The latest medical research on Radiology

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Perinatal outcomes of pregnancies complicated by twin anemia-polycythemia sequence: a systematic review and meta-analysis.

Ultrasound in Obstetrics and Gynecology

To report the perinatal outcome in monochorionic diamniotic (MC) twin pregnancies complicated by twin anemia polycythemia sequence (TAPS).

Medline, Embase and Cochrane Library databases were searched. Inclusion criteria were non-anomalous MCDA twin pregnancies with a diagnosis of TAPS. The primary outcome was mortality; the secondary outcomes were morbidity and preterm birth (PTB). All these outcomes were stratified according to the type of TAPS (spontaneous or following laser treatment) and management option adopted (expectant, laser, intra-uterine transfusion [IUT] and selective reduction [SR]). Random effect meta-analyses of proportions were used to analyze the data.

Spontaneous and post-laser TAPS (506 pregnancies): IUD occurred in 5.32 (95% CI, 3.6-7.1) of spontaneous and in 10.2% (95% CI, 7.4-13.3) of post-laser TAPS, while the corresponding figures for NND were 4.0% (95% CI, 2.6-5.7) and 9.2% (95% CI, 6.6-12.3). Severe neonatal morbidity occurred in 29.3% (95% CI, 25.6-33.1) of twins after spontaneous and 33.3% (95% CI, 17.4-51.8) after post-laser TAPS, while the corresponding figures for severe neurological morbidity were 4.0% (95% CI, 3.5-5.7) and 11.1% (95% CI, 6.2-17.2) respectively. PTB complicated 86.3% (95% CI, 77.2- 93.3) of pregnancies with spontaneous and all cases with post-laser TAPS (95% CI, 84.3-100). Iatrogenic PTB was more frequent than the spontaneous PTB in both groups. Outcome according to different management options (418 pregnancies): IUD occurred in 9.8% (95% CI, 4.3-17.1) of pregnancies managed expectantly and in 13.1% (95% CI, 9.2-17.6), 12.1% (95% CI, 7.7-17.3) and 7.6% (95% CI, 1.3-18.5) of those treated with laser, IUT and SR, respectively. Severe neonatal morbidity affected 27.3% (95% CI, 13.6-43.6) twins in the expectant management group, 28.7% (95% CI, 22.7-35.1) in the laser surgery group, 38.2% (95% CI 18.3-60.5) in the IUT group and 23.3% (95% CI 10.5-39.2) in the SR group. PTB complicated 80.4% (95% CI, 59.8-94.8), 73.4% (95% CI, 48.1- 92.3), 100% (95% CI, 76.5- 100) and 100% (95% CI, 39.8-100) of pregnancies after expectant management, laser, IUT and SR, respectively.

The present meta-analysis provides pooled estimates of perinatal mortality, morbidity and preterm birth in twin pregnancies complicated by TAPS, stratified by the type of TAPS and according to different management options. Although a direct comparison could not be performed, the results from this systematic review suggest that spontaneous TAPS may have a better prognosis than post-Laser TAPS. No differences in terms of mortality and morbidity were observed comparing different management options for TAPS although these findings should be interpreted with caution in view of the limitations of the original studies. An individualized prenatal management, taking into account the severity of TAPS and gestational age, is currently the recommended strategy. This article is protected by copyright. All rights reserved.

Perinatal outcomes of iatrogenic chorioamniotic separation following fetoscopic surgeries: a systematic review and meta-analysis.

Ultrasound in Obstetrics and Gynecology

This systematic review and meta-analysis aims to compare the perinatal outcomes of pregnancies with and without iatrogenic chorioamniotic separation (iCAS) after fetoscopic interventions.

We performed a search in PubMed, Embase, Scopus, Web of Science and Google Scholar from inception up to December 2020 for studies evaluating perinatal variables among pregnancies developing iCAS after fetal interventions for twin to twin transfusion syndrome (TTTS), open neural tube defects (ONTD), congenital diaphragmatic hernia and other fetoscopic guided interventions. Afterward, the random-effects model was used to pool the mean differences (MDs) or odds ratios (OR) and the corresponding 95% confidence intervals (CIs). Primary outcome was neonatal survival. Secondary outcomes included gestational age (GA) at the intervention and delivery, intervention to delivery interval, risks of preterm premature rupture of membranes (PPROM) and preterm delivery.

