Claudia Caissutti

Are women positive for the One Step but negative for the Two Step screening tests for gestational diabetes at higher risk for adverse outcomes

The aim of this study was to evaluate if women meeting criteria for gestational diabetes mellitus (GDM) by the One Step test as per International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria but not by other less strict criteria have adverse pregnancy outcomes compared with GDM‐negative controls. The primary outcome was the incidence of macrosomia, defined as birthweight > 4000 g.

Uterine massage as part of active management of the third stage of labour for preventing postpartum haemorrhage during vaginal delivery: a systematic review and meta-analysis of randomised trials

of the third stage of labour for preventing postpartum haemorrhage during vaginal delivery: a systematic review and meta-analysis of randomised trials G Saccone, C Caissutti, A Ciardulli, H Abdel-Aleem, GJ Hofmeyr, V Berghella a Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy b Department of Experimental Clinical and Medical Science, DISM, Clinic of Obstetrics and Gynaecology, University of Udine, Udine, Italy c Department of Obstetrics and Gynaecology, Catholic University of Sacred Heart, Rome, Italy d Department of Obstetrics and Gynaecology, Women’s Health Hospital, Assiut University Hospital, Assiut, Egypt e Effective Care Research Unit, Eastern Cape Department of Health, Fort Hare and Walter Sisulu Universities and University of the Witwatersrand, Johannesburg, South Africa f Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA Correspondence: V. Berghella, Division of Maternal–Fetal Medicine, Department of Obstetrics and Gynecology, Thomas Jefferson University, 833 Chestnut Street, First Floor, Philadelphia, PA 19107, USA. Email vincenzo.berghella@jefferson.edu

Vaginal Cleansing Before Cesarean Delivery: A Systematic Review and Meta-analysis.

OBJECTIVE To assess the efficacy of vaginal cleansing before cesarean delivery in reducing postoperative endometritis. DATA SOURCES MEDLINE, Ovid, EMBASE, Scopus, Clinicaltrials.gov, and Cochrane Library were searched from their inception to January 2017. METHODS OF STUDY SELECTION Selection criteria included all randomized controlled trials comparing vaginal cleansing (ie, intervention group) with a control group (ie, either placebo or no intervention) in women undergoing cesarean delivery. Any method of vaginal cleansing with any type of antiseptic solution was included. The primary outcome was the incidence of endometritis. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% CI. TABULATION, INTEGRATION, AND RESULTS Sixteen trials (4,837 women) on vaginal cleansing immediately before cesarean delivery were identified as relevant and included in the review. In most of the included studies, 10% povidone-iodine was used as an intervention. The most common way to perform the vaginal cleansing was the use of a sponge stick for approximately 30 seconds. Women who received vaginal cleansing before cesarean delivery had a significantly lower incidence of endometritis (4.5% compared with 8.8%; RR 0.52, 95% CI 0.37-0.72; 15 studies, 4,726 participants) and of postoperative fever (9.4% compared with 14.9%; RR 0.65, 95% CI 0.50-0.86; 11 studies, 4,098 participants) compared with the control group. In the planned subgroup analyses, the reduction in the incidence of endometritis with vaginal cleansing was limited to women in labor before cesarean delivery (8.1% compared with 13.8%; RR 0.52, 95% CI 0.28-0.97; four studies, 440 participants) or those with ruptured membranes (4.3% compared with 20.1%; RR 0.23, 95% CI 0.10-0.52; three studies, 272 participants). CONCLUSION Vaginal cleansing immediately before cesarean delivery in women in labor and in women with ruptured membranes reduces the risk of postoperative endometritis. Because it is generally inexpensive and a simple intervention, we recommend preoperative vaginal preparation before cesarean delivery in these women with sponge stick preparation of povidone-iodine 10% for at least 30 seconds. More data are needed to assess whether this intervention may be also useful for cesarean deliveries performed in women not in labor and for those without ruptured membranes. SYSTEMATIC REVIEW REGISTRATION PROSPERO International prospective register of systematic reviews, https://www.crd.york.ac.uk/PROSPERO/, CRD42017054843.

