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Carter J, Anumba D, Brigante L, Burden C, Draycott T, Gillespie S, Harlev-Lam B, Judge A, Lenguerrand E, Sheehan E, Thilaganathan B, Wilson H, Winter C, Viner M, Sandall J. The Tommy's Clinical Decision Tool, a device for reducing the clinical impact of placental dysfunction and preterm birth: protocol for a mixed-methods early implementation evaluation study. BMC Pregnancy Childbirth 2022; 22:639. [PMID: 35971107 PMCID: PMC9377101 DOI: 10.1186/s12884-022-04867-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 06/23/2022] [Indexed: 11/10/2022] Open
Abstract
Background
Disparities in stillbirth and preterm birth persist even after correction for ethnicity and social deprivation, demonstrating that there is wide geographical variation in the quality of care. To address this inequity, Tommy’s National Centre for Maternity Improvement developed the Tommy’s Clinical Decision Tool, which aims to support the provision of “the right care at the right time”, personalising risk assessment and care according to best evidence. This web-based clinical decision tool assesses the risk of preterm birth and placental dysfunction more accurately than current methods, and recommends best evidenced-based care pathways in a format accessible to both women and healthcare professionals. It also provides links to reliable sources of pregnancy information for women. The aim of this study is to evaluate implementation of Tommy’s Clinical Decision Tool in four early-adopter UK maternity services, to inform wider scale-up.
Methods
The Tommy’s Clinical Decision Tool has been developed involving maternity service users and healthcare professionals in partnership. This mixed-methods study will evaluate: maternity service user and provider acceptability and experience; barriers and facilitators to implementation; reach (whether particular groups are excluded and why), fidelity (degree to which the intervention is delivered as intended), and unintended consequences. Data will be gathered over 25 months through interviews, focus groups, questionnaires and through the Tommy’s Clinical Decision Tool itself. The NASSS framework (Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability) will inform data analysis. Discussion This paper describes the intervention, Tommy’s Clinical Decision Tool, according to TiDIER guidelines, and the protocol for the early adopter implementation evaluation study. Findings will inform future scale up. Trial registration This study was prospectively registered on the ISRCTN registry no. 13498237, on 31st January 2022.
Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04867-w.
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Affiliation(s)
- Jenny Carter
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, 10th Floor, North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK. .,Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.
| | - Dilly Anumba
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Department of Oncology and Metabolism, University of Sheffield, The Jessop Wing, Tree Root Walk, Sheffield, S10 2SF, UK
| | - Lia Brigante
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK
| | - Christy Burden
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Academic Women's Health Unit, University of Bristol, Bristol Medical School, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Tim Draycott
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Royal College of Obstetricians and Gynaecologists, 10-18 Union Street, London, SE1 1SZ, UK
| | - Siobhán Gillespie
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Department of Oncology and Metabolism, University of Sheffield, The Jessop Wing, Tree Root Walk, Sheffield, S10 2SF, UK
| | - Birte Harlev-Lam
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK
| | - Andrew Judge
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Translational Health Sciences, University of Bristol, Bristol Medical School, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Erik Lenguerrand
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Translational Health Sciences, University of Bristol, Bristol Medical School, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Elaine Sheehan
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Maternal Medicine Department, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, SW17 0QT, UK
| | - Basky Thilaganathan
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, SW17 0QT, UK.,Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK
| | - Hannah Wilson
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, 10th Floor, North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK
| | - Cathy Winter
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,PROMPT Maternity Foundation, Department of Women's Health, The Chilterns, Southmead Hospital, Bristol, BS10 5NB, UK
| | - Maria Viner
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK.,Mothers for Mothers, New Fulford Family Centre, Gatehouse Avenue, Bristol, BS13 9AQ, UK
| | - Jane Sandall
