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1.
Intravenous iron versus blood transfusion for postpartum anemia: a systematic review and meta-analysis
Caljé, E., Groom, K. M., Dixon, L., Marriott, J., Foon, R., Oyston, C., Bloomfield, F. H., Jordan, V.
Systematic reviews. 2024;13(1):9
Abstract
BACKGROUND Intravenous iron (IV-iron) is used as an alternative to, or alongside, red blood cell transfusion (RBC-T) to treat more severe postpartum anemia (PPA), although optimal treatment options remain unclear. No previous systematic reviews have examined IV-iron and RBC-T, including patient-reported outcomes and hematological responses. METHODS A systematic review and meta-analysis of randomized trials comparing IV-iron and RBC-T with each other, oral iron, no treatment, and placebo for the treatment of PPA. Key inclusion criteria were PPA (hemoglobin < 12 g/dL) and IV-iron or RBC-T as interventions. Key exclusion criteria were antenatal IV-iron or RBC-T. Fatigue was the primary outcome. Secondary outcomes included hemoglobin and ferritin concentrations, and adverse events. From 27th August 2020 to 26th September 2022, databases, registries, and hand searches identified studies. A fixed-effect meta-analysis was undertaken using RevMan (5.4) software. The quality of the studies and the evidence was assessed using the Cochrane Risk of Bias table, and Grading of Recommendations, Assessment, Development, and Evaluation. This review is registered with the Prospective Register of Systematic Reviews (CRD42020201115). RESULTS Twenty studies and 4196 participants were included: 1834 assigned IV-iron, 1771 assigned oral iron, 330 assigned RBC-T, and 261 assigned non-intervention. Six studies reported the primary outcome of fatigue (1251 participants). Only studies of IV-iron vs. oral iron (15 studies) were available for meta-analysis. Of these, three reported on fatigue using different scales; two were available for meta-analysis. There was a significant reduction in fatigue with IV-iron compared to oral iron (standardized mean difference - 0.40, 95% confidence interval (CI) - 0.62, - 0.18, I(2) = 0%). The direction of effect also favored IV-iron for hemoglobin (mean difference (MD) 0.54 g/dL, 95% confidence interval (CI) 0.47, 0.61, I(2) = 91%), ferritin, (MD 58.07 mcg/L, 95% CI 55.74, 60.41, I(2) = 99%), and total adverse events (risk-ratio 0.63, 95% CI 0.52, 0.77, I(2) = 84%). The overall quality of the evidence was low-moderate. DISCUSSION For all outcomes, the evidence for RBC-T, compared to IV-iron, non-intervention, or dose effects of RBC-T is very limited. Further research is needed to determine whether RBC-T or IV-iron for the treatment of PPA is superior for fatigue and hematological outcomes.
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2.
Clinical outcome post treatment of anemia in pregnancy with intravenous versus oral iron therapy: a systematic review and meta-analysis
Pandey, A. K., Gautam, D., Tolani, H., Neogi, S. B.
Scientific reports. 2024;14(1):179
Abstract
Oral iron therapy is often the most common way of treating anaemia; however intravenous iron is considered effective due to rapid iron replenishment. We have dearth of evidence on clinical outcomes post treatment of anaemia. We have searched studies published in English in PubMed, Cochrane, Scopus, ProQuest, and Google Scholar. Our study analysed the clinical outcomes amongst neonates and mother and the adverse events post treatment and assessed the mean change in maternal haemoglobin concentration in both the groups. Forest plots for the clinical outcomes are presented. From a total of 370 studies, 34 Randomized and quasi experimental studies comparing clinical outcomes post-treatment of anaemia in pregnancy were included for quantitative evidence synthesis. Pooled results of maternal clinical outcomes using random effect model [OR: 0.79 (95% CI 0.66; 0.95); 10 outcomes; 17 studies] showed statistically significant difference among both the groups [Moderate quality evidence]; however no significant difference [OR: 0.99 (95% CI 0.86; 1.14); 7 outcomes; 8 studies] have been observed for neonatal complications [Low quality evidence]. The study found that pregnant women receiving IV iron were significantly less likely to experience adverse events as compared with those receiving oral iron [OR 0.39; (95% CI 0.26-0.60)]; 34 studies; 13,909 women; [Low quality evidence]. Findings from meta-regression analysis showed that IV iron is more likely to reduce maternal complications by 21% compared to oral iron. Increase in odds of adverse maternal outcomes was observed due to increase in gestational age and publication year but no effect for the type of drug used. IV iron increases Hb more and at a higher pace than oral iron. Intravenous iron is more likely to avert adverse maternal outcomes and adverse reactions. However, there is no conclusive evidence on its effectiveness on individual maternal outcome or neonatal outcome/s. Protocol registered with PROSPERO CRD42022368346).
