Browsing by Author "Kumar, Nimisha"

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    Cochrane Review Summaries—July 2020
    (Wolters Kluwer, 2020-07) Jahanfar, Shayesteh; Hill, Matthew; Kariyawasam, Diluma; Kumar, Nimisha; Haas, David M.; Obstetrics and Gynecology, School of Medicine
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    Low-dose oral misoprostol for induction of labour
    (Wiley, 2021-06-22) Kerr, Robbie S.; Kumar, Nimisha; Williams, Myfanwy J.; Cuthbert, Anna; Aflaifel, Nasreen; Haas, David M.; Weeks, Andrew D.; Obstetrics and Gynecology, School of Medicine
    Background: Misoprostol given orally is a commonly used labour induction method. Our Cochrane Review is restricted to studies with low-dose misoprostol (initially ≤ 50 µg), as higher doses pose unacceptably high risks of uterine hyperstimulation. Objectives: To assess the efficacy and safety of low-dose oral misoprostol for labour induction in women with a viable fetus in the third trimester of pregnancy. Search methods: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (14 February 2021) and reference lists of retrieved studies. Selection criteria: Randomised trials comparing low-dose oral misoprostol (initial dose ≤ 50 µg) versus placebo, vaginal dinoprostone, vaginal misoprostol, oxytocin, or mechanical methods; or comparing oral misoprostol protocols (one- to two-hourly versus four- to six-hourly; 20 µg to 25 µg versus 50 µg; or 20 µg hourly titrated versus 25 µg two-hourly static). Data collection and analysis: Using Covidence, two review authors independently screened reports, extracted trial data, and performed quality assessments. Our primary outcomes were vaginal birth within 24 hours, caesarean section, and hyperstimulation with foetal heart changes. Main results: We included 61 trials involving 20,026 women. GRADE assessments ranged from moderate- to very low-certainty evidence, with downgrading decisions based on imprecision, inconsistency, and study limitations. Oral misoprostol versus placebo/no treatment (four trials; 594 women) Oral misoprostol may make little to no difference in the rate of caesarean section (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.59 to 1.11; 4 trials; 594 women; moderate-certainty evidence), while its effect on uterine hyperstimulation with foetal heart rate changes is uncertain (RR 5.15, 95% CI 0.25 to 105.31; 3 trials; 495 women; very low-certainty evidence). Vaginal births within 24 hours was not reported. In all trials, oxytocin could be commenced after 12 to 24 hours and all women had pre-labour ruptured membranes. Oral misoprostol versus vaginal dinoprostone (13 trials; 9676 women) Oral misoprostol probably results in fewer caesarean sections (RR 0.84, 95% CI 0.78 to 0.90; 13 trials, 9676 women; moderate-certainty evidence). Subgroup analysis indicated that 10 µg to 25 µg (RR 0.80, 95% CI 0.74 to 0.87; 9 trials; 8652 women) may differ from 50 µg (RR 1.10, 95% CI 0.91 to 1.34; 4 trials; 1024 women) for caesarean section. Oral misoprostol may decrease vaginal births within 24 hours (RR 0.93, 95% CI 0.87 to 1.00; 10 trials; 8983 women; low-certainty evidence) and hyperstimulation with foetal heart rate changes (RR 0.49, 95% CI 0.40 to 0.59; 11 trials; 9084 women; low-certainty evidence). Oral misoprostol versus vaginal misoprostol (33 trials; 6110 women) Oral use may result in fewer vaginal births within 24 hours (average RR 0.81, 95% CI 0.68 to 0.95; 16 trials, 3451 women; low-certainty evidence), and less hyperstimulation with foetal heart rate changes (RR 0.69, 95% CI 0.53 to 0.92, 25 trials, 4857 women, low-certainty evidence), with subgroup analysis suggesting that 10 µg to 25 µg orally (RR 0.28, 95% CI 0.14 to 0.57; 6 trials, 957 women) may be superior to 50 µg orally (RR 0.82, 95% CI 0.61 to 1.11; 19 trials; 3900 women). Oral misoprostol probably does not increase caesarean sections overall (average RR 1.00, 95% CI 0.86 to 1.16; 32 trials; 5914 women; low-certainty evidence) but likely results in fewer caesareans for foetal distress (RR 0.74, 95% CI 0.55 to 0.99; 24 trials, 4775 women). Oral misoprostol versus intravenous oxytocin (6 trials; 737 women, 200 with ruptured membranes) Misoprostol may make little or no difference to vaginal births within 24 hours (RR 1.12, 95% CI 0.95 to 1.33; 3 trials; 466 women; low-certainty evidence), but probably results in fewer caesarean sections (RR 0.67, 95% CI 0.50 to 0.90; 6 trials; 737 women; moderate-certainty evidence). The effect on hyperstimulation with foetal heart rate changes is uncertain (RR 0.66, 95% CI 0.19 to 2.26; 3 trials, 331 women; very low-certainty evidence). Oral misoprostol versus mechanical methods (6 trials; 2993 women) Six trials compared oral misoprostol to transcervical Foley catheter. Misoprostol may increase vaginal birth within 24 hours (RR 1.32, 95% CI 0.98 to 1.79; 4 trials; 1044 women; low-certainty evidence), and probably reduces the risk of caesarean section (RR 0.84, 95% CI 0.75 to 0.95; 6 trials; 2993 women; moderate-certainty evidence). There may be little or no difference in hyperstimulation with foetal heart rate changes (RR 1.31, 95% CI 0.78 to 2.21; 4 trials; 2828 women; low-certainty evidence). Oral misoprostol one- to two-hourly versus four- to six-hourly (1 trial; 64 women) The evidence on hourly titration was very uncertain due to the low numbers reported. Oral misoprostol 20 µg hourly titrated versus 25 µg two-hourly static (2 trials; 296 women) The difference in regimen may have little or no effect on the rate of vaginal