Ellen Mozurkewich

The effect of perinatal omega‐3 fatty acid supplementation on inflammatory markers and allergic diseases: a systematic review*

Please cite this paper as: Klemens C, Berman D, Mozurkewich E. The effect of perinatal omega‐3 fatty acid supplementation on inflammatory markers and allergic diseases: a systematic review. BJOG 2011;118:916–925.

Indications for induction of labour: a best‐evidence review

Background  Rates of labour induction are increasing.

Meta-analysis of heterogeneous clinical trials: An empirical example

Meta-analysis of heterogeneous clinical trials is currently sub-optimal. This is because there has been no improvement in the method of weighted averaging for such studies since the DL method in 1986. This article presents the argument for the use of situation specific weights to integrate results from such trials. An empirical example is given with data from a meta-analysis done 10 years earlier. Previously reported data on 21 studies that looked at the effect of working conditions on preterm births were re-analyzed. Several methods were used to estimate the overall effect sizes. Study specific scores were included in the weighting process when combining studies and it was shown that this model not only was more conservative than the model of DL but also retains the legitimacy of the pooled effect size. The inclusion of appropriate study specific scores in an appropriate meta-analysis model permits the quantification of the variation between studies based on something tangible as opposed to the random adjustments made by the random effects model to the pooled effect size. It is important that such differences are recognized by the wider research community so that meta-analyses remain a valid tool for synthesizing research.

Methods of induction of labour: A systematic review

BackgroundRates of labour induction are increasing. We conducted this systematic review to assess the evidence supporting use of each method of labour induction.MethodsWe listed methods of labour induction then reviewed the evidence supporting each. We searched MEDLINE and the Cochrane Library between 1980 and November 2010 using multiple terms and combinations, including labor, induced/or induction of labor, prostaglandin or prostaglandins, misoprostol, Cytotec, 16,16,-dimethylprostaglandin E2 or E2, dinoprostone; Prepidil, Cervidil, Dinoprost, Carboprost or hemabate; prostin, oxytocin, misoprostol, membrane sweeping or membrane stripping, amniotomy, balloon catheter or Foley catheter, hygroscopic dilators, laminaria, dilapan, saline injection, nipple stimulation, intercourse, acupuncture, castor oil, herbs. We performed a best evidence review of the literature supporting each method. We identified 2048 abstracts and reviewed 283 full text articles. We preferentially included high quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised or quasi-randomised trials.ResultsWe included 46 full text articles. We assigned a quality rating to each included article and a strength of evidence rating to each body of literature. Prostaglandin E2 (PGE2) and vaginal misoprostol were more effective than oxytocin in bringing about vaginal delivery within 24 hours but were associated with more uterine hyperstimulation. Mechanical methods reduced uterine hyperstimulation compared with PGE2 and misoprostol, but increased maternal and neonatal infectious morbidity compared with other methods. Membrane sweeping reduced post-term gestations. Most included studies were too small to evaluate risk for rare adverse outcomes.ConclusionsResearch is needed to determine benefits and harms of many induction methods.

Premature rupture of membranes at term: A metaanalysis of three management schemes

Objective To compare rates of cearean birth, endometritis, chorioamnionitis, and serious neonatal infections among pregnancies complicated by premature rupture of membranes (PROM) at term and managed by immediate oxytocin induction, by conservative management (or delayed oxytocin induction), or by vaginal (or endocervical) prostaglandin E2 gel, suppositories, or tablets. Data Sources The English-language literature in MED-LINE and other databases was searched through April 1996 using the terms “fetal membranes,” “premature rupture,” and “term.” Methods of Study Selection We included randomized trials comparing two or more management schemes for PROM at term. Tabulation, Integration, and Results Twenty-three studies with a total of 7493 subjects met the inclusion criteria and were included for analysis. Data regaridng chorioamnionitis, endometritis, neonatal infections, and cesarean delivery were extracted. Meta-analyses were performed for the three interventions for these outcomes of interest using the Dersimonian and Laird and Mantel-Haenszel techniques to estimate the pooled odds ratios (ORs). No statistically significant differences in cesarean deliveries or neonatal infections were noted among management schemes. Vaginal prostaglandins resulted in more chorioamnionitis than immediate oxytocin (OR 1.55, 95% confidence interval [CI] 1.09, 2.21), but less chorioamnionitis than immediate oxytocin induction resulted in fewer cases of chorioamnionitis (OR 0.67, 95% CI 0.52 0.85) and endometritis (OR 0.71, 95% CI 0.51, 0.99) than conservative management, although these results achieved significance only with the Mantel-Haenszel technique. Conclusion Conservative management may result in more maternal infections than immediate induction with oxytocin or prostaglandins.

