Pharmacologic Interventions to Minimize Fluid Absorption at the Time of Hysteroscopy: A Systematic Review and Meta-analysis.

OBJECTIVE: To assess which interventions are effective in reducing fluid absorption at the time of hysteroscopy. DATA SOURCE: Ovid MEDLINE, Ovid EMBASE, PubMed (non-MEDLINE records only), EBM Reviews-Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov , and Web of Science were searched from inception to February 2022 without restriction on language or geographic origin. METHODS OF STUDY SELECTION: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, all English-language, full-text articles reporting fluid balance, with an intervention and comparator arm, were included. Title and abstract screening and full-text review were completed independently by two authors. Conflicts were resolved through discussion and consensus. Studies' risk of bias was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale for observational studies. TABULATION, INTEGRATION, AND RESULTS: The search identified 906 studies, 28 of which were eligible for inclusion, examining the following interventions: gonadotropin-releasing hormone (GnRH) agonist; ulipristal acetate; vasopressin; danazol; oxytocin; and local, general, and regional anesthesia. A significant reduction in mean fluid absorption was seen in patients preoperatively treated with danazol (-175.7 mL, 95% CI -325.4 to -26.0) and a GnRH agonist (-139.68 mL, 95% CI -203.2, -76.2) compared with patients in a control group. Ulipristal acetate and type of anesthesia showed no difference. Data on type of anesthesia and vasopressin use were not amenable to meta-analysis; however, four studies favored vasopressin over control regarding fluid absorption. Mean operative time was reduced after preoperative treatment with ulipristal acetate (-7.1 min, 95% CI -11.31 to -2.9), danazol (-7.5 min, 95% CI -8.7 to -6.3), and a GnRH agonist (-3.3 min, 95% CI -5.6 to -0.98). CONCLUSION: Preoperative treatment with a GnRH agonist and danazol were both found to be effective in reducing fluid absorption and operative time across a range of hysteroscopic procedures. High-quality research aimed at evaluating other interventions, such as combined hormonal contraception, progestin therapy, and vasopressin, are still lacking in the literature. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021233804.

Obstetrical and Newborn Outcomes Among Patients With SARS-CoV-2 During Pregnancy.

We report on the perinatal outcomes of pregnant patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from 2 hospitals in Montréal, Québec. Outcomes of 45 patients with SARS-CoV-2 during pregnancy were compared with those of 225 patients without infection. Sixteen percent of patients with SARS-CoV-2 delivered preterm, compared with 9% of patients without (P = 0.28). Median gestational age at delivery (39.3 (interquartile range [IQR] 37.7-40.4) wk vs. 39.1 [IQR 38.3-40.1] wk) and median birth weight (3250 [IQR 2780-3530] g vs. 3340 [IQR 3025-3665] g) were similar between groups. The rate of cesarean delivery was 29% for patients with SARS-CoV-2. Therefore, we did not find important differences in outcomes associated with SARS-CoV-2. Our findings may be limited to women with mild COVID-19 diagnosed in the third trimester.

Placenta previa and the risk of intrauterine growth restriction (IUGR): a systematic review and meta-analysis.

Background Whether placental location confers specific neonatal risks is controversial. In particular, whether placenta previa is associated with intra-uterine growth restriction (IUGR)/small for gestational age (SGA) remains a matter of debate. Methods We searched Medline, EMBASE, Google Scholar, Scopus, ISI Web of Science and Cochrane database search, as well as PubMed (www.pubmed.gov) until the end of December 2018 to conduct a systematic review and meta-analysis to determine the risk of IUGR/SGA in cases of placenta previa. We defined IUGR/SGA as birth weight below the 10th percentile, regardless of the terminology used in individual studies. Risk of bias was assessed using the Cochrane Handbook for Systematic Reviews of Interventions. We used odds ratios (OR) and a fixed effects (FE) model to calculate weighted estimates in a forest plot. Statistical homogeneity was checked with the I2 statistic using Review Manager 5.3.5 (The Cochrane Collaboration, 2014). Results We obtained 357 records, of which 13 met the inclusion criteria. All study designs were retrospective in nature, and included 11 cohort and two case-control studies. A total of 1,593,226 singleton pregnancies were included, of which 10,575 had a placenta previa. The incidence of growth abnormalities was 8.7/100 births in cases of placenta previa vs. 5.8/100 births among controls. Relative to cases with alternative placental location, pregnancies with placenta previa were associated with a mild increase in the risk of IUGR/SGA, with a pooled OR [95% confidence interval (CI)] of 1.19 (1.10-1.27). Statistical heterogeneity was high with an I2 = 94%. Conclusion Neonates from pregnancies with placenta previa have a mild increase in the risk of IUGR/SGA.

Recent advances in the antepartum management of diabetes.

Gestational and pre-gestational diabetes are frequent problems encountered in obstetrical practice and their complications may influence both the mother (such as hypertension, pre-eclampsia, increased caesarean rates) and the foetus (such as macrosomia, shoulder dystocia, respiratory distress, hypoglycaemia, or childhood obesity and diabetes). Given the important implications for mothers and their offspring, screening and appropriate management of diabetes during pregnancy are essential. This is a review of articles published between 2015 and 2018 on Medline via Ovid that focus on advances in the management of diabetes in pregnancy. Recent data have concentrated predominantly on optimising glycaemic control, which is key for minimising the burden of maternal and foetal complications. Lifestyle changes, notably physical exercise and diet adjustments, appear to have beneficial effects. However, data are inconclusive with respect to which diet and form of exercise provide optimal benefits. Oral glycaemic agents-in particular, metformin-are gaining acceptance as more data indicating their long-term safety for the foetus and newborn emerge. Recent reviews present inconclusive data on the efficacy and safety of insulin analogues. New technologies such as continuous insulin pumps for type 1 diabetes and telemedicine-guided management of diabetes are significantly appreciated by patients and represent promising clinical tools. There are few new data addressing the areas of antenatal foetal surveillance, the timing and need for induction of delivery, and the indications for planned caesarean section birth.

Surgical Management of the Placenta Accreta Spectrum: An Institutional Experience.

OBJECTIVE: The incidence of placenta accreta spectrum (PAS) has risen over the past decades, primarily in response to increasing Caesarean section rates. The surgical management of PAS is associated with significant morbidity, including hemorrhage and intensive care unit (ICU) admission. This study sought to evaluate the surgical outcomes of a PAS operative approach. METHODS: A single-centre retrospective chart review of all Caesarean hysterectomies for PAS by an assigned surgeon over a 16-year period was performed. Surgical outcomes were described (Canadian Task Force Classification II-2). RESULTS: The described surgical approach involves a midline skin incision, high midline hysterotomy, a rapid single-layer uterine closure with no placental removal attempt, constant cephalad uterine traction, and liberal choice of subtotal hysterectomy. A total of 47 patients were included: 19 (40.4%) with placenta accreta, 14 (29.8%) with placenta increta, and 14 (29.8%) with placenta percreta. Mean estimated blood loss was 1416 ± 699 mL, and mean operative time was 112 ± 49 minutes. Overall, 16 patients (34.0%) required blood transfusion, and 4 patients (8.5%) required ICU admission. The average hospitalization was 5.2 days, with no re-admission within 30 days. The use of internal iliac balloons did not result in a difference in blood loss or operative time (P > 0.05). Patients with placenta percreta had significantly more blood loss (P = 0.02) and longer operative time (P = 0.007) compared with those with placenta accreta and increta. CONCLUSION: The current surgical model for planned Caesarean hysterectomy for PAS exhibits a low complication rate. Further research is needed for developing a standardized approach to the management of PAS.