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3.
Utilization of non-pneumatic anti-shock garment for treating obstetric hemorrhage and associated factors among obstetric care providers in Ethiopia: A systematic review and meta-analysis
Addisu, D., Gebeyehu, N. A., Belachew, Y. Y., Mekie, M.
PloS one. 2023;18(11):e0294052
Abstract
BACKGROUND The non-pneumatic anti-shock garment (NASG) is a life-saving device that can help to avoid delays and prevent further complications in the case of obstetric hemorrhage. Although there are many fragmented primary studies on the NASG utilization in Ethiopia, the pooled utilization rate is unknown. In addition, a disagreement was observed among those studies while reporting the associated factors. Therefore, this study was intended to determine the pooled level of NASG utilization and its associated factors among obstetric care providers in Ethiopia. METHODS A total of 51 studies were retrieved from PubMed, Google Scholar, the African Journal of Online, direct open-access journals, and Ethiopian universities' institutional repositories. This study was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The quality of studies was evaluated using the modified Newcastle-Ottawa quality assessment tool. The data were extracted by two authors independently using Microsoft Excel and analyzed by Stata version 11. A random-effects model was applied to calculate the pooled level of NASG utilization and its associated factors. The PROSPERO registration number for the review is CRD42023414043. RESULT A total of 8 studies comprising 2,575 study participants were involved in this meta-analysis. The pooled utilization rate of NASG was found to be 39.56%. Having NASG training (pooled odds ratio (OR) = 3.99, 95%CI = 2.35, 6.77), good knowledge about NASG (OR = 2.92, 95%CI = 2.04, 4.17), a positive attitude towards NASG (OR = 3.17, 95%CI = 2.10, 4.79), and having ≥ 2 NASGs in the health facility (OR = 10.59, 95%CI = 6.59, 17.01) were significantly associated with NASG utilization. CONCLUSION Utilization of NASG for the treatment of obstetric hemorrhage was low in Ethiopia. To increase its utilization, Ministry of Health should improve the accessibility of NASG at each health facility and increase the Health professionals' knowledge and attitude through in-service and pre-service training.
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4.
Tranexamic acid versus misoprostol for management of postpartum hemorrhage: A systematic review and meta-analysis of randomized controlled trials
Abu-Zaid, A., Baradwan, S., Albouq, B., Ghazi, A., Khadawardi, K., Bukhari, I. A., Alyousef, A., Abdulmalik, N. A., Alblewi, H., Alsehaimi, S. O., et al
European journal of obstetrics, gynecology, and reproductive biology. 2023;291:61-69
Abstract
AIM: To conduct the first-ever systematic review and meta-analysis of randomized controlled trials (RCTs) on the antihemorrhagic utility and safety of tranexamic acid (TXA) versus misoprostol for management (prevention and/or treatment) of postpartum hemorrhage (PPH). METHODS Six databases were screened from inception until May 2023 and updated in September 2023. The RCTs were assessed for quality according to the Cochrane's risk of bias tool. The endpoints were summarized as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) in a random-effects model. RESULTS Ten RCTs with 2121 patients (TXA = 1061 and misoprostol = 1060) were analyzed. There was no significant difference between TXA and misoprostol groups regarding the mean intraoperative blood loss (n = 9 RCTs, MD = 17.32 ml, 95% CI [-40.43, 75.07], p = 0.56), mean change in hemoglobin (n = 6 RCTs, MD = 0.11 mg/dl, 95% CI [-0.1, 0.31], p = 0.30), mean hospital stay (n = 2 RCTs, MD = -0.3 day, 95% CI [-0.61, 0.01], p = 0.06), blood transfusion rate (n = 4 RCTs, RR = 0.49, 95% CI [0.16, 1.47], p = 0.2), and rate of additional uterotonic agents (n = 4 RCTs, RR = 1.05, 95% CI [0.72, 1.53], p = 0.81). Leave-one-out sensitivity analysis showed robustness of the results, and there was no evidence of publication bias. Regarding safety endpoints, there was no significant difference between both groups regarding the rates of minor side effects, such as diarrhea, fever, nausea, and vomiting. No patient developed thromboembolic events in the TXA group. CONCLUSION There was no significant antihemorrhagic efficacy between adjunct TXA and misoprostol for the management of PPH. The safety profile was comparable between both agents.