Docosahexaenoic acid pretreatment confers neuroprotection in a rat model of perinatal cerebral hypoxia-ischemia

OBJECTIVE We hypothesized that pretreatment with docosahexaenoic acid (DHA), a potentially neuroprotective polyunsaturated fatty acid, would improve function and reduce brain damage in a rat model of perinatal hypoxia-ischemia. STUDY DESIGN Seven-day-old rats were divided into 3 treatment groups that received intraperitoneal injections of DHA 1, 2.5, or 5 mg/kg as DHA-albumin complex and 3 controls that received 25% albumin, saline, or no injection. Subsequently, rats underwent right carotid ligation followed by 90 minutes of 8% oxygen. Rats underwent sensorimotor testing (vibrissae-stimulated forepaw placing) and morphometric assessment of right-sided tissue loss on postnatal day 14. RESULTS DHA pretreatment improved forepaw placing response to near-normal levels (9.5 +/- 0.9 treatment vs 7.1 +/- 2.2 controls; normal = 10; P < .0001). DHA attenuated hemisphere damage compared with controls (P = .0155), with particular benefit in the hippocampus with 1 mg/kg (38% protection vs albumin controls). CONCLUSION DHA pretreatment improves functional outcome and reduces volume loss after hypoxia-ischemia in neonatal rats.

Critical care in obstetrics: pregnancy-specific conditions

This chapter summarizes the clinical presentation, pathophysiology, evaluation and management of six commonly encountered complications unique to pregnancy that require critical care management: obstetric haemorrhage; pre-eclampsia/HELLP (haemolysis-elevated liver enzymes-low platelets) syndrome; acute fatty liver of pregnancy; peripartum cardiomyopathy; amniotic fluid embolism; and trauma.

The MisoPROM study: A multicenter randomized comparison of oral misoprostol and oxytocin for premature rupture of membranes at term ☆

OBJECTIVE This study was undertaken to determine whether induction of labor with oral misoprostol will result in fewer cesarean deliveries than intravenous oxytocin in nulliparous women with premature rupture of membranes at term. STUDY DESIGN Three hundred five women at 10 centers were randomly assigned to receive oral misoprostol, 100 microg every 6 hours to a maximum of two doses or intravenous oxytocin. The primary outcome measure was cesarean deliveries. Secondary outcomes were time from induction to vaginal delivery and measures of maternal and neonatal safety. RESULTS The study was stopped prematurely because of recruitment difficulties. We present the results for the 305 enrolled women. There was no difference in the proportion of women who underwent cesarean delivery (20.1% in the misoprostol group, 19.9% in the oxytocin group). The time interval from induction to vaginal delivery was also similar (11.9 hours for the misoprostol group, and 11.8 hours for the oxytocin group). Maternal and neonatal safety outcomes were similar for the two treatments. More infants born to women in the misoprostol group received intravenous antibiotics in the neonatal period (16.4% vs 6.9%, P=.01), although there were no differences in chorioamnionitis or in proven neonatal infections. Women receiving misoprostol were less likely to have postpartum hemorrhage than those receiving oxytocin (1.9% vs 6.2%, P=.05). CONCLUSION Oral misoprostol does not offer any advantage in time from induction to vaginal delivery or risk of cesarean section.

Omega-3 fatty acids and pregnancy: current implications for practice.

Purpose of review We conducted this review to evaluate the evidence for maternal supplementation with omega-3 fatty acids during pregnancy for the prevention or treatment of common complications of pregnancy including preterm birth, pregnancy-induced hypertension and preeclampsia, as well as perinatal depression. We also evaluated the evidence supporting maternal omega-3 fatty acid supplementation to optimize infant neurocognitive development and for primary prevention of allergic diseases in childhood. Recent findings Omega-3 fatty acids through diet or dietary supplementation may reduce the risk for early preterm birth. Preliminary findings from small randomized controlled trials suggest that maternal omega-3 fatty acid supplementation during pregnancy may reduce the risk for allergic disease in childhood, but this observation requires confirmation by large appropriately powered randomized controlled trials. More research is needed before routine maternal supplementation for this indication can be recommended. Summary Although it is biologically plausible that maternal omega-3 fatty acid supplementation might prevent a number of pregnancy complications and optimize child health and development, indications for supplementation other than prevention of preterm births are currently investigational.

Prelabor rupture of membranes at term: induction techniques.

The clinical management of premature rupture of membranes (PROM) at term has been a matter of considerable controversy. Management options have included expectant management or induction of labor with oxytocin, dinoprostone (PGE2), or misoprostol. Early studies suggested that immediate oxytocin induction of labor might reduce maternal and neonatal infections while increasing risk for cesarean section. The definitive TermPROM study found no difference in neonatal infections between immediate and delayed induction with oxytocin and PGE2. However, neither PGE2 nor delayed induction resulted in fewer cesarean sections than immediate oxytocin. Misoprostol offers several theoretical advantages over oxytocin in the setting of PROM at term. However, randomized trials to date have found no significant advantage for misoprostol administration compared with other agents for women with PROM.