- Department of Women and Children's Health, School of Life Course and Population Sciences, King's College London, 10th Floor, North Wing, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.,Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists/Royal College of Midwives, 10-18 Union Street, London, SE1 1SZ, UK
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2
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Phung J, Williams KP, McAullife L, Martin WN, Flint C, Andrew B, Hyett J, Park F, Pennell CE. Vaginal progesterone for prevention of preterm birth in asymptomatic high-risk women with a normal cervical length: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2021; 35:7093-7101. [PMID: 34210207 DOI: 10.1080/14767058.2021.1943657] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: To determine whether vaginal progesterone reduces spontaneous preterm birth (sPTB) before 37 weeks in asymptomatic high-risk women with a singleton pregnancy and normal mid-gestation cervical length.Study design: Databases were searched (from inception to December 2020) with the search terms "progesterone" and "premature birth" or "preterm birth". Studies were screened and included if they assessed vaginal progesterone compared to placebo in women with normal cervical length. Data were pooled and synthesized in a meta-analysis using a random effects model.Data sources: MEDLINE and Embase databases.Study synthesis: Following PRISMA screening guidelines, data from 1127 women across three studies were available for synthesis. All studies had low risk of bias and were of high quality. The primary outcome was sPTB <37 weeks, with secondary outcomes of sPTB <34 weeks. Vaginal progesterone did not significantly reduce sPTB before 37 weeks, or before 34 weeks with a relative risk (RR) of 0.76 (95% CI 0.37-1.55, p = .45) and 0.51 (95% CI 0.12-2.13, p = .35), respectively.Conclusions: Vaginal progesterone does not decrease the risk of sPTB in high-risk singleton pregnancies with a normal mid-gestation cervical length.
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Affiliation(s)
- J Phung
- University of Newcastle, Newcastle, Australia.,Department of Maternity & Gynaecology, John Hunter Hospital, Newcastle, Australia
| | | | - L McAullife
- University of Newcastle, Newcastle, Australia
| | - W N Martin
- University of Newcastle, Newcastle, Australia
| | - C Flint
- University of Newcastle, Newcastle, Australia
| | - B Andrew
- Department of Maternity & Gynaecology, John Hunter Hospital, Newcastle, Australia
| | - J Hyett
- Sydney Institute for Women, Children and Families, Royal Prince Alfred Hospital, Sydney, Australia
| | - F Park
- Department of Maternity & Gynaecology, John Hunter Hospital, Newcastle, Australia
| | - C E Pennell
- University of Newcastle, Newcastle, Australia.,Department of Maternity & Gynaecology, John Hunter Hospital, Newcastle, Australia
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3
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Medley N, Cuthbert A, Crew R, Stewart L, Smith CT, Alfirevic Z. Developing a topic-based repository of clinical trial individual patient data: experiences and lessons learned from a pilot project. Syst Rev 2021; 10:162. [PMID: 34059123 PMCID: PMC8167976 DOI: 10.1186/s13643-021-01717-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Accepted: 05/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Building a dataset of individual participant data (IPD) for meta-analysis represents considerable research investment as well as collaboration across multiple institutions and researchers. Making arrangements to curate and share the dataset beyond the IPD meta-analysis project for which it was established, for reuse in future research projects, would maximise the value of this investment. METHODS Our aim was to establish the Cochrane repository for individual patient data from clinical trials in pregnancy and childbirth (CRIB) as an example of how an IPD repository could become part of Cochrane infrastructure. We believed that establishing CRIB under Cochrane auspices would engender trust and encourage trial investigators to share data, and at the same time position Cochrane to take steps towards expanding the number of reviews with IPD synthesis. RESULTS CRIB was designed as a web-based platform to receive, host and facilitate onward sharing of de-identified data. Development was not straightforward and we did not fully achieve our aim as intended. We describe the challenges encountered and suggest ways that future repositories might overcome these. In particular, securing the legal agreements required to facilitate data sharing proved to be the main barrier, being time-consuming and more complex than anticipated. CONCLUSIONS We would recommend that researchers conducting IPD meta-analysis should consider discussing the option to transfer the curated IPD datasets to a repository at the end of the initial meta-analysis and this should be recognised within the data sharing agreements made with the original data contributors.
