediction models. The attitudes of women and care providers, and the clinical and resource implications must be explored prior to recommending the use of prediction models for determining the success of labor induction.

Reported Outcomes in Perinatal Iron Deficiency Anemia Trials: A Systematic Review

BACKGROUND/AIMS

Iron deficiency (ID) and iron deficiency anemia (IDA) are global health concerns associated with adverse perinatal effects. Despite efforts taken at the international level, there is no consensus on unified prevention/treatment strategies, largely stemming from inconsistencies of outcome reporting. Our objective was to comprehensively assess outcome reporting perinatal iron intervention trials as Phase 1 of core outcome set (COS) development to inform future research.

METHODS

Systematic search in MEDLINE, EMBASE, Cochrane Databases, and CINAHL (January 2000 - April 2016), with inclusion of trials involving pregnant or postpartum women with ID/IDA confirmed before recruitment. Articles were independently screened and selected by 2 reviewers; data were extracted in duplicate. Quality was assessed using published scoring systems. Outcome definitions and measurement methods were tabulated.

RESULTS

Of 7,046 citations, 33 randomized controlled trials were included. Sixty-nine reported outcomes were categorized into 8 domains. High methodological quality characterized 25 (76%) studies. Reporting quality was low in 16 (49%), moderate in 13 (39%), and high in 4 (12%) studies. Variation was greatest for outcome definition, timing of assessment and measurement methods.

CONCLUSION

This review identifies a comprehensive long-list of outcomes reported of perinatal iron interventions for ID/IDA. Beyond highlighting existing variation in outcome reporting, it provides a foundation for development of a COS for future trials.

Brainstem gliomas in pregnancy: a systematic review†

Introduction: Although brainstem gliomas are a rare group of neoplasias, when they affect pregnant women, there can be challenges with diagnosis and management. This study describes a case of brainstem glioma diagnosed in pregnancy and systematically reviews the literature on brainstem gliomas in pregnancy to provide guidance for management.Material and methods: We searched five databases from inception until October 2016 using subject headings and keywords related to pregnancy and brainstem glioma, and included original research articles that described pregnancy outcomes in women with brainstem glioma. Data extraction and quality assessment using the Joanna Briggs Institute Critical Appraisal Checklist for case reports were performed in duplicate. Outcomes were reported as proportions. The study protocol was registered with the Prospero International Prospective Register of Systematic Reviews (CRD42017060196).Results: We screened 2737 titles and abstracts, and 89 full-texts. Twelve articles describing 17 pregnancies in 16 women were included in the analysis. The median gestational age at presentation was 23 weeks. All but one case presented with neurologic deficit. Magnetic resonance (MRI) imaging conclusively diagnosed all cases. Surgical tumor resection (n = 4) and radiation therapy (n = 3) were successfully undertaken during pregnancy. There were no reported sequelae of maternal oncological management on neonatal wellbeing. Maternal mortality was high (8/16, 50%) both during (n = 5) and within 4 weeks (n = 3) of pregnancy. Pregnancy losses included one pregnancy termination and four miscarriages (associated with maternal mortality). Of the 12 live-born babies, five were premature. Two of these were the result of spontaneous preterm labor and three were delivered prematurely to facilitate glioma management. There was one case of fetal growth restriction.Conclusions: Although the symptoms of brainstem gliomas often mimic those commonly encountered in pregnancy, neurologic deficits warrant urgent investigation. MRI is the diagnostic modality of choice in pregnancy. Brainstem gliomas are associated with high maternal mortality and appropriate management, including surgical tumor resection and radiation therapy, should not be delayed on account of pregnancy. Pregnancy outcomes are favorable although there is a risk of preterm birth.Key messageBrainstem gliomas are associated with high maternal mortality and timely diagnosis using magnetic resonance imaging and treatment including surgical resection and radiation therapy should not be delayed during pregnancy. Pregnancy outcomes are generally favorable except for risk of preterm birth.