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Effectiveness of care bundles for prevention and treatment of postpartum hemorrhage: a systematic review
Vogel, J. P., Nguyen, P. Y., Ramson, J., De Silva, M. S., Pham, M. D., Sultana, S., McDonald, S., Adu-Bonsaffoh, K., McDougall, A. R. A.
American journal of obstetrics and gynecology. 2024
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Abstract
OBJECTIVE Care bundles are a promising approach to reducing postpartum hemorrhage (PPH)-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for PPH prevention and/or treatment. DATA SOURCES We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to 9 June 2023) and ClinicalTrials.gov and ICTRP (last 5 years) using a phased search strategy, combining terms for PPH and care bundles. STUDY ELIGIBILITY CRITERIA Peer-review studies evaluating PPH-related care bundles. Care bundles were defined as interventions comprising three or more components implemented collectively, concurrently or in rapid succession. Randomized and non-randomized controlled trials, interrupted time series and before-after studies (controlled or uncontrolled) were eligible. STUDY APPRAISAL AND SYNTHESIS Risk of bias assessed using ROB2 (randomized trials) and ROBINS-I (non-randomized studies). For controlled studies, we reported risk ratios for dichotomous outcomes and mean differences for continuous outcomes, with certainty of evidence determined using GRADE. For uncontrolled studies we used effect direction tables and summarized results narratively. RESULTS Twenty-two studies were included for analysis. For prevention-only bundles (two studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization and ICU stay, and maternal wellbeing. For treatment-only bundles (nine studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (RR 0.40; 95% CI 0.32-0.50) as well as blood transfusion for bleeding, PPH, severe PPH, and mean blood loss. One non-randomized trial and seven uncontrolled studies suggest other PPH treatment bundles might reduce blood loss and severe PPH, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative (CMQCC) care bundle may reduce severe maternal morbidity (RR 0.64, 95% CI 0.57-0.72). Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types. Nearly all uncontrolled studies did not use suitable statistical methods for single-group pretest-posttest comparisons and should thus be interpreted with caution. CONCLUSIONS The E-MOTIVE intervention improves PPH-related outcomes among women delivering vaginally, and the CMQCC bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.
PICO Summary
Population
Women experiencing vaginal birth or caesarean delivery (22 studies).
Intervention
Care bundles for postpartum haemorrhage (PPH) prevention and/or treatment.
Comparison
Outcome
For prevention-only bundles (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization and intensive care unit stay, and maternal wellbeing. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (RR 0.40; 95% CI [0.32, 0.50] as well as blood transfusion for bleeding, PPH, severe PPH, and mean blood loss. One non-randomized trial and seven uncontrolled studies suggest other PPH treatment bundles might reduce blood loss and severe PPH, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative (CMQCC) care bundle may reduce severe maternal morbidity (RR 0.64; 95% CI [0.57, 0.72]. Ten uncontrolled studies variably showed possible benefits, no effects, or harms for other bundle types.
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The impact of the Safe Delivery Application on knowledge and skills managing postpartum haemorrhage in a low resource setting: a cluster randomized controlled trial in West Wollega region, Ethiopia
Christiansen, A. H., Sørensen, B. L., Boas, I. M., Bedesa, T., Fekede, W., Nielsen, H. S., Lund, S.