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Affiliation(s)
- Nancy Medley
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, UK
| | - Anna Cuthbert
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, UK
| | - Richard Crew
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Lesley Stewart
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Catrin Tudur Smith
- Department of Health Data Science, University of Liverpool, Liverpool, UK
| | - Zarko Alfirevic
- Cochrane Pregnancy and Childbirth, University of Liverpool, Liverpool, UK.
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4
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Simons NE, Leeuw M, van’t Hooft J, Limpens J, Roseboom TJ, Oudijk MA, Pajkrt E, Finken MJJ, Painter RC. The long-term effect of prenatal progesterone treatment on child development, behaviour and health: a systematic review. BJOG 2021; 128:964-974. [PMID: 33112462 PMCID: PMC8246867 DOI: 10.1111/1471-0528.16582] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Progesterone is widely used in prenatal care. However, long-term effects of prenatal progesterone treatment on child development are unclear. OBJECTIVES To evaluate long-term outcomes in children after prenatal progesterone treatment. SEARCH STRATEGY MEDLINE, Embase and Cochrane Central Register of Controlled Trials from inception to 24 May 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting outcomes in children born to women who received progesterone treatment (compared with placebo or another intervention) during any trimester in pregnancy. DATA COLLECTION AND ANALYSIS Two authors independently selected and extracted data. We used the Cochrane Risk of Bias tool for randomised trials and Quality In Prognosis Studies. MAIN RESULTS Of 388 papers, we included seven articles based on five RCTs, comprising 4222 measurements of children aged 6 months to 8 years. All studies compared progesterone to placebo in second and/or third trimester for the prevention of preterm birth. Meta-analysis (two studies, n = 890 children) showed no difference in neurodevelopment as assessed by the Bayley-III Cognitive Composite score at 2 years between children exposed to progesterone versus placebo (Standardised Mean Difference -0.04, 95% Confidence Interval -0.26 to 0.19), I2 = 22%. Heterogeneity prohibited additional meta-analyses. Other long-term outcomes showed no differences. CONCLUSIONS Our systematic review comprising a multitude of developmental measurements with a broad age range did not find evidence of benefit or harm in offspring prenatally exposed to progesterone treatment for the prevention of preterm birth. We identified an urgent need for follow-up studies of prenatal progesterone administration in early pregnancy and effects in offspring beyond early childhood. TWEETABLE ABSTRACT Progesterone to prevent preterm birth: no effect on child development. Outcomes after first trimester progesterone are unclear.
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Affiliation(s)
- NE Simons
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - M Leeuw
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - J van’t Hooft
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - J Limpens
- Medical LibraryResearch SupportAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - TJ Roseboom
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Epidemiology and Data ScienceAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - MA Oudijk
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - E Pajkrt
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - MJJ Finken
- Department of Paediatric EndocrinologyEmma Children’s HospitalAmsterdam UMCAmsterdamThe Netherlands
| | - RC Painter
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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5
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Stewart LA, Simmonds M, Duley L, Llewellyn A, Sharif S, Walker RAE, Beresford L, Wright K, Aboulghar MM, Alfirevic Z, Azargoon A, Bagga R, Bahrami E, Blackwell SC, Caritis SN, Combs CA, Croswell JM, Crowther CA, Das AF, Dickersin K, Dietz KC, Elimian A, Grobman WA, Hodkinson A, Maurel KA, McKenna DS, Mol BW, Moley K, Mueller J, Nassar A, Norman JE, Norrie J, O'Brien JM, Porcher R, Rajaram S, Rode L, Rouse DJ, Sakala C, Schuit E, Senat MV, Sharif S, Simmonds M, Simpson JL, Smith K, Tabor A, Thom EA, van Os MA, Whitlock EP, Wood S, Walley T. Evaluating Progestogens for Preventing Preterm birth International Collaborative (EPPPIC): meta-analysis