The electronic search identified 348 records, of which seven studies (6 on TTTS and 1 on ONTD fetoscopic repair) assessed perinatal outcome of iCAS pregnancies after fetoscopic interventions. Given that only one study reported on fetoscopic ONTD repair, this meta-analysis was limited to TTTS pregnancies. Six studies for TTTS (total of 1881 pregnancies) were included for final analysis. Development of iCAS after fetoscopic laser photocoagulation (FLP) for TTTS was associated with significantly lower GA at the time of intervention (weeks) (MD -1.07, 95% CI -1.89, -0.24, P 0.01), lower GA at delivery (weeks) (MD -1.74, 95% CI: -3.13, -0.34, P 0.01) and lower neonatal survival (OR 0.41, 95% CI: 0.24, 0.70, p 0.001). In addition, iCAS in the TTTS group significantly increased risks for PPROM < 34 weeks (OR 3.98; 95% CI: 1.76, 9.03, P < 0.001) and preterm delivery < 32 weeks (OR 1.80; 95% CI: 1.16, 2.80, P 0.008; I2 48%) in this population.

Iatrogenic chorioamniotic separation is a commonly observed complication after FLP for TTTS. In the TTTS patients, iCAS tends to develop more with earlier GA at intervention and is associated with earlier GA at delivery, higher risk of PPROM, preterm delivery before 32 weeks' gestation and lower neonatal survival. Given the limitations of this meta-analysis and lack of literature reporting on other types of fetoscopic interventions, the presented findings should be interpreted with caution and should not be generalized to fetoscopic procedures used to treat other fetal conditions. This article is protected by copyright. All rights reserved.

Maternal cardiac function at 19-23 weeks' gestation in the prediction of gestational diabetes mellitus.

Ultrasound in Obstetrics and Gynecology

To examine differences in maternal cardiovascular indices at 19-23 weeks' gestation between pregnancies that develop gestational diabetes mellitus (GDM) and those without GDM and determine whether such cardiovascular changes are the consequence of maternal demographic characteristics and medical history or the GDM per se.

This was a prospective observational study in women attending for a routine hospital visit at 19+1 - 23+3 weeks' gestation. This visit included recording of maternal demographic characteristics and medical history and maternal echocardiography for assessment of E/A, E/e', myocardial performance index, global longitudinal systolic strain, left ventricular ejection fraction, peripheral vascular resistance, left ventricular cardiac output and left ventricular mass indexed for body surface area. The measurements of the maternal cardiac indices were standardized to remove the effects of maternal characteristics and elements from the medical history and the adjusted values in the GDM group were compared to those in the non-GDM group. Likelihood ratios were derived for those indices that were significantly altered in GDM and these were used to modify the prior risk derived from maternal demographic characteristics and medical history. The area under the receiver operating characteristic (ROC) curve (AUC) and detection rate (DR) of GDM, at 10%, 20% and 40% false positive rate (FPR), in screening by a combination of maternal factors with cardiovascular indices were determined.

The study population of 2,853 pregnancies contained 199 (7.0%) that developed GDM. The main findings of the study were: first, in pregnancies that developed GDM there were significant differences from the non-GDM group in E/A, E/e', myocardial performance index and global longitudinal systolic strain; second, after adjustment for maternal demographic characteristics and medical history known to affect cardiac indices the only cardiovascular indices that were significantly different between the GDM and non-GDM groups were peripheral vascular resistance and myocardial performance index and they were both marginally increased; and third, the performance of screening for GDM by maternal demographic characteristics and medical history was not improved by the addition of cardiovascular indices.

Women with GDM have subtle functional and hemodynamic cardiac changes prior to the development of GDM. These cardiac changes are mostly related to the adverse risk factor profile of these women. Maternal cardiac assessment at 20 weeks does not offer additional predictive information for GDM development in pregnancy to that calculated based on demographic characteristics and medical history. This article is protected by copyright. All rights reserved.