Reproductive health. 2023;20(1):91
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Abstract
BACKGROUND Postpartum haemorrhage is one of the leading causes of maternal mortality in low-income countries. Improving health workers' competencies in obstetric emergencies in low-income settings, has been recognized as an important factor in preventing maternal mortality and morbidity. mHealth interventions in maternal and newborn health care has shown the potential to improve health service delivery. Strong study designs such as randomized controlled trials are missing to estimate the effectiveness of the mHealth interventions. METHODS Between August 2013 and August 2014, 70 health facilities in West Wollega Region, Ethiopia were included and randomized to intervention or control in a cluster randomized controlled trial. At intervention facilities birth attendants were provided with a smartphone with the SDA installed. Of 176 midwives and "health extension workers," 130 completed at 12 months follow-up. At baseline and after 6- and 12-months participants were assessed. Knowledge was tested by a Key Feature Questionnaire, skills by an Objective Structured Assessment of Technical Skills in a structured role-play scenario. RESULTS Baseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI 24.2-35.1 compared to 1·8; 95% CI - 2.7 to 6.3 in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI 8.3-18.3 compared to 3.1; 95% CI - 1.0 to 7.3 in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI 2.0-15.0). CONCLUSION The Safe Delivery App more than doubled clinical skills for managing postpartum haemorrhage among birth attendants making it an attractive tool to reduce maternal mortality. TRIAL REGISTRATION Clinicaltrial.gov Identifier NCT01945931. September 5, 2013. Maternal mortality caused by postpartum haemorrhage is a major public health concern in many low-income countries. Having access to skilled health care professionals during pregnancy and childbirth can prevent maternal deaths related to postpartum haemorrhage. mHealth interventions like the Safe Delivery App (SDA), a smartphone application, has shown the potential to improve the quality of care in emergency situations related to childbirth in low-income health system settings.This study examines the SDA as a training/education tool for improving health workers’ competencies and performances in managing postpartum haemorrhage. The SDA contained animated instruction videos on how to prevent and treat postpartum haemorrhage and a list of essential drugs and basic equipment.In Ethiopia, 70 health facilities and 176 birth attendants were included in a randomized controlled trial. The intervention group received a smartphone with the SDA installed and half a day of introduction to the use of the app. Birth attendants’ skills and knowledge in managing postpartum haemorrhage in the control and the intervention group were tested at baseline, 6 and 12 months after intervention.Our study found that the SDA is an effective tool to improve and sustain birth attendants’ knowledge and skills in the management of postpartum haemorrhage in a rural, low-resource health system setting in Ethiopia, which confirms findings in other non-randomized studies examining the SDA on the management of postpartum haemorrhage. eng
PICO Summary
Population
Midwives and health extension workers attending deliveries in 70 health facilities in Ethiopia (n= 176).
Intervention
Smartphone application ‘Safe Delivery App’ (SDA), (35 facilities, n= 87).
Comparison
No provision of the SDA (35 facilities, n= 89).
Outcome
The total scores in skills and knowledge tests for management of postpartum haemorrhage were the outcomes of this cluster randomised controlled trial. A total of 130 (74%) health workers completed the 6 and 12 months follow up, 65 in each arm, and were included in the analysis. Baseline skills scores were low and comparable with a median of 12/100 in the intervention and the control group. After 6 months skills had doubled in the intervention group (adjusted mean difference 29.6; 95% CI [24.2, 35.1] compared to 1.8; 95% CI [-2.7, 6.3] in the control group). At 12 months skills had further improved in the intervention group (adjusted mean difference 13.3; 95% CI [8.3, 18.3] compared to 3.1; 95% CI [-1.0, 7.3] in the control group). Knowledge scores also significantly improved in the intervention group compared to the control (adjusted mean difference after 12 months 8.5; 95% CI [2.0, 15.0]).
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Tranexamic Acid to Prevent Obstetrical Hemorrhage after Cesarean Delivery
Pacheco LD, Clifton RG, Saade GR, Weiner SJ, Parry S, Thorp JM Jr, Longo M, Salazar A, Dalton W, Tita ATN, et al
The New England journal of medicine. 2023;388(15):1365-1375
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Abstract
BACKGROUND Prophylactic use of tranexamic acid at the time of cesarean delivery has been shown to decrease the calculated blood loss, but the effect on the need for blood transfusions is unclear. METHODS We randomly assigned patients undergoing cesarean delivery at 31 U.S. hospitals to receive either tranexamic acid or placebo after umbilical-cord clamping. The primary outcome was a composite of maternal death or blood transfusion by hospital discharge or 7 days post partum, whichever came first. Key secondary outcomes were estimated intraoperative blood loss of more than 1 liter (prespecified as a major secondary outcome), interventions for bleeding and related complications, the preoperative-to-postoperative change in the hemoglobin level, and postpartum infectious complications. Adverse events were assessed. RESULTS A total of 11,000 participants underwent randomization (5529 to the tranexamic acid group and 5471 to the placebo group); scheduled cesarean delivery accounted for 50.1% and 49.2% of the deliveries in the respective groups. A primary-outcome event occurred in 201 of 5525 participants (3.6%) in the tranexamic acid group and in 233 of 5470 (4.3%) in the placebo group (adjusted relative risk, 0.89; 95.26% confidence interval [CI], 0.74 to 1.07; P = 0.19). Estimated intraoperative blood loss of more than 1 liter occurred in 7.3% of the participants in the tranexamic acid group and in 8.0% of those in the placebo group (relative risk, 0.91; 95% CI, 0.79 to 1.05). Interventions for bleeding complications occurred in 16.1% of the participants in the tranexamic acid group and in 18.0% of those in the placebo group (relative risk, 0.90; 95% CI, 0.82 to 0.97); the change in the hemoglobin level was -1.8 g per deciliter and -1.9 g per deciliter, respectively (mean difference, -0.1 g per deciliter; 95% CI, -0.2 to -0.1); and postpartum infectious complications occurred in 3.2% and 2.5% of the participants, respectively (relative risk, 1.28; 95% CI, 1.02 to 1.61). The frequencies of thromboembolic events and other adverse events were similar in the two groups. CONCLUSIONS Prophylactic use of tranexamic acid during cesarean delivery did not lead to a significantly lower risk of a composite outcome of maternal death or blood transfusion than placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT03364491.).
