Abdominal Decompression For Suspected Fetal Compromise Pre-Eclampsia

Abdominal decompression for suspected fetal compromise/
pre-eclampsia (Review)
Hofmeyr GJ
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2007, Issue 4
http://www.thecochranelibrary.com
1 Abdominal decompression for suspected fetal compromise/pre-eclampsia (Review)
Copyright 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
T A B L E O F C O N T E N T S
1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .
2 SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .
2 METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3 SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4 Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 Comparison 01. Abdominal decompression for suspected fetal compromise/pre-eclampsia . . . . . . . . . .
5 INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 Analysis 01.01. Comparison 01 Abdominal decompression for suspected fetal compromise/pre-eclampsia, Outcome 01
Unchanged or worsening pre-eclampsia . . . . . . . . . . . . . . . . . . . . . . . . . .
Induction of labour (all indications) . . . . . . . . . . . . . . . . . . . . . . . . . . .
Induction for placental insufciency . . . . . . . . . . . . . . . . . . . . . . . . . . .
Fetal distress in labour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Low birthweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Apgar score <6 at 1 minute . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Perinatal mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Urinary oestriol increase mg per week . . . . . . . . . . . . . . . . . . . . . . . . .
Fetal biparietal diameter increase mm per week . . . . . . . . . . . . . . . . . . . . . .
Birthweight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
i Abdominal decompression for suspected fetal compromise/pre-eclampsia (Review)
Abdominal decompression for suspected fetal compromise/
pre-eclampsia (Review)
Hofmeyr GJ
This record should be cited as:
Hofmeyr GJ. Abdominal decompression for suspected fetal compromise/pre-eclampsia. Cochrane Database of Systematic Reviews 1996,
Issue 1. Art. No.: CD000004. DOI: 10.1002/14651858.CD000004.
This version rst published online: 22 April 1996 in Issue 1, 1996.
Date of most recent substantive amendment: 12 February 1996
A B S T R A C T
Background
Abdominal decompression was developed as a means of pain relief during labour. It has also been used for complications of pregnancy,
and in healthy pregnant women in an attempt to improve fetal wellbeing and intellectual development.
Objectives
The objective of this review was to assess the effects of antenatal abdominal decompression for maternal hypertension or impaired fetal
growth, on perinatal outcome.
Search strategy
The Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register were searched. Date of last
search: 25 October 2004.
Selection criteria
Randomised or quasi-randomised trials comparing abdominal decompression with no decompression in women with pre-eclampsia
and/or fetuses thought to be compromised.
Data collection and analysis
Eligibility and trial quality were assessed by one reviewer.
Main results
Three studies were included, all with the possibility of containing serious bias.
Therapeutic abdominal decompression was associated with the following reductions: persistent pre-eclampsia (relative risk 0.36, 95%
condence interval 0.18 to 0.72); fetal distress in labour (relative risk 0.37, 95% condence interval 0.19 to 0.71); low birthweight
(relative risk 0.50, 95% condence interval 0.40 to 0.63); Apgar scores less than six at one minute (relative risk 0.26, 95% condence
interval 0.12 to 0.56); and perinatal mortality (relative risk 0.39, 95% condence interval 0.22 to 0.71).
Authors conclusions
Due to the methodological limitations of the studies, the effects of therapeutic abdominal decompression are not clear. The apparent
improvements in birthweight and perinatal mortality warrant further evaluation of abdominal decompression where there is impaired
fetal growth and possibly for women with pre-eclampsia.
P L A I N L A N G U A G E S U M M A R Y
Synopsis pending
B A C K G R O U N D
Abdominal decompression was developed initially as a method
of enhancing the forward movement of the uterus during labour
contractions with a view to relieving pain. Unanticipated appar-
ent benecial effects on fetal condition led to its investigation for
this purpose. A rigid dome is placed about the abdomen and cov-
ered with an airtight suit. The space around the abdomen is de-
compressed to -50 to -100mmHg for 15-30 seconds out of each
minute for 30 minutes once to thrice daily, or continuously during
labour. This is thought to pump blood through the intervillous
space. See also (Hofmeyr 1989).
