Prophylactic antibiotics for preventing infection after continence surgery in women with stress urinary incontinence

BACKGROUND

Surgical options for treating stress urinary incontinence (SUI) are usually explored after conservative interventions have failed. Surgeries fall into two categories: traditional techniques (open surgery) and minimally invasive procedures, such as laparoscopic procedures, midurethral sling and injections with urethral bulking agents. Postsurgery infections, such as infections of the surgical site or urinary tract, are common complications. To minimise the risk of postoperative bacterial infections, prophylactic antibiotics may be given before or during surgery.  OBJECTIVES: To assess the effects of prophylactic antibiotics for preventing infection following continence surgery in women with stress urinary incontinence.  SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register, which contains trials identified from CENTRAL, MEDLINE, MEDLINE In-Process, MEDLINE Epub Ahead of Print, CINAHL, ClinicalTrials.gov and WHO ICTRP; and handsearched journals and conference proceedings to 18 March 2021. We also searched the reference lists of relevant articles.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs assessing prophylactic antibiotics in women undergoing continence surgery to treat SUI.

DATA COLLECTION AND ANALYSIS

Two review authors selected potentially eligible trials, extracted data and assessed risk of bias. We expressed results as risk ratios (RR) for dichotomous outcomes and as mean differences (MD) for continuous outcomes, both with 95% confidence intervals (CIs). We assessed the certainty of evidence using the GRADE approach.

MAIN RESULTS

We identified one quasi-RCT and two RCTs, involving a total of 390 women. One study performed retropubic urethropexy surgery requiring a transverse suprapubic incision, while the other two studies performed midurethral sling surgery. It should be noted that none of the included studies clearly specified the timing of outcome assessment. We are very uncertain whether prophylactic antibiotics (cefazolin) have an effect on surgical site infections (RR 0.56, 95% CI 0.03 to 12.35; 2 studies, 85 women; very low-certainty evidence) or urinary tract infections or bacteriuria (RR 0.84, 95% CI 0.05 to 13.24; 2 studies, 85 women; very low-certainty evidence). The effect of prophylactic antibiotics (cefazolin) on febrile morbidity is also uncertain (RR 0.08, 95% CI 0.00 to 1.29; 2 studies, 85 women; very low-certainty evidence). We are very uncertain whether prophylactic antibiotics (cefazolin) have any effect on mesh exposure (RR 0.32, 95% CI 0.01 to 7.61; 1 study, 59 women; very low-certainty evidence). None of the three included studies described the assessment of adverse events from antibiotic use, sepsis or bacteraemia in their reports.

AUTHORS' CONCLUSIONS

Only limited data are available from the three included studies and, overall, the certainty of evidence was very low. Moreover, the three included studies evaluated different surgical procedures and dosages of antibiotic administration. Thus, there is insufficient evidence to support or refute the use of prophylactic antibiotics to prevent infection following anti-incontinence surgery. In addition, there were no data regarding adverse effects of prophylactic antibiotics. More RCTs are required.

Anaesthesia/analgesia for manual removal of retained placenta

BACKGROUND

As a retained placenta is a potential life-threatening obstetrical complication, effective and timely management is important. The estimated mortality rates from a retained placenta in developing countries range from 3% to 9%. One possible factor contributing to the high mortality rates is a delay in initiating manual removal of the placenta. Effective anaesthesia or analgesia during this procedure will provide adequate uterine relaxation and pain control, enabling it to be carried out effectively.

OBJECTIVES

To assess the effectiveness and safety of general, regional, and local anaesthesia or analgesia during manual removal of a retained placenta.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform to 30 September 2019, and reference lists of retrieved studies.

SELECTION CRITERIA

We sought randomised controlled trials (RCTs), quasi-randomised controlled trials, and cluster-randomised trials that compared different methods of preoperative or intraoperative anaesthetic or analgesic, administered during the manual removal of a retained placenta.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the study reports for inclusion, and risk of bias, extracted data and checked them for accuracy. We followed standard Cochrane methodology.

MAIN RESULTS

We identified only one randomised controlled trial (N = 30 women) that evaluated the effect of paracervical block on women undergoing manual removal of a retained placenta compared with intravenous pethidine and diazepam. The study was conducted in a hospital in Papua New Guinea. The study was at high risk of bias of performance bias and detection bias, low risk of attrition bias, and an unclear risk of selection bias, reporting bias, and other bias. The included study did not measure this review's primary outcomes of pain intensity and adverse events. The study reported that there were no women, in either group, who experienced an estimated postpartum blood loss of more than 500 mL. We are uncertain about the providers' satisfaction with the procedure, defined as their perception of achieving good pain relief during the procedure (risk ratio (RR) 1.50, 95% confidence interval (CI) 0.71 to 3.16, one study, 30 women; very low quality evidence). We are also uncertain about the women's satisfaction with the procedure, defined as their perception of achieving good pain relief during the procedure (RR 0.82, 95% CI 0.49 to 1.37; one study, 30 women; very low quality evidence). The included study did not report on any of our other outcomes of interest.

AUTHORS' CONCLUSIONS

There is insufficient evidence from one small study to evaluate the effectiveness and safety of anaesthesia or analgesia during the manual removal of a retained placenta. The quality of the available evidence was very low. We downgraded based on issues of limitations in study design (risk of bias) and imprecision (single study with small sample size, few or no events, and wide confidence intervals). There is a need for well-designed, multi-centre, randomised, controlled trials to evaluate the effectiveness and safety of different types of anaesthesia and analgesia during manual removal of a retained placenta. These studies could report on the important outcomes outlined in this review.

Early-Onset Neonatal Sepsis and Antibiotic Use in Northeast Thailand

OBJECTIVE

Antibiotics are commonly prescribed in neonatal intensive care units (NICUs) for suspected sepsis because of the nonspecific clinical symptoms of sepsis. The overuse of antibiotic is associated with adverse outcomes. This study aimed to determine the rate of early-onset sepsis (EOS) and antibiotic use in neonates admitted to three NICUs in Northeast Thailand STUDY DESIGN:  This is a descriptive study using the data collected in the South East Asia-Using Research for Change in Hospital-acquired Infection in Neonates project. Neonates admitted within 3 days of life were included. EOS was defined as neonates who presented with three or more clinical signs or laboratory results suggested sepsis and received antibiotics for at least 5 days. Those with positive blood culture were culture-proven EOS. Antibiotic use within 3 days of life and up to 28 days was described.

RESULTS

Among 1,897 neonates, 160 cases were classified as EOS (8.4%) with culture-proven EOS in 4 cases (0.2%). The median durations of antibiotic use in culture-proven and culture-negative EOSs were 15 and 8 days, respectively.

CONCLUSION

The rate of culture-proven EOS was low, but there was a high rate of antibiotic use. Antibiotic stewardship should be emphasized.

An outcome-based definition of low birthweight for births in low- and middle-income countries: a secondary analysis of the WHO global survey on maternal and perinatal health

Background

2500 g has been used worldwide as the definition of low birthweight (LBW) for almost a century. While previous studies have used statistical approaches to define LBW cutoffs, a LBW definition using an outcome-based approach has not been evaluated. We aimed to identify an outcome-based definition of LBW for live births in low- and middle-income countries (LMICs), using data from a WHO cross-sectional survey on maternal and perinatal health outcomes in 23 countries.

Methods

We performed a secondary analysis of all singleton live births in the WHO Global Survey (WHOGS) on Maternal and Perinatal Health, conducted in African and Latin American countries (2004–2005) and Asian countries (2007–2008). We used a two-level logistic regression model to assess the risk of early neonatal mortality (ENM) associated with subgroups of birthweight (< 1500 g, 1500–2499 g with 100 g intervals; 2500–3499 g as the reference group). The model adjusted for potential confounders, including maternal complications, gestational age at birth, mode of birth, fetal presentation and facility capacity index (FCI) score. We presented adjusted odds ratios (aORs) with 95% confidence intervals (CIs). A lower CI limit of at least two was used to define a clinically important definition of LBW.

Results

We included 205,648 singleton live births at 344 facilities in 23 LMICs. An aOR of at least 2.0 for the ENM outcome was observed at birthweights below 2200 g (aOR 3.8 (95% CI; 2.7, 5.5) of 2100–2199 g) for the total population. For Africa, Asia and Latin America, the 95% CI lower limit aORs of at least 2.0 were observed when birthweight was lower than 2200 g (aOR 3.6 (95% CI; 2.0, 6.5) of 2100–2199 g), 2100 g (aOR 7.4 (95% CI; 5.1, 10.7) of 2000–2099 g) and 2200 g (aOR 6.1 (95% CI; 3.4, 10.9) of 2100–2199 g) respectively.

Conclusion

A birthweight of less than 2200 g may be an outcome-based threshold for LBW in LMICs. Regional-specific thresholds of low birthweight (< 2200 g in Africa, < 2100 g in Asia and < 2200 g in Latin America) may also be warranted.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1546-z) contains supplementary material, which is available to authorized users.

Interventions for intra-operative pain relief during postpartum mini-laparotomy tubal ligation

BACKGROUND

Postpartum mini-laparotomy tubal ligation (PPTL) is a contraceptive method that works by interrupting the patency of the fallopian tubes. Several methods are used for intraoperative pain relief, such as systemic administration of opioids or intraperitoneal instillation of lidocaine.

OBJECTIVES

To evaluate the effectiveness of and adverse effects associated with interventions for pain relief in women undergoing PPTL.

SEARCH METHODS

We searched for eligible studies published on or before 31 July 2017 in the CENTRAL Register of Studies Online, MEDLINE, Embase, PsycINFO, and CINAHL. We examined review articles and searched registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCT) that compared perioperative pain relief measures during PPTL.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles, abstracts, and full-text articles of potentially relevant studies for inclusion. We extracted the data from the included studies, assessed risk of bias, and calculated and compared results. Discrepancies were resolved by discussion, or by consulting a third review author. We computed the inverse variance risk ratio (RR) with 95% confidence interval (CI) for binary outcomes, and the mean difference (MD) with 95% CI for continuous variables.

MAIN RESULTS

We found only three RCTs, in which a total of 230 postpartum women participated. Most of our analyses were based on relatively small numbers of patients and studies. Overall, the certainty of evidence regarding the effectiveness of interventions was low, due to risk of bias and imprecision. We found very low-certainty evidence regarding the safety of interventions because of risk of bias and imprecision. Two studies had unclear risk of selection bias. One study had unclear risk of reporting bias and a high risk of other bias associated with the study protocol.Women who received an intraperitoneal instillation of lidocaine experienced lower intensity intraperitoneal pain than those given a placebo (pooled MD -3.34, 95% CI -4.19 to -2.49, three studies, 190 participants, low-certainty evidence), or an intramuscular injection of morphine (MD -4.8, 95% CI -6.43 to -3.17, one study, 40 participants, low-certainty evidence). We found no clear difference in intraperitoneal pain between women who had an intramuscular injection of morphine added to an intraperitoneal instillation of lidocaine and those who had an intraperitoneal instillation of lidocaine alone (MD -0.40, 95% CI -1.52 to 0.72, one study, 40 participants, low-certainty evidence). An intramuscular injection of morphine alone was not effective for intraperitoneal pain relief compared to placebo (MD 0.50, 95% CI -1.33 to 2.33, one study, 40 women, low-certainty evidence). None of the studies reported any serious adverse events but the evidence was very low-certainty. Intraperitoneal instillation of lidocaine may reduce the number of women requiring additional pain control when compared to placebo (RR 0.27, 95% CI 0.17 to 0.44, three studies, 190 women, low-certainty evidence).

AUTHORS' CONCLUSIONS

An intraperitoneal instillation of lidocaine during postpartum mini-laparotomy tubal ligation before fallopian tubes were tied may offer better intraperitoneal pain control, although the evidence regarding adverse effects is uncertain. We found no clear difference in intraperitoneal pain between women who received a combination of an injection of morphine, and intraperitoneal instillation of lidocaine and those who received an intraperitoneal instillation of lidocaine alone. These results must be interpreted with caution, since the evidence overall was low to very low-certainty.

