Background: Cervical ripening in labour induction using a combination of methods is gaining popularity, but the effectiveness and safety of this approach are not clear. Objective: To compare the effectiveness, perinatal and maternal safety of cervical ripening in the induction of labour (IOL) using a balloon catheter with concurrent low-dose vaginal misoprostol (combined group) versus low-dose vaginal misoprostol alone. Search Strategy: MEDLINE, Embase, Emcare, Scopus, Cochrane Library, WHO ICTRP and clinicaltrials.gov. Selection Criteria: Randomised controlled trials (RCTs), viable singleton gestation, no language restrictions, published and unpublished data. Data Collection and Analysis: Systematic search, screening for trustworthiness and study quality, and an individual participant data (IPD) meta-analysis were conducted. Main Results: Eight of 22 RCTs provided IPD, of which three were excluded due to trustworthiness concerns after IPD checking (604 women). Thirteen of 22 RCTs (59.1%) were identified as ‘ not meeting trustworthiness criteria’. This IPD meta-analysis included five RCTs (649 women): two had prospective, another two had retrospective trial registrations, and one RCT was unregistered. Vaginal delivery rate, composite adverse perinatal and maternal outcomes were comparable between the two groups in the IPD meta-analysis. Vaginal delivery rate, based on aggregate data from eight RCTs ‘meeting trustworthiness criteria’ (IPD and non-IPD), had an Odds Ratio (OR) of 1.07 (95% CI 0.68;1.68). In comparison, data from thirteen RCTs ‘not meeting trustworthiness criteria’ (IPD and non-IPD) showed an OR of 1.25 (95% CI 0.88;1.77). Conclusions: Based on trustworthy data, the effectiveness of the combined group and the low-dose vaginal misoprostol group is likely to be comparable. We are uncertain about the safety of using a balloon catheter with concurrent low-dose vaginal misoprostol due to low data retrieval and trustworthiness concerns among the underlying RCTs.

Background: Postpartum haemorrhage (PPH) is the leading cause of maternal mortality. Uterotonics are the mainstay of PPH prevention. Objectives: To compare the efficacy of misoprostol and oxytocin for the prevention of PPH, and to evaluate the trustworthiness of trials comparing these uterotonics. Search strategy and selection criteria: Seven databases were searched for peer-reviewed literature, meeting the inclusion criteria of randomized controlled trials (RCTs) comparing misoprostol and oxytocin for the prevention of PPH. Data Collection and Analysis: Data were collected by two independent reviewers. Individual participant data (IPD) was meta-analyzed for outcomes PPH≥500mL and PPH≥1000mL. RCTs that did not share IPD were classified as trustworthy or not and were included in an aggregate data meta-analysis according to trustworthiness. Main results: Of 79 eligible RCTs, ten (12.7%) provided IPD, of which six were included. Analysis of IPD showed PPH≥500mL to be significantly higher in the misoprostol than the oxytocin group (2,022 women, aOR 1.84, 95% CI 1.43- 2.34). For PPH≥1000mL, analysis of IPD showed misoprostol and oxytocin were comparable (2022 women, OR 1.14, 95% CI 0.68- 1.91). Of the 69 studies that did not provide IPD, 23 (33.3%) were assessed as trustworthy. Analysis of trustworthy data (IPD and 23 aggregate data RCTs) showed no difference between misoprostol and oxytocin for PPH≥500mL (24,334 women, OR 1.01, 95% CI 0.69- 1.49), while misoprostol significantly increased the risk for PPH≥1000 (25,249 women, OR 1.36, 95% CI 1.16- 1.59). Conclusions: Of 79 RCTs comparing misoprostol and oxytocin for the prevention of PPH, 36.7% met trustworthiness criteria. Analysis of trustworthy data suggests oxytocin is superior to misoprostol for preventing PPH.

A document by Shi Ting Pang. Click on the document to view its contents.

Background: Multiple gestation has a higher incidence of preterm birth(PTB), especially in the presence of a short cervix. Objectives: To perform a systematic review and network meta-analysis(NMA) evaluating the effect of progesterone, cerclage, cervical pessary and their combination as treatments for preventing PTB<34 weeks. Search strategy: PubMed, MEDLINE, Cochrane Library, EMBASE, Web of Science, BVS, Scopus, and grey literature were explored. Selection criteria: We included randomized controlled trials that compared an intervention with a control group or another intervention to prevent PTB in women with a twin pregnancy and a short cervix<40mm. Data collection and Analysis:Studies were checked for trustworthiness. We presented summary relative effect sizes(Odds Ratios) for each possible pair of interventions and we used the surface under the cumulative ranking curves(SUCRA) to rank all interventions. Main Results: A total of 20 studies participated in NMA. We found no evidence that the combined treatment of pessary and vaginal progesterone reduced the risk of spontaneous PTB <34 weeks when compared to no intervention(OR 0.68; 95%CI 0.16 to 2.9). Also, pessary(OR 0.78; 95%CI 0.49 to 1.3), vaginal progesterone(OR 0.79; CI95% 0.45 to 1.4) and injectable 17-OH progesterone alone(OR 0.85; CI95% 0.26 to 2.8) did not show a statistically significant reduction in spontaneous PTB. For overall PTB<34 weeks, findings were similar. Conclusions: We found no evidence that progesterone, cervical pessary, cerclage or their combination reduce PTB<34 weeks. There is an urgent need for randomized trials assessing these treatments in women with a multiple pregnancy and a short cervix.