O B J E C T I V E S
To assess the effects on fetal growth and perinatal morbidity and
mortality of abdominal decompression for the treatment of fetal
compromise.
C R I T E R I A F O R C O N S I D E R I N G
S T U D I E S F O R T H I S R E V I E W
Types of studies
Clinical trials comparing the effect of therapeutic abdominal de-
compression on clinically meaningful outcomes, with a control
group (no decompression); randomor quasi-random allocation to
the treatment and control group; violations of allocated manage-
ment not sufcient to materially affect outcomes.
Types of participants
Women with pre-eclampsia and/or fetuses that were thought to
be compromised.
Types of intervention
Antenatal abdominal decompression.
Types of outcome measures
Maternal blood pressure and proteinuria, morbidity and perinatal
outcome.
Outcomes included if clinically meaningful; reasonable measures
taken to minimise observer bias; missing data insufcient to ma-
terially inuence conclusions; data available for analysis accord-
ing to original allocation, irrespective of protocol violations; data
available in format suitable for analysis.
S E A R C H M E T H O D S F O R
I D E N T I F I C A T I O N O F S T U D I E S
See: methods used in reviews.
This review has drawn on the search strategy developed for the
Pregnancy and Childbirth Group as a whole.
Relevant trials were identied in the Groups Specialised Register
of Controlled Trials. See Review Groups details for more
information.
The Cochrane Controlled Trials Register is searched periodically
on the term abdominal decompression. Date of last search: 25
October 2004.
M E T H O D S O F T H E R E V I E W
Trials under consideration were evaluated for methodological
quality and appropriateness for inclusion according to the
prestated selection criteria, without consideration of their results.
Individual outcome data were included in the analysis if they met
the prestated criteria in Types of outcome measures. Included
trial data were processed as described in Clarke 1999.
Data were extracted from the sources and entered onto the
Review Manager (RevMan) computer software (Update Software,
Oxford, UK), checked for accuracy, and analysed as above using
the RevMan software. For dichotomous data, relative risks and
95% condence intervals were calculated, and in the absence of
heterogeneiety, results were pooled using a xed effects model.
Continuous data were pooled using weighted mean differences
and 95% condence intervals.
D E S C R I P T I O N O F S T U D I E S
See Table of Characteristics of included studies.
M E T H O D O L O G I C A L Q U A L I T Y
See Table of Characteristics of included studies, particularly the
Methods and Notes sections.
One study (Blecher 1967) does not exclude the possibility of selec-
tion and observer bias. Allocation of 160 women with pre-eclamp-
sia, essential hypertension or chronic nephritis to study and con-
trol groups was by alternation. Observers were not blind to the
allocation of each woman, and the assessment of outcome as un-
changed or worsening pre-eclampsia is somewhat subjective.
MacRae 1971 do not dene their method of selecting at random
28womenwithfetuses estimatedtobe small for gestational age and
with urinary oestriol levels belowthe normal range, for abdominal
decompression, and 28 to serve as controls.
Varma 1973 allocated 140 women with clinically small for dates
fetuses and biparietal diameters below the 10th percentile by al-
ternation to decompression and control groups. The allocation
of seven women from each group was changed because of non-
acceptance of abdominal decompression. It has not been possible
to reanalyse the data according to the original constitution of the
groups. The observers were not blind to the allocation of each
woman, and certain of the measures of outcome were to some
extent subjective.
Interpretation of the results of these studies must be guarded be-
cause of the possibility of selection, observer and analysis bias out-
lined above.
R E S U L T S
In the trial reported by Blecher 1967, abdominal decompression
appeared to have a benecial effect on the progression of pre-
eclampsia. Inboth of the other trials (MacRae 1971; Varma 1973),
abdominal decompression appeared to be associated with a sig-
nicantly greater increase in levels of urinary oestriol, although
only Varma 1973 actually presented data (1.68 [1.21] versus 0.91
[0.74] mg per week, mean values [SD]). In addition, Varma 1973
found that abdominal decompression was associated with statisti-
cally signicant faster weekly growth in the fetal biparietal diam-
eter (2.08 [0.36] versus 1.49 [0.71] mm per week, mean values
[SD]). Blecher 1967 did not report a reduction in the incidence
of induction of labour, while Varma 1973 showed a trend to fewer
inductions of labour in the decompression group, the more so
for inductions for placental insufciency. Varma 1973 also re-
ported signicantly less fetal distress during labour and depressed
1-minute Apgar scores in the group who had received abdominal
decompression.