Global, regional, and national estimates of levels of preterm birth in 2014: a systematic review and modelling analysis

BACKGROUND

Preterm birth is the leading cause of death in children younger than 5 years worldwide. Although preterm survival rates have increased in high-income countries, preterm newborns still die because of a lack of adequate newborn care in many low-income and middle-income countries. We estimated global, regional, and national rates of preterm birth in 2014, with trends over time for some selected countries.

METHODS

We systematically searched for data on preterm birth for 194 WHO Member States from 1990 to 2014 in databases of national civil registration and vital statistics (CRVS). We also searched for population-representative surveys and research studies for countries with no or limited CRVS data. For 38 countries with high-quality data for preterm births in 2014, data are reported directly. For countries with at least three data points between 1990 and 2014, we used a linear mixed regression model to estimate preterm birth rates. We also calculated regional and global estimates of preterm birth for 2014.

FINDINGS

We identified 1241 data points across 107 countries. The estimated global preterm birth rate for 2014 was 10·6% (uncertainty interval 9·0-12·0), equating to an estimated 14·84 million (12·65 million-16·73 million) live preterm births in 2014. 12· 0 million (81·1%) of these preterm births occurred in Asia and sub-Saharan Africa. Regional preterm birth rates for 2014 ranged from 13·4% (6·3-30·9) in North Africa to 8·7% (6·3-13·3) in Europe. India, China, Nigeria, Bangladesh, and Indonesia accounted for 57·9 million (41×4%) of 139·9 million livebirths and 6·6 million (44×6%) of preterm births globally in 2014. Of the 38 countries with high-quality data, preterm birth rates have increased since 2000 in 26 countries and decreased in 12 countries. Globally, we estimated that the preterm birth rate was 9×8% (8×3-10×9) in 2000, and 10×6% (9×0-12×0) in 2014.

INTERPRETATION

Preterm birth remains a crucial issue in child mortality and improving quality of maternal and newborn care. To better understand the epidemiology of preterm birth, the quality and volume of data needs to be improved, including standardisation of definitions, measurement, and reporting.

FUNDING

WHO and the March of Dimes.

Non-clinical interventions for reducing unnecessary caesarean section

BACKGROUND

Caesarean section rates are increasing globally. The factors contributing to this increase are complex, and identifying interventions to address them is challenging. Non-clinical interventions are applied independently of a clinical encounter between a health provider and a patient. Such interventions may target women, health professionals or organisations. They address the determinants of caesarean births and could have a role in reducing unnecessary caesarean sections. This review was first published in 2011. This review update will inform a new WHO guideline, and the scope of the update was informed by WHO's Guideline Development Group for this guideline.

OBJECTIVES

To evaluate the effectiveness and safety of non-clinical interventions intended to reduce unnecessary caesarean section.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers in March 2018. We also searched websites of relevant organisations and reference lists of related reviews.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series studies and repeated measures studies were eligible for inclusion. The primary outcome measures were: caesarean section, spontaneous vaginal birth and instrumental birth.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane. We narratively described results of individual studies (drawing summarised evidence from single studies assessing distinct interventions).

MAIN RESULTS

We included 29 studies in this review (19 randomised trials, 1 controlled before-after study and 9 interrupted time series studies). Most of the studies (20 studies) were conducted in high-income countries and none took place in low-income countries. The studies enrolled a mixed population of pregnant women, including nulliparous women, multiparous women, women with a fear of childbirth, women with high levels of anxiety and women having undergone a previous caesarean section.Overall, we found low-, moderate- or high-certainty evidence that the following interventions have a beneficial effect on at least one primary outcome measure and no moderate- or high-certainty evidence of adverse effects.Interventions targeted at women or familiesChildbirth training workshops for mothers alone may reduce caesarean section (risk ratio (RR) 0.55, 95% confidence interval (CI) 0.33 to 0.89) and may increase spontaneous vaginal birth (RR 2.25, 95% CI 1.16 to 4.36). Childbirth training workshops for couples may reduce caesarean section (RR 0.59, 95% CI 0.37 to 0.94) and may increase spontaneous vaginal birth (RR 2.13, 95% CI 1.09 to 4.16). We judged this one study with 60 participants to have low-certainty evidence for the outcomes above.Nurse-led applied relaxation training programmes (RR 0.22, 95% CI 0.11 to 0.43; 104 participants, low-certainty evidence) and psychosocial couple-based prevention programmes (RR 0.53, 95% CI 0.32 to 0.90; 147 participants, low-certainty evidence) may reduce caesarean section. Psychoeducation may increase spontaneous vaginal birth (RR 1.33, 95% CI 1.11 to 1.61; 371 participants, low-certainty evidence). The control group received routine maternity care in all studies.There were insufficient data on the effect of the four interventions on maternal and neonatal mortality or morbidity.Interventions targeted at healthcare professionalsImplementation of clinical practice guidelines combined with mandatory second opinion for caesarean section indication slightly reduces the risk of overall caesarean section (mean difference in rate change -1.9%, 95% CI -3.8 to -0.1; 149,223 participants). Implementation of clinical practice guidelines combined with audit and feedback also slightly reduces the risk of caesarean section (risk difference (RD) -1.8%, 95% CI -3.8 to -0.2; 105,351 participants). Physician education by local opinion leader (obstetrician-gynaecologist) reduced the risk of elective caesarean section to 53.7% from 66.8% (opinion leader education: 53.7%, 95% CI 46.5 to 61.0%; control: 66.8%, 95% CI 61.7 to 72.0%; 2496 participants). Healthcare professionals in the control groups received routine care in the studies. There was little or no difference in maternal and neonatal mortality or morbidity between study groups. We judged the certainty of evidence to be high.Interventions targeted at healthcare organisations or facilitiesCollaborative midwifery-labourist care (in which the obstetrician provides in-house labour and delivery coverage, 24 hours a day, without competing clinical duties), versus a private practice model of care, may reduce the primary caesarean section rate. In one interrupted time series study, the caesarean section rate decreased by 7% in the year after the intervention, and by 1.7% per year thereafter (1722 participants); the vaginal birth rate after caesarean section increased from 13.3% before to 22.4% after the intervention (684 participants). Maternal and neonatal mortality were not reported. We judged the certainty of evidence to be low.We studied the following interventions, and they either made little or no difference to caesarean section rates or had uncertain effects.Moderate-certainty evidence suggests little or no difference in caesarean section rates between usual care and: antenatal education programmes for physiologic childbirth; antenatal education on natural childbirth preparation with training in breathing and relaxation techniques; computer-based decision aids; individualised prenatal education and support programmes (versus written information in pamphlet).Low-certainty evidence suggests little or no difference in caesarean section rates between usual care and: psychoeducation; pelvic floor muscle training exercises with telephone follow-up (versus pelvic floor muscle training without telephone follow-up); intensive group therapy (cognitive behavioural therapy and childbirth psychotherapy); education of public health nurses on childbirth classes; role play (versus standard education using lectures); interactive decision aids (versus educational brochures); labourist model of obstetric care (versus traditional model of obstetric care).We are very uncertain as to the effect of other interventions identified on caesarean section rates as the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

We evaluated a wide range of non-clinical interventions to reduce unnecessary caesarean section, mostly in high-income settings. Few interventions with moderate- or high-certainty evidence, mainly targeting healthcare professionals (implementation of guidelines combined with mandatory second opinion, implementation of guidelines combined with audit and feedback, physician education by local opinion leader) have been shown to safely reduce caesarean section rates. There are uncertainties in existing evidence related to very-low or low-certainty evidence, applicability of interventions and lack of studies, particularly around interventions targeted at women or families and healthcare organisations or facilities.

Processed electroencephalogram and evoked potential techniques for amelioration of postoperative delirium and cognitive dysfunction following non-cardiac and non-neurosurgical procedures in adults

BACKGROUND

Postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) may complicate a patient's postoperative recovery in several ways. Monitoring of processed electroencephalogram (EEG) or evoked potential (EP) indices may prevent or minimize POD and POCD, probably through optimization of anaesthetic doses.

OBJECTIVES

To assess whether the use of processed EEG or auditory evoked potential (AEP) indices (bispectral index (BIS), narcotrend index, cerebral state index, state entropy and response entropy, patient state index, index of consciousness, A-line autoregressive index, and auditory evoked potentials (AEP index)) as guides to anaesthetic delivery can reduce the risk of POD and POCD in non-cardiac surgical or non-neurosurgical adult patients undergoing general anaesthesia compared with standard practice where only clinical signs are used.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and clinical trial registry databases up to 28 March 2017. We updated this search in February 2018, but these results have not been incorporated in the review.

SELECTION CRITERIA

We included randomized or quasi-randomized controlled trials comparing any method of processed EEG or evoked potential techniques (entropy, BIS, AEP etc.) against a control group where clinical signs were used to guide doses of anaesthetics in adults aged 18 years or over undergoing general anaesthesia for non-cardiac or non-neurosurgical elective operations.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane. Our primary outcomes were: occurrence of POD; and occurrence of POCD. Secondary outcomes included: all-cause mortality; any postoperative complications; and postoperative length of stay. We used GRADE to assess the quality of evidence for each outcome.

MAIN RESULTS

We included six randomized controlled trials (RCTs) with 2929 participants comparing processed EEG or EP indices-guided anaesthesia with clinical signs-guided anaesthesia. There are five ongoing studies and one study awaiting classification.Anaesthesia administration guided by the indices from a processed EEG (bispectral index) probably reduces the risk of POD within seven days after surgery with risk ratio (RR) of 0.71 (95% CI 0.59 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) of 17, 95% CI 11 to 34; 2197 participants; 3 RCTs; moderate quality of evidence). Three trials also showed the lower rate of POCD at 12 weeks after surgery (RR 0.71, 95% CI 0.53 to 0.96; NNTB 38, 95% CI 21 to 289; 2051 participants; moderate-quality evidence), but it is uncertain whether processed EEG indices reduce POCD at one week (RR 0.84, 95% CI 0.69 to 1.02; 3 trials; 1989 participants; moderate-quality evidence), and at 52 weeks (RR 0.30, 95% CI 0.05 to 1.80; 1 trial; 59 participants; very low quality of evidence). There may be little or no effect on all-cause mortality (RR 1.01, 95% CI 0.62 to 1.64; 1 trial; 1155 participants; low-quality evidence). One trial suggested a lower risk of any postoperative complications with processed EEG (RR 0.51, 95% CI 0.37 to 0.71; 902 participants, moderate-quality evidence). There may be little or no effect on reduced postoperative length of stay (mean difference -0.2 days, 95% CI -2.02 to 1.62; 1155 participants; low-quality evidence).

AUTHORS' CONCLUSIONS

There is moderate-quality evidence that optimized anaesthesia guided by processed EEG indices could reduce the risk of postoperative delirium in patients aged 60 years or over undergoing non-cardiac surgical and non-neurosurgical procedures. We found moderate-quality evidence that postoperative cognitive dysfunction at three months could be reduced in these patients. The effect on POCD at one week and over one year after surgery is uncertain. There are no data available for patients under 60 years. Further blinded randomized controlled trials are needed to elucidate strategies for the amelioration of postoperative delirium and postoperative cognitive dysfunction, and their consequences such as dementia (including Alzheimer's disease (AD)) in both non-elderly (below 60 years) and elderly (60 years or over) adult patients. The one study awaiting classification and five ongoing studies may alter the conclusions of the review once assessed.

Prognostic models for complete recovery in ischemic stroke: a systematic review and meta-analysis

Background

Prognostic models have been increasingly developed to predict complete recovery in ischemic stroke. However, questions arise about the performance characteristics of these models. The aim of this study was to systematically review and synthesize performance of existing prognostic models for complete recovery in ischemic stroke.

Methods

We searched journal publications indexed in PUBMED, SCOPUS, CENTRAL, ISI Web of Science and OVID MEDLINE from inception until 4 December, 2017, for studies designed to develop and/or validate prognostic models for predicting complete recovery in ischemic stroke patients. Two reviewers independently examined titles and abstracts, and assessed whether each study met the pre-defined inclusion criteria and also independently extracted information about model development and performance. We evaluated validation of the models by medians of the area under the receiver operating characteristic curve (AUC) or c-statistic and calibration performance. We used a random-effects meta-analysis to pool AUC values.