PICO Summary
Population
Patients undergoing caesarean delivery at 31 U.S. hospitals (n= 11,000).
Intervention
Tranexamic acid (n= 5,529).
Comparison
Placebo (n= 5,471).
Outcome
The primary outcome was a composite of maternal death or blood transfusion by hospital discharge or 7 days postpartum, whichever came first. A primary-outcome event occurred in 201 of 5,525 participants (3.6%) in the tranexamic acid group and in 233 of 5,470 (4.3%) in the placebo group (adjusted relative risk, 0.89; 95.26% CI [0.74, 1.07]). Estimated intraoperative blood loss of more than 1 litre occurred in 7.3% of the participants in the tranexamic acid group and in 8.0% of those in the placebo group (relative risk, 0.91; 95% CI [0.79, 1.05]). Interventions for bleeding complications occurred in 16.1% of the participants in the tranexamic acid group and in 18.0% of those in the placebo group (relative risk, 0.90; 95% CI [0.82, 0.97]); the change in the haemoglobin level was -1.8 g per decilitre and -1.9 g per decilitre, respectively (mean difference, -0.1 g per decilitre; 95% CI [-0.2, -0.1]); and postpartum infectious complications occurred in 3.2% and 2.5% of the participants, respectively (relative risk, 1.28; 95% CI [1.02, 1.61]). The frequencies of thromboembolic events and other adverse events were similar in the two groups.
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Randomized Controlled Trial Comparing Ferrous Sulfate and Iron Sucrose in Iron Deficiency Anemia in Pregnancy
Chauhan N, Dogra P, Sharma R, Kant S, Soni M
Cureus. 2023;15(2):e34858
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Abstract
INTRODUCTION Anemia among pregnant women is one of the major health concerns for healthcare workers. The management becomes a concern in the pregnancy where the question arises of which is better the intravenous iron sucrose or the oral ferrous sulfate tablets. To answer this, a randomized control trial comparing both the treatment options in a tertiary care government hospital was set up in the hilly terrains of India. This study discusses the effectiveness and practical aspect of using both, which seems to be the better out of both, and why. METHODS The study was conducted as a parallel-group, open-label randomized controlled trial (RCT) in the Department of Obstetrics and Gynecology of a tertiary care government hospital in India, with approximately 4,000 delivery loads annually. Ethical clearance was obtained from the institute's ethics committee (IEC), and the trial was registered with the Clinical Trial Registry of India (REF/2022/06/055013). Two hundred sixty-eight pregnant women between 18 and 45 years of age with moderate iron deficiency anemia (IDA) (hemoglobin (Hb) 7-9g/dl, microcytic-hypochromic, and serum ferritin <30ng/ml) were included in the study. Patients were randomly divided into two groups: group 1 with 134 patients to receive intravenous iron sucrose and group 2 with 134 patients to receive oral ferrous sulfate tablets. RESULTS The intravenous iron sucrose is superior in terms of tolerability and correction of iron deficiency anemia during pregnancy. CONCLUSION It yields a quicker rise in Hb and serum ferritin with no major side effects. In the difficult terrain of Himachal Pradesh, this makes IV iron sucrose a better option for anemic pregnant women who do not have easy access to health facilities resulting in a large number of them reaching hospitals with moderate to severe anemia at a later gestation.