Observer bias and possibly reporting bias may account for some
or all of the putative effects of abdominal decompression noted
above. The assessment of birthweight is less susceptible to ob-
server bias, and data are available from all three trials. Abdominal
decompression was associated with a substantial reduction in the
incidence of low birthweight in two of the trials and an increase
in mean birthweight and placental weight in the third (MacRae
1971). Perinatal mortality was also reduced in all three trials.
D I S C U S S I O N
For outcomes assessed in more than one study, all results are com-
patible.
A U T H O R S C O N C L U S I O N S
Implications for practice
Because of the methodological shortcomings mentioned above,
clinical use of abdominal decompression cannot be supported on
the basis of these trials.
Implications for research
The large improvement in birthweight and perinatal mortality re-
ported in all three studies is sufciently striking to warrant the fur-
ther evaluation of abdominal decompression in cases of impaired
fetal growth, and possibly pre-eclampsia, by means of method-
ologically sound controlled trials.
P O T E N T I A L C O N F L I C T O F
I N T E R E S T
None known.
A C K N O W L E D G E M E N T S
None.
S O U R C E S O F S U P P O R T
External sources of support
South African Medical Research Council SOUTH AFRICA
The Nufeld Trust UK
Internal sources of support
University of the Witwatersrand SOUTH AFRICA
R E F E R E N C E S
References to studies included in this review
Blecher 1967 {published data only}
Blecher JA. Aspects of the physiology of decompression and its usage
in the toxaemias of pregnancy and in fetal distress in labour [MD
thesis]. Vol. 1, South Africa: University of the Witwatersrand, 1967:
1222.
MacRae 1971 {published data only}
MacRae DJ, Mohamedally SM, Willmott MP. Clinical and en-
docrinological aspects of dysmaturity and the use of intermittent ab-
dominal decompression in pregnancy. J Obstet Gynaecol Br Cmmwlth
1971;78:636641.
Varma 1973 {published data only}
Varma TR, Curzen P. The effects of abdominal decompression on
pregnancy complicated by the small-for-dates fetus. J Obstet Gynaecol
Br Cmmwlth 1973;80:10861094.
Additional references
Clarke 1999
Clarke M, Oxman AD, editors. Cochrane Reviewers Handbook 4.0
[updated July 1999]. In: ReviewManager (RevMan) [Computer pro-
gram]. Version 4.0. Oxford, England: The Cochrane Collaboration,
1999.
Hofmeyr 1989
Hofmeyr GJ. Abdominal decompression during pregnancy. In:
ChalmersI, EnkinMW, KeirseMJNCeditor(s). Effective Care in Preg-
nancy and Childbirth. Oxford: Oxford University Press, 1989:647
652.
T A B L E S
Characteristics of included studies
Study Blecher 1967
Methods Alternation.
Participants Women with pre-eclampsia, essential hypertension or chronic nephritis.
Interventions Women who received abdominal decompression compared with control group.
Outcomes Unchanged or worsening pre-eclampsia; induction of labour; low birthweight; perinatal mortality.
Notes Assessment of pre-eclampsia as unchanged or worsening somewhat subjective.
Allocation concealment C Inadequate
Study MacRae 1971
Methods Selected at random, method not specied.
Participants Women with fetuses estimated to be small for gestational age and urinary oestriol levels below the normal
range.
Interventions Participants were allocated either to receive repeated abdominal decompression, or to act as controls.
Outcomes Urinary oestriol levels; perinatal mortality.
Notes Reported signicantly greater urinary oestriol increase with abdominal decompression, but data not given.
Study Varma 1973
Methods Alternation. Allocation of 7 women from each group changed because of non-acceptance of abdominal
decompression.
