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Editor's Choice
  • Mustafa HJ
  • Sambatur EV
  • Pagani G
  • D'Antonio F
  • Maisonneuve E
  • et al.
Am J Obstet Gynecol. 2024 Apr 7; doi: 10.1016/j.ajog.2024.03.044.
POPULATION:

Pregnancies with red blood cell alloimmunization (9 studies, n= 194).

INTERVENTION:

Intravenous immunoglobulin (IVIG) at <17 weeks of gestation (n= 97).

COMPARISON:

No IVIG (n= 97).

OUTCOME:

The primary outcome was gestational age (GA) at the first intrauterine transfusion (IUT). Individual patient data analysis included eight studies comprising 97 cases and 97 controls. IVIG was associated with prolonged delta GA at first IUT (GA of current pregnancy - GA at prior pregnancy) (mean difference (MD) 3.19 weeks; 95% CrI [1.28, 5.05]), prolonged GA at first IUT (MD 1.32 weeks; 95% CrI [0.08, 2.5]), reduced risk of fetal hydrops at time of first IUT (incidence rate ratio (IRR) 0.19; 95% CrI [0.07, 0.45]), reduced risk of fetal demise (IRR 0.23; 95% CrI [0.10, 0.47]), higher chances of live birth ≥28 weeks, ≥32 weeks, and survival at birth (IRR 1.88; 95% CrI [1.31, 2.69]; IRR 1.93; 95% CrI [1.32, 2.83]; IRR 1.82; 95% CrI [1.30 to 2.61], respectively). There were no significant differences in numbers of IUT, haemoglobin level at birth, bilirubin level at birth, or survival at hospital discharge for live births.

OBJECTIVE:

This study aimed to investigate the outcomes associated with the administration of maternal intravenous immunoglobulin in high-risk red blood cell-alloimmunized pregnancies.

DATA SOURCES:

Medline, Embase, and Cochrane Library were systematically searched until June 2023.

STUDY ELIGIBILITY CRITERIA:

This review included studies reporting on pregnancies with severe red blood cell alloimmunization, defined as either a previous fetal or neonatal death or the need for intrauterine transfusion before 24 weeks of gestation in the previous pregnancy as a result of hemolytic disease of the fetus and newborn.

METHODS:

Cases were pregnancies that received intravenous immunoglobulin, whereas controls did not. Individual patient data meta-analysis was performed using the Bayesian framework.

RESULTS:

Individual patient data analysis included 8 studies consisting of 97 cases and 97 controls. Intravenous immunoglobulin was associated with prolonged delta gestational age at the first intrauterine transfusion (gestational age of current pregnancy - gestational age at previous pregnancy) (mean difference, 3.19 weeks; 95% credible interval, 1.28-5.05), prolonged gestational age at the first intrauterine transfusion (mean difference, 1.32 weeks; 95% credible interval, 0.08-2.50), reduced risk of fetal hydrops at the time of first intrauterine transfusion (incidence rate ratio, 0.19; 95% credible interval, 0.07-0.45), reduced risk of fetal demise (incidence rate ratio, 0.23; 95% credible interval, 0.10-0.47), higher chances of live birth at ≥28 weeks (incidence rate ratio, 1.88; 95% credible interval, 1.31-2.69;), higher chances of live birth at ≥32 weeks (incidence rate ratio, 1.93; 95% credible interval, 1.32-2.83), and higher chances of survival at birth (incidence rate ratio, 1.82; 95% credible interval, 1.30-2.61). There was no substantial difference in the number of intrauterine transfusions, hemoglobin level at birth, bilirubin level at birth, or survival at hospital discharge for live births.

CONCLUSION:

Intravenous immunoglobulin treatment in pregnancies at risk of severe early hemolytic disease of the fetus and newborn seems to have a clinically relevant beneficial effect on the course and severity of the disease.

Editor's Choice
  • Provinciatto H
  • Barbalho ME
  • da Câmara PM
  • Donadon IB
  • Fonseca LM
  • et al.
Can J Anaesth. 2024 Apr;71(4):465-478 doi: 10.1007/s12630-024-02715-3.
POPULATION:

Patients undergoing caesarean delivery (38 randomised controlled trials, n= 22,940).

INTERVENTION:

Postpartum haemorrhage (PPH) prophylaxis with tranexamic acid (TXA).

COMPARISON:

Placebo or no treatment.

