Abstract

INTRODUCTION Iron deficiency anemia (IDA) is common among obstetric and gynecologic patients. This systematic review aimed to assess the comparative efficacy and safety of commonly used intravenous (IV) iron formulations, ferric carboxymaltose (FCM), and iron sucrose (IS) in the treatment of IDA in obstetric and gynecologic patients. METHODS We systematically searched PubMed, EMBASE, Cochrane CENTRAL, and Google Scholar for eligible randomized controlled trials (RCTs) comparing IV iron replacement using FCM and IS up to October 2019. The primary outcome was to compare the efficacy of FCM and IS, assessed by measuring serum hemoglobin (Hb) and ferritin levels before and after iron replacement. The secondary outcome was to compare the safety of FCM and IS, assessed by the incidence of adverse events during iron replacement. The meta-analysis was performed using RevMan 5.3. RESULTS We identified 9 RCTs with 910 patients (FCM group, n = 456; IS group, n = 454). Before iron replacement, FCM and IS group patients had similar baseline Hb (mean difference [MD], 0.04 g/dL; 95% confidence interval [CI], -0.07 to 015; I2 = 0%; P = 0.48) and ferritin levels (MD, -0.42 ng/mL; 95% CI, -1.61 to 0.78; I2 = 45%; P = 0.49). Following iron replacement, patients who received FCM had higher Hb (MD, 0.67; 95% CI, 0.25-1.08; I2 = 92%; P = 0.002) and ferritin levels (MD, 24.41; 95% CI, 12.06-36.76; I2 = 75%; P = 0.0001) than patients who received IS. FCM group showed a lower incidence of adverse events following iron replacement than IS group (risk ratio, 0.53; 95% CI, 0.35-0.80; I2 = 0%; P = 0.003). Serious adverse events were not reported in any group. CONCLUSION FCM group showed better efficacy in increasing Hb and ferritin levels and a favorable safety profile with fewer adverse events compared with IS group for IDA treatment among obstetric and gynecologic patients. However, this meta-analysis was limited by the small number of RCTs and high heterogeneity. TRIAL REGISTRATION The review was prospectively registered with the International Prospective Registry of Systematic Reviews (https://www.crd.york.ac.uk/prospero/, registration number CRD42019148905).

Abstract

PURPOSE Platelet-rich plasma (PRP) has become a novel treatment in various aspects of medicine including orthopedics, cardiothoracic surgery, plastic surgery, dermatology, dentistry, and diabetic wound healing. PRP is now starting to become an area of interest in reproductive medicine more specifically focusing on infertility. Poor ovarian reserve, menopause, premature ovarian failure, and thin endometrium have been the main areas of research. The aim of this article is to review the existing literature on the effects of autologous PRP in reproductive medicine providing a summation of the current studies and assessing the need for additional research. METHODS A literature search is performed using PubMed, MEDLINE, and CINAHL Plus to identify studies focusing on the use of PRP therapy in reproductive medicine. Articles were divided into 3 categories: PRP in thin lining, PRP in poor ovarian reserve, and PRP in recurrent implantation failure. RESULTS In women with thin endometrium, the literature shows an increase in endometrial thickness and increase in chemical and clinical pregnancy rates following autologous PRP therapy. In women with poor ovarian reserve, autologous intraovarian PRP therapy increased anti-Mullerian hormone (AMH) levels and decreased follicle-stimulating hormone (FSH), with a trend toward increasing clinical and live birth rates. This trend was also noted in women with recurrent implantation failure. CONCLUSIONS Limited literature shows promise in increasing endometrial thickness, increasing AMH, and decreasing FSH levels, as well as increasing chemical and clinical pregnancy rates. The lack of standardization of PRP preparation along with the lack of large randomized controlled trials needs to be addressed in future studies. Until definitive large RCTs are available, PRP use should be considered experimental.