PICO Summary
Population
Pregnant women with moderate iron deficiency anaemia (n= 268).
Intervention
Intravenous iron sucrose (n= 134).
Comparison
Oral ferrous sulfate tablets (n= 134).
Outcome
All women were followed up at four weeks after drug administration and at 36 weeks of gestation to check for the rise in serum ferritin and haemoglobin (Hb). The mean Hb after four weeks of therapy was 11.76 ± 1.29g/dl and 10.84 ± 0.67g/dl in the intravenous iron sucrose and oral ferrous sulfate group, respectively. The Hb at four weeks post-treatment was significantly higher in the intravenous group compared to the oral group. The mean Hb (g/dl) at 36 weeks of gestation was 12 ± 1.1g/dl and 11.28 ± 0.59g/dl in the intravenous iron sucrose and oral ferrous sulfate groups, respectively. The difference between the two groups was statistically significant. The rise in haemoglobin was 3.48g/dl and was significantly high in the intravenous iron sucrose group compared to the oral ferrous sulfate group which was 2.39g/dl after four weeks of treatment. The rise was 3.6g/dl and 2.82g/dl in the intravenous iron sucrose and oral ferrous sulfate group, respectively, at 36 weeks of gestation, and the difference was significant.
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Maternal anaemia and the risk of postpartum haemorrhage: a cohort analysis of data from the WOMAN-2 trial
The Lancet. Global health. 2023
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Abstract
BACKGROUND Worldwide, more than half a billion women of reproductive age are anaemic. Each year, about 70 000 women who give birth die from postpartum haemorrhage. Almost all deaths are in low-income or middle-income countries. We examined the association between anaemia and the risk of postpartum haemorrhage. METHODS We did a prospective cohort analysis of data from the World Maternal Antifibrinolytic-2 (WOMAN-2) trial. This trial enrols women with moderate or severe anaemia giving birth vaginally in hospitals in Pakistan, Nigeria, Tanzania, and Zambia. Hospitals in each country where anaemia in pregnancy is common were identified from a network established during previous obstetric trials. Women who were younger than 18 years without permission provided by a guardian, had a known tranexamic acid allergy, or developed postpartum haemorrhage before the umbilical cord was cut or clamped were excluded from the study. Prebirth haemoglobin, the exposure, was measured after hospital arrival and just before giving birth. Postpartum haemorrhage, the outcome, was defined in three ways: (1) clinical postpartum haemorrhage (estimated blood loss ≥500 mL or any blood loss sufficient to compromise haemodynamic stability); (2) WHO-defined postpartum haemorrhage (estimated blood loss of at least 500 mL); and (3) calculated postpartum haemorrhage (calculated estimated blood loss of ≥1000 mL). Calculated postpartum haemorrhage was estimated from the peripartum change in haemoglobin concentration and bodyweight. We used multivariable logistic regression to examine the association between haemoglobin and postpartum haemorrhage, adjusting for confounding factors. FINDINGS Of the 10 620 women recruited to the WOMAN-2 trial between Aug 24, 2019, and Nov 1, 2022, 10 561 (99·4%) had complete outcome data. 8751 (82·9%) of 10 561 women were recruited from hospitals in Pakistan, 837 (7·9%) from hospitals in Nigeria, 525 (5·0%) from hospitals in Tanzania, and 448 (4·2%) from hospitals in Zambia. The mean age was 27·1 years (SD 5·5) and mean prebirth haemoglobin was 80·7 g/L (11·8). Mean estimated blood loss was 301 mL (SD 183) for the 8791 (83·2%) women with moderate anaemia and 340 mL (288) for the 1770 (16·8%) women with severe anaemia. 742 (7·0%) women had clinical postpartum haemorrhage. The risk of clinical postpartum haemorrhage was 6·2% in women with moderate anaemia and 11·2% in women with severe anaemia. A 10 g/L reduction in prebirth haemoglobin increased the odds of clinical postpartum haemorrhage (adjusted odds ratio [aOR] 1·29 [95% CI 1·21-1·38]), WHO-defined postpartum haemorrhage (aOR 1·25 [1·16-1·36]), and calculated postpartum haemorrhage (aOR 1·23 [1·14-1·32]). 14 women died and 68 either died or had a near miss. Severe anaemia was associated with seven times higher odds of death or near miss (OR 7·25 [95% CI 4·45-11·80]) than was moderate anaemia. INTERPRETATION Anaemia is strongly associated with postpartum haemorrhage and the risk of death or near miss. Attention should be given to the prevention and treatment of anaemia in women of reproductive age. FUNDING The WOMAN-2 trial is funded by Wellcome and the Bill & Melinda Gates Foundation.
