Edna Keeney

Labour induction with prostaglandins: a systematic review and network meta-analysis.

Objectives To assess the effectiveness and safety of prostaglandins used for labour induction. Design Systematic review with Bayesian network meta-analysis Data sources The Cochrane Pregnancy and Childbirth Group’s Database of Trials (which incorporates the results of a broad generic search for all pregnancy and postpartum trials). Sources included are CENTRAL, Medline, Embase, NHS Economic Evaluation Database, CINAHL, relevant journals, conference proceedings, and registries of ongoing trials. Eligibility criteria for selecting studies Randomised clinical trials of prostaglandin or prostaglandin analogues used for third trimester cervical ripening or labour induction versus placebo or no treatment, alternative prostaglandin dose or administration, or a different type of prostaglandin. We included studies recruiting women with a viable fetus, but had no other restrictions relating to indication for labour induction or language of publication. Outcomes assessed were serious neonatal morbidity (trialist defined) or perinatal death; serious maternal morbidity (trialist defined) or death; vaginal delivery not achieved within 24 hours, caesarean section, and uterine hyperstimulation with fetal heart rate changes. Results 280 randomised clinical trials were included (48 068 women) in the review. Maternal and neonatal mortality and serious morbidity were rarely reported and are summarized narratively. Unresolved inconsistency was observed for the hyperstimulation outcome. Relative to placebo, the odds of failing to achieve a vaginal delivery were lowest for vaginal misoprostol (≥50 µg) (odds ratio 0.06 (95% credible interval 0.02 to 0.12)), with a 39% absolute probability of event (95% credible interval 1% to 94%). Compared with placebo, odds of caesarean section were lowest for titrated oral misoprostol solution (<50 µg) (odds ratio 0.65 (0.49 to 0.83)), with an absolute probability of event of 15% (3% to 40%). Conclusions Low dose(<50 µg) titrated oral misoprostol solution had the lowest probability of caesarean section, whereas vaginal misprostol (≥50 µg) had the highest probability of achieving a vaginal delivery within 24 hours. These findings have important implications for a series of current national and international guidelines for induction of labour and future research in this area. Systematic review registration PROSPERO 2013:CRD42013005116

Methods to induce labour: A systematic review, network meta-analysis and cost-effectiveness analysis

To compare the clinical effectiveness and cost‐effectiveness of labour induction methods.

Data extraction for complex meta-analysis (DECiMAL) guide

As more complex meta-analytical techniques such as network and multivariate meta-analyses become increasingly common, further pressures are placed on reviewers to extract data in a systematic and consistent manner. Failing to do this appropriately wastes time, resources and jeopardises accuracy. This guide (data extraction for complex meta-analysis (DECiMAL)) suggests a number of points to consider when collecting data, primarily aimed at systematic reviewers preparing data for meta-analysis. Network meta-analysis (NMA), multiple outcomes analysis and analysis combining different types of data are considered in a manner that can be useful across a range of data collection programmes. The guide has been shown to be both easy to learn and useful in a small pilot study.

Outcomes reported in trials of methods for the induction of labour

Background Labour inductions have increased steadily over the past two decades, with overall rates in many countries now exceeding 20% of all births. We have conducted a systematic review, network meta-analysis and cost-effectiveness analysis to determine which treatments for induction perform best on pre-specified safety and efficacy outcomes. This poster reports analysis of the outcomes reported in trials.

Different Methods for Modelling Severe Hypoglycaemic Events: Implications for Effectiveness, Costs and Health Utilities

BackgroundClinical trials report severe hypoglycaemic events as the number of patients with at least one event out of the total randomised or number of events for a given total exposure. Different network meta-analysis models have been used to analyse these different data types.ObjectiveThis aim of this article was to establish the impact of using the different models on effectiveness, costs and health utility estimates.MethodsWe analysed a dataset used in a recent network meta-analysis of severe hypoglycaemic events conducted to inform National Institute for Health and Care Excellence recommendations regarding basal insulin choice for patients with type 1 diabetes mellitus. We fitted a model with a binomial likelihood reporting odds ratios (using a logit link) or hazard ratios (complementary log-log link), a model with a Poisson likelihood reporting hazard ratios and a shared-parameter model combining different types of data. We compared the results in terms of relative effects and resulting cost and disutility estimates.ResultsRelative treatment effects are similar regardless of which model or scale is used. Differences were seen in the probability of having an event on the baseline treatment with the logit model giving a baseline probability of 0.07, the complementary log-log 0.17 and the Poisson 0.29. These translate into differences of up to £110 in the yearly cost of a hypoglycaemic event and 0.004 in disutility.ConclusionWhile choice of network meta-analysis model does not have a meaningful impact on relative effects for this outcome, care should be taken to ensure that the baseline probabilities used in an economic model are accurate to avoid misrepresenting costs and effects.

Fixed-dose combination inhalers compared to long-acting bronchodilators for COPD: a network meta-analysis

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:To compare the efficacy and safety of two different types of fixed-dose dual inhalers (i.e. LABA/LAMA vs ICS/LABA) as well as combination therapies versus LABA or LAMA monotherapy for patients with moderate to very severe COPD.

labour induction with prostaglandins: what works best? A systematic review, network meta-analysis and cost-effectiveness analysis

• A network meta-analysis (NMA) of randomised controlled trials (RCTs) was conducted comparing 12 different prostaglandins used for labour induction. Different methods were compared with each other and with no treatment or placebo. • Data were extracted for five key outcomes in terms of effectiveness and safety: serious neonatal morbidity or perinatal death, serious maternal morbidity or death, uterine hyperstimulation with fetal heart rate changes, failure to achieve vaginal delivery within 24 hours, and caesarean section. • Relative treatment effects are reported as posterior median odds ratios (OR) and 95% Credible Intervals (CrI). • The probability of each treatment being 1st, 2nd, 3rd, etc. most effective was calculated for each outcome. • All analysis were conducted within a Bayesian framework using OpenBUGS. LABOUR INDUCTION WITH PROSTAGLANDINS: WHAT WORKS BEST? A SYSTEMATIC REVIEW, NETWORK META-ANALYSIS AND COST-EFFECTIVENESS ANALYSIS Keeney E1, Welton NJ1, Dowswell T2, Dias S1, Medley N2, Jones L2, Navaratnam K2 , Alfirevic Z2 , Caldwell DM1