Abstracts of Cochrane Reviews

International Journal of Gynecology and Obstetrics (2008) 103, 189–191

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w w w. e l s e v i e r. c o m / l o c a t e / i j g o

EVIDENCE BASED OBSTETRICS AND GYNECOLOGY Abstracts of Cochrane Reviews

The editors of the International Journal of Gynecology & Obstetrics have selected the following abstracts of articles published in The Cochrane Library, because of their particular interest to practicing specialists in obstetrics and gynecology in all areas of the world. The full text of the review is available in The Cochrane Library (ISSN 1464–780X). From the Cochrane Database of Systematic Reviews 2008 Issue 3. Copyright © 2008. The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.

Immediate start of hormonal contraceptives for contraception Lopez LM, Newmann SJ, Grimes DA, Nanda K, Schulz KF. Immediate start of hormonal contraceptives for contraception. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006260. DOI: 10.1002/14651858.CD006260.pub2.

Summary Immediate start of hormonal birth control Health care providers often tell women to wait until their next menstrual cycle to begin birth control pills. The main reason is to avoid using birth control during an undetected pregnancy. Another method involves starting the pills right away (‘immediate start’ or ‘quick start’). Another birth control method should be used as back-up for the first seven days. Unclear issues are whether quick start of hormonal birth control works as well as the usual start and whether women like it. The quick start method might improve women's use of hormonal birth control. We did computer searches for randomized controlled trials of the quick-start method for pills and other hormonal birth control. We contacted researchers to find other studies. We included trials that compared quick start to the usual start of birth control. Also included were studies that compared quick start of different types of hormonal birth control with each other. Birth control methods could have the hormones estrogen and progestin (combined hormonal birth control) or just the progestin. Five studies were included. In a study of ‘depo,’ a progestin-only injection, fewer women with quick start of

doi:10.1016/j.ijgo.2008.08.004

depo became pregnant than those who used another method for 21 days before depo. In this review, the numbers of women who stopped using their birth control method early were similar between groups in all trials. In the depo trial, more women with quick start of depo were very satisfied. A trial of two quick-start methods showed women with the vaginal ring had less long-term bleeding and less frequent bleeding than those with pills. For six side effects, including changes in breasts, mood, and nausea, quick start of the ring showed fewer problems than quick start of pills. For satisfaction in that trial, more women in the ring group were very satisfied with their method of birth control. We found little strong evidence that quick start leads to fewer pregnancies or fewer women stopping early. However, fewer women on quick-start of depo became pregnant than the women who started with another method. Other differences were between types of birth control rather than start times. Women using the vaginal ring had fewer problems than women using birth control pills. More studies are needed comparing quick start versus usual start of the same hormonal birth control method. Abstract Background: Health care providers often tell women to wait until the next menses to begin hormonal contraception. The main intent is to avoid contraceptive use during an undetected pregnancy. An alternative is to start hormonal contraception immediately with back-up birth control for the first seven days. Immediate initiation was first introduced with combined oral contraceptives (COCs), and has expanded to other hormonal contraceptives. How immediate start compares to conventional menses-dependent start is unclear regarding effectiveness, continuation, and acceptability. The immediate-start approach may improve women's access to, and continuation of, hormonal contraception. Objectives: This review examined randomized controlled trials of immediate-start hormonal contraception for differences in effectiveness, continuation, and acceptability.

190 Search strategy: We searched MEDLINE, CENTRAL, POPLINE, EMBASE, and LILACS for trials of immediate-start hormonal contraceptives. We contacted researchers to find other studies. Selection criteria: We included randomized controlled trials that compared immediate start to conventional start of hormonal contraception. Also included were trials that compared immediate start of different hormonal contraceptive methods with each other. Data collection and analysis: Data were abstracted by two authors and entered into RevMan. The Peto odds ratio (OR) with 95% confidence interval (CI) was calculated. Main results: Five studies were included. Method discontinuation was similar between groups in all trials. Bleeding patterns and side effects were similar in trials that compared immediate with conventional start. In a study of depot medroxyprogesterone acetate (DMPA), immediate start of DMPA showed fewer pregnancies than a ‘bridge’ method before DMPA (OR 0.36; 95% CI 0.16 to 0.84). Further, more women in the immediate-DMPA group were very satisfied versus those with a ‘bridge’ method (OR 1.99; 95% CI 1.05 to 3.77). A trial of two immediate-start methods showed the vaginal ring group had less prolonged bleeding (OR 0.42; 95% CI 0.20 to 0.89) and less frequent bleeding (OR 0.23; 95% CI 0.05 to 1.03) than COC users. The ring group also reported fewer side effects. For satisfaction, more immediate ring users were very satisfied than immediate COC users (OR 2.88; 95% CI 1.59 to 5.22). Authors' conclusions: We found limited evidence that immediate start of hormonal contraception reduces unintended pregnancies or increases method continuation. However, the pregnancy rate was lower with immediate start of DMPA versus another method. Some differences were associated with contraceptive type rather than initiation method, that is, immediate ring versus immediate COC. More studies are needed of immediate versus conventional start of the same hormonal contraceptive.

Laparoscopic entry techniques Ahmad G, Duffy JMN, Phillips K, Watson A. Laparoscopic Entry Techniques. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD006583. DOI: 10.1002/14651858.CD006583. pub2.