Chewing gum improves postoperative recovery of gastrointestinal function after cesarean delivery: a systematic review and meta-analysis of randomized trials

Abstract Objective: To examine whether chewing gum hastens the return of gastrointestinal function after a cesarean delivery. Methods: All randomized controlled trials comparing the use of chewing gum in the immediate postoperative recovery period (i.e. intervention group) with a control group were included in the meta-analysis. The primary outcome was the time to first flatus in hours. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). Results: Seventeen trials, including 3041 women, were analyzed. Trials were of moderate to low quality with different inclusion criteria. In most of the included trials chewing gum was given right after delivery, three times a day for 30 min each and until the first flatus. Women who were randomized to the chewing gum group had a significantly lower mean time to first flatus (MD – 6.49 h, 95%CI −8.65 to −4.33), to first bowel sounds (MD – 8.48 h, 95%CI −9.04 to −7.92), less duration of stay (MD – 0.39 days, 95%CI –0.78 to −0.18), lower time to first feces (MD – 9.57 h, 95% CI −10.28 to 8.87) and to the first feeling of hunger (MD – 2.89 h, 95%CI −4.93 to −0.85), less number of episodes of nausea or vomiting (RR 0.33, 95%CI 0.12 to 0.87), less incidence of ileus (RR 0.39, 95%CI 0.19 to 0.80) and significantly higher satisfaction. Conclusions: Gum chewing starting right after cesarean delivery three times a day for about 30 min until the first flatus is associated with early recovery of bowel motility. As this is a simple, generally inexpensive intervention, providers should consider implementing cesarean postoperative care with gum chewing.

Very tight vs. tight control: what should be the criteria for pharmacologic therapy dose adjustment in diabetes in pregnancy? Evidence from randomized controlled trials

There is inconclusive evidence from randomized controlled trials (RCTs) to support any specific criteria for pharmacologic therapy dose adjustment in diabetes in pregnancy. Our objective was to analyze the criteria for dose adjustment of pharmacologic treatment for diabetes mellitus (DM) in pregnancy.

Uterine massage for preventing postpartum hemorrhage at cesarean delivery: Which evidence?

BACKGROUND Cesarean delivery could be complicated by postpartum hemorrhage (PPH), the first cause of maternal death. OBJECTIVES To evaluate the efficacy of uterine massage in preventing postpartum hemorrhage at cesarean delivery. DATA SOURCES Electronic databases from their inception until October 2017. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS We included all RCTs comparing uterine massage alone or as part of the active management of labor before or after delivery of the placenta, or both, with non-massage in the setting of cesarean delivery. DATA COLLECTION AND ANALYSIS The primary outcome was PPH, defined as blood loss >1000 mL. Meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of mean difference (MD) or relative risk (RR) with 95% confidence interval (CI). RESULTS Only 3 RCTs comparing uterine massage vs no uterine massage were found. The quality of these 3 trials in general was very low with high or unclear risk of bias. All of them included only women in the setting of spontaneous vaginal delivery and none of them included cesarean delivery, and therefore the meta-analysis was not feasible. CONCLUSIONS There is not enough evidence to determine if uterine massage prevents postpartum hemorrhage at cesarean delivery.

Effectiveness of seminal plasma in in vitro fertilization treatment: a systematic review and meta‐analysis

With in vitro fertilization (IVF) techniques, only 20–25% of the transferred embryos lead to a pregnancy.

Scientific Evidence for Different Options for GDM Screening and Management: Controversies and Review of the Literature.

Background. Gestational diabetes (GDM) affects up to 7% of pregnant women and is associated with several maternal and perinatal morbidities. International organizations suggest several different recommendations regarding how to screen and to manage GDM. Objective. We aimed to analyze the most important and employed guidelines about screening and management of GDM and we investigated existing related literature. Results. We found several different criteria for screening for GDM, for monitoring GDM, and for starting pharmacological therapy. When using IADPSG criteria, GDM rate increased, perinatal outcomes improved, and screening became cost-effective. Compared to no treatment, treatment of women meeting criteria for GDM by IADPSG criteria but not by other less strict criteria has limited evidence for an effect on adverse pregnancy outcomes.