Abstract

OBJECTIVE This study aimed to review the effect of endometriosis on the prevalence of placenta previa, postpartum hemorrhage, and surgical outcomes in placenta previa patients with endometriosis. DATA SOURCES In compliance with the Preferred Reporting Items for Systematic Reviews guidelines, a systematic review of the literature was conducted through December 31, 2020, using PubMed, Scopus, and the Cochrane Library. STUDY ELIGIBILITY CRITERIA Comparative studies between pregnant women with and without endometriosis, as well as studies that investigated the surgical outcomes in placenta previa patients with and without endometriosis, were included. STUDY APPRAISAL AND SYNTHESIS METHODS Two reviewers independently screened the titles and abstracts, completed data extraction, and assessed the reporting quality using the Risk Of Bias In Nonrandomized Studies of Interventions tool. RESULTS Nineteen studies (2010 to 2020) met the inclusion criteria (98,463 pregnancies with endometriosis and 7,184,313 pregnancies without endometriosis). In the adjusted-pooled analysis, endometriosis was associated with a higher rate of placenta previa (adjusted odds ratio [aOR] 3.17, 95% confidence interval [CI] 2.58-3.89), whereas the incidence of postpartum hemorrhage was similar between pregnant women with and without endometriosis (aOR 1.15, 95%CI 0.99-1.34). When the analysis was restricted to histologically confirmed endometriosis cases, the relationship of endometriosis with placenta previa (aOR 4.23, 95%CI 1.74-10.30) and postpartum hemorrhage (aOR 1.29, 95%CI 0.50-3.34) was consistent with results from the nonrestricted analysis. No study examined surgical outcomes in placenta previa patients with endometriosis. Three studies examined the effect of endometriosis on surgical outcomes during cesarean delivery: one study showed that endometriosis was associated with increased intraoperative bleeding during emergent cesarean delivery, the other study showed that endometriosis was associated with an increased incidence of postpartum hemorrhage during cesarean delivery (aOR 1.1, 95%CI 1.0-1.2), especially in primiparous, singleton pregnant women (aOR 1.7, 95%CI 1.5-2.0), and another study suggested a significantly higher rate of hysterectomy (7.1%) and bladder injury (7.1%) in those with endometriosis than in those without. CONCLUSIONS Endometriosis can potentially be associated with adverse surgical outcomes during cesarean delivery. Although there is a correlation between endometriosis and increased rate of placenta previa, surgical outcomes in placenta previa patients with endometriosis remain understudied.

Abstract

OBJECTIVE To review data of elagolix plus estradiol and norethindrone acetate as add-back therapy for the treatment of heavy menstrual bleeding (HMB) in premenopausal women with uterine fibroids. DATA SOURCES Literature search of PubMed/MEDLINE and SCOPUS was performed using the search terms Oriahnn; elagolix, estradiol, norethindrone AND heavy menstrual bleeding; elagolix AND heavy menstrual bleeding; and gonadotropin-releasing hormone receptor antagonist AND heavy menstrual bleeding between January 1, 1996, to March 2, 2021. Additional data were obtained from prescribing information, references of identified articles, and abstracts from scientific meetings. STUDY SELECTION/DATA EXTRACTION Clinical trials and articles discussing elagolix plus add-back therapy for the management of HMB in women with leiomyomas were included. DATA SYNTHESIS Phase 3 trials met the primary end point of menstrual blood loss (MBL) less than 80 mL at month 6 and at least a 50% reduction in MBL from baseline to the final month in 68.5% of women taking elagolix plus add-back therapy enrolled in UF-1 (8.7% placebo) and 76.5% of women in UF-2 (10% placebo). The most common adverse effects include hot flushes, nausea, headache, and night sweats. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Women with symptomatic uterine fibroids can experience significant HMB resulting in distress, depression, and anxiety. Surgical intervention remains the most commonly recommended and chosen treatment. Elagolix plus add-back therapy is a nonsurgical, oral option. CONCLUSIONS Elagolix plus add-back therapy is effective in reducing menstrual bleeding associated with uterine fibroids. However, there are several warnings and precautions that must be considered.

Abstract

Therapeutic plasma exchange (TPE) is indicated as a treatment for a wide array of diseases, extensively addressed in the Guidelines of the American Society for Apheresis. In pregnancy, TPE is an uncommon event and application is largely based on extrapolation of efficacy and safety in a non-pregnant population. This review intends to describe the currently available experience of TPE in pregnancy to help clinicians recognise indications during pregnancy and to support current guideline recommendations with literature-based experiences. In order to identify the clinical indications for which TPE is applied in pregnant women, we performed a literature search including studies till November 2019, without a start date restriction. Data extraction included medical indication for TPE and safety of TPE in pregnant women. 279 studies were included for analysis. Nowadays, TPE is predominantly applied for thrombotic microangiopathies, lipid disorders and a variety of autoimmune diseases. The application of TPE during pregnancy remains largely empiric and relies on individual case reports in the absence of high-quality studies and definitive evidence-based guidelines. Safety profile of TPE during pregnancy appears to be comparable to application of TPE in non-pregnant patients. In conclusion, based on the limited evidence that we found in literature with a high risk of publication bias, TPE procedures can be used safely during pregnancy with the appropriate preparation and experience of a multidisciplinary team.