PICO Summary
Population
Women with moderate or severe anaemia giving birth vaginally in hospitals, enrolled in the WOMAN-2 trial in Pakistan, Nigeria, Tanzania, and Zambia (n= 10,620).
Intervention
This prospective cohort analysis of data from the WOMAN-2 trial examined the association between anaemia and the risk of postpartum haemorrhage.
Comparison
Outcome
Postpartum haemorrhage was defined in three ways: clinical postpartum haemorrhage; WHO-defined postpartum haemorrhage; and calculated postpartum haemorrhage. There was complete outcome data for 10,561 participants. Mean estimated blood loss was 301 mL (SD= 183) for the 8,791 (83.2%) women with moderate anaemia and 340 mL (288) for the 1,770 (16.8%) women with severe anaemia. 742 (7.0%) women had clinical postpartum haemorrhage. The risk of clinical postpartum haemorrhage was 6.2% in women with moderate anaemia and 11.2% in women with severe anaemia. A 10 g/L reduction in prebirth haemoglobin increased the odds of clinical postpartum haemorrhage (adjusted odds ratio (aOR)= 1.29; 95% CI [1.21, 1.38]), WHO-defined postpartum haemorrhage (aOR= 1.25; 95% CI [1.16, 1.36]), and calculated postpartum haemorrhage (aOR= 1.23; 95% CI [1.14, 1.32]). 14 women died and 68 either died or had a near miss. Severe anaemia was associated with seven times higher odds of death or near miss (OR= 7.25; 95% CI [4.45, 11.80]) than was moderate anaemia.
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LIBERTY Randomized Withdrawal Study: Relugolix Combination Therapy for Heavy Menstrual Bleeding Associated With Uterine Fibroids
Al-Hendy, A., Venturella, R., Arjona Ferreira, J. C., Li, Y., Soulban, G., Wagman, R. B., Lukes, A. S.
American journal of obstetrics and gynecology. 2023
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Abstract
BACKGROUND In the pivotal LIBERTY 1 and 2 trials and long-term extension (LTE) study, once-daily relugolix combination therapy (relugolix CT: relugolix 40 mg, estradiol 1 mg, norethindrone acetate 0.5 mg) reduced menstrual blood loss (MBL) volume and pain in women with uterine fibroids (UF). Relugolix CT was well tolerated, with preservation of bone mineral density (BMD) through 52 weeks. OBJECTIVE To report the 2-year relugolix CT efficacy and safety results of the phase 3 LIBERTY randomized withdrawal study (RWS). STUDY DESIGN Women with UF-associated heavy menstrual bleeding (HMB) who completed the 24-week LIBERTY 1 or 2 trials followed by the 28-week LTE study (up to 52 weeks total treatment), and who met responder criteria (MBL volume <80 mL and ≥50% reduction from pivotal study baseline at week 48 (Week 24 of LTE) were randomized 1:1 to blinded treatment with relugolix CT or placebo for 52 weeks (total treatment period:104 weeks). For women who had a relapse of HMB during the study (MBL volume ≥80 mL), open-label relugolix CT was offered. Primary endpoint was the proportion of women who maintained MBL volume <80 mL through week 76 (Week 24 of RWS). Secondary endpoints included time to MBL volume ≥80 mL, proportion of women who maintained a MBL volume of <80 mL through week 104 (over the 52-week randomized treatment period), the proportion of women achieving or maintaining amenorrhea at week 76/end-of-treatment and change in UFS-Qol BPD and symptom severity scores. Analyses were performed in the modified intent-to-treat (mITT) population including all randomized women who received ≥1 dose of study drug. RESULTS Of the 229 randomized women (relugolix CT:115, placebo:114), 228 received study drug and 175 (76.7%) completed the RWS. Through week 76, 78.4% of women on relugolix CT maintained MBL volume <80 mL vs 15.1% in the placebo group difference of 63.4% [95%CI:52.9%-73.9%];p < 0.0001). At week 104, 69.8% of women on relugolix CT maintained MBL volume <80 mL vs 11.8% in the placebo group (difference of 58.0% [95%CI:47.0%-69.1%];p<0.0001 ). Through week 104, 88.3% of women on placebo relapsed with HMB (median time to relapse of 5.9 weeks). Among the 89 women in the placebo group who relapsed and received open-label rescue treatment, 87 women responded to relugolix CT, with an MBL volume <80 mL. The proportion of women who achieved or maintained amenorrhea were 57.4% vs 13.3% at week 76 (difference of 44.1% [95%CI:33.10%-55.1];p<0.0001) and 58.3% vs 10.6% at