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Antenatal and postpartum prevention of Rh alloimmunization: A systematic review and GRADE analysis.

ABSTRACT: BACKGROUND:Existing systematic reviews of Rh immunoprophylaxis include only data from randomized controlled trials, have dated searches, and some do not report on all domains of risk of bias or evaluate the certainty of the evidence. Our objective was to perform an updated review, by including new trials, any comparative observational studies, and assessing the certainty of the evidence using the GRADE framework. METHODS:We searched MEDLINE, Embase and the Cochrane Library from 2000 to November 26, 2019. Relevant websites and bibliographies of systematic reviews and guidelines were searched for studies published before 2000. Outcomes of interest were sensitization and adverse events. Risk of bias was evaluated with the Cochrane tool and ROBINS-I. The certainty of the evidence was performed using the GRADE framework. RESULTS:Thirteen randomized trials and eight comparative cohort studies were identified, evaluating 12 comparisons. Although there is some evidence of beneficial treatment effects (e.g., at 6-months postpartum, fewer women who received RhIg at delivery compared to no RhIg became sensitized [70 fewer sensitized women per 1,000 (95%CI: 67 to 71 fewer); I2 = 73%]), due to very low certainty of the evidence, the magnitude of the treatment effect may be overestimated. The certainty of the evidence was very low for most outcomes often due to high risk of bias (e.g., randomization method, allocation concealment, selective reporting) and imprecision (i.e., few events and small sample sizes). There is limited evidence on prophylaxis for invasive fetal procedures (e.g. amniocentesis) in the comparative literature, and few studies reported adverse events. CONCLUSION:Serious risk of bias and low to very low certainty of the evidence is found in existing RCTs and comparative observational studies addressing optimal effectiveness of Rh immunoprophylaxis. Guideline development committees should exercise caution when assessing the strength of the recommendations that inform and influence clinical practice in this area.

SUBMITTER: Hamel C

PROVIDER: S-EPMC7482964 | biostudies-literature | 2020

REPOSITORIES: biostudies-literature

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Antenatal and postpartum prevention of Rh alloimmunization: A systematic review and GRADE analysis.

Hamel Candyce C Esmaeilisaraji Leila L Thuku Micere M Michaud Alan A Sikora Lindsey L Fung-Kee-Fung Karen K

PloS one 20200910 9

<h4>Background</h4>Existing systematic reviews of Rh immunoprophylaxis include only data from randomized controlled trials, have dated searches, and some do not report on all domains of risk of bias or evaluate the certainty of the evidence. Our objective was to perform an updated review, by including new trials, any comparative observational studies, and assessing the certainty of the evidence using the GRADE framework.<h4>Methods</h4>We searched MEDLINE, Embase and the Cochrane Library from 20 ...[more]

PMID: 32913362

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Project description:The postpartum period is a crucial starting point for the delivery of family planning services. To date, there are numerous primary studies in Ethiopia on postpartum contraceptive use and related factors. However, the results of key variables are inconsistent, making it difficult to use the results to advance the service dimensions of postpartum contraceptive use in the country. Therefore, this systematic review and meta-analysis was required to summarize this inconsistency and compile the best available evidence on the impact of maternal educational status, antenatal care and menstrual resumption on postpartum contraceptive use in Ethiopia. PubMed, Google Scholar, Scopus, Science Direct, and the repositories of online research institutes were searched. Data were extracted with Microsoft Excel and analyzed with the statistical software STATA (version 14). Data on the study area, design, population, sample size, and observed frequency were extracted using the Joanna Briggs Institute tool. To obtain the pooled effect size, a meta-analysis was performed using a weighted inverse variance random effects model. Cochran's Q X2 test, and I2 statistics were used to test for heterogeneity, estimate the total quantity, and measure the variability attributed to heterogeneity. A mixed-effects meta-regression analysis was performed to identify possible sources of heterogeneity. To examine publication bias, the Eggers regression test and the Beggs correlation test were used at a p-value threshold of 0.001. Of the 654 articles reviewed, 18 studies met the inclusion criteria and were included in this meta-analysis. Overall, the final analysis includes 11,263 study participants. In Ethiopia, postpartum contraceptive use correlated significantly with maternal educational status (OR = 3.121:95% CI 2.127-4.115), antenatal care follow-up (OR = 3.286; 95% CI 2.353-4.220), and return of the mother's menses (OR = 3.492; 95% CI 1.843-6.615). A uniform meta-regression was performed based on publication year (p = 0.821), sample size (p = 0.989), and city of residence (p = 0.104), which revealed that none of these factors are significant. The use of postpartum contraceptives was found to be better among mothers who are educated, attended antenatal appointments, and resumed their menstrual cycle. Based on our research, we strongly recommended that antenatal care use and maternal educational accessibility need to improve. For family planning professionals, removing barriers to menstruation resumption should be a key priority.