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5.
Efficacy and safety of tranexamic acid in prevention of postpartum hemorrhage: a systematic review and meta-analysis of 18,649 patients
Al-Dardery, N. M., Abdelwahab, O. A., Abouzid, M., Albakri, K., Elkhadragy, A., Katamesh, B. E., Hamamreh, R., Mohd, A. B., Abdelaziz, A., Khaity, A.
BMC pregnancy and childbirth. 2023;23(1):817
Abstract
BACKGROUND In this meta-analysis, we aimed to update the clinical evidence regarding the efficacy and safety of TXA in the prevention of PPH. METHODS A literature search of PubMed, Scopus, Web of Science, Google Scholar, and Cochrane Library from inception until December 2022 was conducted. We included randomized controlled trials (RCTs) comparing TXA with a placebo among pregnant women. All relevant outcomes, such as total blood loss, the occurrence of nausea and/or vomiting, and changes in hemoglobin, were combined as odds ratios (OR) or mean differences (MD) in the meta-analysis models using STATA 17 MP. RESULTS We included 59 RCTs (18,649 patients) in this meta-analysis. For cesarean birth, TXA was favored over the placebo in reducing total blood loss (MD= -2.11 mL, 95%CI [-3.09 to -1.14], P < 0.001), and occurrence of nausea or/and vomiting (OR = 1.36, 95%CI [1.07 to 1.74], P = 0.01). For vaginal birth, the prophylactic use of TXA was associated with lower total blood loss, and higher occurrence of nausea and/or vomiting (MD= -0.89 mL, 95%CI [-1.47 to -0.31], OR = 2.36, 95%CI [1.32 to 4.21], P = 0.02), respectively. However, there were no differences between the groups in changes in hemoglobin during vaginal birth (MD = 0.20 g/dl, 95%CI [-0.07 to 0.48], P = 0.15). The overall risk of bias among the included studies varies from low to high risk of bias using ROB-II tool for RCTs. CONCLUSIONS This meta-analysis suggested that TXA administration is effective among women undergoing cesarean birth or vaginal birth in lowering total blood loss and limiting the occurrence of PPH. Further clinical trials are recommended to test its efficacy on high-risk populations.
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6.
Desmopressin to prevent and treat bleeding in pregnant women with an inherited bleeding disorder: A systematic literature review
Al Arashi, W., Romano, L. G. R., Leebeek, F. W. G., Kruip, Mjha, van Galen, K. P. M., Turan, O., Kadir, R. A., Cnossen, M. H.
Journal of thrombosis and haemostasis : JTH. 2023
Abstract
BACKGROUND Although desmopressin (DDAVP) is an accessible and inexpensive hemostatic drug, its use in pregnancy is still debated due to safety uncertainties. OBJECTIVE We aim to review safety and effectiveness of DDAVP in women with an inherited bleeding disorder during pregnancy and delivery. METHODS Databases were searched for articles up to July 25(th) 2022, reporting maternal and/or neonatal outcomes. PRISMA methodology was followed (PROSPERO CRD42022316490). RESULTS Fifty-three studies were included, comprising 273 pregnancies. Regarding maternal outcomes, DDAVP was administered in 73 pregnancies during pregnancy and in 232 pregnancies during delivery. Safety outcome was reported in 245 pregnancies, with severe adverse event reported in two (1%; hyponatremia with neurological symptoms).Overall, DDAVP was used as monotherapy in 234 pregnancies with effectiveness reported in 153 pregnancies (82% effective; 18% ineffective). Regarding neonatal outcomes, out of 60 pregnancies with reported neonatal outcomes after DDAVP use during pregnancy, two children (3%) had a severe adverse event (preterm delivery n=1; fetal growth restriction n=1). Of the 232 deliveries, 169 neonates were exposed to DDAVP during delivery and in 114 neonates, safety outcome was reported. Two children (2%) experienced a moderate adverse event (low Apgar score n=1; transient hyperbilirubinemia not associated with DDAVP n=1). CONCLUSION DDAVP use during pregnancy and delivery seems safe for the mother with special attention to the occurrence of hyponatremia and for the child, especially during delivery. However, due to poor study designs and limited documentation of outcomes, a well-designed prospective study is warranted.