Assessment of pelvic floor muscles with 3D/4D transperineal ultrasound in women with deep infiltrating endometriosis and superficial dyspareunia treated with pelvic floor muscle physiotherapy: a randomized controlled trial.

Ultrasound in Obstetrics and Gynecology

Deep infiltrating endometriosis is associated with chronic pelvic pain, dyspareunia, and pelvic floor muscle hypertone. The primary aim of the study was to evaluate the effects of pelvic floor physiotherapy on changes in the area of levator ani muscle hiatus under Valsalva maneuver assessed with transperineal ultrasound in women with deep infiltrating endometriosis suffering from superficial dyspareunia.

In this randomized controlled trial, 34 nulliparous women diagnosed with deep infiltrating endometriosis and associated superficial dyspareunia were enrolled. After an initial clinical examination, evaluation of pain symptoms using Numerical Rating Scale and 3D/4D transperineal ultrasound, eligible women were randomly assigned (1:1) to no intervention (control group, 17 women) or treatment with five individual sessions of pelvic floor physiotherapy (study group, 17 women). Four months after the first examination, all women underwent a second evaluation of pain symptoms and transperineal ultrasound. During both ultrasound examinations, the levator hiatal area was measured at rest, upon maximum pelvic floor muscle contraction and maximum Valsalva maneuver. The primary outcome measure was the change in the levator hiatal area at maximum Valsalva maneuver between the two examinations in the two groups.

Thirty women completed the study and were included in the analysis: 17 in the study group and 13 in the control group. The percentage change in levator hiatal area at maximum Valsalva maneuver between the two examinations was higher in the study group than in the control group (20.0±24.8% vs. -0.5±3.3%, P=0.02). After treatment, the change in the Numerical Rating Scale score of superficial dyspareunia was higher in the study group than in the control group (median [interquartile range] -3 [-4,-2] vs. 0 [0,0], P <0.01). Moreover, at second examination significant differences between the two groups were found regarding chronic pelvic pain (0 [-2,0] vs. 0 [0,1], P =0.01).

In women with deep infiltrating endometriosis, pelvic floor physiotherapy seems to be effective in the improvement of superficial dyspareunia, chronic pelvic pain, and pelvic floor muscle relaxation, leading to an increase in levator hiatal area under Valsalva maneuver observed by 3D/4D transperineal ultrasound. This article is protected by copyright. All rights reserved.

Fetal neurosonography detects differences in cortical development and corpus callosum in late-onset small fetuses.

Ultrasound in Obstetrics and Gynecology

The aim of this study was to explore whether neurosonography can detect differences in cortical development and corpus callosum length in late-onset small fetuses sub-classified into small-for-gestational age (SGA) or fetal growth restriction (FGR).

A prospective cohort study in 318 singleton pregnancies including 97 normally grown and 221 late-onset small fetuses (birthweight below the 10th centile diagnosed after 32 weeks of gestation). Small fetuses were sub-classified into SGA (birthweight between the 3rd and 9th centile and normal fetoplacental Doppler; n=67) and FGR (birthweight <3rd centile and/or abnormal cerebroplacental ratio and/or uterine artery Doppler; n=154). Neurosonography was performed at 33+/-1 weeks to assess insula, Sylvian fissure, parieto-occipital sulcus depth in the axial views and corpus callosum length in the mid-sagittal plane. Measurements were performed off-line using the Alma Workstation software and adjusted by biparietal diameter or cephalic index. Data analysis was adjusted for confounding factors as gender, gestational age at neurosonography, nulliparity and preeclampsia by linear regression analysis.

Compared to controls, both SGA and FGR showed significantly thicker insula depth (mm) [control 0.329 (0.312-0.342) vs. SGA 0.339 (0.321-0.347) vs. FGR 0.336 (0.325-0.349), p=0.009]. A linear tendency to reduced Sylvian fissure depth (mm) [control 0.148±0.021 vs. SGA 0.142±0.025 vs. FGR 0.139±0.022, p=0.003] was also observed across the study groups. Corpus callosum length was significantly reduced in FGR cases, while there were no differences between SGA and controls [control 0.500 (0.478-0.531), SGA 0.502 (0.487-0.526) vs. IUGR 0.475 (0.447-0.508), p=0.073 (FGR vs control p=0.02; SGA vs control p= 0,69]. No differences were found in parieto-occipital sulcus depth.