Summary Laparoscopy enables direct visualisation of the pelvic and abdominal organs with a special telescope called a laparoscope so key-hole surgery can be performed as indicated. To perform laparoscopy, gas is inserted into the abdomen. Although usually safe, a small minority of patients experience life-threatening complications, including injuries to the blood vessels (0.9 per 1000 procedures) and the bowel (1.8 per 1000 procedures). These complications often occur when the laparoscope is passed through

EVIDENCE BASED OBSTETRICS AND GYNECOLOGY the abdominal wall for the first step of the procedure, using specialised instruments to insert the gas. Different doctors use different specialised instruments and techniques. This review found no evidence that any single technique or specialised instrument used to enter the abdomen helped to prevent life-threatening complications. More research is required. Abstract Background: Laparoscopy is a very common procedure in gynaecology. Complications associated with laparoscopy are often related to entry. The life-threatening complications include injury to the bowel, bladder, major abdominal vessels, and anterior abdominal-wall vessel. Other less serious complications can also occur, such as post-operative infection, subcutaneous emphysema and extraperitoneal insufflation. There is no clear consensus as to the optimal method of entry into the peritoneal cavity. Objectives: The objective of this study was to compare the different laparoscopic entry techniques in terms of their influence on intra-operative and post-operative complications. Search strategy: This review has drawn on the search strategy developed by the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched through to July, 2007. Selection criteria: Randomised controlled trials were included when one laparoscopic primary-port-entry technique was compared with another. Data collection and analysis: Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the fourth author. Results for each study were expressed as odds ratio (Peto version) with their 95% confidence intervals. Main results: The 17 included randomised controlled trials concerned 3,040 individuals undergoing laparoscopy. Overall there was no evidence of advantage using any single technique in terms of preventing major complications. However, there were two advantages with direct-trocar entry when compared with Veress-Needle entry, in terms of avoiding extraperitoneal insufflation (OR 0.06, 95%CI 0.02, 0.23) and failed entry (OR 0.22, 95%CI 0.08, 0.56). There was also an advantage with radially expanding access system (STEP) trocar entry when compared with standard trocar entry, in terms of trocar site bleeding (OR 0.06, 95%CI 0.01, 0.46). Finally, there was an advantage of not lifting the abdominal wall before Veress-Needle insertion when compared to lifting in terms of failed entry without an increase in the complication rate (OR 5.17, 95%CI 2.24, 11.90). However, studies were limited to small numbers, excluding many patients with previous abdominal surgery and women with a raised body mass index, who often had unusually high complication rates. Authors' conclusions: On the basis of evidence investigated in this review, there appears to be no evidence of benefit in terms of safety of one technique over another. However, the

EVIDENCE BASED OBSTETRICS AND GYNECOLOGY included studies are small and cannot be used to confirm safety of any particular technique.

Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes McDonald SJ, Middleton P. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD004074. DOI: 10.1002/14651858.CD004074.pub2.

Summary Effect of timing of umbilical cord clamping at birth of term infants on mother and baby outcomes At the time of birth, the infant is still attached to the mother via the umbilical cord, which is part of the placenta. The infant is usually separated from the placenta by clamping the cord. The timing of this clamping is one part of the third stage of labour (the time from birth until delivery of the placenta) which can vary according to clinical policy and practice. Early cord clamping is believed to lead to a reduced risk of bleeding after birth (postpartum haemorrhage). This review of 11 trials showed no significant difference in postpartum haemorrhage rates when early and late cord clamping were compared. For neonatal outcomes it is important to weigh the growing evidence that delayed cord clamping confers improved iron status in infants up to six months after birth, with a possible additional risk of jaundice severe enough to require phototherapy. Abstract Background: Policies for timing of cord clamping vary, with early cord clamping generally carried out in the first 60 seconds after birth, whereas later cord clamping usually involves clamping the umbilical cord greater than one minute after the birth or when cord pulsation has ceased. Objectives: To determine the effects of different policies of timing of cord clamping at delivery of the placenta on maternal and neonatal outcomes.

191 Search strategy: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (December 2007). Selection criteria: Randomised controlled trials comparing early and late cord clamping. Data collection and analysis: Two review authors independently assessed trial eligibility and quality and extracted data. Main results: We included 11 trials of 2989 mothers and their babies. No significant differences between early and late cord clamping were seen for postpartum haemorrhage or severe postpartum haemorrhage in any of the five trials (2236 women) which measured this outcome (relative risk (RR) for postpartum haemorrhage 500 mls or more 1.22, 95% confidence interval (CI) 0.96 to 1.55). For neonatal outcomes, our review showed both benefits and harms for late cord clamping. Following birth, there was a significant increase in infants needing phototherapy for jaundice (RR 0.59, 95% CI 0.38 to 0.92; five trials of 1762 infants) in the late compared with early clamping group. This was accompanied by significant increases in newborn haemoglobin levels in the late cord clamping group compared with early cord clamping (weighted mean difference 2.17 g/dL; 95% CI 0.28 to 4.06; three trials of 671 infants), although this effect did not persist past six months. Infant ferritin levels remained higher in the late clamping group than the early clamping group at six months. Authors' conclusions: One definition of active management includes directions to administer an uterotonic with birth of the anterior shoulder of the baby and to clamp the umbilical cord within 30–60 seconds of birth of the baby (which is not always feasible in practice). In this review delaying clamping of the cord for at least two to three minutes seems not to increase the risk of postpartum haemorrhage. In addition, late cord clamping can be advantageous for the infant by improving iron status which may be of clinical value particularly in infants where access to good nutrition is poor, although delaying clamping increases the risk of jaundice requiring phototherapy.