Participants Women with clinically small for dates fetuses and biparietal diameters below the 10th percentile.
Interventions Women who received abdominal decompression compared with control group.
Outcomes Induction of labour; induction of labour for placental insufciency; fetal distress in labour; low birthweight;
Apgar score <6 at 1 minute; perinatal mortality; urinary oestriol increase (mean 1.68 mg per week [sd 1.21]
versus 0.91 [0.74]; weekly growth in fetal biparietal diameter (2.08 [0.36] versus 1.49 [0.71])
Notes Use of reduced biparietal diameter as a selection criterion may have resulted in the inclusion of women with
incorrect dates rather than growth impairment.
A N A L Y S E S
Comparison 01. Abdominal decompression for suspected fetal compromise/pre-eclampsia
Outcome title
No. of
studies
No. of
participants
Statistical method Effect size
01 Unchanged or worsening pre-
eclampsia
1 80 Relative Risk (Fixed) 95% CI 0.36 [0.18, 0.72]
02 Induction of labour (all
indications)
03 Induction for placental
insufciency
04 Fetal distress in labour 1 140 Relative Risk (Fixed) 95% CI 0.37 [0.19, 0.71]
05 Low birthweight 2 304 Relative Risk (Fixed) 95% CI 0.50 [0.40, 0.63]
06 Apgar score <6 at 1 minute 1 140 Relative Risk (Fixed) 95% CI 0.26 [0.12, 0.56]
07 Perinatal mortality 3 367 Relative Risk (Fixed) 95% CI 0.39 [0.22, 0.71]
08 Urinary oestriol increase mg
per week
Weighted Mean Difference (Fixed) 95% CI Totals not selected
09 Fetal biparietal diameter
increase mm per week
Weighted Mean Difference (Fixed) 95% CI Totals not selected
10 Birthweight Weighted Mean Difference (Fixed) 95% CI Totals not selected
I N D E X T E R M S
Medical Subject Headings (MeSH)
Fetal Diseases [
prevention & control];

Lower Body Negative Pressure; Pre-Eclampsia [
prevention & control]; Pregnancy Outcome

MeSH check words
Female; Humans; Pregnancy
C O V E R S H E E T
Title Abdominal decompression for suspected fetal compromise/pre-eclampsia
Authors Hofmeyr GJ
Contribution of author(s) GJH prepared and maintains the review.
Issue protocol rst published 1996/2
Review rst published 1996/2
Date of most recent amendment 22 February 2006
Date of most recent
SUBSTANTIVE amendment
12 February 1996
Whats New 25 October 2004: Search updated. No new trials identied.
27 January 2004: Search updated. No new trials identied.
Date new studies sought but
none found
25 October 2004
Date new studies found but not
yet included/excluded
Information not supplied by author
Date new studies found and
included/excluded
Date authors conclusions
section amended
Contact address Prof G Justus Hofmeyr
Director/Hon. Professor, Effective Care Research Unit
Department of Obstetrics and Gynaecology, East London Hospital Complex
University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of
Health
Frere and Cecilia Makiwane Hospitals
Private Bag X 9047
East London
Eastern Cape
5200
SOUTH AFRICA
E-mail: gjh@global.co.za
Tel: +27 43 7092483
Fax: +27 43 7092483
DOI 10.1002/14651858.CD000004
Cochrane Library number CD000004
Editorial group Cochrane Pregnancy and Childbirth Group