week 104 (difference 47.6% [95%CI:37.0%-58.3%];nominal p<0.0001) for relugolix CT and the placebo group, respectively. Relugolix CT was generally well tolerated; no new safety signals were identified, and the adverse event profile over the second year was consistent with that reported through the first year of treatment. BMD remained stable in women who received relugolix CT from week 52 to week 104. In women continuously treated with relugolix CT up to 2 years, BMD was generally preserved. CONCLUSIONS After 2 years of treatment with relugolix CT, there was evidence of durability of effect in maintaining low MBL volume in women with symptomatic UF. Most women had return of HMB and associated symptoms after treatment cessation, which improved upon retreatment with relugolix CT. Relugolix CT was well tolerated, the adverse event profile remained consistent and mean BMD was generally preserved through 2 years of treatment.
PICO Summary
Population
Women with uterine fibroid-associated heavy menstrual bleeding who completed the 24-week LIBERTY 1 or 2 trials (n= 229).
Intervention
Relugolix combination therapy (CT), (n= 115).
Comparison
Placebo (n= 114).
Outcome
The LIBERTY randomized withdrawal study was conducted to evaluate the 2-year relugolix CT efficacy and safety results. Relugolix CT was generally well tolerated; no new safety signals were identified, and the adverse event profile over the second year was consistent with that reported through the first year of treatment. Bone mineral density (BMD) remained stable in women who received relugolix CT from week 52 to week 104. In women continuously treated with relugolix CT up to 2 years, BMD was generally preserved.
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Effective management of foetal anaemia in Rh(D) alloimmunised pregnant women with intrauterine transfusion: a Systematic Review
Prescott, B., Jackson, D. E.
Hematology, transfusion and cell therapy. 2023
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Abstract
BACKGROUND Foetal anaemia is caused by a severe pregnancy complication, haemolytic disease of the foetus and newborn. Intrauterine transfusions (IUTs) are performed to treat foetal anaemia in alloimmunised pregnant women. If left untreated hydrops can develop thereby reducing the chance of survival. Survival rates have improved but the procedure is not without complications. Procedure-related complications can be associated with early gestational age, hence delaying IUT could improve outcomes. This review aims to determine the effectiveness and safety of IUTs by examining survival and mortality rates, procedure-related complications with associated foetal mortality and the influence of hydrops. STUDY DESIGN AND METHOD A systematic review was conducted by searching keywords in four scientific databases from January 2000 to April 2022. A meta-analysis was performed with the OpenMeta-Analyst software using an arcsine transformed proportion with the binary random-effects model and maximum likelihood method. RESULTS Fifteen studies were identified as eligible and used in the meta-analysis. The forest plots all showed statistically significant outcomes with heterogeneity of data. Results indicated a greater foetal survival rate with IUT to treat anaemic foetuses, a low foetal mortality rate, and low risk of procedure-related complications associated with foetal loss but a higher risk of foetal mortality when hydrops is present. CONCLUSION The findings of this systematic review and meta-analysis provide evidence that IUT is a safe and effective treatment for foetal anaemia in the absence of hydrops when experienced personnel perform the procedure to minimise the risk of procedure-related complications.
PICO Summary
Population
Rh(D) alloimmunised pregnant women (15 studies).
Intervention
Systematic review and meta-analysis to determine the effectiveness and safety of intrauterine transfusions (IUTs).
Comparison
Outcome
The forest plots all showed statistically significant outcomes with heterogeneity of data. Results indicated a greater foetal survival rate with IUT to treat anaemic foetuses, a low foetal mortality rate, and low risk of procedure-related complications associated with foetal loss but a higher risk of foetal mortality when hydrops is present.