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7.
Side-effects of intravenously versus intramuscularly oxytocin for postpartum hemorrhage: a systematic review and meta-analysis of randomized controlled trials
Ai, W., Zeng, Y., Zhen, M., Lao, L., Ma, Y., Liu, L., Zhang, Y.
Frontiers in pharmacology. 2023;14:1273771
Abstract
Background: Oxytocin is the gold standard uterotonic agent for prevention of postpartum hemorrhage. However, there is no consensus with clear evidence about the side-effects of oxytocin administered intravenously or intramuscularly for management of the third stage of labor. We conducted a systematic review and meta-analysis of randomized controlled trials to evaluate the side-effects of intravenously or intramuscularly oxytocin for preventing postpartum hemorrhage in the third stage of labor. Methods: Six representative databases were searched from the inception to July 2023. Randomized controlled trials which explored the intravenously and intramuscularly oxytocin and provided at least one side-effect were included. Statistical analysis included random or fixed-effect meta-analyses using relative risk. Results: Nine studies included, involving 8,295 participants. Ten types of side-effects were reported. There was no statistical difference in hypotension (RR = 1.01, 95%CI = 0.88-1.15), anemia (0.98, 0.83-1.15), tachycardia (0.90, 0.69-1.17), shivering (0.90, 0.69-1.17), headache (0.86, 0.31-2.37), nausea (0.70, 0.20-2.42), vomiting (0.97, 0.26-3.58), uvular edema (0.82, 0.23-2.91), diarrhea (0.97, 0.26-3.58), and fever (0.97, 0.26-3.58) between intravenously or intramuscularly groups. Conclusion: There are no significant differences of side-effects between intravenously and intramuscularly administration of oxytocin for preventing postpartum hemorrhage in the third labor. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=407571.
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8.
Safety and efficacy of intrauterine balloon tamponade vs uterine gauze packing in managing postpartum hemorrhage: A systematic review and meta-analysis
Abul A, Al-Naseem A, Althuwaini A, Al-Muhanna A, Clement NS
AJOG global reports. 2023;3(1):100135
Abstract
BACKGROUND There is debate on whether uterine gauze packing or intrauterine balloon tamponade is safer and more effective as a surgical management option for treating postpartum hemorrhage. OBJECTIVE This study aimed to compare intra- and postoperative outcomes of intrauterine balloon tamponade and uterine gauze packing in patients with postpartum hemorrhage. STUDY DESIGN A range of databases such as Cochrane and PubMed were searched using terms including "post-partum haemorrhage," "uterine balloon tamponade," and "uterine gauze packing." All observational studies comparing intrauterine balloon tamponade with uterine gauze packing were included. Five studies were identified enrolling 821 adult patients diagnosed with postpartum hemorrhage. Primary outcomes included blood loss volume, success rates, and maternal mortality. Secondary outcomes comprised requiring additional interventions, postoperative hemoglobin levels, and requiring blood transfusions. Fixed and random models were used for analysis. RESULTS Intrauterine balloon tamponade seemed to be a superior option to uterine gauze packing. Intrauterine balloon tamponade was better in reducing intraoperative blood loss, with a statistically significant improvement (P<.0001). Cases managed with intrauterine balloon tamponade seemed to have statistically significant shorter operative time (P=.023) and hospital length of stay (P=.020) in one study. CONCLUSION Intrauterine balloon tamponade remains more effective and safer as a first-line surgical management option for postpartum hemorrhage compared with uterine gauze packing.
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9.