Results

We included 10 studies with 23 models developed from elderly patients with a moderately severe ischemic stroke, mainly in three high income countries. Sample sizes for each study ranged from 75 to 4441. Logistic regression was the only analytical strategy used to develop the models. The number of various predictors varied from one to 11. Internal validation was performed in 12 models with a median AUC of 0.80 (95% CI 0.73 to 0.84). One model reported good calibration. Nine models reported external validation with a median AUC of 0.80 (95% CI 0.76 to 0.82). Four models showed good discrimination and calibration on external validation. The pooled AUC of the two validation models of the same developed model was 0.78 (95% CI 0.71 to 0.85).

Conclusions

The performance of the 23 models found in the systematic review varied from fair to good in terms of internal and external validation. Further models should be developed with internal and external validation in low and middle income countries.

Electronic supplementary material

The online version of this article (10.1186/s12883-018-1032-5) contains supplementary material, which is available to authorized users.

Management of pregnancy at and beyond 41 completed weeks of gestation in low-risk women: a secondary analysis of two WHO multi-country surveys on maternal and newborn health

BACKGROUND

The World Health Organization (WHO) recommends induction of labour (IOL) for women who have reached 41 completed weeks of pregnancy without spontaneous onset of labour. Many women with prolonged pregnancy and/or their clinicians elect not to induce, and chose either elective caesarean section (ECS) or expectant management (EM). This study intended to assess pregnancy outcomes of IOL, ECS and EM at and beyond 41 completed weeks.

METHODS

This study is a secondary analysis of the WHO Global Survey (WHOGS) and the WHO Multi-country Survey (WHOMCS) conducted in Africa, Asia, Latin America and the Middle East. There were 33,003 women with low risk singleton pregnancies at ≥41 completed weeks from 292 facilities in 21 countries. Multilevel logistic regression model was used to assess associations of different management groups with each pregnancy outcome accounted for hierarchical survey design. The results were presented by adjusted odds ratios (aORs) with 95% confidence intervals (CIs) after adjusting for age, education, marital status, parity, previous caesarean section (CS), birth weight, and facility capacity index score.

RESULTS

The prevalence of prolonged pregnancy at facility setting in WHOGS, WHOMCS and combined databases were 7.9%, 7.5% and 7.7% respectively. Regarding to maternal adverse outcomes, EM was significantly associated with decreased risk of CS rate consistently in both databases i.e. (aOR0.76; 95% CI: 0.66-0.87) in WHOGS, (aOR0.67; 95% CI: 0.59-0.76) in WHOMCS and (aOR0.70; 95% CI: 0.64-0.77) in combined database, compared to IOL. Regarding the adverse perinatal outcomes, ECS was significantly associated with increased risks of neonatal intensive care unit admission (aOR1.76; 95% CI: 1.28-2.42) in WHOMCS and (aOR1.51; 95% CI: 1.19-1.92) in combined database compared to IOL but not significant in WHOGS database.

CONCLUSIONS

Compared to IOL, ECS significantly increased risk of NICU admission while EM was significantly associated with decreased risk of CS. ECS should not be recommended for women at 41 completed weeks of pregnancy. However, the choice between IOL and EM should be cautiously considered since the available evidences are still quite limited.

Immediate versus delayed postpartum insertion of contraceptive implant for contraception

BACKGROUND

The spacing of pregnancies has a positive impact on maternal and newborn health. The progestin contraceptive implant, which is a long-acting, reversible method of contraception, has a well-established low failure rate that is compatible with tubal sterilization. The standard provision of contraceptive methods on the first postpartum visit may put some women at risk of unintended pregnancy, either due to loss to follow-up or having sexual intercourse prior to receiving contraception. Therefore, the immediate administration of contraception prior to discharge from the hospital that has high efficacy may improve contraceptive prevalence and prevent unintended pregnancy.

OBJECTIVES

To compare the initiation rate, effectiveness, and side effects of immediate versus delayed postpartum insertion of implant for contraception.

SEARCH METHODS

We searched for eligible studies up to 28 October 2016 in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and POPLINE. We examined review articles and contacted investigators. We also checked registers of ongoing clinical trials, citation lists of included studies, key textbooks, grey literature, and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We sought randomised controlled trials (RCTs) that compared immediate postpartum versus delayed insertion of contraceptive implant for contraception.

DATA COLLECTION AND ANALYSIS

Two review authors (JS, YW) independently screened titles and abstracts of the search results, and assessed the full-text articles of potentially relevant studies for inclusion. They extracted data from the included studies, assessed risk of bias, compared results, and resolved disagreements by consulting a third review author (PL or SK). We contacted investigators for additional data, where possible. We computed the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI) for binary outcomes and the mean difference (MD) with 95% CI for continuous variables.

MAIN RESULTS

Three studies that included 410 participants met the inclusion criteria of the review. We did not identify any ongoing trials. Two included studies were at low risk of selection, attrition, and reporting biases, but were at high risk of performance and detection biases due to the inability to blind participants to the intervention. One included study was at high risk of attrition bias. The overall quality of the evidence for each comparison ranged from very low to moderate; the main limitations were risk of bias and imprecision.Initiation rate of contraceptive implants at the first postpartum check-up visit was significantly higher in the immediate insertion group than in the delayed insertion group (RR 1.41, 95% CI 1.28 to 1.55; three studies, 410 participants; moderate quality evidence).There appeared to be little or no difference between the groups in the continuation rate of contraceptive implant used at six months after insertion (RR 1.02, 95% CI 0.93 to 1.11; two studies, 125 participants; low quality evidence) or at 12 months after insertion (RR 1.04; 95% CI 0.81 to 1.34; one study, 64 participants;very low quality evidence)Women who received an immediate postpartum contraceptive implant insertion had a higher mean number of days of abnormal vaginal bleeding within six weeks postpartum (MD 5.80 days, 95% CI 3.79 to 7.81; one study, 215 participants; low quality evidence) and a higher rate of other side effects in the first six weeks after birth (RR 2.06, 95% CI 1.38 to 3.06; one study, 215 participants; low quality evidence) than those who received a delayed postpartum insertion. There appeared to be little or no difference between the groups in heavy, irregular vaginal bleeding or associated severe cramping within 12 months (RR 1.01, 95% CI 0.72 to 1.44, one study, 64 participants;very low quality evidence).It was unclear whether there was any difference between the groups in scores for participant satisfaction on a 0-10 scale (MD -0.40, 95% CI -1.26 to 0.46, low quality evidence), or in rates of unintended pregnancy (RR 1.82, 95% CI 0.38 to 8.71, 1 RCT, 64 women, very low quality evidence) at 12 months, or in rate of breastfeeding rate at six months (RR 2.01, 95% CI 0.72 ro 5.63, 1 RCT, 64 women, very low quality evidence) rate did not differ significantly between the groups.

AUTHORS' CONCLUSIONS

Evidence from this review indicates that the rate of initiation of contraceptive implant at the first postpartum check-up visit was higher with immediate postpartum insertion than with delayed insertion. There appeared to be little or no difference between the groups in the continuation rate of contraceptive implant use at 6 months. It was unclear whether there was any difference between the groups in continuation of contraceptive use at 12 months or in the unintended pregnancy rate at 12 months.

Prevalence of early initiation of breastfeeding and determinants of delayed initiation of breastfeeding: secondary analysis of the WHO Global Survey

Early initiation of breastfeeding (EIBF) within 1 hour of birth can decrease neonatal death. However, the prevalence of EIBF is approximately 50% in many developing countries, and data remains unavailable for some countries. We conducted a secondary analysis using the WHO Global Survey on Maternal and Perinatal Health to identify factors hampering EIBF. We described the coverage of EIBF among 373 health facilities for singleton neonates for whom breastfeeding was initiated after birth. Maternal and facility characteristics of EIBF were compared to those of breastfeeding >1 hour after birth, and multiple logistic regression analysis was performed. In total, 244,569 singleton live births without severe adverse outcomes were analysed. The EIBF prevalence varied widely among countries and ranged from 17.7% to 98.4% (average, 57.6%). There was less intra-country variation for BFI <24 hours. After adjustment, EIBF was significantly lower among women with complications during pregnancy and caesarean delivery. Globally, EIBF varied considerably across countries. Maternal complications during pregnancy, caesarean delivery and absence of postnatal/neonatal care guidelines at hospitals may affect EIBF. Our findings suggest that to better promote EIBF, special support for breastfeeding promotion is needed for women with complications during pregnancy and those who deliver by caesarean section.

Behavioural interventions to promote workers' use of respiratory protective equipment

BACKGROUND

Respiratory hazards are common in the workplace. Depending on the hazard and exposure, the health consequences may include: mild to life-threatening illnesses from infectious agents, acute effects ranging from respiratory irritation to chronic lung conditions, or even cancer from exposure to chemicals or toxins. Use of respiratory protective equipment (RPE) is an important preventive measure in many occupational settings. RPE only offers protection when worn properly, when removed safely and when it is either replaced or maintained regularly. The effectiveness of behavioural interventions either directed at employers or organisations or directed at individual workers to promote RPE use in workers remains an important unanswered question.

OBJECTIVES

To assess the effects of any behavioural intervention either directed at organisations or at individual workers on observed or self-reported RPE use in workers when compared to no intervention or an alternative intervention.

SEARCH METHODS

We searched the Cochrane Work Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 07), MEDLINE (1980 to 12 August 2016), EMBASE (1980 to 20 August 2016) and CINAHL (1980 to 12 August 2016).

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled before and after (CBA) studies and interrupted time-series (ITS) comparing behavioural interventions versus no intervention or any other behavioural intervention to promote RPE use in workers.

DATA COLLECTION AND ANALYSIS

Four authors independently selected relevant studies, assessed risk of bias and extracted data. We contacted investigators to clarify information. We pooled outcome data from included studies where the studies were sufficiently similar.

MAIN RESULTS

We included 14 studies that evaluated the effect of training and education on RPE use, which involved 2052 participants. The included studies had been conducted with farm, healthcare, production line, office and coke oven workers as well as nursing students and people with mixed occupations. All included studies reported the effects of interventions as use of RPE, as correct use of RPE or as indirect measures of RPE use. We did not find any studies where the intervention was delivered and assessed at the whole organization level or in which the main focus was on positive or negative incentives. We rated the quality of the evidence for all comparisons as low to very low. Training versus no trainingOne CBA study in healthcare workers compared training with and without a fit test to no intervention. The study found that the rate of properly fitting respirators was not considerably different in the workers who had received training with a fit test (RR 1.17, 95% Confidence Interval (CI) 0.97 to 1.10) or training without a fit test (RR 1.16, 95% CI 0.95 to 1.42) compared to those who had no training. Two RCTs that evaluated training did not contribute to the analyses because of lack of data. Conventional training plus additions versus conventional training aloneOne cluster-randomised trial compared conventional training plus RPE demonstration versus training alone and reported no significant difference in appropriate use of RPE between the two groups (RR 1.41, 95% CI 0.96 to 2.07).One RCT compared interactive training with passive training, with an information screen, and an information book. The mean RPE performance score for the active group was not different from that of the passive group (MD 2.10, 95% CI -0.76 to 4.96). However, the active group scored significantly higher than the book group (MD 4.20, 95% CI 0.89 to 7.51) and the screen group (MD 7.00, 95% CI 4.06 to 9.94).One RCT compared computer-simulation training with conventional personal protective equipment (PPE) training but reported only results for donning and doffing full-body PPE. Education versus no educationOne RCT found that a multifaceted educational intervention increased the use of RPE (risk ratio (RR) 1.69, 95% CI 1.10 to 2.58) at three years' follow-up when compared to no intervention. However, there was no difference between intervention and control at one year's, two years' or four years' follow-up. Two RCTs did not report enough data to be included in the analysis.Four CBA studies evaluated the effectiveness of education interventions and found no effect on the frequency or correctness of RPE use, except in one study for the use of an N95 mask (RR 4.56, 95% CI 1.84 to 11.33, 1 CBA) in workers. Motivational interviewing versus traditional lecturesOne CBA study found that participants given motivational group interviewing-based safety education scored higher on a checklist measuring PPE use (MD 2.95, 95% CI 1.93 to 3.97) than control workers given traditional educational sessions.