OUTCOME:

The main outcomes were PPH, blood transfusion, need for additional uterotonics, and adverse events. Patients treated with TXA had significantly fewer cases of PPH (risk ratio (RR) 0.51; 95% confidence interval (CI) [0.38, 0.69]); less blood transfusion (RR 0.43; 95% CI [0.30, 0.61]), and less use of additional uterotonics (RR 0.52; 95% CI [0.40, 0.68]). No significant differences were found between the groups in terms of adverse effects and thromboembolic events.

PURPOSE:

Postpartum hemorrhage (PPH) is a leading cause of maternal mortality worldwide. Although several studies on the prophylactic use of tranexamic acid (TXA) in parturients undergoing Cesarean delivery have been published, conflicting results raise questions regarding its use. Thus, we aimed to investigate the safety and efficacy of PPH prophylaxis with TXA.

SOURCE:

We searched PubMed®, Embase, Cochrane Central, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing prophylactic TXA with placebo or no treatment in parturients undergoing Cesarean delivery. Our main outcomes were PPH, any blood transfusion, need for additional uterotonics, and adverse events. We performed a trial sequential analysis (TSA) of all outcomes to investigate the reliability and conclusiveness of findings.

PRINCIPAL FINDINGS:

We included 38 RCTs including 22,940 parturients, 11,535 (50%) of whom were randomized to receive prophylactic TXA. Patients treated with TXA had significantly fewer cases of PPH (risk ratio [RR], 0.51; 95% confidence interval [CI], 0.38 to 0.69; P < 0.001); less blood transfusion (RR, 0.43; 95% CI, 0.30 to 0.61; P < 0.001), and less use of additional uterotonics (RR, 0.52; 95% CI, 0.40 to 0.68; P < 0.001). No significant differences were found between the groups in terms of adverse effects and thromboembolic events.

CONCLUSION:

Prophylactic TXA administration for parturients undergoing Cesarean delivery significantly reduced blood loss, without increasing adverse events, supporting its use as a safe and effective strategy for reducing PPH in this population.

STUDY REGISTRATION:

PROSPERO (CRD42023422188); first submitted 27 April 2023.

Editor's Choice
  • Vogel JP
  • Nguyen PY
  • Ramson J
  • De Silva MS
  • Pham MD
  • et al.
Am J Obstet Gynecol. 2024 Feb 7; doi: 10.1016/j.ajog.2024.01.012.
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.

OBJECTIVE:

Care bundles are a promising approach to reducing postpartum hemorrhage-related morbidity and mortality. We assessed the effectiveness and safety of care bundles for postpartum hemorrhage prevention and/or treatment.

DATA SOURCES:

We searched MEDLINE, Embase, Cochrane CENTRAL, Maternity and Infant Care Database, and Global Index Medicus (inception to June 9, 2023) and ClinicalTrials.gov and the International Clinical Trials Registry Platform (last 5 years) using a phased search strategy, combining terms for postpartum hemorrhage and care bundles.

STUDY ELIGIBILITY CRITERIA:

Peer-reviewed studies evaluating postpartum hemorrhage-related care bundles were included. Care bundles were defined as interventions comprising ≥3 components implemented collectively, concurrently, or in rapid succession. Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies (controlled or uncontrolled) were eligible.

METHODS:

Risk of bias was assessed using RoB 2 (randomized trials) and ROBINS-I (nonrandomized 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 (2 studies), low-certainty evidence suggests possible benefits in reducing blood loss, duration of hospitalization, and intensive care unit stay, and maternal well-being. For treatment-only bundles (9 studies), high-certainty evidence shows that the E-MOTIVE intervention reduced risks of composite severe morbidity (risk ratio, 0.40; 95% confidence interval, 0.32-0.50) and blood transfusion for bleeding, postpartum hemorrhage, severe postpartum hemorrhage, and mean blood loss. One nonrandomized trial and 7 uncontrolled studies suggest that other postpartum hemorrhage treatment bundles might reduce blood loss and severe postpartum hemorrhage, but this is uncertain. For combined prevention/treatment bundles (11 studies), low-certainty evidence shows that the California Maternal Quality Care Collaborative care bundle may reduce severe maternal morbidity (risk ratio, 0.64; 95% confidence interval, 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.

CONCLUSION:

The E-MOTIVE intervention improves postpartum hemorrhage-related outcomes among women delivering vaginally, and the California Maternal Quality Care Collaborative bundle may reduce severe maternal morbidity. Other bundle designs warrant further effectiveness research before implementation is contemplated.

Editor's Choice
  • Prescott B
  • Jackson DE
Hematol Transfus Cell Ther. 2023 Oct 14; doi: 10.1016/j.htct.2023.07.013.
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.

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.