One-step versus two-step diagnostic testing for gestational diabetes: a randomized controlled trial

Abstract Objective: To evaluate the incidence of gestational diabetes mellitus (GDM) using the one-step as compared with the two-step approach. Study design: This was a parallel group nonblinded randomized trial conducted at Thomas Jefferson University Hospital (TJUH) in Philadelphia, Pennsylvania from June 2016 to December 2016. The primary outcome was GDM incidence in the one-step compared to the two-approach. Pregnant women without a history of pregestational diabetes were offered screening for GDM at gestational age 24–28 weeks. Obese women, defined as having a BMI ≥30 kg/m2, as well as those with a history of a pregnancy complicated by GDM, a history of a macrosomic baby (>4000 g), or with polycystic ovarian syndrome (PCOS), were offered early screening at their initial prenatal visit, and screening was repeated at 24–28 weeks if initially normal. Women were excluded if they had pre-existing diabetes or had a history of bariatric surgery. Women who were eligible were randomized in a 1:1 ratio to either the one-step or two-step approaches. A sample size of 142 women was planned per group. Women randomized to the one-step approach, after an overnight fast, were given a 2-h glucose tolerance test, which consisted of a 75-g glucose load. Blood glucose levels were measured fasting, at 1 h and 2 h after the glucose load. Diagnostic cutoffs for GDM diagnosis were one value of either fasting ≥92 mg/dL, 1 h ≥180 mg/dL, or 2 h ≥153 mg/dL, respectively. Women randomized to the two-step approach were given a nonfasting 50-g glucose load, and the blood glucose level was measured an hour after the glucose load. If that value was ≥135 mg/dL, the patient had a 3-h glucose tolerance test consisting of a 100-g glucose load. Diagnostic cutoffs for GDM diagnosis for this 3-h test were ≥2 abnormal values of fasting ≥95 mg/dL, 1 h ≥180 mg/dL, 2 h ≥155 mg/dL and 3 h ≥140 mg/dL, respectively. All analyses were done using an intention-to-treat approach, evaluating women according to the treatment group to which they were randomly allocated. Results: Two hundred eighty-four women agreed to take part in the study and underwent randomization from June 2015 to December 2015. Of them, 249 completed the screening and were followed up for the primary endpoint. Out of the 249 women who completed the screening, 123 were assigned to the one-step group and 126 to the two-step group. GDM occurred in 10 women (8.1%) in the one-step group, and 7 women (5.6%) in the two-step group (p = .42). Preeclampsia, preterm birth (PTB), induction of labor, mode of delivery and incidence of gestational age (OASIS) were not significantly different. Perinatal outcomes were similar as well. Conclusions: Screening for GDM with one-step, compared with the two-step approach, resulted in a similar incidence of GDM.

Which criteria should be used for starting pharmacologic therapy for management of gestational diabetes in pregnancy? Evidence from randomized controlled trials

Abstract Introduction: There is inconclusive evidence to support any specific criteria for starting pharmacologic therapy after diet in women with gestational diabetes mellitus (GDM). We aimed to analyze the most used criteria for starting pharmacologic treatment for patients with GDM. Material and methods: Electronic databases were searched from their inception to September 2017. We included all the randomized controlled trials (RCTs) of GDM managed initially by diet and exercise reporting criteria for starting pharmacologic therapy. RCTs in women with pregestational diabetes were excluded. Data regarding glucose values used for starting pharmacologic therapy were extracted and carefully reviewed. Results: We included 15 RCTs (4307 women) in the meta-analysis. For fasting glucose target, 8/14 (57%) used a value lower or equal to 90 mg/dL and the remainder used values <99 mg/dL. Of the 10 RCTs targeting 2-h postprandial values, the majority (9/10, 90%) used 120 mg/dL. The majority of RCTs (13/15, 87%) recommended pharmacologic therapy if either 1 or 2 values per 1- or 2-week period were higher than the target values: 7/13 (54%) used 1 value and 6/13 (46%) used 2 values higher than target values. One RCT (7%) used >50% of the values higher than the target values and another one (7%) used >30%. Conclusion: The majority of RCTs (87%) used very tight criteria of either 1 or 2 values over the target values in the 1 or 2-week period for starting pharmacologic treatment for patients with GDM; more than 50% used 2 values. Key Message Pharmacologic therapy should be considered in women with gestational diabetes when, despite an adequate diet and exercise, 1 or 2 blood glucose values are over the target values of 90mg/dL fasting or 120mg/dL 2-hour postprandial over 1 or 2 weeks.