AUTHORS' CONCLUSIONS

There is very low quality evidence that behavioural interventions, namely education and training, do not have a considerable effect on the frequency or correctness of RPE use in workers. There were no studies on incentives or organisation level interventions. The included studies had methodological limitations and we therefore need further large RCTs with clearer methodology in terms of randomised sequence generation, allocation concealment and assessor blinding, in order to evaluate the effectiveness of behavioural interventions for improving the use of RPE at both organisational and individual levels. In addition, further studies should consider some of the barriers to the successful use of RPE, such as experience of health risk, types of RPE and the employer's attitude to RPE use.

Antenatal breastfeeding education for increasing breastfeeding duration

BACKGROUND

Breast milk is well recognised as the best food source for infants. The impact of antenatal breastfeeding (BF) education on the duration of BF has not been evaluated.

OBJECTIVES

To assess the effectiveness of antenatal breastfeeding (BF) education for increasing BF initiation and duration.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register on 1 March 2016, CENTRAL (The Cochrane Library, 2016, Issue 3), MEDLINE (1966 to 1 March 2016) and Scopus (January 1985 to 1 March 2016). We contacted experts and searched reference lists of retrieved articles.

SELECTION CRITERIA

All identified published, unpublished and ongoing randomised controlled trials (RCTs) assessing the effect of formal antenatal BF education or comparing two different methods of formal antenatal BF education, on the duration of BF. We included RCTs that only included antenatal interventions and excluded those that combined antenatal and intrapartum or postpartum BF education components. Cluster-randomised trials were included in this review. Quasi-randomised trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

We assessed all potential studies identified as a result of the search strategy. Two review authors extracted data from each included study using the agreed form and assessed risk of bias. We resolved discrepancies through discussion. We assessed the quality of the evidence using the GRADE approach.

MAIN RESULTS

This review update includes 24 studies (10,056 women). Twenty studies (9789 women) contribute data to analyses. Most studies took place in high-income countries such as the USA, UK, Canada and Australia. In the first five comparisons, we display the included trials according to type of intervention without pooling data. For the 'Summary of findings' we pooled data for a summary effect.Five included studies were cluster-randomised trials: all of these adjusted data and reported adjustments as odds ratios (OR). We have analysed the data using the generic inverse variance method and presented results as odds ratios, because we were unable to derive a cluster-adjusted risk ratio from the published cluster-trial. We acknowledge that the use of odds ratio prevents the pooling of these cluster trials in our main analyses. One method of BF education with standard (routine) careThere were no group differences for duration of any BF in days or weeks. There was no evidence that interventions improved the proportion of women with any BF or exclusive BF at three or six months. Single trials of different interventions were unable to show that education improved initiation of BF, apart from one small trial at high risk of attrition bias. Many trial results marginally favoured the intervention but had wide confidence intervals crossing the line of no effect. BF complications such as mastitis and other BF problems were similar in treatment arms in single trials reporting these outcomes. Multiple methods of BF education versus standard careFor all trials included in this comparison we have presented the cluster-adjusted odds ratios as reported in trial publications. One three-arm study found the intervention of BF booklet plus video plus Lactation Consultant versus standard care improved the proportion of women exclusively BF at three months (OR 2.60, 95% CI 1.25 to 5.40; women = 159) and marginally at six months (OR 2.40, 95% CI 1.00 to 5.76; women = 175). For the same trial, an intervention arm without a lactation consultant but with the BF booklet and video did not have the same effect on proportion of women exclusively BF at three months (OR 1.80, 95% CI 0.80 to 4.05; women = 159) or six months (OR 0.90, 95% CI 0.30 to 2.70; women = 184). One study compared monthly BF sessions and weekly cell phone message versus standard care and reported improvements in the proportion of women exclusively BF at both three and six months (three months OR 1.80, 95% CI 1.10 to 2.95; women = 390; six months OR 2.40, 95% CI 1.40 to 4.11; women = 390). One study found monthly BF sessions and weekly cell phone messages improved initiation of BF over standard care (OR 2.61, 95% CI 1.61 to 4.24; women = 380). BF education session versus standard care, pooled analyses for 'Summary of findings' (SoF)This comparison does not include cluster-randomised trials reporting adjusted odds ratios. We did not downgrade any evidence for trials' lack of blinding; no trial had adequate blinding of staff and participants. The SoF table presents risk ratios for all outcomes analysed. For proportion of women exclusively BF there is no evidence that antenatal BF education improved BF at three months (RR 1.06, 95% CI 0.90 to 1.25; women = 822; studies = 3; moderate quality evidence) or at six months (RR 1.07, 95% CI 0.87 to 1.30; women = 2161; studies = 4; moderate quality evidence). For proportion of women with any BF there were no group differences in BF at three (average RR 0.98, 95% CI 0.82 to 1.18; women = 654; studies = 2; I² = 60%; low-quality evidence) or six months (average RR 1.05, 95% CI 0.90 to 1.23; women = 1636; studies = 4; I² = 61%; high-quality evidence). There was no evidence that antenatal BF education could improve initiation of BF (average RR 1.01, 95% CI 0.94 to 1.09; women = 3505; studies = 8; I² = 69%; high-quality evidence). Where we downgraded evidence this was due to small sample size or wide confidence intervals crossing the line of no effect, or both.There was insufficient data for subgroup analysis of mother's occupation or education.

AUTHORS' CONCLUSIONS

There was no conclusive evidence supporting any antenatal BF education for improving initiation of BF, proportion of women giving any BF or exclusively BF at three or six months or the duration of BF. There is an urgent need to conduct a high-quality, randomised controlled study to evaluate the effectiveness and adverse effects of antenatal BF education, especially in low- and middle-income countries. Evidence in this review is primarily relevant to high-income settings.

Deliberate hypotension with propofol under anaesthesia for functional endoscopic sinus surgery (FESS)

BACKGROUND

Functional endoscopic sinus surgery (FESS) is a minimally invasive technique that is used to treat chronic sinusitis. Small bleeding areas can reduce operative visibility and result in destruction of surrounding structures. Deliberate hypotension (lowering the mean arterial blood pressure to between 50 and 65 mm Hg in normotensive patients) using a range of pharmacological agents during general anaesthesia reduces blood loss in many operations. This review was originally published in 2013 and updated in February 2016.

OBJECTIVES

We aimed to compare the use of propofol versus other techniques for achieving deliberate intraoperative hypotension during FESS procedures with regard to blood loss and operative conditions.

SEARCH METHODS

We searched the following databases in the updated review: the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2), MEDLINE (1950 to February 2016), Embase (1980 to February 2016), LILACS (1982 to February 2016), and ISI Web of Science (1946 to February 2016). We also searched the reference lists of relevant articles and conference proceedings and contacted the authors of included trials.

SELECTION CRITERIA

We sought all randomized controlled trials comparing propofol with other techniques for deliberate hypotension during FESS with regard to blood loss and operative conditions in both adults and children. Our primary outcome was total blood loss (TBL). Other outcomes included surgical field quality, operation time, mortality within 24 hours, complications, and failure to reach target blood pressure.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently extracted details of trial methodology and outcome data from the reports of all trials considered eligible for inclusion. We made all analyses on an intention-to-treat basis where possible. When I2 was less than 40% and the P value from the Chi2 test was higher than 0.10, we pooled data using the fixed-effect model. Otherwise, we pooled data using the random-effects model.

MAIN RESULTS

We found no new studies. This updated review therefore includes four studies with 278 participants. Most analyses were based on data from few participants and low-quality evidence, so our results should be interpreted with caution. Deliberate hypotension with propofol did not decrease TBL (millilitres) when compared with inhalation anaesthetics in either children (1 study; 70 participants; very low-quality evidence), or adults (1 study; 88 participants; moderate-quality evidence). Propofol improved the quality of the surgical field by less than one category on a scale from 0 (no bleeding) to 5 (severe bleeding) (mean difference -0.64, 95% CI -0.91 to -0.37; 4 studies; 277 participants; low-quality evidence), but no difference in operation time was reported (3 studies; 214 participants; low-quality evidence). Failure to lower blood pressure to target was less common in the propofol group (risk ratio of failure with propofol 0.24, 95% CI 0.09 to 0.66; 1 study; 88 participants; moderate-quality evidence).

AUTHORS' CONCLUSIONS

Using propofol to achieve deliberate hypotension probably improves the surgical field, but the effect is small. Deliberate hypotension with propofol did not decrease TBL and the operation time. However, due to the very low quality of the evidence, this conclusion is not definitive. Randomized controlled trials with good-quality methodology and large sample size are required to investigate the effectiveness of deliberate hypotension with propofol for FESS.

Meta-analyses involving cluster randomization trials: a review of published literature in health care

Throughout the 1980s and 1990s cluster randomization trials have been increasingly used to evaluate effectivenessof health care intervention. Such trials have raised several methodologic challenges in analysis. Meta-analyses involving cluster randomization trials are becoming common in the area of health care intervention. However, as yet there has been no empirical evidence of current practice in the meta-analyses. Thus a review was performed to identify and examine synthesis approaches of meta-analyses involving cluster randomization trials in the published literature. Electronic databases were searched for meta-analyses involving cluster randomization trials from the earliest date available to 2000. Once a meta-analysis was identified, papers on the relevant cluster randomization trials included were also requested. Each of the original papers of cluster randomization trials included was examined for its randomized design and unit, and adjustment for clustering effect in analysis. Each of the selected meta-analyses was then evaluated as to its synthesis concerning clustering effect. In total, 25 eligible meta-analyses were reviewed. Of these, 15 meta-analyses reported simple conventional methods of the fixed-effect model as method of analysis, while six did not incorporate the cluster randomization trial results in the synthesis methods but described the trial results individually. Three meta-analyses attempted to account for the clustering effect in the synthesis methods but approaches were in arbitrary. Fifteen meta-analyses included more than one cluster randomization trial, each of which included cluster randomization trials with a mixture of randomized designs and units, and units of analysis. These mixture situations might increase heterogeneity, but have not been considered in any meta-analysis. Some methods dealing with a binary outcome for some specific situations have been discussed. In conclusion, some difficulties in the quantitative synthesis procedures were found in the meta-analyses involving cluster randomization trials. Recommendations in the applications of approaches to some specific situations in a binary outcome variable have also been provided. There are still, however, several methodologic issues of the meta-analyses involving cluster randomization trials that need to be investigated further.

Global, regional and national levels and trends of preterm birth rates for 1990 to 2014: protocol for development of World Health Organization estimates

Background

The official WHO estimates of preterm birth are an essential global resource for assessing the burden of preterm birth and developing public health programmes and policies. This protocol describes the methods that will be used to identify, critically appraise and analyse all eligible preterm birth data, in order to develop global, regional and national level estimates of levels and trends in preterm birth rates for the period 1990 – 2014.

Methods

We will conduct a systematic review of civil registration and vital statistics (CRVS) data on preterm birth for all WHO Member States, via national Ministries of Health and Statistics Offices. For Member States with absent, limited or lower-quality CRVS data, a systematic review of surveys and/or research studies will be conducted. Modelling will be used to develop country, regional and global rates for 2014, with time trends for Member States where sufficient data are available. Member States will be invited to review the methodology and provide additional eligible data via a country consultation before final estimates are developed and disseminated.

Discussion

This research will be used to generate estimates on the burden of preterm birth globally for 1990 to 2014. We invite feedback on the methodology described, and call on the public health community to submit pertinent data for consideration.

Trial registration

Registered at PROSPERO CRD42015027439

Contact: pretermbirth@who.int

WITHDRAWN: Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults

Review withdrawn from Issue 4, 2016. Review replaced by 'Systemic and topical antibiotics for chronic rhinosinusitis' (Head 2016).

The editorial group responsible for this previously published document have withdrawn it from publication.

Pharmacological interventions for generalised itching (not caused by systemic disease or skin lesions) in pregnancy

BACKGROUND

Generalised itching is one of the most common dermatological symptoms in pregnant women. Having itchy skin during pregnancy may be very frustrating and can lead to poor sleep, exhaustion and impaired quality of life. There is a need for a systematic review to evaluate the effectiveness and safety of pharmacological interventions for treating itching in pregnancy.