of individual participant data from randomised controlled trials. Lancet 2021; 397:1183-1194. [PMID: 33773630 DOI: 10.1016/s0140-6736(21)00217-8] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 01/05/2021] [Accepted: 01/12/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes. METHODS We did a systematic review of randomised trials comparing vaginal progesterone, intramuscular 17-hydroxyprogesterone caproate (17-OHPC), or oral progesterone with control, or with each other, in asymptomatic women at risk of preterm birth. We identified published and unpublished trials that completed primary data collection before July 30, 2016, (12 months before data collection began), by searching MEDLINE, Embase, CINAHL, the Maternity and Infant Care Database, and relevant trial registers between inception and July 30, 2019. Trials of progestogen to prevent early miscarriage or immediately-threatened preterm birth were excluded. Individual participant data were requested from investigators of eligible trials. Outcomes included preterm birth, early preterm birth, and mid-trimester birth. Adverse neonatal sequelae associated with early births were assessed using a composite of serious neonatal complications, and individually. Adverse maternal outcomes were investigated as a composite and individually. Individual participant data were checked and risk of bias assessed independently by two researchers. Primary meta-analyses used one-stage generalised linear mixed models that incorporated random effects to allow for heterogeneity across trials. This meta-analysis is registered with PROSPERO, CRD42017068299. FINDINGS Initial searches identified 47 eligible trials. Individual participant data were available for 30 of these trials. An additional trial was later included in a targeted update. Data were therefore available from a total of 31 trials (11 644 women and 16185 offspring). Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0·78, 95% CI 0·68-0·90), 17-OHPC (five trials, 3053 women; 0·83, 0·68-1·01), and oral progesterone (two trials, 181 women; 0·60, 0·40-0·90). Results for other birth and neonatal outcomes were consistently favourable, but less certain. A possible increase in maternal complications was suggested, but this was uncertain. We identified no consistent evidence of treatment interaction with any participant characteristics examined, although analyses within subpopulations questioned efficacy in women who did not have a short cervix. Trials in multifetal pregnancies mostly included women without additional risk factors. For twins, vaginal progesterone did not reduce preterm birth before 34 weeks (eight trials, 2046 women: RR 1·01, 95% CI 0·84-1·20) nor did 17-OHPC for twins or triplets (eight trials, 2253 women: 1·04, 0·92-1·18). Preterm premature rupture of membranes was increased with 17-OHPC exposure in multifetal gestations (rupture <34 weeks RR 1·59, 95% CI 1·15-2·22), but we found no consistent evidence of benefit or harm for other outcomes with either vaginal progesterone or 17-OHPC. INTERPRETATION Vaginal progesterone and 17-OHPC both reduced birth before 34 weeks' gestation in high-risk singleton pregnancies. Given increased underlying risk, absolute risk reduction is greater for women with a short cervix, hence treatment might be most useful for these women. Evidence for oral progesterone is insufficient to support its use. Shared decision making with woman with high-risk singleton pregnancies should discuss an individual's risk, potential benefits, harms and practicalities of intervention. Treatment of unselected multifetal pregnancies with a progestogen is not supported by the evidence. FUNDING Patient-Centered Outcomes Research Institute.
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6
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Medley N, Donegan S, Nevitt SJ, Goodfellow L, Hampson L, Caldwell DM, Tudur Smith C, Alfirevic Z. Interventions to prevent spontaneous preterm birth in high‐risk women with singleton pregnancy: a systematic review and network meta‐analysis. Cochrane Database Syst Rev 2019; 2019:CD013455. [PMCID: PMC6812738 DOI: 10.1002/14651858.cd013455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To compare the efficacy of current, relevant interventions to prevent preterm birth in women with singleton pregnancy and high individual risk of spontaneous preterm birth. We will consider interventions for women with a history of spontaneous preterm birth or short cervical length and women with asymptomatic vaginal infections.