Editorial group code HM-PREG
G R A P H S A N D O T H E R T A B L E S
Analysis 01.01. Comparison 01 Abdominal decompression for suspected fetal compromise/pre-eclampsia,
Outcome 01 Unchanged or worsening pre-eclampsia
Review: Abdominal decompression for suspected fetal compromise/pre-eclampsia
Comparison: 01 Abdominal decompression for suspected fetal compromise/pre-eclampsia
Outcome: 01 Unchanged or worsening pre-eclampsia
Study Treatment Control Relative Risk (Fixed) Weight Relative Risk (Fixed)
n/N n/N 95% CI (%) 95% CI
Blecher 1967 8/42 20/38 100.0 0.36 [ 0.18, 0.72 ]
Total (95% CI) 42 38 100.0 0.36 [ 0.18, 0.72 ]
Total events: 8 (Treatment), 20 (Control)
Test for heterogeneity: not applicable
Test for overall effect z=2.88 p=0.004
0.1 0.2 0.5 1 2 5 10
Outcome 02 Induction of labour (all indications)
Outcome: 02 Induction of labour (all indications)
n/N n/N 95% CI (%) 95% CI
Blecher 1967 25/80 22/80 34.4 1.14 [ 0.70, 1.84 ]
Varma 1973 37/70 42/70 65.6 0.88 [ 0.66, 1.18 ]
Total (95% CI) 150 150 100.0 0.97 [ 0.75, 1.25 ]
Test for heterogeneity chi-square=0.83 df=1 p=0.36 I =0.0%
0.1 0.2 0.5 1 2 5 10
Outcome 03 Induction for placental insufciency
Outcome: 03 Induction for placental insufciency
n/N n/N 95% CI (%) 95% CI
Varma 1973 20/70 27/70 100.0 0.74 [ 0.46, 1.19 ]
Total (95% CI) 70 70 100.0 0.74 [ 0.46, 1.19 ]
0.1 0.2 0.5 1 2 5 10
Outcome 04 Fetal distress in labour
Outcome: 04 Fetal distress in labour
n/N n/N 95% CI (%) 95% CI
Varma 1973 10/70 27/70 100.0 0.37 [ 0.19, 0.71 ]
Total (95% CI) 70 70 100.0 0.37 [ 0.19, 0.71 ]
0.1 0.2 0.5 1 2 5 10
Outcome 05 Low birthweight
Outcome: 05 Low birthweight
n/N n/N 95% CI (%) 95% CI
Blecher 1967 40/84 55/80 49.3 0.69 [ 0.53, 0.91 ]
Varma 1973 18/70 58/70 50.7 0.31 [ 0.21, 0.47 ]
Total (95% CI) 154 150 100.0 0.50 [ 0.40, 0.63 ]
Test for overall effect z=6.01 p<0.00001
0.1 0.2 0.5 1 2 5 10
Outcome 06 Apgar score <6 at 1 minute
Outcome: 06 Apgar score <6 at 1 minute
n/N n/N 95% CI (%) 95% CI
Varma 1973 7/70 27/70 100.0 0.26 [ 0.12, 0.56 ]
Total (95% CI) 70 70 100.0 0.26 [ 0.12, 0.56 ]
0.1 0.2 0.5 1 2 5 10
Outcome 07 Perinatal mortality
Outcome: 07 Perinatal mortality
n/N n/N 95% CI (%) 95% CI
Blecher 1967 10/84 24/87 70.2 0.43 [ 0.22, 0.85 ]
MacRae 1971 1/28 2/28 6.0 0.50 [ 0.05, 5.20 ]
Varma 1973 2/70 8/70 23.8 0.25 [ 0.06, 1.14 ]
Total (95% CI) 182 185 100.0 0.39 [ 0.22, 0.71 ]
0.1 0.2 0.5 1 2 5 10
Outcome 08 Urinary oestriol increase mg per week
Outcome: 08 Urinary oestriol increase mg per week
Study Treatment Control Weighted Mean Difference (Fixed) Weighted Mean Difference (Fixed)
N Mean(SD) N Mean(SD) 95% CI 95% CI
Varma 1973 70 1.68 (1.21) 70 0.91 (0.74) 0.77 [ 0.44, 1.10 ]
-10.0 -5.0 0 5.0 10.0
Outcome 09 Fetal biparietal diameter increase mm per week
Outcome: 09 Fetal biparietal diameter increase mm per week
Varma 1973 70 2.08 (0.36) 70 1.49 (0.71) 0.59 [ 0.40, 0.78 ]
-10.0 -5.0 0 5.0 10.0
Outcome 10 Birthweight
Outcome: 10 Birthweight
MacRae 1971 28 2800.00 (591.00) 28 2296.00 (364.00) 504.00 [ 246.91, 761.09 ]
-10.0 -5.0 0 5.0 10.0

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