OBJECTIVES

To assess the effectiveness and safety of pharmacological interventions for treating generalised itching (not caused by systemic diseases or skin lesions) in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2016) and the reference list of the one identified study.

SELECTION CRITERIA

All published, unpublished and ongoing randomised controlled trials (RCTs) evaluating interventions for itching in pregnancy.Quasi-RCTs, cluster-RCTs, RCTs using a cross-over design, and studies reported in abstract form (without full text) were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the one trial report that was identified from the search strategy and this was subsequently excluded.

MAIN RESULTS

There are no included studies as we did not identify any relevant trials.

AUTHORS' CONCLUSIONS

Generalised itching (not caused by systemic disease or skin lesions) is quite a common symptom in pregnancy. However, there is no evidence from randomised controlled trials to guide practice in terms of the effectiveness and safety of pharmacological interventions for treating this condition.Well-designed randomised controlled trials are needed in order to evaluate the effectiveness of topical and systemic pharmacological interventions as well as any adverse effects of the interventions. Such studies should consider important outcomes such as relief of itching, women's satisfaction, sleep disturbance, and adverse effects.

Effectiveness of tranexamic acid in reducing blood loss during cytoreductive surgery for advanced ovarian cancer

BACKGROUND

Ovarian cancer is the third most common gynaecological cancer worldwide, with an age-standardised incidence rate of 6.1 per 10,000 women. Standard therapy for advanced epithelial ovarian cancer (EOC) includes a combination of cytoreductive surgery and platinum-based chemotherapy. Cytoreductive surgery aims to remove as much of the visible tumour as possible. As extensive intraperitoneal metastases are typical of advanced EOC, cytoreductive surgery is usually an extensive procedure with the risk of excessive bleeding. Tranexamic acid given perioperatively is effective in reducing blood loss and allogeneic blood transfusion requirements in a variety of surgical settings. Therefore, tranexamic acid seems to be a promising agent for minimising blood loss and the need for blood transfusion among women with advanced EOC undergoing cytoreductive surgery.

OBJECTIVES

To assess the effects of tranexamic acid for reducing blood loss associated with cytoreductive surgery in women with advanced EOC (stage III to IV).

SEARCH METHODS

We searched the Cochrane Gynaecological, Neuro-oncology and Orphan Cancers Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 5, 2015), MEDLINE, EMBASE and conference proceedings to May 2015. We also checked registers of clinical trials, citation lists of included studies, key textbooks and previous systematic reviews for potentially relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing tranexamic acid given during surgery versus placebo or no treatment, in adult women diagnosed with advanced EOC.

DATA COLLECTION AND ANALYSIS

Two review authors (CK, AS) independently selected potentially relevant trials, extracted data, assessed risk of bias, compared results and resolved disagreements by discussion.

MAIN RESULTS

We found only one study that met our inclusion criteria. This was a randomised double blind, placebo-controlled multicentre study conducted to evaluate the effectiveness of a single dose of intravenous tranexamic acid (15 mg/kg body weight) versus placebo, given immediately before surgery for reducing blood loss and the need for red blood cell transfusion. The mean total estimated blood loss was 668.34 mL and 916.93 mL for participants assigned to tranexamic acid and placebo groups, respectively. The mean difference (MD) of total estimated blood loss between the groups did not show a clinically important effect (MD - 248.59 mL; 95% confidence interval (CI) - 550.9 to 53.79; one study, 100 participants; moderate quality evidence). The mean number of transfused units of blood components was not different between the two groups (low quality evidence). There were no noted differences in the incidence of reoperation, readmission or thromboembolic events (very low quality evidence). We considered the methodology of the included study to be at low risk of selection, detection, and reporting biases. However, we were concerned about an imbalance of some baseline characteristics between the groups, and as there was no protocol for blood transfusion, the rate of blood transfusion may vary depending on the practice of each participating hospital.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence to recommend the routine use of tranexamic acid for reducing blood loss in women undergoing cytoreductive surgery for advanced EOC, as only limited data are available from a single, low quality RCT at low overall risk of bias.

Interval debulking surgery for advanced epithelial ovarian cancer

BACKGROUND

Interval debulking surgery (IDS), following induction or neoadjuvant chemotherapy, may have a role in treating advanced epithelial ovarian cancer (stage III to IV) where primary debulking surgery is not an option.

OBJECTIVES

To assess the effectiveness and complications of IDS for women with advanced stage epithelial ovarian cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group's Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) 2012, Issue 6, MEDLINE and EMBASE for the original review in to June 2012. We updated the searches in June 2009, 2012 and 2015 for the review updates.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing survival of women with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of women who had conventional treatment (primary debulking surgery and adjuvant chemotherapy).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Searches for additional information from study authors were attempted. We performed meta-analysis of overall and progression-free survival (PFS), using random-effects models.

MAIN RESULTS

Three RCTs randomising 853 women, of whom 781 were evaluated, met the inclusion criteria. Meta-analysis of three trials for overall survival (OS) found no statistically significant difference between IDS and chemotherapy alone (hazard ratio (HR) = 0.80, 95% confidence interval (CI) 0.61 to 1.06, I² = 58%). Subgroup analysis for OS in two trials, where the primary surgery was not performed by gynaecologic oncologists or was less extensive, showed a benefit of IDS (HR = 0.68, 95% CI 0.53 to 0.87, I² = 0%). Meta-analysis of two trials for PFS found no statistically significant difference between IDS and chemotherapy alone (HR = 0.88, 95% CI 0.57 to 1.33, I² = 83%). Rates of toxic reactions to chemotherapy were similar in both arms (risk ratio = 1.19, 95% CI 0.53 to 2.66, I² = 0%), but little information was available for other adverse events or quality or life (QoL).

AUTHORS' CONCLUSIONS

We found no conclusive evidence to determine whether IDS between cycles of chemotherapy would improve or decrease the survival rates of women with advanced ovarian cancer, compared with conventional treatment of primary surgery followed by adjuvant chemotherapy. IDS appeared to yield benefit only in women whose primary surgery was not performed by gynaecologic oncologists or was less extensive. Data on QoL and adverse events were inconclusive.

Searching for the definition of macrosomia through an outcome-based approach in low- and middle-income countries: a secondary analysis of the WHO Global Survey in Africa, Asia and Latin America

Background

No consensus definition of macrosomia currently exists among researchers and obstetricians. We aimed to identify a definition of macrosomia that is more predictive of maternal and perinatal mortality and morbidity in low- and middle-income countries.

Methods

We conducted a secondary data analysis using WHO Global Survey on Maternal and Perinatal Health data on Africa and Latin America from 2004 to 2005 and Asia from 2007 to 2008. We compared adverse outcomes, which were assessed by the composite maternal mortality and morbidity index (MMMI) and perinatal mortality and morbidity index (PMMI) in subgroups with birthweight (3000–3499 g [reference group], 3500–3999 g, 4000–4099 g, 4100–4199 g, 4200–4299 g, 4300–4399 g, 4400–4499 g, 4500–4999 g) or country-specific birthweight percentile for gestational age (50^th–74^th percentile [reference group], 75^th–89^th, 90^th–94^th, 95^th–96^th, and ≥97^th percentile). Two-level logistic regression models were used to estimate odds ratios of MMMI and PMMI.

Results

A total of 246,659 singleton term births from 363 facilities in 23 low- and middle-income countries were included. Adjusted odds ratios (aORs) for intrapartum caesarean sections exceeded 2.0 when birthweight was greater than 4000 g (2 · 00 [95 % CI: 1 · 68, 2 · 39], 2 · 42 [95 % CI: 2 · 02, 2 · 89], 2 · 01 [95 % CI: 1 · 74, 2 · 33] in Africa, Asia and Latin America, respectively). aORs of MMMI reached 2.0 when birthweight was greater than 4000 g, 4500 g in Asia and Africa, respectively. aORs of PMMI approached to 2.0 (1 · 78 [95 % CI: 1 · 16, 2 · 74]) when birthweight was greater than 4500 g in Latin America. When birthweight was at the 90^th percentile or higher, aORs of MMMI and PMMI increased, but none exceeded 2.0.

Conclusions

The population-specific definition of macrosomia using birthweight cut-off points irrespective of gestational age (4500 g in Africa and Latin America, 4000 g in Asia) is more predictive of maternal and perinatal adverse outcomes, and simpler to apply compared to the definition based on birthweight percentile for a given gestational age.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-015-0765-z) contains supplementary material, which is available to authorized users.

Virtual reality training for improving the skills needed for performing surgery of the ear, nose or throat

BACKGROUND

Virtual reality simulation uses computer-generated imagery to present a simulated training environment for learners. This review seeks to examine whether there is evidence to support the introduction of virtual reality surgical simulation into ear, nose and throat surgical training programmes.

OBJECTIVES

1. To assess whether surgeons undertaking virtual reality simulation-based training achieve surgical ('patient') outcomes that are at least as good as, or better than, those achieved through conventional training methods.2. To assess whether there is evidence from either the operating theatre, or from controlled (simulation centre-based) environments, that virtual reality-based surgical training leads to surgical skills that are comparable to, or better than, those achieved through conventional training.

SEARCH METHODS

The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 6); PubMed; EMBASE; ERIC; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 27 July 2015.

SELECTION CRITERIA

We included all randomised controlled trials and controlled trials comparing virtual reality training and any other method of training in ear, nose or throat surgery.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration. We evaluated both technical and non-technical aspects of skill competency.

MAIN RESULTS

We included nine studies involving 210 participants. Out of these, four studies (involving 61 residents) assessed technical skills in the operating theatre (primary outcomes). Five studies (comprising 149 residents and medical students) assessed technical skills in controlled environments (secondary outcomes). The majority of the trials were at high risk of bias. We assessed the GRADE quality of evidence for most outcomes across studies as 'low'. Operating theatre environment (primary outcomes) In the operating theatre, there were no studies that examined two of three primary outcomes: real world patient outcomes and acquisition of non-technical skills. The third primary outcome (technical skills in the operating theatre) was evaluated in two studies comparing virtual reality endoscopic sinus surgery training with conventional training. In one study, psychomotor skill (which relates to operative technique or the physical co-ordination associated with instrument handling) was assessed on a 10-point scale. A second study evaluated the procedural outcome of time-on-task. The virtual reality group performance was significantly better, with a better psychomotor score (mean difference (MD) 1.66, 95% CI 0.52 to 2.81; 10-point scale) and a shorter time taken to complete the operation (MD -5.50 minutes, 95% CI -9.97 to -1.03). Controlled training environments (secondary outcomes) In a controlled environment five studies evaluated the technical skills of surgical trainees (one study) and medical students (three studies). One study was excluded from the analysis. Surgical trainees: One study (80 participants) evaluated the technical performance of surgical trainees during temporal bone surgery, where the outcome was the quality of the final dissection. There was no difference in the end-product scores between virtual reality and cadaveric temporal bone training. Medical students: Two other studies (40 participants) evaluated technical skills achieved by medical students in the temporal bone laboratory. Learners' knowledge of the flow of the operative procedure (procedural score) was better after virtual reality than conventional training (SMD 1.11, 95% CI 0.44 to 1.79). There was also a significant difference in end-product score between the virtual reality and conventional training groups (SMD 2.60, 95% CI 1.71 to 3.49). One study (17 participants) revealed that medical students acquired anatomical knowledge (on a scale of 0 to 10) better during virtual reality than during conventional training (MD 4.3, 95% CI 2.05 to 6.55). No studies in a controlled training environment assessed non-technical skills.

AUTHORS' CONCLUSIONS

There is limited evidence to support the inclusion of virtual reality surgical simulation into surgical training programmes, on the basis that it can allow trainees to develop technical skills that are at least as good as those achieved through conventional training. Further investigations are required to determine whether virtual reality training is associated with better real world outcomes for patients and the development of non-technical skills. Virtual reality simulation may be considered as an additional learning tool for medical students.

Interventions for treating constipation in pregnancy

BACKGROUND

Constipation is a common symptom experienced during pregnancy. It has a range of consequences from reduced quality of life and perception of physical health to haemorrhoids. An understanding of the effectiveness and safety of treatments for constipation in pregnancy is important for the clinician managing pregnant women.