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Affiliation(s)
- Nancy Medley
- University of LiverpoolHarris‐Wellbeing Preterm Birth Research Centre, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Sarah Donegan
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesLiverpoolUKL3 5QA
| | - Sarah J Nevitt
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Laura Goodfellow
- The University of LiverpoolDepartment of Women's and Children's HealthCrown StreetLiverpoolUKL8 7SS
| | - Lynn Hampson
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Deborah M Caldwell
- University of BristolPopulation Health Sciences, Bristol Medical SchoolCanynge Hall, 39 Whatley RoadBristolUKBS8 2PS
| | - Catrin Tudur Smith
- University of LiverpoolDepartment of BiostatisticsBlock F, Waterhouse Building1‐5 Brownlow HillLiverpoolUKL69 3GL
| | - Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthCrown StreetLiverpoolUKL8 7SS
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7
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Goodfellow L, Care A, Sharp A, Ivandic J, Poljak B, Roberts D, Alfirevic Z. Effect of QUiPP prediction algorithm on treatment decisions in women with a previous preterm birth: a prospective cohort study. BJOG 2019; 126:1569-1575. [PMID: 31339631 DOI: 10.1111/1471-0528.15886] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE The QUiPP algorithm combines cervical length, quantitative fetal fibronectin (qfFN) and medical history to quantify risk of preterm birth. We assessed the utility of QUiPP to inform preterm birth prevention treatment decisions. DESIGN A prospective cohort study with a subsequent impact assessment using the QUiPP risk of birth before 34 weeks' gestation. SETTING A UK tertiary referral hospital. SAMPLE In all, 119 women with previous spontaneous preterm birth (sPTB) or preterm premature rupture of membranes (PPROM) before 34 weeks' gestation. METHODS Cervical length and qfFN were measured at 19+0 to 23+0 weeks' gestation. Clinical management was based on history and cervical length. After birth, clinicians were unblinded to qfFN results and QUiPP analysis was undertaken. MAIN OUTCOME MEASURES Predictive statistics of QUiPP algorithm using 10% risk of sPTB before 34+0 weeks as treatment threshold. RESULTS Fifteen of 119 women (13%) had PPROM or sPTB before 34 weeks. Of these, 53% (8/15) had QUiPP risk of sPTB before 34+0 weeks above 10%. Applying this treatment threshold in practice would have doubled our treatment rate (20 versus 42%). QUIPP threshold of 10% had positive likelihood ratio (LR) of 1.3 (95% CI 0.76-2.18), and negative LR of 0.8 (95% CI 0.45-1.40) for predicting sPTB before 34+0 weeks. CONCLUSIONS Use of the QUiPP algorithm in this population may lead to substantial increase in interventions without evidence that currently available treatment options are beneficial for this particular group. TWEETABLE ABSTRACT Independent study finds that the QUiPP algorithm could lead to substantial increases in treatment without evidence of benefit.