Abstract

This study aims to analyze the patient profile and presentation of endometriosis-related hemorrhagic ascites and review its management to raise awareness among gynecologists and improve treatment strategies. We present a case report and engage in a systematic review involving human cases of histologically proven endometriosis with hemorrhagic ascites. Keywords were searched in PubMed/MEDLINE, Cochrane Library, EMBASE, and Ovid Discovery databases from inception until December 2018. Studies that did not include a description of ascites or histopathologic results confirming endometriosis or those that involved patients with other conditions that may contribute to ascites were excluded. The review yielded 73 articles describing 84 premenopausal women with histologically proven endometriosis-related hemorrhagic ascites. Of note, 83% (65/78) of the patients were nulliparous and 69.35% (43/62) were of African descent. The most common chief complaint was abdominal enlargement (58.33%, 49/84) but a host of other symptoms were also reported. Pleural effusion was reported in 32.14% (27/84), and elevated CA-125 was seen in 74.42% (32/43). The majority (64.29%, 54/84) of the patients underwent laparotomy, and an increasing trend of minimally invasive surgical approaches (p<0.001) and fertility-sparing techniques (p<0.001) was observed. The mean ascites volume was 4228.27 mL (SD: 2625.66). Moderate to severe endometriosis was seen in 97.44% (76/78) of cases. The majority of the patients who received medical treatment were given gonadotropin-releasing hormone (GnRH) agonists (63.79%, 37/58). The rate of recurrence after termination or suppression of ovarian function was 8.33% (7/84), and there was a mortality rate of 1.19% (1/84). Diagnosis of endometriosis-related hemorrhagic ascites may be challenging because it mimics several disease entities that cause ascites, thereby warranting a heightened clinical suspicion. Minimally invasive techniques are usually employed to establish a histologic diagnosis. The prevention of recurrence involves the recognition of endometriosis-related hemorrhagic ascites as a manifestation of severe endometriosis, which should prompt therapies directed at suppressing ovarian function. Since affected women are of childbearing age, ovary-preserving surgeries are generally preferred. The rate of recurrence is low after appropriate surgical and medical interventions.

Abstract

BACKGROUND Maternal hypotension is the most frequent complication of spinal anesthesia for cesarean delivery, and intravenous fluid preloading is a preventive measure. We aimed to assess the efficacy of colloids versus crystalloids for preloading to reduce the incidence of spinal anesthesia-induced hypotension and vasopressor requirement in healthy parturients during elective cesarean delivery. METHODS We searched the Cochrane Library, MEDLINE and EMBASE to identify all studies published to June, 2019, through OVID and PubMed. We included randomized controlled trials, comparing colloid preloading with crystalloid preloading in women having spinal anesthesia for cesarean delivery. Primary outcomes were the incidence of hypotension and vasopressor requirement. Secondary outcomes included nausea and/or vomiting, neonatal Apgar score, neonatal umbilical blood pH. We used standardized mean differences for expressing continuous outcomes and risk ratios for dichotomous outcomes. Random-effect model was performed to estimate the pooled risk ratios and standardized mean differences. RESULTS Thirty-three randomized controlled trials contributed data for this meta-analysis. Fewer women experienced hypotension in the colloid group compared with the crystalloid group (risk ratio: 0.72, 95% confidence interval: 0.63-0.82; 2566 women, 32 studies; P < .00001). The total ephedrine dose required was significantly lower with colloid preloading (standardized mean difference: -0.37, 95% CI: -0.64 to -0.09; 1472 women, 19 studies; P = .009). Colloid preloading was also associated with fewer phenylephrine requirement compared with crystalloid preloading (standardized mean difference: -0.54, 95% CI: -0.82 to -0.25; 169 women; P = .0002). The incidence of nausea and/or vomiting was significantly reduced with colloid preloading (risk ratio: 0.72, 95% CI: 0.55-0.95; 1601 women, 20 studies; P = .02). However, the incidence of 1-minute Apgar score < 7, umbilical artery pH < 7.2 and umbilical vein pH < 7.2 were not statistically different between groups. CONCLUSIONS Colloid preloading is superior to crystalloid preloading in reducing the incidence of hypotension induced by spinal anesthesia and vasopressor requirement in the healthy parturients undergoing elective cesarean delivery.The PROSPERO registration number: CRD42018096402.