OBJECTIVES

To assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (30 April 2015) and reference lists of retrieved studies.

SELECTION CRITERIA

We considered all published, unpublished and ongoing randomised controlled trials (RCTs), cluster-RCTs and quasi-RCTs, evaluating interventions (pharmacological and non-pharmacological) for constipation in pregnancy. Cross-over studies were not eligible for inclusion in this review. Trials published in abstract form only (without full text publication) were not eligible for inclusion.We compared one intervention (pharmacological or non-pharmacological) against another intervention, placebo or no treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Four studies were included, but only two studies with a total of 180 women contributed data to this review. It was not clear whether they were RCTs or quasi-RCTs because the sequence generation was unclear. We classified the overall risk of bias of three studies as moderate and one study as high risk of bias. No meta-analyses were carried out due to insufficient data.There were no cluster-RCTs identified for inclusion. Comparisons were available for stimulant laxatives versus bulk-forming laxatives, and fibre supplementation versus no intervention. There were no data available for any other comparisons.During the review process we found that studies reported changes in symptoms in different ways. To capture all data available, we added a new primary outcome (improvement in constipation) - this new outcome was not prespecified in our published protocol. Stimulant laxatives versus bulk-forming laxativesNo data were identified for any of this review's prespecified primary outcomes: pain on defecation, frequency of stools and consistency of stools.Compared to bulk-forming laxatives, pregnant women who received stimulant laxatives had significantly more improvement in constipation (risk ratio (RR) 1.59, 95% confidence interval (CI) 1.21 to 2.09; 140 women, one study, moderate quality of evidence), but also significantly more abdominal discomfort (RR 2.33, 95% CI 1.15 to 4.73; 140 women, one study, low quality of evidence), and borderline difference in diarrhoea (RR 4.50, 95% CI 1.01 to 20.09; 140 women, one study, moderate quality of evidence). In addition, there was no significant difference in women's satisfaction (RR 1.06, 95% CI 0.77 to 1.46; 140 women, one study, moderate quality of evidence).No usable data were identified for any of this review's secondary outcomes: quality of life; dehydration; electrolyte imbalance; acute allergic reaction; or asthma. Fibre supplementation versus no interventionPregnant women who received fibre supplementation had significantly higher frequency of stools compared to no intervention (mean difference (MD) 2.24 times per week, 95% CI 0.96 to 3.52; 40 women, one study, moderate quality of evidence). Fibre supplementation was associated with improved stool consistency as defined by trialists (hard stool decreased by 11% to 14%, normal stool increased by 5% to 10%, and loose stool increased by 0% to 6%).No usable data were reported for either the primary outcomes of pain on defecation and improvement in constipation or any of this review's secondary outcomes as listed above. Quality Five outcomes were assessed with the GRADE software: improvement in constipation, frequency of stools, abdominal discomfort, diarrhoea and women's satisfaction. These were assessed to be of moderate quality except for abdominal discomfort which was assessed to be of low quality. The results should therefore be interpreted with caution. There were no data available for evaluation of pain on defecation or consistency of stools.

AUTHORS' CONCLUSIONS

There is insufficient evidence to comprehensively assess the effectiveness and safety of interventions (pharmacological and non-pharmacological) for treating constipation in pregnancy, due to limited data (few studies with small sample size and no meta-analyses). Compared with bulk-forming laxatives, stimulant laxatives appear to be more effective in improvement of constipation (moderate quality evidence), but are accompanied by an increase in diarrhoea (moderate quality evidence) and abdominal discomfort (low quality evidence) and no difference in women's satisfaction (moderate quality evidence). Additionally, fibre supplementation may increase frequency of stools compared with no intervention (moderate quality evidence), although these results were of moderate risk of bias.There were no data for a comparison of other types of interventions, such as osmotic laxatives, stool softeners, lubricant laxatives and enemas and suppositories.More RCTs evaluating interventions for treating constipation in pregnancy are needed. These should cover different settings and evaluate the effectiveness of various interventions (including fibre, osmotic, and stimulant laxatives) on improvement in constipation, pain on defecation, frequency of stools and consistency of stools.

A global reference for caesarean section rates (C-Model): a multicountry cross-sectional study

Objective

To generate a global reference for caesarean section (CS) rates at health facilities.

Design

Cross‐sectional study.

Setting

Health facilities from 43 countries.

Population/Sample

Thirty eight thousand three hundred and twenty‐four women giving birth from 22 countries for model building and 10 045 875 women giving birth from 43 countries for model testing.

Methods

We hypothesised that mathematical models could determine the relationship between clinical‐obstetric characteristics and CS. These models generated probabilities of CS that could be compared with the observed CS rates. We devised a three‐step approach to generate the global benchmark of CS rates at health facilities: creation of a multi‐country reference population, building mathematical models, and testing these models.

Main outcome measures

Area under the ROC curves, diagnostic odds ratio, expected CS rate, observed CS rate.

Results

According to the different versions of the model, areas under the ROC curves suggested a good discriminatory capacity of C‐Model, with summary estimates ranging from 0.832 to 0.844. The C‐Model was able to generate expected CS rates adjusted for the case‐mix of the obstetric population. We have also prepared an e‐calculator to facilitate use of C‐Model (www.who.int/reproductivehealth/publications/maternal_perinatal_health/c-model/en/).

Conclusions

This article describes the development of a global reference for CS rates. Based on maternal characteristics, this tool was able to generate an individualised expected CS rate for health facilities or groups of health facilities. With C‐Model, obstetric teams, health system managers, health facilities, health insurance companies, and governments can produce a customised reference CS rate for assessing use (and overuse) of CS.

Tweetable abstract

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

The C‐Model provides a customized benchmark for caesarean section rates in health facilities and systems.

Diet or exercise, or both, for preventing excessive weight gain in pregnancy

BACKGROUND

This is an update of a Cochrane review first published in 2012, Issue 4. Excessive weight gain during pregnancy is associated with poor maternal and neonatal outcomes including gestational diabetes, hypertension, caesarean section, macrosomia, and stillbirth. Diet or exercise interventions, or both, may reduce excessive gestational weight gain (GWG) and associated poor outcomes; however, evidence from the original review was inconclusive.

OBJECTIVES

To evaluate the effectiveness of diet or exercise, or both, interventions for preventing excessive weight gain during pregnancy and associated pregnancy complications.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (5 November 2014), contacted investigators of the previously identified ongoing studies and scanned reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or exercise, or both, interventions for preventing excessive weight gain in pregnancy.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We organised RCTs according to the type of interventions and pooled data using the random-effects model in the Review Manager software. We also performed subgroup analyses according to the initial risk of adverse effects related to poor weight control. We performed sensitivity analysis to assess the robustness of the findings.

MAIN RESULTS

We included 65 RCTs, out of which 49 RCTs involving 11,444 women contributed data to quantitative meta-analysis. Twenty studies were at moderate-to-high risk of bias. Study interventions involved mainly diet only, exercise only, and combined diet and exercise interventions, usually compared with standard care. Study methods varied widely; therefore, we estimated the average effect across studies and performed sensitivity analysis, where appropriate, by excluding outliers and studies at high risk of bias.Diet or exercise, or both, interventions reduced the risk of excessive GWG on average by 20% overall (average risk ratio (RR) 0.80, 95% confidence interval (CI) 0.73 to 0.87; participants = 7096; studies = 24; I² = 52%). This estimate was robust to sensitivity analysis, which reduced heterogeneity, therefore we graded this evidence as high-quality. Interventions involving low glycaemic load diets, supervised or unsupervised exercise only, or diet and exercise combined all led to similar reductions in the number of women gaining excessive weight in pregnancy.Women receiving diet or exercise, or both interventions were more likely to experience low GWG than those in control groups (average RR 1.14, 95% CI 1.02 to 1.27; participants = 4422; studies = 11; I² = 3%; moderate-quality evidence). We found no difference between intervention and control groups with regard to pre-eclampsia (RR 0.95, 95% CI 0.77 to 1.16; participants = 5330; studies = 15; I² = 0%; high-quality evidence); however, maternal hypertension (not a pre-specified outcome) was reduced in the intervention group compared with the control group overall (average RR 0.70, 95% CI 0.51 to 0.96; participants = 5162; studies = 11; I² = 43%; low-quality evidence).There was no clear difference between groups with regard to caesarean delivery overall (RR 0.95, 95% CI 0.88 to 1.03; participants = 7534; studies = 28; I² = 9%; high-quality evidence); although the effect estimate suggested a small difference (5%) in favour of the interventions. In addition, for combined diet and exercise counselling interventions there was a 13% (-1% to 25%) reduction in this outcome (borderline statistical significance).We found no difference between groups with regard to preterm birth overall (average RR 0.91, 95% CI 0.68 to 1.22; participants = 5923; studies = 16; I² = 16%; moderate-quality evidence); however limited evidence suggested that these effect estimates may differ according to the types of interventions, with a trend towards an increased risk for exercise-only interventions.We found no clear difference between intervention and control groups with regard to infant macrosomia (average RR 0.93, 95% CI 0.86 to 1.02; participants = 8598; studies = 27; I² = 0%; high-quality evidence), although the effect estimate suggested a small difference (7% reduction) in favour of the intervention group. The largest effect size occurred in the supervised exercise-only intervention group (RR 0.81, 95% CI 0.64 to 1.02; participants = 2445; studies = 7; I² = 0%), which approached statistical significance (P = 0.07). Furthermore, in subgroup analysis by risk, high-risk women (overweight or obese women, or women with or at risk of gestational diabetes) receiving combined diet and exercise counselling interventions experienced a 15% reduced risk of infant macrosomia (average RR 0.85, 95% CI 0.73 to 1.00; participants = 3252; studies = nine; I² = 0; P = 0.05; moderate-quality evidence)There were no differences in the risk of poor neonatal outcomes including shoulder dystocia, neonatal hypoglycaemia, hyperbilirubinaemia, or birth trauma (all moderate-quality evidence) between intervention and control groups; however, infants of high-risk women had a reduced risk of respiratory distress syndrome if their mothers were in the intervention group (RR 0.47, 95% CI 0.26 to 0.85; participants = 2256; studies = two; I² = 0%; moderate-quality evidence).

AUTHORS' CONCLUSIONS

High-quality evidence indicates that diet or exercise, or both, during pregnancy can reduce the risk of excessive GWG. Other benefits may include a lower risk of caesarean delivery, macrosomia, and neonatal respiratory morbidity, particularly for high-risk women receiving combined diet and exercise interventions. Maternal hypertension may also be reduced. Exercise appears to be an important part of controlling weight gain in pregnancy and more research is needed to establish safe guidelines. Most included studies were carried out in developed countries and it is not clear whether these results are widely applicable to lower income settings.

Azithromycin for acute lower respiratory tract infections

BACKGROUND

Acute lower respiratory tract infections (LRTI) range from acute bronchitis and acute exacerbations of chronic bronchitis to pneumonia. Approximately five million people die from acute respiratory tract infections annually. Among these, pneumonia represents the most frequent cause of mortality, hospitalisation and medical consultation. Azithromycin is a macrolide antibiotic, structurally modified from erythromycin and noted for its activity against some gram-negative organisms associated with respiratory tract infections, particularly Haemophilus influenzae (H. influenzae).

OBJECTIVES

To compare the effectiveness of azithromycin to amoxycillin or amoxycillin/clavulanic acid (amoxyclav) in the treatment of LRTI, in terms of clinical failure, incidence of adverse events and microbial eradication.

SEARCH METHODS

We searched CENTRAL (2014, Issue 10), MEDLINE (January 1966 to October week 4, 2014) and EMBASE (January 1974 to November 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs, comparing azithromycin to amoxycillin or amoxycillin/clavulanic acid in participants with clinical evidence of an acute LRTI, such as acute bronchitis, pneumonia and acute exacerbation of chronic bronchitis.

DATA COLLECTION AND ANALYSIS

The review authors independently assessed all potential studies identified from the searches for methodological quality. We extracted and analysed relevant data separately. We resolved discrepancies through discussion. We initially pooled all types of acute LRTI in the meta-analyses. We investigated the heterogeneity of results using the forest plot and Chi(2) test. We also used the index of the I(2) statistic to measure inconsistent results among trials. We conducted subgroup and sensitivity analyses.