Active management of the third stage of labour in Ethiopia: A systematic review and meta-analysis
Mihretie GN, Ayele AD, Liyeh TM, Beyene FY, Kassa BG, Arega DT, Belay HG, Worke MD
PloS one. 2023;18(4):e0281343
Abstract
BACKGROUND Post-partum haemorrhage occurs in over 10% of all births and is the leading cause of maternal mortality, accounting for 25% of all maternal deaths worldwide. Active management of the third stage of labor is the most important intervention for reducing maternal morbidity and mortality by preventing postpartum hemorrhage. Previously, documented primary studies had been great discrepancy, inconsistent results, and there is a lack of comprehensive study. Hence, this systematic review and meta-analysis were intended to assess the prevalence and associated factors of the practice of active management of the third stage of labour among obstetric care providers in Ethiopia. METHOD Cross-sectional studies were systematically searched from January 01, 2010, to December 24, 2020, using PubMed, Google Scholar, HINARI, Cochrane Library, and grey literature. The pooled prevalence of active management of the third stage of labour practice and associated factors was estimated using DerSemonial-Laird Random Effect Model. Stata (version 16.0) was used to analyze the data. The I-squared statistic was used to assess the studies' heterogeneity. A funnel plot and Egger's test were used to check for publication bias. A subgroup analysis was performed to minimize the underline heterogeneity depending on the study years and the sample sizes. RESULTS Seven hundred fifty articles were extracted. The final ten studies were included in this systematic review, including 2438 participants. The pooled prevalence of practices of active management of the third stage of labour among obstetric care providers in Ethiopia was 39.65% (30.86, 48.45%). Educational status (OR = 6.11, 95%CI, 1.51-10.72), obstetric care training (OR = 3.56, 95% CI: 2.66, 4.45), work experience (OR = 2.17, 95%CI, 0.47, 3.87) and knowledge of active management of the third stage of labour (OR = 4.5, 95% CI: 2.71, 6.28) were significantly associated with active management of the third stage of labour practices. CONCLUSION The practice of active management of the third stage of labour in Ethiopia was low. This study showed that educational status, taking obstetric care training, knowledge of AMTSL, and work experience of obstetric care providers were associated with of practices of active management of the third stage of labour. Therefore, obstetric care professionals should improve their academic level, knowledge, and skills in order to provide useful service to AMTSL and save mothers' lives. All obstetric care providers should get obstetric care training. Furthermore, the government should increase obstetric care professionals' educational level.
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10.
Endometrial ablation and resection versus hysterectomy for heavy menstrual bleeding: an updated systematic review and meta-analysis of effectiveness and complications
Deehan, C., Georganta, I., Strachan, A., Thomson, M., McDonald, M., McNulty, K., Anderson, E., Mostafa, D. A.
Obstetrics & gynecology science. 2023
Abstract
To evaluate the clinical efficacy, safety, and cost-effectiveness of endometrial ablation or resection (E:A/R) compared to hysterectomy for the treatment of heavy menstrual bleeding (HMB). Literature-search was performed for all the randomized control trials (RCTs) comparing (E:A/R) versus hysterectomy for the treatment of HMB. The literature-search was last updated in November 2022. The primary outcomes were objective and subjective reduction in HMB and patient-satisfaction rates in improving the bleeding symptoms at 1-14 years. The data were analyzed using Review Manager software. Twelve RCTs with 2,028 women (hysterectomy: n=977 vs. E:A/R: n=1,051) were included. Hysterectomy was compared with endometrial ablation in 5 studies, endometrial resection in 5 studies, and both ablation and resection in 2 studies. The meta-analysis revealed that the hysterectomy group showed improved patient-reported and objective bleeding-symptoms more than those of the EA/R group with risk ratios (RR) of (MD, 0.75; 95% CI, 0.71 to 0.79) and (MD, 44.00; 95% CI, 36.09 to 51.91), respectively. The patient-satisfaction was higher post-hysterectomy up to a follow-up period of 2 years (RR, 0.90; 95% CI, 0.86 to 0.94) but this effect was absent with long term follow-up. This meta-analysis shows that E:A/R offers alternatives to hysterectomy. Although both procedures are highly effective, safe, and improve the quality of life, hysterectomy is significantly superior at improving the bleeding symptoms and patient satisfaction up to two-years. However, hysterectomy is associated with longer operating times and recovery periods and has a higher rate of postoperative complications. The initial cost of E:A/R is less than that of hysterectomy but further surgical requirements are common, therefore there is no difference in the cost for the long term follow-up.