Abstract

Preterm prelabor rupture of membranes (PPROM) is the main cause of preterm delivery, resulting in increased perinatal morbidity and mortality. Several techniques have been studied for the healing of ruptured membranes, with some success. Before new techniques using tissue/organ engineering are applied in clinical practice, these techniques must be validated in clinical trials. To address this issue, the objective of this study was to summarize the current literature on interventions to seal or heal the amniotic membranes after PPROM. An electronic search was conducted using the keywords "fetal membranes," "premature rupture," "amnion," "tissue engineering," "fibrin tissue adhesive," "regenerative medicine," "tissue adhesive," "wound healing," and "fetoscopy" through the MEDLINE, Embase, and Cochrane CENTRAL databases, with the limitation of English-language studies. Through a review of the identified studies, it was found that spontaneous healing of the fetal membrane has not been successful. Several efforts have been made to seal membranes before or after rupture using different methods, including amniopatches, collagen, tissue patches, fibrin sealant, mussel-mimetic sealant, engineered cell matrix, and immunological supplements. However, most studies have been conducted in ex vivo or in vivo settings, so the safety and applicability of these techniques to spontaneous rupture of membranes in clinical settings have not been sufficiently tested. Overall, the current evidence is limited regarding the safety and effectiveness of interventions against PPROM.

Abstract

IMPORTANCE Postpartum hemorrhage (PPH) is an emergent obstetric complication and the leading cause of maternal mortality. Pelvic arterial embolization (PAE) is an effective treatment for intractable PPH. However, a unique protocol has not been accepted in obstetrical practice. OBJECTIVE To evaluate its efficiency, safety, complications, and outcomes, we conducted a systematic review and meta-analysis of PAE for PPH in the literature. EVIDENCE ACQUISITION The Medline, the database of abstract of reviews, the index to allied health literature, and the Chinese database Sino-Med were searched on March 31, 2020, for studies on PAE for PPH. The data for PAE indication, agents, arteries, success rate, complications, and outcomes were extracted and syncretized for meta-analysis. RESULTS From 1075 identified articles, 113 abstracts or full articles were retrieved and 43 studies were finally identified as meeting the including criteria. The results demonstrated that the indications for PAE were as follows: uterine atony, placental abnormality, delivery tract injury, disseminated intravascular coagulation, arteriovenous malformation, and vaginal hematoma. The embolization agents mostly in order were gelatin sponge particles, polyvinyl alcohol particles, Gelfoam, N-butyl cyanoacrylate, microcoil, and glue; for arteries, they were mostly uterine artery and internal iliac artery. The clinical success rate was 90.5%, whereas the technical success rate was 99.3%. The most common complications of PAE were postembolization syndrome and menstrual abnormality. CONCLUSIONS AND RELEVANCE The emergent PAE is a safe and effective method with high success rate in life-threatening PPH management. Gelatin sponge granules measuring 500 to 1000 μm in diameter have safe results. Pelvic arterial embolization may affect the recovery of menses and increase PPH in the subsequent pregnancy, but there was no noted correlation with fetal growth restriction.

Abstract

OBJECTIVE To conduct a systematic review and meta-analysis to assess the efficacy of platelet-rich plasma (PRP) infusion after adhesiolysis in patients with intrauterine adhesions (IUAs) by establishing the evidence from published randomized controlled trials (RCTs). METHODS PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar databases were screened from inception till June 2021. Risk of bias of included studies was evaluated according to the Cochrane's Collaboration tool. The efficacy endpoints were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) under the fixed-effects model. RESULTS Three RCTs met the inclusion criteria, comprising a total of 260 patients (132 and 128 patients were allocated to PRP and control groups, respectively). The RCTs revealed an overall low risk of bias. Compared with the control group, the PRP group had a statistically significant higher rate of patients with IUAs grade I-II after intervention (n=3 RCTs, RR=1.23, 95% CI [1.11 to 1.36], p<0.001), higher duration of menstrual menses after intervention (n=3 RCTs, MD=1.13 days, 95% CI [0.86 to 1.41], p<0.001), and higher amount of menstrual menses after intervention (n=3 RCTs, MD=2.96 pads, 95% CI [0.31 to 3.61], p<0.001). All pooled analyses were homogeneous. CONCLUSION PRP treatment after hysteroscopic adhesiolysis is effective in decreasing the IUA grade and improving the duration and amount of menstrual menses. Nonetheless, additional RCTs are warranted to validate these conclusions.