MAIN RESULTS

We included 16 trials involving 2648 participants. We were able to analyse 15 of the trials with 2496 participants. The pooled analysis of all the trials showed that there was no significant difference in the incidence of clinical failure on about days 10 to 14 between the two groups (risk ratio (RR), random-effects 1.09; 95% confidence interval (CI) 0.64 to 1.85). A subgroup analysis in trials with acute bronchitis participants showed significantly lower clinical failure in the azithromycin group compared to amoxycillin or amoxyclav (RR random-effects 0.63; 95% CI 0.45 to 0.88). A sensitivity analysis showed a non-significant reduction in clinical failure in azithromycin-treated participants (RR 0.55; 95% CI 0.25 to 1.21) in three adequately concealed studies, compared to RR 1.32; 95% CI 0.70 to 2.49 in 12 studies with inadequate concealment. Twelve trials reported the incidence of microbial eradication and there was no significant difference between the two groups (RR 0.95; 95% CI 0.87 to 1.03). The reduction of adverse events in the azithromycin group was RR 0.76 (95% CI 0.57 to 1.00).

AUTHORS' CONCLUSIONS

There is unclear evidence that azithromycin is superior to amoxycillin or amoxyclav in treating acute LRTI. In patients with acute bronchitis of a suspected bacterial cause, azithromycin tends to be more effective in terms of lower incidence of treatment failure and adverse events than amoxycillin or amoxyclav. However, most studies were of unclear methodological quality and had small sample sizes; future trials of high methodological quality and adequate sizes are needed.

Calcium supplementation (other than for preventing or treating hypertension) for improving pregnancy and infant outcomes

BACKGROUND

Maternal nutrition during pregnancy is known to have an effect on fetal growth and development. It is recommended that women increase their calcium intake during pregnancy and lactation, although the recommended dosage varies among professionals. Currently, there is no consensus on the role of routine calcium supplementation for pregnant women other than for preventing or treating hypertension.

OBJECTIVES

To determine the effect of calcium supplementation on maternal, fetal and neonatal outcomes (other than for preventing or treating hypertension) as well as any possible side effects.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30th September 2014).

SELECTION CRITERIA

We considered all published, unpublished and ongoing randomised controlled trials (RCTs) comparing maternal, fetal and neonatal outcomes in pregnant women who received calcium supplementation versus placebo or no treatment. Cluster-RCTs were eligible for inclusion but none were identified. Quasi-RCTs and cross-over studies were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

Twenty-five studies met the inclusion criteria, but only 23 studies contributed data to the review. These 23 trials recruited 18,587 women, with 17,842 women included in final analyses. There were no statistically significant differences between women who received calcium supplementation and those who did not in terms of reducing preterm births less than 37 weeks' gestation (risk ratio (RR) 0.86, 95% confidence interval (CI) 0.70 to 1.05; 13 studies, 16,139 women; random-effects model) or less than 34 weeks' gestation (RR 1.04, 95% CI 0.80 to 1.36; four trials, 5669). Most studies were of low risk of bias. We conducted sensitivity analysis for the outcome of preterm birth less than 37 weeks by removing two trials with unclear risk of bias for allocation concealment; the results then favoured treatment with calcium supplementation (RR 0.80, 95% CI 0.65 to 0.99; 11 trials, 15,379 women). There was no significant difference in infant low birthweight between the two treatment groups (RR 0.93, 95% CI 0.81 to 1.07; six trials, 14,162 infants; random-effects model). However, when compared to the control group, women in the calcium supplementation group gave birth to slightly heavier birthweight infants (mean difference 56.40, 95% CI 13.55 to 99.25; 21 trials, 9202 women; random-effects model).Three outcomes were chosen for assessment with the GRADE software: preterm birth less than 37 weeks; preterm birth less than 34 weeks; and low birthweight less than 2500 g. Evidence for these outcomes was assessed as of moderate quality.

AUTHORS' CONCLUSIONS

This review indicates that there are no clear additional benefits to calcium supplementation in prevention of preterm birth or low infant birthweight. While there was a statistically significant difference of 56 g identified in mean infant birthweight, there was significant heterogeneity identified, and the clinical significance of this difference is uncertain.

Routine blood cultures in the management of pyelonephritis in pregnancy for improving outcomes

BACKGROUND

Pyelonephritis is a type of urinary tract infection (UTI) that affects the upper urinary tract and kidneys, and is one of the most common conditions for hospitalisation among pregnant women, aside from delivery. Samples of urine and blood are obtained and used for cultures as part of the diagnosis and management of the condition. Acute pyelonephritis requires hospitalisation with intravenous administration of antimicrobial agents. Several studies have questioned the necessity of obtaining blood cultures in addition to urine cultures, citing cost and questioning whether blood testing is superfluous. Pregnant women with bacteraemia require a change in the initial empirical treatment based on the blood culture. However, these cases are not common, and represent approximately 15% to 20% of cases. It is unclear whether blood cultures are essential for the effective management of the condition.

OBJECTIVES

To assess the effectiveness of routine blood cultures to improve health outcomes in the management of pyelonephritis in pregnant women.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register without language or date restrictions (31 December 2014).

SELECTION CRITERIA

Randomised controlled trials and quasi-randomised trials comparing outcomes among pregnant women with pyelonephritis who received initial management with or without blood cultures. Cluster-randomised trials were eligible for inclusion in this review but none were identified. Clinical trials using a cross-over design were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed one trial report for inclusion.

MAIN RESULTS

We identified one trial report but this was excluded. No clinical trials met the inclusion criteria for this review.

AUTHORS' CONCLUSIONS

There are no large-scale randomised controlled trials to assess outcomes in the management of pyelonephritis in pregnancy with or without blood cultures. Randomised controlled trials are needed to evaluate the effectiveness of managing pyelonephritis in pregnant women with or without blood cultures, and to assess any adverse outcomes as well as the cost-effectiveness of excluding blood cultures from treatment.

Antenatal lower genital tract infection screening and treatment programs for preventing preterm delivery

BACKGROUND

Genital tract infection is associated with preterm birth (before 37 weeks' gestation). Screening for infections during pregnancy may therefore reduce the numbers of babies being born prematurely. However, screening for infections may have some adverse effects, such as increased antibiotic drug resistance and increased cost of treatment.

OBJECTIVES

To assess the effectiveness of antenatal lower genital tract infection screening and treatment programs for reducing preterm birth and subsequent morbidity.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 November 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2014, Issue 7) and reference lists of retrieved reports.

SELECTION CRITERIA

We included all published and unpublished randomised controlled trials in any language that evaluated any described methods of antenatal lower genital tract infection screening compared with no screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy.

MAIN RESULTS

One study (4155 women at less than 20 weeks' gestation) met the inclusion criteria. The intervention group (2058 women) received infection screening and treatment for bacterial vaginosis, trichomonas vaginalis and candidiasis; the control group (2097 women) also received screening, but the results of the screening program were not revealed and women received routine antenatal care. The rate of preterm birth before 37 weeks' gestation was significantly lower in the intervention group (3% versus 5% in the control group) with a risk ratio (RR) of 0.55 (95% confidence interval (CI) 0.41 to 0.75; the evidence for this outcome was graded as of moderate quality). The incidence of preterm birth for infants with a weight equal to or below 2500 g (low birthweight) and infants with a weight equal to or below 1500 g (very low birthweight) were significantly lower in the intervention group than in the control group (RR 0.48, 95% CI 0.34 to 0.66 and RR 0.34; 95% CI 0.15 to 0.75, respectively; both graded as moderate quality evidence). Based on a subset of costs for preterm births of < 1900 g, the authors reported that for each of those preterm births averted, EUR 60,262 would be saved.

AUTHORS' CONCLUSIONS

There is evidence from one trial that infection screening and treatment programs for pregnant women before 20 weeks' gestation reduce preterm birth and preterm low birthweight. Infection screening and treatment programs are associated with cost savings when used for the prevention of preterm birth. Future trials should evaluate the effects of different types of infection screening programs.

Adjuvant chemotherapy after concurrent chemoradiation for locally advanced cervical cancer

BACKGROUND

Current standard treatment for patients with cervical cancer who have locally advanced stage disease (International Federation of Gynecology and Obstetrics (FIGO) stage IIB to IVA) is concurrent chemoradiation therapy (CCRT). However, less than two-thirds of patients in this group survive for longer than five years post treatment. Adjuvant chemotherapy (ACT) can be given in an attempt to improve survival by eradicating residual disease in the pelvis and treating occult disease outside the pelvic radiation field. However, inconsistency in trial design, inclusion criteria for participants, interventions and survival benefit has been noted among trials of ACT after CCRT for locally advanced cervical cancer (LACC).

OBJECTIVES

To evaluate the effect of adjuvant chemotherapy (ACT) after concurrent chemoradiation (CCRT) on survival of women with locally advanced cervical cancer compared with CCRT alone.

SEARCH METHODS

We searched the Cochrane Gynaecological Review Group Trial Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and conference proceedings to March 2014. We handsearched citation lists of relevant studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing CCRT alone versus CCRT plus ACT were included. Patients were diagnosed with cervical cancer FIGO stage IIB to IVA with a histopathology of squamous cell carcinoma, adenosquamous cell carcinoma, adenocarcinoma or undifferentiated carcinoma.

DATA COLLECTION AND ANALYSIS

Two review authors (ST, KK) selected relevant trials, extracted data, assessed risk of bias independently, compared results and resolved disagreements by discussion.

MAIN RESULTS

We identified two RCTs involving 978 women with cervical cancer stage IIB to IVA. As the trials were significantly different clinically, we did not perform meta-analyses. One industry-funded trial involving 515 women compared CCRT (cisplatin) versus CCRT (cisplatin and gemcitabine) plus ACT (two additional cycles). This trial reported significant improvement in progression-free survival (PFS) and overall survival (OS) in women who were given CCRT plus ACT compared with those treated with CCRT alone: Three-year PFS was 74.4% versus 65.0% (hazard ratio (HR) 0.68, 95% confidence interval (CI) 0.49 to 0.95, P value 0.027), and three-year OS was 80% versus 69% (HR 0.68, 95% CI 0.49 to 0.95, P value 0.022). However, as the CCRT chemotherapy differed between the two arms, we considered the findings to be at high risk of bias.The second trial was a four-arm study from which we extracted data on 463 women in two study arms receiving CCRT (intravenous mitomycin C and oral 5-fluorouracil (5-FU)) or CCRT plus ACT (oral 5-FU for three cycles). The HR for OS in women who received ACT after CCRT compared with the HR for OS in those who were given CCRT alone was 1.309 (95% CI 0.795 to 2.157), and the HR for disease-free survival (DFS) was 1.125 (95% CI 0.799 to 1.586).Haematological adverse events were more common in the ACT arms of both trials. Quality of life (QoL) was not reported in either trial.

AUTHORS' CONCLUSIONS

With limited data from only two trials, we found insufficient evidence to support the use of ACT after CCRT. Future large trials are required to demonstrate efficacy, toxicities and QoL.

Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones

BACKGROUND

Stones in the urinary tract are a common medical problem in the general population. At present, the great expansion in minimally invasive techniques has led to the decrease in open surgery. Extracorporeal shock wave lithotripsy (ESWL) has been introduced as an alternative approach which disintegrates stones in the kidney and upper urinary tract through the use of shock waves. Nevertheless, as there are limitations with the success rate in ESWL, other minimally invasive modalities for kidney stones such as percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) are also widely applied. This is an update of a review first published in 2009.

OBJECTIVES

This review aimed to assess the effectiveness and complications of ESWL for kidney stones compared with PCNL or RIRS.

SEARCH METHODS

We searched the Cochrane Renal Group's Specialised Register to 3 March 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review.

SELECTION CRITERIA

Randomised controlled trials (RCTs) assessing the use of ESWL compared to PCNL or RIRS for kidney stone management.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed all the studies for inclusion. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI).