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Maternal low and high hemoglobin concentrations and associations with adverse maternal and infant health outcomes: an updated global systematic review and meta-analysis
Young MF, Oaks BM, Rogers HP, Tandon S, Martorell R, Dewey KG, Wendt AS
BMC pregnancy and childbirth. 2023;23(1):264
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Abstract
BACKGROUND Growing evidence suggests low and high maternal hemoglobin (Hb) concentrations may have adverse consequences for maternal and child health. There remain questions on specific Hb thresholds to define anemia and high Hb as well as how cutoffs may vary by anemia etiology and timing of assessment. METHODS We conducted an updated systematic review (using PubMed and Cochrane Review) on low (< 110 g/L) and high (≥ 130 g/L) maternal Hb concentrations and associations with a range of maternal and infant health outcomes. We examined associations by timing of Hb assessment (preconception; first, second, and third trimesters, as well as at any time point in pregnancy), varying cutoffs used for defining low and high hemoglobin concentrations and performed stratified analyses by iron-deficiency anemia. We conducted meta-analyses to obtain odds ratios (OR) and 95% confidence intervals. RESULTS The updated systematic review included 148 studies. Low maternal Hb at any time point in pregnancy was associated with: low birthweight, LBW (OR (95% CI) 1.28 (1.22-1.35)), very low birthweight, VLBW (2.15 (1.47-3.13)), preterm birth, PTB (1.35 (1.29-1.42)), small-for-gestational age, SGA (1.11 (1.02-1.19)), stillbirth 1.43 (1.24-1.65)), perinatal mortality (1.75 (1.28-2.39)), neonatal mortality (1.25 (1.16-1.34), postpartum hemorrhage (1.69 (1.45-1.97)), transfusion (3.68 (2.58-5.26)), pre-eclampsia (1.57 (1.23-2.01)), and prenatal depression (1.44 (1.24-1.68)). For maternal mortality, the OR was higher for Hb < 90 (4.83 (2.17-10.74)) than for Hb < 100 (2.87 (1.08-7.67)). High maternal Hb was associated with: VLBW (1.35 (1.16-1.57)), PTB (1.12 (1.00-1.25)), SGA (1.17 (1.09-1.25)), stillbirth (1.32 (1.09-1.60)), maternal mortality (2.01 (1.12-3.61)), gestational diabetes (1.71 (1.19-2.46)), and pre-eclampsia (1.34 (1.16-1.56)). Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent. Lower Hb cutoffs were associated with greater odds of poor outcomes; for high Hb, data were too limited to identify patterns. Information on anemia etiology was limited; relationships did not vary by iron-deficiency anemia. CONCLUSION Both low and high maternal Hb concentrations during pregnancy are strong predictors of adverse maternal and infant health outcomes. Additional research is needed to establish healthy reference ranges and design effective interventions to optimize maternal Hb during pregnancy.
PICO Summary
Population
Women during pregnancy or preconception (148 studies, n= 13,839,327).
Intervention
Updated systematic review on low (< 110 g/L) and high (≥ 130 g/L) maternal haemoglobin (Hb) concentrations and associations with adverse maternal and infant health outcomes.
Comparison
Outcome
Low maternal Hb at any time point in pregnancy was associated with: Low birthweight, very low birthweight (VLBW), preterm birth (PTB), small-for-gestational age (SGA), stillbirth, perinatal mortality, neonatal mortality, postpartum haemorrhage, transfusion, pre-eclampsia, and prenatal depression. For maternal mortality, the OR was higher for Hb < 90 (OR, 4.83; 95% CI [2.17, 10.74]) than for Hb < 100 (OR, 2.87; 95% CI [1.08, 7.67]). High maternal Hb was associated with: VLBW, PTB, SGA, stillbirth, maternal mortality, gestational diabetes, and pre-eclampsia. Stronger associations were noted earlier in pregnancy for low Hb and adverse birth outcomes while the role of timing of high Hb was inconsistent.