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Affiliation(s)
- L Goodfellow
- University of Liverpool and Liverpool Women's Hospital, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - A Care
- University of Liverpool and Liverpool Women's Hospital, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - A Sharp
- University of Liverpool and Liverpool Women's Hospital, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - J Ivandic
- University of Liverpool and Liverpool Women's Hospital, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - B Poljak
- Liverpool Health Partners, Liverpool, UK.,Liverpool Women's Hospital, Liverpool, UK
| | - D Roberts
- Liverpool Health Partners, Liverpool, UK.,Liverpool Women's Hospital, Liverpool, UK
| | - Z Alfirevic
- University of Liverpool and Liverpool Women's Hospital, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
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8
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Hallman M, Haapalainen A, Huusko JM, Karjalainen MK, Zhang G, Muglia LJ, Rämet M. Spontaneous premature birth as a target of genomic research. Pediatr Res 2019; 85:422-431. [PMID: 30353040 DOI: 10.1038/s41390-018-0180-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Revised: 08/20/2018] [Accepted: 08/23/2018] [Indexed: 01/23/2023]
Abstract
Spontaneous preterm birth is a serious and common pregnancy complication associated with hormonal dysregulation, infection, inflammation, immunity, rupture of fetal membranes, stress, bleeding, and uterine distention. Heredity is 25-40% and mostly involves the maternal genome, with contribution of the fetal genome. Significant discoveries of candidate genes by genome-wide studies and confirmation in independent replicate populations serve as signposts for further research. The main task is to define the candidate genes, their roles, localization, regulation, and the associated pathways that influence the onset of human labor. Genomic research has identified some candidate genes that involve growth, differentiation, endocrine function, immunity, and other defense functions. For example, selenocysteine-specific elongation factor (EEFSEC) influences synthesis of selenoproteins. WNT4 regulates decidualization, while a heat-shock protein family A (HSP70) member 1 like, HSPAIL, influences expression of glucocorticoid receptor and WNT4. Programming of pregnancy duration starts before pregnancy and during placentation. Future goals are to understand the interactive regulation of the pathways in order to define the clocks that influence the risk of prematurity and the duration of pregnancy. Premature birth has a great impact on the duration and the quality of life. Intensification of focused research on causes, prediction and prevention of prematurity is justified.
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Affiliation(s)
- Mikko Hallman
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, and Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.
| | - Antti Haapalainen
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, and Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Johanna M Huusko
- Division of Human Genetics, Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, March of Dimes Prematurity Research Center Ohio Collaborative, Cincinnati, OH, USA
| | - Minna K Karjalainen
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, and Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Ge Zhang
- Division of Human Genetics, Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, March of Dimes Prematurity Research Center Ohio Collaborative, Cincinnati, OH, USA
| | - Louis J Muglia
- Division of Human Genetics, Center for Prevention of Preterm Birth, Perinatal Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, March of Dimes Prematurity Research Center Ohio Collaborative, Cincinnati, OH, USA
| | - Mika Rämet
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, and Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
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9
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Medley N, Vogel JP, Care A, Alfirevic Z. Interventions during pregnancy to prevent preterm birth: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018; 11:CD012505. [PMID: 30480756 PMCID: PMC6516886 DOI: 10.1002/14651858.cd012505.pub2] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Preterm birth (PTB) is a major factor contributing to global rates of neonatal death and to longer-term health problems for surviving infants. Both the World Health Organization and the United Nations consider prevention of PTB as central to improving health care for pregnant women and newborn babies. Current preventative clinical strategies show varied efficacy in different populations of pregnant women, frustrating women and health providers alike, while researchers call for better understanding of the underlying mechanisms that lead to PTB. OBJECTIVES We aimed to summarise all evidence for interventions relevant to the prevention of PTB as reported in Cochrane systematic reviews (SRs). We intended to highlight promising interventions and to identify SRs in need of an update. METHODS We searched the Cochrane Database of Systematic Reviews (2 November 2017) with key words to capture any Cochrane SR that prespecified or reported a PTB outcome. Inclusion criteria focused on pregnant women without signs of preterm labour or ruptured amniotic membranes. We included reviews of interventions for pregnant women irrespective of their risk status. We followed standard Cochrane methods.We applied GRADE criteria to evaluate the quality of SR evidence. We