Neurosonography seems to be a sensitive tool to detect subtle structural differences in brain development in late-onset small fetuses. This article is protected by copyright. All rights reserved.

Recurrent Cesarean scar pregnancy: case series and literature review.

Ultrasound in Obstetrics and Gynecology

To determine the rate of recurrent Cesarean scar pregnancy (CSP) in our clinical practices and to evaluate whether the mode of treatment of a CSP is associated with the risk of recurrent CSP, as well as to review the published literature on recurrent CSP.

We performed a retrospective search of our six obstetrical and gynecologic departmental ultrasound databases for all CSPs and recurrent CSPs between 2010 and 2019. We extracted various data, including numbers of CSPs with follow-up, numbers attempting and numbers achieving pregnancy following treatment of the CSP and numbers of recurrent CSPs, as well as details of the treatment of the original CSP. After analyzing the clinical data, we evaluated whether the mode of treatment terminating the previous CSP was associated with the risk of recurrent CSP. We also performed a PubMed search for: 'recurrent Cesarean scar pregnancy' and 'recurrent Cesarean scar ectopic pregnancy'. Articles were reviewed for year of publication and extraction and analysis of the same data as those obtained from our departmental databases.

Our database search identified 252 cases of CSP. The overall rate of clinical follow-up ranged between 71.4% and 100%, according to treatment site (mean, 90.9%). Among these, 105 were followed by another pregnancy after treatment of the previous CSP. Of these, 36 (34.3%) pregnancies were recurrent CSP, with 27 women having a single recurrence and three women having multiple recurrences, one with two, one with three and one with four. We did not find any particular single or combination treatment mode terminating the previous CSP to be associated with recurrent CSP. The literature search identified 17 articles that yielded sufficient information for us to evaluate their reported prevalence of recurrent CSP. They reported 1743 primary diagnoses of CSP, and 944 had reliable follow-up. There were data for 489 cases in which a woman attempted to conceive again, and on 327 pregnancies achieved, after treatment of a previous CSP. Of these, 67 (20.5%) were recurrent CSP.

On the basis of our pooled clinical data and review of the literature, recurrent CSP is apparently more common than was previously assumed based upon mostly single case reports or series with few cases. This should be borne in mind when counseling patients undergoing treatment for CSP regarding their risk of recurrence. We found no obvious causal relationship or association between the type of treatment for the previous CSP and recurrence of CSP. Patients pregnant after treatment for a CSP should be encouraged to have an early (5-7-week) first-trimester transvaginal scan to determine the location of the gestation. This article is protected by copyright. All rights reserved.

Prenatal features of ductus arteriosus related branch pulmonary stenosis in fetal pulmonary atresia.

Ultrasound in Obstetrics and Gynecology

Ductus arteriosus (DA)-related branch pulmonary stenosis (DA-PS), related to ductal tissue in the proximal pulmonary artery (PA) ipsilateral to the DA, is common in newborns with pulmonary atresia (PAtr) and contributes importantly to their mortality and morbidity. We sought to define fetal echocardiographic predictors of DA-PS in PAtr.

We identified all neonates prenatally diagnosed with PAtr and a DA-dependent pulmonary circulation, with a DA that joins the underbelly of the arch, who had undergone surgical or catheter intervention in our hospital between 2009-2018. We reviewed postnatal echocardiograms and clinical records to confirm the presence or absence of DA-PS based on need for angioplasty at initial intervention and/or evolution of proximal PA stenosis post intervention. Fetal echocardiograms were examined for features of DA-PS.