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Predicting postpartum haemorrhage: A systematic review of prognostic models
Carr BL, Jahangirifar M, Nicholson AE, Li W, Mol BW, Licqurish S
The Australian & New Zealand journal of obstetrics & gynaecology. 2022
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Editor's Choice
Abstract
BACKGROUND Postpartum haemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide, and the rate is increasing. Using a reliable predictive model could identify those at risk, support management and treatment, and improve maternal outcomes. AIMS To systematically identify and appraise existing prognostic models for PPH and ascertain suitability for clinical use. MATERIALS AND METHODS MEDLINE, CINAHL, Embase, and the Cochrane Library were searched using combinations of terms and synonyms, including 'postpartum haemorrhage', 'prognostic model', and 'risk factors'. Observational or experimental studies describing a prognostic model for risk of PPH, published in English, were included. The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist informed data extraction and the Prediction Model Risk of Bias Assessment Tool guided analysis. RESULTS Sixteen studies met the inclusion criteria after screening 1612 records. All studies were hospital settings from eight different countries. Models were developed for women who experienced vaginal birth (n = 7), caesarean birth (n = 2), any type of birth (n = 2), hypertensive disorders (n = 1) and those with placental abnormalities (n = 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation. CONCLUSIONS No existing prognostic models for PPH are ready for clinical application. Future research is needed to externally validate existing models and potentially develop a new model that is reliable and applicable to clinical practice.
PICO Summary
Population
Pregnant women (16 studies from eight different countries).
Intervention
Systematic review to identify and appraise existing prognostic models for post-partum haemorrhage (PPH) and ascertain suitability for clinical use.
Comparison
Various prognostic models for PPH, (e.g., based on prior hospital admissions for chronic diseases, based on medical history and clinical characteristics, using available antenatal and intrapartum variables, using prepartum fibrinogen levels).
Outcome
All studies were hospital settings. Models were developed for women who experienced vaginal birth (n= 7), caesarean birth (n= 2), any type of birth (n= 2), hypertensive disorders (n= 1) and those with placental abnormalities (n= 4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation.
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Testing equivalence of two doses of intravenous iron to treat iron deficiency in pregnancy: A randomised controlled trial
Froessler B, Schubert KO, Palm P, Church R, Aboustate N, Kelly TL, Dekker GA, Hodyl NA
BJOG: an international journal of obstetrics and gynaecology. 2022
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Editor's Choice
Abstract
OBJECTIVE To test equivalence of two doses of intravenous iron (ferric carboxymaltose) in pregnancy. DESIGN Parallel, two-arm equivalence randomised controlled trial with an equivalence margin of 5%. SETTING Single centre in Australia. POPULATION 278 pregnant women with iron deficiency. METHODS Participants received either 500 mg (n=152) or 1000mg (n=126) of intravenous ferric carboxymaltose in the second or third trimester. MAIN OUTCOME MEASURES The proportion of participants requiring additional intravenous iron (500mg) to achieve and maintain ferritin >30ug/L (diagnostic threshold for iron deficiency) at 4 weeks post-infusion, and at 6 weeks, and 3-, 6- and 12-months postpartum. Secondary endpoints included repeat infusion rate, iron status, birth, and safety outcomes. RESULTS The two doses were not equivalent within a 5% margin at any timepoint. At 4 weeks post infusion, 26/73 (36%) participants required a repeat infusion in the 500 mg group compared with 5/67 (8%) in the 1000 mg group (difference in proportions, 0.283 95% confidence interval (0.177, 0.389)). Overall, participants in the 500 mg arm received twice the repeat infusion rate (0.81 (SD= 0.824 vs 0.40 (SD= 0.69), rate ratio 2.05, 95% CI (1.45, 2.91)). CONCLUSIONS Administration of 1000 mg ferric carboxymaltose in pregnancy maintains iron stores and reduces the need for repeat infusions. A 500 mg dose requires ongoing monitoring to ensure adequate iron stores are reached and sustained.
PICO Summary
Population
Pregnant women with iron deficiency (n= 278).
Intervention
500 mg of intravenous ferric carboxymaltose (n= 152).
Comparison
1,000 mg of intravenous ferric carboxymaltose (n= 126).
Outcome
The two doses were not equivalent within a 5% margin at any timepoint. At 4 weeks post-infusion, 26/73 (36%) participants required a repeat infusion in the 500 mg group compared with 5/67 (8%) in the 1,000 mg group (difference in proportions, 0.283 95% confidence interval (0.177, 0.389)). Overall, participants in the 500 mg arm received twice the repeat infusion rate (0.81 (SD= 0.824 vs. 0.40 (SD= 0.69), rate ratio 2.05, 95% CI (1.45, 2.91)).