births in 24 hours (RR 0.97, 95% CI 0.80 to 1.16; low-certainty evidence). The evidence is of very low certainty for all other reported outcomes. Authors' conclusions: Low-dose oral misoprostol is probably associated with fewer caesarean sections (and therefore more vaginal births) than vaginal dinoprostone, and lower rates of hyperstimulation with foetal heart rate changes. However, time to birth may be increased, as seen by a reduced number of vaginal births within 24 hours. Compared to transcervical Foley catheter, low-dose oral misoprostol is associated with fewer caesarean sections, but equivalent rates of hyperstimulation. Low-dose misoprostol given orally rather than vaginally is probably associated with similar rates of vaginal birth, although rates may be lower within the first 24 hours. However, there is likely less hyperstimulation with foetal heart changes, and fewer caesarean sections performed due to foetal distress. The best available evidence suggests that low-dose oral misoprostol probably has many benefits over other methods for labour induction. This review supports the use of low-dose oral misoprostol for induction of labour, and demonstrates the lower risks of hyperstimulation than when misoprostol is given vaginally. More trials are needed to establish the optimum oral misoprostol regimen, but these findings suggest that a starting dose of 25 µg may offer a good balance of efficacy and safety.
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    Pre- and post-conception planning in autoimmune disorders
    (2020-03) Kumar, Nimisha; Aksu, Eric; Gensel, Annie; Burger, Taylor; Pease, Kensey
    Background: Autoimmune diseases are often multisystem, requiring many specialists. However, there are no clear recommendations for many of these disorders for planning pregnancy and preventing exacerbations. Intervention: Little time is devoted to patient counseling about contraception or care antepartum, intrapartum, and postpartum. Contraception and many first-line interventions can have varying effects in different diseases, which can be further complicated by multiple diagnoses. Many of these disorders also can have postpartum complications, making follow-up essential. Results:Systemic lupus erythematosus (SLE) is known to cause exacerbations during pregnancy and has serious adverse outcomes for both mother and baby. Active disease is associated with higher rates of preterm birth, pre-eclampsia, thromboses, fetal loss, and neonatal lupus. Patients are at increased risk of these complications with a history of lupus nephritis, cessation of hydroxychloroquine, and primigravidity. Multiple sclerosis (MS) has lower rates of relapse during pregnancy, but higher rates in the first postpartum year. This has been attributed to the rapid increase in progesterone during pregnancy improving symptoms, while the rapid decrease after pregnancy promotes relapses. Additionally, neonatal morbidity does not increase as a result of MS. For other autoimmune diseases such as Sjögren's Syndrome or Grave’s Disease, the clinical picture may be complicated by the physiology of pregnancy, but is unclear whether pregnancy exacerbates the autoimmune component of the disease. Conclusions: Pregnancy and contraception could improve or worsen symptoms in autoimmune diseases, even up to a year postpartum. There is a significant gap in practice guidelines regarding contraception and pregnancy despite many diseases’ onset during childbearing years. Pregnancy and contraception counseling should be part of initial conversations at diagnosis to prepare women.
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    Priority setting for the Cochrane Pregnancy and Childbirth Group review updates: a Delphi process
    (Elsevier, 2020) Kumar, Nimisha; Grant, Sean; Haas, David M.; Obstetrics and Gynecology, School of Medicine
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    The Association between Sleep and Depression during Late Pregnancy and the Early Postpartum Period
    (Thieme, 2024-01-23) Jones, Angela G.; Hadaie, Bachar S.; Bennett, Rachel; Kumar, Nimisha; Saha, Chandan K.; Haas, David M.; Obstetrics and Gynecology, School of Medicine
    Objective: To assess and correlate sleep quality and depressed mood symptoms in the late pregnancy and early postpartum periods. Study Design: In a prospective pilot observational study, participants completed the Pittsburgh Sleep Quality Index (PSQI) and the Edinburgh Postnatal Depression Scale (EPDS) questionnaires at delivery, 1, and 2 months postpartum. Pearson's correlation coefficients and PROC MIXED function estimated overall correlation for repeated measures. Results: Twenty-six women were enrolled with a mean gestational age at delivery of 38.4 (± 2.4) weeks. Sleep quality and mood data were available at the three time points for 24, 16, and 11 participants, respectively. Poor sleep scores were noted by 75.0, 87.5, and 72.7% of women at the three time points. An elevated EPDS score of 10 or higher was claimed by 20.8, 12.5, and 18.2% of women, respectively. Higher PSQI scores were positively associated with higher EPDS scores overall ( r  = 0.71, p  < 0.001) and at each of the individual time points ( r  = 0.79, p  < 0.0001; r  = 0.52, p  = 0.04; and r  = 0.70, p  = 0.016, respectively). None of the women reporting good sleep quality had elevated EPDS scores. Conclusion: Poor sleep is commonly reported around delivery, and at 1 and 2 months postpartum, and there is an association between poor sleep and depression symptoms.