Project description:BACKGROUND:There is widespread, increasing use of magnesium sulphate in obstetric practice for pre-eclampsia, eclampsia, and preterm fetal neuroprotection; benefit for preventing preterm labour and birth (tocolysis) is unproven. We conducted a systematic review and meta-analysis to assess whether antenatal magnesium sulphate is associated with unintended adverse neonatal outcomes. METHODS AND FINDINGS:CINAHL, Cochrane Library, LILACS, MEDLINE, Embase, TOXLINE, and Web of Science, were searched (inceptions to 3 September 2019). Randomised, quasi-randomised, and non-randomised trials, cohort and case-control studies, and case reports assessing antenatal magnesium sulphate for pre-eclampsia, eclampsia, fetal neuroprotection, or tocolysis, compared with placebo/no treatment or a different magnesium sulphate regimen, were included. The primary outcome was perinatal death. Secondary outcomes included pre-specified and non-pre-specified adverse neonatal outcomes. Two reviewers screened 5,890 articles, extracted data, and assessed risk of bias following Cochrane Handbook and RTI Item Bank guidance. For randomised trials, pooled risk ratios (RRs) or mean differences, with 95% confidence intervals (CIs), were calculated using fixed- or random-effects meta-analysis. Non-randomised data were tabulated and narratively summarised. We included 197 studies (40 randomised trials, 138 non-randomised studies, and 19 case reports), of mixed quality. The 40 trials (randomising 19,265 women and their babies) were conducted from 1987 to 2018 across high- (16 trials) and low/middle-income countries (23 trials) (1 mixed). Indications included pre-eclampsia/eclampsia (24 trials), fetal neuroprotection (7 trials), and tocolysis (9 trials); 18 trials compared magnesium sulphate with placebo/no treatment, and 22 compared different regimens. For perinatal death, no clear difference in randomised trials was observed between magnesium sulphate and placebo/no treatment (RR 1.01; 95% CI 0.92 to 1.10; 8 trials, 13,654 babies), nor between regimens. Eleven of 138 non-randomised studies reported on perinatal death. Only 1 cohort (127 babies; moderate to high risk of bias) observed an increased risk of perinatal death with >48 versus ≤48 grams magnesium sulphate exposure for tocolysis. No clear secondary adverse neonatal outcomes were observed in randomised trials, and a very limited number of possible adverse outcomes warranting further consideration were identified in non-randomised studies. Where non-randomised studies observed possible harms, often no or few confounders were controlled for (moderate to high risk of bias), samples were small (200 babies or fewer), and/or results were from subgroup analyses. Limitations include missing data for important outcomes across most studies, heterogeneity of included studies, and inclusion of published data only. CONCLUSIONS:Our findings do not support clear associations between antenatal magnesium sulphate for beneficial indications and adverse neonatal outcomes. Further large, high-quality studies (prospective cohorts or individual participant data meta-analyses) assessing specific outcomes, or the impact of regimen, pregnancy, or birth characteristics on these outcomes, would further inform safety recommendations. PROSPERO: CRD42013004451.

Project description:ObjectiveTo identify and quantify risk factors for atonic postpartum hemorrhage.Data sourcesPubMed, CINAHL, EMBASE, Web of Science, and and ClinicalTrials.gov databases were searched for English language studies with no restrictions on date or location. Studies included randomized trials, prospective or retrospective cohort studies, and case-control studies of pregnant patients who developed atonic postpartum hemorrhage and reported at least one risk factor.Methods of study selectionTitle, abstract, and full-text screening were performed using the Raayan web application. Of 1,239 records screened, 27 studies were included in this review. Adjusted or unadjusted odds ratios (ORs), relative risks, or rate ratios were recorded or calculated. For each risk factor, a qualitative synthesis of low and moderate risk of bias studies classifies the risk factor as definite, likely, unclear, or not a risk factor. For risk factors with sufficiently homogeneous definitions and reference ranges, a quantitative meta-analysis of low and moderate risk of bias studies was implemented to estimate a combined OR.Tabulation, integration, and resultsForty-seven potential risk factors for atonic postpartum hemorrhage were identified in this review, of which 15 were judged definite or likely risk factors. The remaining 32 assessed risk factors showed no association with atonic postpartum hemorrhage or had conflicting or unclear evidence.ConclusionA substantial proportion of postpartum hemorrhage occurs in the absence of recognized risk factors. Many risk factors for atonic hemorrhage included in current risk-assessment tools were confirmed, with the greatest risk conferred by prior postpartum hemorrhage of any etiology, placenta previa, placental abruption, uterine rupture, and multiple gestation. Novel risk factors not currently included in risk-assessment tools included hypertension, diabetes, and ethnicity. Obesity and magnesium were not associated with atonic postpartum hemorrhage in this review.Systematic review registrationPROSPERO, CRD42020157521.

Dataset Information

Antenatal and postpartum prevention of Rh alloimmunization: A systematic review and GRADE analysis.

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Antenatal and postpartum prevention of Rh alloimmunization: A systematic review and GRADE analysis.

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