MAIN RESULTS

Five studies (338 patients) were included, four studies compared ESWL to PCNL and one compared ESWL with RIRS. Random sequence generation was reported in three studies and unclear in two. Allocation concealment was not reported in any of the included studies. Blinding of participants and investigators could not be undertaken due to the nature of the interventions; blinding of outcome assessors was not reported. Reporting bias was judged to be low risk in all studies. One study was funded by industry and in one study the number of participants in each group was unbalanced.The success of treatment at three months was significantly greater in the PCNL compared to the ESWL group (3 studies, 201 participants: RR 0.46, 95% CI 0.35 to 0.62). Re-treatment (1 study, 122 participants: RR 1.81, 95% CI 0.66 to 4.99) and using auxiliary procedures (2 studies, 184 participants: RR 9.06, 95% CI 1.20 to 68.64) was significantly increased with ESWL group compared to PCNL. The efficiency quotient (EQ; used to assess the effectiveness of procedures) higher for PCNL than ESWL; however EQ decreased when stone size increased. Duration of treatment (MD -36.00 min, 95% CI -54.10 to -17.90) and hospital stay (1 study, 49 participants: MD -3.30 days, 95% CI -5.45 to -1.15) were significantly shorter in the ESWL group. Overall more complications were reported with PCNL, however we were unable to meta-analyse the included studies due to the differing outcomes reported and the timing of the outcome measurements.One study compared ESWL versus RIRS for lower pole kidney stones. The success of treatment was not significantly different at the end of the third month (58 participants: RR 0.91, 95% CI 0.64 to 1.30). Mean procedural time and mean hospital stay was reported to be longer in the RIRS group.

AUTHORS' CONCLUSIONS

Results from five small studies, with low methodological quality, indicated ESWL is less effective for kidney stones than PCNL but not significantly different from RIRS. Hospital stay and duration of treatment was less with ESWL. Larger RCTs with high methodological quality are required to investigate the effectiveness and complications of ESWL for kidney stones compared to PCNL if there is any technological progress in the non-invasive elimination of the residual fragments. Moreover, further research is required for the outcomes of ESWL and RIRS in lower and non-lower pole studies including PCNL versus RIRS.

Use of antenatal corticosteroids and tocolytic drugs in preterm births in 29 countries: an analysis of the WHO Multicountry Survey on Maternal and Newborn Health

BACKGROUND

Despite the global burden of morbidity and mortality associated with preterm birth, little evidence is available for use of antenatal corticosteroids and tocolytic drugs in preterm births in low-income and middle-income countries. We analysed data from the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS) to assess coverage for these interventions in preterm deliveries.

METHODS

WHOMCS is a facility-based, cross-sectional survey database of birth outcomes in 359 facilities in 29 countries, with data collected prospectively from May 1, 2010, to Dec 31, 2011. For this analysis, we included deliveries after 22 weeks' gestation and we excluded births that occurred outside a facility or quicker than 3 h after arrival. We calculated use of antenatal corticosteroids in women who gave birth between 26 and 34 weeks' gestation, when antenatal corticosteroids are known to be most beneficial. We also calculated use in women at 22-25 weeks' and 34-36 weeks' gestation. We assessed tocolytic drug use, with and without antenatal corticosteroids, in spontaneous, uncomplicated preterm deliveries at 26-34 weeks' gestation.

FINDINGS

Of 303,842 recorded deliveries after 22 weeks' gestation, 17,705 (6%) were preterm. 3900 (52%) of 7547 women who gave birth at 26-34 weeks' gestation, 94 (19%) of 497 women who gave birth at 22-25 weeks' gestation, and 2276 (24%) of 9661 women who gave birth at 35-36 weeks' gestation received antenatal corticosteroids. Rates of antenatal corticosteroid use varied between countries (median 54%, range 16-91%; IQR 30-68%). Of 4677 women who were potentially eligible for tocolysis drugs, 1276 (27%) were treated with bed rest or hydration and 2248 (48%) received no treatment. β-agonists alone (n=346, 7%) were the most frequently used tocolytic drug. Only 848 (18%) of potentially eligible women received both a tocolytic drug and antenatal corticosteroids.

INTERPRETATION

Use of interventions was generally poor, despite evidence for their benefit for newborn babies. A substantial proportion of antenatal corticosteroid use occurred at gestational ages at which benefit is controversial, and use of less effective or potentially harmful tocolytic drugs was common. Implementation research and contextualised health policies are needed to improve drug availability and increase compliance with best obstetric practice.

FUNDING

UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Aspiration of the elbow joint for treating radial head fractures

BACKGROUND

Radial head fracture is the most common fracture of the elbow. It usually results from a fall onto an outstretched arm. In 1954, Mason classified these fractures into type 1 (undisplaced), type 2 (simple displaced), and type 3 (comminuted fractures). Aspiration of the elbow joint aims to relieve pressure in the elbow joint and has been used as an initial treatment option for radial head fractures. However, it is an invasive technique with the potential for complications such as infection and injury to nerves and vessels.

OBJECTIVES

To assess the effects (benefits and harms) of elbow joint aspiration for treating radial head fracture in adults.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (14 April 2014), the Cochrane Central Register of Controlled Trials (CENTRAL) (14 April 2014), MEDLINE (1946 to April Week 1 2014) and EMBASE (1980 to 2014 Week 15), trial registries, bibliographies and conference proceedings.

SELECTION CRITERIA

Randomised and quasi-randomised controlled clinical trials comparing aspiration versus no aspiration for treating radial head fractures in adults.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected articles, assessed risk of bias and extracted data. Disagreements were resolved by discussion. Where appropriate, we pooled results of comparable studies using fixed-effect meta-analysis.

MAIN RESULTS

We included two trials that involved 126 participants but provided results for only 108 participants. Most participants were adults, typically over 30 years of age. Both trials were at high risk of selection, performance, detection and reporting bias. Reflecting this high risk of bias, we downgraded the quality of evidence two levels for study limitations and a further level for imprecision. Thus we judged the evidence for all outcomes to be 'very low' quality, meaning that we are very uncertain about these estimates.One trial included participants with Mason type 1, 2 or 3 radial head fractures and also a few cases of traumatic elbow hemarthrosis without fracture. The other trial included participants with Mason type 1 and 2 fractures. All participants were managed non-surgically.Neither trial reported functional outcome based on validated patient-reported outcome measures of function or pain using validated measures such as a visual analogue scale. Very low quality evidence (108 participants, two trials) indicates little difference between aspiration and no aspiration in impaired function (unable to carry heavy loads; discomfort when carrying loads) at 12 months (9/51 in aspiration group versus 7/57 in the no aspiration group; risk ratio 1.43 favouring no aspiration, 95% confidence interval (CI) 0.57 to 3.58). Very low quality evidence (two trials) suggests a beneficial effect of aspiration on pain relief immediately after aspiration. Very low quality evidence (one trial, 28 participants) shows less pain after aspiration at three weeks, but it is unclear whether this applies subsequently. Neither trial reported on adverse events (for example, nerve and vascular injuries; deep or superficial infection) from the procedure, but aspiration was reported as being unsuccessful in three participants (7.9%) in one trial. Very low quality evidence indicates little difference in range of motion (based on elbow extension) between the two groups at six weeks (28 participants, one trial) or 12 months (108 participants, two trials). The report of adverse events was incomplete, but one trial (80 participants) reported the absence of three specific complications: myositis ossificans, joint instability or late displacement of the fracture.

AUTHORS' CONCLUSIONS

There is insufficient evidence to determine the effectiveness of joint aspiration for the initial treatment of radial head fracture in terms of function, pain and range of motion or to determine the safety of the procedure. An examination of current aspiration use, the prospective collection of adverse events and consultation with patients as to their preferences and values would be helpful in guiding decisions about the future design of a multicentre randomised trial aiming to obtain definitive evidence on the use of aspiration for treating radial head fractures.

Hepatitis B vaccination during pregnancy for preventing infant infection

BACKGROUND

Infant hepatitis B infection increases the risk of chronic infection, cirrhosis or liver cancer (hepatocellular carcinoma) in the adult. Perinatal transmission is a common route of infection.

OBJECTIVES

To assess the effectiveness and adverse effects of hepatitis B vaccine administered to pregnant women for preventing hepatitis B virus infection in infants.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014).

SELECTION CRITERIA

Randomized controlled trials (RCTs) assessing hepatitis B vaccination compared with placebo or no treatment during pregnancy for preventing infant infection. Quasi-RCTs and cross-over studies were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion. If any studies had been included, we planned to assess the risk of bias, extract data and check the data for accuracy of all included studies.

MAIN RESULTS

We did not identify any studies for inclusion.

AUTHORS' CONCLUSIONS

We found no RCTs that assessed the effects of hepatitis B vaccine during pregnancy for preventing infant infection. Consequently, this review cannot provide guidance for clinical practice in this area. However, it does identify the need for well-designed randomized clinical trials to assess the effect of hepatitis B vaccine during pregnancy on the incidence of infant infection and to determine any adverse effects.

Antibiotics for meconium-stained amniotic fluid in labour for preventing maternal and neonatal infections

BACKGROUND

Chorioamnionitis is more likely to occur when meconium-stained amniotic fluid (MSAF) is present. Meconium may enhance the growth of bacteria in amniotic fluid by serving as a growth factor, inhibiting bacteriostatic properties of amniotic fluid. Many adverse neonatal outcomes related to MSAF result from meconium aspiration syndrome (MAS). MSAF is associated with both maternal and newborn infections. Antibiotics may be an effective option to reduce such morbidity.

OBJECTIVES

The objective of this review is to assess the efficacy and side effects of prophylactic antibiotics for MSAF during labour in preventing maternal and neonatal infections.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2014). 

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing prophylactic antibiotics with placebo or no treatment during labour for women with MSAF.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

MAIN RESULTS

We included two studies with 362 pregnant women. Both studies compared ampicillin-sulbactam (N = 183) versus normal saline (N = 179) in pregnant women with MSAF. Prophylactic antibiotics appeared to have no statistically significant reduction in the incidence of neonatal sepsis (risk ratio (RR) 1.00, 95% CI 0.21 to 4.76), neonatal intensive care unit (NICU) admission (RR 0.83, 95% CI 0.39 to 1.78) and postpartum endometritis (RR 0.50, 95% CI 0.18 to 1.38). However, there was a significant decrease in the risk of chorioamnionitis (RR 0.36, 95% CI 0.21 to 0.62). No serious adverse effects were reported. Drug resistance, duration of mechanical ventilation and duration of admission to NICU/hospital were not reported. Most of the domains for risk of bias were at low risk of bias for one study and at unclear risk of bias for the other study. The quality of the evidence using GRADE was low for neonatal sepsis, postpartum endometritis, and neonatal mortality and morbidity prior to discharge (Neonatal intensive care admissions) and of moderate quality for chorioamnionitis.

AUTHORS' CONCLUSIONS

Current evidence indicates that compared to placebo, antibiotics for MSAF in labour may reduce chorioamnionitis. There was no evidence that antibiotics could reduce postpartum endometritis, neonatal sepsis and NICU admission. This systematic review identifies the need for more well-designed, adequately powered RCTs to assess the effect of prophylactic antibiotics in the incidence of maternal and neonatal complications.

Prophylactic antibiotics for manual removal of retained placenta in vaginal birth

BACKGROUND

Retained placenta is a potentially life-threatening condition because of its association with postpartum hemorrhage. Manual removal of placenta increases the likelihood of bacterial contamination in the uterine cavity.

OBJECTIVES

To compare the effectiveness and side-effects of routine antibiotic use for manual removal of placenta in vaginal birth in women who received antibiotic prophylaxis and those who did not and to identify the appropriate regimen of antibiotic prophylaxis for this procedure.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2014).

SELECTION CRITERIA

All randomized controlled trials comparing antibiotic prophylaxis and placebo or non antibiotic use to prevent endometritis after manual removal of placenta in vaginal birth.

DATA COLLECTION AND ANALYSIS

There are no included trials. In future updates, if we identify eligible trials, two review authors will independently assess trial quality and extract data

MAIN RESULTS

No studies that met the inclusion criteria were identified.

AUTHORS' CONCLUSIONS

There are no randomized controlled trials to evaluate the effectiveness of antibiotic prophylaxis to prevent endometritis after manual removal of placenta in vaginal birth.