Luis Sanchez-Ramos

Expectant management versus labor induction for suspected fetal macrosomia: a systematic review

OBJECTIVE To systematically review and summarize the medical literature regarding the effects of expectant management and labor induction on mode of delivery and perinatal outcomes in patients with suspected fetal macrosomia. DATA SOURCES: We supplemented a search of entries in electronic databases with references cited in original studies and review articles to identify studies assessing management of patients with suspected fetal macrosomia. METHODS OF STUDY SELECTION We evaluated, abstracted data, and performed quantitative analyses in studies assessing the outcome of patients with suspected fetal macrosomia. Observational studies and randomized trials were included in this systematic review. TABULATION, INTEGRATION, AND RESULTS Twenty‐nine studies were identified, 11 of which met our criteria for systematic review and meta‐analysis. These 11 studies included 3751 subjects. Of these, 2700 were managed expectantly, and 1051 underwent labor induction. We calculated an estimate of the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes, using random‐ and fixed‐effects models for outcomes. Summary statistics for the nine observational studies showed that, compared with those whose labor was induced, women who experienced spontaneous onset of labor had a lower incidence of cesarean delivery (OR 0.39, 95% CI 0.30, 0.50) and higher rates of spontaneous vaginal delivery (OR 2.07, 95% CI 1.34, 3,19); however, significant differences in these outcomes were not noted when the two randomized trials were assessed. No differences were noted in rates of operative vaginal deliveries, incidence of shoulder dystocia, or abnormal Apgar scores in the analyses of the observational or randomized studies. CONCLUSION Based on data from observational studies, labor induction for suspected fetal macrosomia results in an increased cesarean delivery rate without improving perinatal outcomes. Although their statistical power is limited, randomized clinical trials have not confirmed these findings.

Pregnancy outcomes in women with polycystic ovary syndrome: a metaanalysis

OBJECTIVE The purpose of this study was to examine which maternal and neonatal complications are associated with polycystic ovary syndrome (PCOS) in pregnant women. STUDY DESIGN The studies that were included compared pregnancy outcomes between women with PCOS and those without diagnosed PCOS. Our primary outcomes included gestational diabetes mellitus, pregnancy-induced hypertension, and preeclampsia. Secondary outcomes included cesarean delivery rates, operative vaginal delivery rates, preterm delivery, small-for-gestational-age (SGA) infants and large-for-gestational-age infants. RESULTS We found that PCOS in pregnancy was associated with higher rates of gestational diabetes mellitus, pregnancy-induced hypertension, preeclampsia, preterm delivery, cesarean delivery, operative vaginal delivery, SGA, and large-for-gestational age. Only gestational diabetes mellitus, pregnancy-induced hypertension, preeclampsia, preterm delivery, and SGA infants were found to be statistically significant. CONCLUSION This metaanalysis confirms the higher association of pregnancy complications and PCOS compared with patients who do not have PCOS. Additionally, there may be a stronger association between PCOS and hypertensive disorders than has been shown previously.

Diagnostic accuracy of transvaginal sonography for the diagnosis of adenomyosis: systematic review and metaanalysis

OBJECTIVE The purpose of this study was to critically appraise the diagnostic accuracy of transvaginal sonography for diagnosing adenomyosis. STUDY DESIGN Computerized databases were used to identify relevant reports published between 1966 and 2007 reporting data on the accuracy of transvaginal sonography for diagnosing adenomyosis in women having hysterectomy. The presence or absence of adenomyosis was confirmed by histopathologic analysis of hysterectomy specimens. The total analysis included 14 trials with 1895 aggregate participants. Two authors independently assessed methodological quality and constructed tables for the assessment of diagnostic measures. RESULTS Transvaginal ultrasound predicted adenomyosis with a likelihood ratio of 4.67 (95% confidence interval [CI], 3.13-6.17). The overall prevalence of adenomyosis was 27.9% (95% CI, 25.5-30.3). The probability of adenomyosis with an abnormal transvaginal ultrasound was 66.2% (95% CI, 61.6- 70.6). The probability of adenomyosis with a normal transvaginal ultrasound was 9.1% (95% CI, 7.3-11.1). CONCLUSION Transvaginal sonography appears to be an accurate diagnostic test for adenomyosis.