assigned graphic icons to classify the effectiveness of interventions as: clear evidence of benefit; clear evidence of harm; clear evidence of no effect or equivalence; possible benefit; possible harm; or unknown benefit or harm. We defined clear evidence of benefit and clear evidence of harm to be GRADE moderate- or high-quality evidence with a confidence interval (CI) that does not cross the line of no effect. Clear evidence of no effect or equivalence is GRADE moderate- or high-quality evidence with a narrow CI crossing the line of no effect. Possible benefit and possible harm refer to GRADE low-quality evidence with a clear effect (CI does not cross the line of no effect) or GRADE moderate- or high-quality evidence with a wide CI. Unknown harm or benefit refers to GRADE low- or very low-quality evidence with a wide CI. MAIN RESULTS We included 83 SRs; 70 had outcome data. Below we highlight key results from a subset of 36 SRs of interventions intended to prevent PTB. OUTCOME preterm birthClear evidence of benefitFour SRs reported clear evidence of benefit to prevent specific populations of pregnant women from giving birth early, including midwife-led continuity models of care versus other models of care for all women; screening for lower genital tract infections for pregnant women less than 37 weeks' gestation and without signs of labour, bleeding or infection; and zinc supplementation for pregnant women without systemic illness. Cervical cerclage showed clear benefit for women with singleton pregnancy and high risk of PTB only.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, bedrest for women with singleton pregnancy and antibiotic prophylaxis during the second and third trimester were of no effect or equivalent to a comparator.Possible benefitFour SRs found possible benefit in: group antenatal care for all pregnant women; antibiotics for pregnant women with asymptomatic bacteriuria; pharmacological interventions for smoking cessation for pregnant women who smoke; and vitamin D supplements alone for women without pre-existing conditions such as diabetes.Possible harmOne SR reported possible harm (increased risk of PTB) with intramuscular progesterone, but this finding is only relevant to women with multiple pregnancy and high risk of PTB. Another review found possible harm with vitamin D, calcium and other minerals for pregnant women without pre-existing conditions. OUTCOME perinatal deathClear evidence of benefitTwo SRs reported clear evidence of benefit to reduce pregnant women's risk of perinatal death: midwife-led continuity models of care for all pregnant women; and fetal and umbilical Doppler for high-risk pregnant women.Clear evidence of harmNo included SR reported clear evidence of harm.No effect or equivalenceFor pregnant women at high risk of PTB, antibiotic prophylaxis during the second and third trimester was of no effect or equivalent to a comparator.Possible benefitOne SR reported possible benefit with cervical cerclage for women with singleton pregnancy and high risk of PTB.Possible harmOne SR reported possible harm associated with a reduced schedule of antenatal visits for pregnant women at low risk of pregnancy complications; importantly, these women already received antenatal care in settings with limited resources. OUTCOMES preterm birth and perinatal deathUnknown benefit or harmFor pregnant women at high risk of PTB for any reason including multiple pregnancy, home uterine monitoring was of unknown benefit or harm. For pregnant women at high risk due to multiple pregnancy: bedrest, prophylactic oral betamimetics, vaginal progesterone and cervical cerclage were all of unknown benefit or harm. AUTHORS' CONCLUSIONS Implications for practiceThe overview serves as a map and guide to all current evidence relevant to PTB prevention published in the Cochrane Library. Of 70 SRs with outcome data, we identified 36 reviews of interventions with the aim of preventing PTB. Just four of these SRs had evidence of clear benefit to women, with an additional four SRs reporting possible benefit. No SR reported clear harm, which is an important finding for women and health providers alike.The overview summarises no evidence for the clinically important interventions of cervical pessary, cervical length assessment and vaginal progesterone because these Cochrane Reviews were not current. These are active areas for PTB research.The graphic icons we assigned to SR effect estimates do not constitute clinical guidance or an endorsement of specific interventions for pregnant women. It remains critical for pregnant women and their healthcare providers to carefully consider whether specific strategies to prevent PTB will be of benefit for individual women, or for specific populations of women.Implications for researchFormal consensus work is needed to establish standard language for overviews of reviews and to define the limits of their interpretation.Clinicians, researchers and funders must address the lack of evidence for interventions relevant to women at high risk of PTB due to multiple pregnancy.
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Affiliation(s)
- Nancy Medley
- The University of LiverpoolCochrane Pregnancy and Childbirth Group, Department of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Joshua P Vogel
- Burnet InstituteMaternal and Child Health85 Commercial RoadMelbourneAustralia
| | - Angharad Care
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Zarko Alfirevic
- The University of LiverpoolDepartment of Women's and Children's HealthFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
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