Background: Postpartum Haemorrhage (PPH) remains a leading cause of maternal mortality and morbidity worldwide, and the rate is increasing. Using a reliable predictive model could identify those at risk, support management and treatment, and improve maternal outcomes. Objectives: To systematically identify and appraise existing prognostic models for PPH and ascertain suitability for clinical use. Search strategy: MEDLINE, CINAHL, Embase, and the Cochrane Library were searched using combinations of terms and synonyms including ‘postpartum haemorrhage’, ‘prognostic model’, and ‘risk factors’ that were developed from a scoping review. Selection Criteria: Observational or experimental studies describing a prognostic model for risk of PPH, published in English. Data Collection and Analysis: The Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies checklist informed data extraction and Prediction Model Risk of Bias Assessment Tool guided analysis. Main Results: 16 studies met the inclusion criteria after screening 1612 records. All studies were hospital settings from 8 different countries. Models were developed for women who experienced vaginal birth (n=7), caesarean birth(n=2), any type of birth(n=2), hypertensive disorders(n=1) and those with placental abnormalities(n=4). All studies were at high risk of bias due to use of inappropriate analysis methods or omission of important statistical considerations or suboptimal validation. Conclusions: No existing prognostic models for PPH are ready for clinical application. Future research is needed to externally validate existing models and potentially develop a new model that is reliable and applicable to clinical practice. Funding: This study received no funding. Keywords: Postpartum haemorrhage, prognostic model, prediction tool.

Background: As pregnancy is a physiological prothrombotic state, pregnant women may be at increased risk of developing coagulopathic and/or thromboembolic complications associated with COVID-19. Objectives: To investigate the occurrence of haemostatic and thrombo-embolic complications in pregnant women with COVID-19. Search Strategy: Two biomedical databases were searched between September 2019 and June 2020 for case reports and series of pregnant women with COVID-19. Additional registry cases known to the authors were included. Steps were taken to minimise duplicate patients. Selection criteria: Pregnant women with COVID-19 based either on a positive swab or high clinical suspicion e.g. symptoms and radiographic evidence. Data Collection and Analysis: Information on coagulopathy based on abnormal coagulation test results or clinical evidence of disseminated intravascular coagulation (DIC), and on arterial or venous thrombosis, were extracted using a standard form. If available, detailed laboratory results and information on maternal outcomes were analysed. Main Results: 1063 women met the inclusion criteria, of which three (0.28%) had arterial and/or venous thrombosis, seven (0.66%) had DIC, and a further three (0.28%) had coagulopathy without meeting the definition of DIC. Five hundred and thirty-seven women (56%) had been reported as having given birth and 426 (40%) as having an ongoing pregnancy. There were 17 (1.6%) maternal deaths in which DIC was reported as a factor in two. Conclusions: Our data suggests that coagulopathy and thromboembolism are both increased in pregnancies affected by COVID-19. Detection of the former may be useful in the identification of women at risk of deterioration.

Authors’ reply re: ’Maternal transmission of SARS-COV-2 to the neonate, and possible routes for such transmission: A systematic review and critical analysis (Response to BJOG-20-1416)Kate F Walker1, Keelin O’Donoghue2, Nicky Grace3, Jon Dorling4, Jeannette L Comeau4, Wentao Li5 Jim G Thornton11Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham2The Irish Centre for Maternal and Child Health, University College Cork, Cork University Maternity Hospital, Cork, Ireland3 School of English, University of Nottingham4Department of Pediatrics, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada5Department of Obstetrics and Gynaecology, Monash University, Clayton, AustraliaThank you for the opportunity to comment on the letter by Dr Xue from Shanghai Jiao Tong University. We agree there are many weaknesses in the data we reviewed. Dr Xue has identified one. Others are the incomplete reporting of infant feeding and mother-child interactions, and the frequent lack of infant testing to confirm or refute the possibility of vertical transmission of COVID-19. Finally, although we simply provided summary totals, it would be statistically preferable to combine series using the Mantel-Haenszel method and calculate a relative risk. We judged that doing this in light of the uncertainties around the data which Dr Xue has identified, might give a spurious precision to our results. As he says, more work is needed. For now we think it remains reasonable to not regard COVID-19 in itself, as an indication for Caesarean, artificial feeding or separation, in the mother and baby’s interest.