The short-term prediction of preterm birth: a systematic review and diagnostic metaanalysis

OBJECTIVE To assess the diagnostic accuracy of fetal fibronectin (fFN), fetal breathing movements (FBM), and cervical length (CL) for the short-term prediction of preterm birth in symptomatic patients. STUDY DESIGN Diagnostic metaanalysis using bivariate methods. RESULTS Pooled sensitivities for fFN, FBM, and CL for delivery within 48 hours of testing were 0.62 (95% confidence interval [CI], 0.43-0.78), 0.75 (95% CI, 0.57-0.87) and 0.77 (95% CI, 0.54-0.90), respectively. Pooled specificities for fFN, FBM, and CL for delivery within 48 hours were 0.81 (95% CI, 0.74-0.86), 0.93 (95% CI, 0.75-0.98) and 0.88 (95% CI, 0.84-0.91). Pooled sensitivities for fFN, FBM, and CL for delivery within 7 days were 0.75 (95% CI, 0.69-0.80), 0.67 (95% CI, 0.43-0.84), and 0.74 (95% CI, 0.58-0.85). Pooled specificities for fFN, FBM, and CL for delivery within 7 days were 0.79 (95% CI, 0.76-0.83), 0.98 (95% CI, 0.83-1.00) and 0.89 (95% CI, 0.85-0.92). Based on a pretest probability of 10% for delivery within 48 hours, posttest probabilities (positive and negative) were 27% and 5% for fFN, 54% and 3% for fFN, and 42% and 3% for CL. For a pretest probability of 20% for delivery within 7 days, posttest probabilities (positive and negative) were 48% and 7% for fFN, 89% and 8% for FBM, and 63% and 7% for CL. CONCLUSION In symptomatic patients, for fFN, absence of FBM, and CL have diagnostic use as predictors of delivery within 48 hours and within 7 days of testing. Absence of FBM appears to be the best test for predicting preterm birth.

Labor induction with intravaginal misoprostol compared with the dinoprostone vaginal insert: a systematic review and metaanalysis.

OBJECTIVE The purpose of this study was to review randomized trials that compared the efficacy of the dinoprostone 10-mg controlled-release vaginal insert with that of vaginally administered misoprostol tablets in cervical ripening and labor induction. STUDY DESIGN Electronic databases were used to identify randomized clinical trials that compared dinoprostone with misoprostol. Estimates of the relative risk for individual studies and risk difference from dichotomous outcomes with the use of random and fixed-effects models were calculated. RESULTS Women who received misoprostol had a higher incidence of vaginal delivery within 12 and 24 hours of prostaglandin application, compared with dinoprostone. Both modalities had similar incidences of cesarean delivery, uterine hyperstimulation, and fetal tachysystole. There was an increased need for oxytocin augmentation in the dinoprostone group. No significant difference in neonatal outcomes was noted between the 2 groups. CONCLUSION Vaginally administered misoprostol was more effective than the dinoprostone vaginal insert for cervical ripening and labor induction. The safety profiles of both drugs were similar.

Antenatal exposure to indomethacin increases the risk of severe intraventricular hemorrhage, necrotizing enterocolitis, and periventricular leukomalacia: a systematic review with metaanalysis.

OBJECTIVE The purpose of this study was to provide an updated summary of the literature regarding the effects of tocolysis with indomethacin on neonatal outcome by systematically reviewing previously and recently reported data. STUDY DESIGN All previously reported studies pertaining to indomethacin tocolysis and neonatal outcomes along with recently reported data were identified with the use of electronic databases that had been supplemented with references that were cited in original studies and review articles. Observational studies that compared neonatal outcomes among preterm infants who were exposed and not exposed to indomethacin were included in this systematic review. Data were extracted and quantitative analyses were performed on those studies that assessed the neonatal outcomes of patients that received antenatal tocolysis with indomethacin. RESULTS Twenty-seven observational studies that met criteria for systematic review and metaanalysis were identified. These studies included 8454 infants, of whom 1731 were exposed to antenatal indomethacin and 6723 were not exposed. Relative risks with 95% confidence intervals were calculated for dichotomous outcomes with the use of random and fixed-effects models. Metaanalysis revealed no statistically significant differences in the rates of respiratory distress syndrome, patent ductus arteriosus, neonatal mortality rate, neonatal sepsis, bronchopulmonary dysplasia, or intraventricular hemorrhage (all grades). However, antenatal exposure to indomethacin was associated with an increased risk of severe intraventricular hemorrhage (grade III-IV based on Papiles criteria; relative risk, 1.29; 95% confidence interval, 1.06-1.56), necrotizing enterocolitis (relative risk, 1.36; 95% confidence interval, 1.08-1.71), and periventricular leukomalacia (relative risk, 1.59; 95% confidence interval, 1.17-2.17). CONCLUSION The use of indomethacin as a tocolytic agent for preterm labor is associated with an increased risk for severe intraventricular hemorrhage, necrotizing enterocolitis, and periventricular leukomalacia.

Cumulative oxytocin dose during induction of labor according to maternal body mass index.

To determine the cumulative oxytocin dose needed to achieve vaginal delivery among obese and non‐obese women.

Human chorionic gonadotropin in cervicovaginal secretion as a predictor of preterm delivery.

Background: Preterm delivery is one of the important problems in obstetrics and finding a way for its prediction and prevention has always been under investigation. Materials and Methods: This study carried out to determine whether human chorionic gonadotropin (HCG) detected in cervicovaginal secretion of patients with symptoms suggestive of preterm labor is a predictor of preterm birth, and to determine the cut-off values for HCG in prediction of delivery before 37 weeks of pregnancy. 150 pregnant women with gestational age 24-34 weeks and diagnosis of preterm labor and intact membrane were enrolled to the study. The patients were allocated in two groups and HCG in cervicovaginal secretion was measured in all of them. The patients were followed until their delivery and were divided in two groups. Seventy one cases delivered after 37 weeks of pregnancy (term) and 79 before 37 weeks (preterm). The amount of HCG in cervicovaginal secretion of the two groups was compared. Results: Mean concentration of HCG in cervicovaginal secretion in term group was 7.9 ± 34.1 miu/ml and in preterm group 61.12 ± 66.84 miu/ml which was statistically significant (p Conclusion: Quantitative HCG concentration measurement from cervicovaginal secretions may be a useful predictor of preterm birth in symptomatic patients. This test has the advantage of low cost and wide availability.

Balancing the efficacy and safety of misoprostol: a meta‐analysis comparing 25 versus 50 micrograms of intravaginal misoprostol for the induction of labour

The optimal dose of misoprostol for the induction of labour remains uncertain.

Intrapartum amnioinfusion for meconium‐stained amniotic fluid: a systematic review of randomised controlled trials

Sir, After reading the recent article by Xu et al.,1 I wish to inform you that an inappropriate version of the manuscript was published. The published version of this systematic review concluded that ‘In clinical settings with standard peripartum surveillance, the evidence did not support the use of amnioinfusion (AI) for meconium-stained amniotic fluid (MSAF). In settings with limited peripartum surveillance, where complications of MSAF are common, AI appears to reduce risk of meconium aspiration syndrome (MAS). However, this finding requires confirmation by further studies’. As one of the peer reviewers of this manuscript, I was surprised and perplexed to read the published version. After extensively revising their original manuscript as requested by the peer reviewers, the authors have concluded, in their revised version, that AI appeared to reduce the risk of MAS based on the result of their meta-analysis. This conclusion, however, markedly differs from that of the published manuscript. Prior to the publication of their planned multicentre randomised trial in 2000,2 two published meta-analyses3,4 have found that AI was effective in reducing the risk of MAS. Upon completion and publication of their multicentre randomised trial,5 the authors reached a different conclusion and stated that AI did not reduce the risk of moderate or severe MAS, perinatal death or other major or neonatal disorders. However, including the results of their multicentre randomised trial in an updated meta-analysis would not have altered the pooled effect estimates significantly. However, peer reviewers of the first draft of meta-analysis of Xu et al. felt that the authors have selectively included and excluded studies, leading to biased conclusions consistent with the findings of their trial. The originally submitted manuscript of meta-analysis of Xu et al. contained a table depicting the effect of AI on the risk of MAS. This table included a total of 13 trials and representing 4145 subjects overall (2052 had received AI and 2093 comprised the comparison group). The effect estimates for the original table showed a relative risk (RR) and 95% confidence intervals (CI) of 0.90 (0.64–1.28) for the standard peripartum surveillance group and 0.25 (0.13–0.47) for the limited peripartum surveillance group. The overall RR and 95% CI was 0.51 (0.25–1.06). Consistent with extensive revisions to the meta-analysis as recommended by peer reviewers, the authors added to their analysis three trials they had initially excluded (Sood et al., Adam et al., and Ilagan et al.). Another trial included in the original manuscript was excluded as recommended by referees because it contained duplicate information (Alvarez et al.). The table included in the revised manuscript therefore included 15 trials and a total of 4339 subjects (2150 received AI and 2189 served as comparisons). The effect estimates for this revised table showed an RR and 95% CI of 0.53 (0.29– 0.98) for the standard peripartum surveillance group and 0.25 (0.13–0.47) for the limited peripartum surveillance group. The overall RR and 95% CI was 0.46 (0.26–0.84). However, this revised table was not published. Instead, the authors unilaterally chose to substitute a non-peer-reviewed table they referred to as the ‘main meta-analysis’, which was ultimately published as Table 3. This table included a total of 12 trials and a total of 4030 subjects (1999 received AI and 2031 served as comparisons). The effect estimates for this non-peer-reviewed table showed an RR and 95% CI of 0.59 (0.28–1.25) for the standard peripartum surveillance group and 0.25 (0.13–0.47) for the limited peripartum surveillance group. The overall RR and 95% CI in the non-peer-reviewed table was 0.47 (0.22–0.99). The published version of the manuscript should have shown a significant reduction in MAS in the ‘main metaanalysis’ for those trials performed in countries with standard peripartum surveillance (0.53 [0.29–0.98]) as well as those performed in countries with limited peripartum surveillance (0.25 [0.13–0.47]). The overall effect estimate agreed upon was 0.46 (0.26–0.84). By submitting a manuscript with important non-peer-reviewed changes (the table detailed above represents only one of the many changes the authors made from the version approved by the referees), the authors have published a manuscript that may cause harm because of unwarranted restriction of AI in labouring women with MSAF. DOI: 10.1111/j.1471-0528.2007.01600.x www.blackwellpublishing.com/bjog Correspondence