Of 53 fetuses with PAtr, 34(64%) had analyzable images including 20(59%) with and 14(41%) without DA-PS. Difficulty visualizing the branch PAs on the same plane, largely associated with abnormal DA insertion into the ipsilateral PA (85% of cases), carried a sensitivity, specificity, positive (PPV) and negative (NPV) predictive value of 75%,100%, 100%, 74%, respectively. The mean branch PA posterior bifurcation angle was more obtuse in those with DA-PS (117°±17 vs 79°±17, p<0.001) and an obtuse angle had a sensitivity, specificity, PPV and NPV of 88%, 79%, 82% and 85%, respectively. The presence of one or both features had a sensitivity, specificity, PPV and NPV of 82%, 92%, 90% and 85%. The ROC curve revealed an angle of 105° as predictive for DA-PS with a sensitivity and specificity of 88% and 100%.

Difficulty in visualizing the branch PAs on the same plane with abnormal insertion of the DA in most, and/or the presence of a posterior PA bifurcation angle of >100° are features of postnatal DA-PS in fetuses with PAtr. This article is protected by copyright. All rights reserved.

Sonographic, demographic characteristics, and the Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE) in the prediction of tumor recurrence or progression.

Ultrasound in Obstetrics and Gynecology

To identify and assess demographic, sonographic and Proactive Molecular Risk Classifier for Endometrial cancer (ProMisE) prognostic factors for recurrence or progression in endometrial cancer (EC).

We prospectively included 339 women with EC, undergoing expert transvaginal ultrasound before surgery. Tumors were classified according to FIGO, and ProMisE (MMR-D, POLE EDM, p53wt and p53abn). ProMisE subtypes were compared regarding demographic, sonographic characteristics, recurrence or progression, and survival. Cox regression was used to identify prognostic factors associated with recurrence or progression, with univariable models to study crude associations and multivariable models to study adjusted associations. Logistic regression and ROC curves analysis was used to assess the predictive ability of the prognostic factors, regarding recurrence or progression within three years, and to compared their predictive ability to that of the European Society for Medical Oncology (ESMO) classification. In separate sub analysis, tumors were stratified by p53 status (present/absent) and ultrasound tumor size (< 2 cm/≥ 2 cm).

Median follow-up time was 58 (IQR, 48-71, range 0-102) months. Recurrence/progression occurred in 51/339 (15%), in MMR-D 14%, POLE EDM 8%, p53wt 9%, and p53abn 46%. The multivariable 'ProMisE model' (ProMisE subtype, age, waist circumference, ultrasound tumor extension and ultrasound tumor size) (AUC 0.89, 95% CI 0.85-0.93) predicted recurrence/progression with comparable ability to the multivariable 'histotype and grade model' (histotype and grade, age, waist circumference, ultrasound tumor extension and ultrasound tumor size) (AUC 0.88, 95% CI 0.83-0.92) and with higher ability than both the preoperative (AUC 0.74, 95% CI 0.67-0.82), p <0.01), and postoperative (AUC 0.79, 95% CI 0.72-0.86), p <0.01) ESMO classification. The 48% with the combination of non-p53abn subtype and tumor size <2cm had a very low risk (1.8%) of recurrence/progression.

A combination of demographic, sonographic and ProMisE prognostic factors had higher ability to predict recurrence or progression than the ESMO classification, supporting their use in preoperative risk stratification. The p53 status combined with ultrasound tumor size has the potential to preoperatively identify a large group of women with a very low risk of recurrence or progression. This article is protected by copyright. All rights reserved.

Ovarian cancer as an imitator of severe pre-eclampsia: role of angiogenic factors.

Ultrasound in Obstetrics and Gynecology

Preeclampsia (PE) is a common disorder in pregnancy that constitutes one of the leading causes of maternal and perinatal morbidity and mortality. S...

Maternal cardiac function at 19-23 weeks' gestation in the prediction of pre-eclampsia.

Ultrasound in Obstetrics and Gynecology

First, to examine the factors from maternal characteristics and medical history that affect maternal cardiovascular indices, and second, to examine the potential value of maternal cardiovascular indices at 19-23 weeks' gestation on their own and in combination with the established biomarkers of preeclampsia (PE), including uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFLT), in the prediction of subsequent development of PE.

This was a prospective observational study in women attending for a routine hospital visit at 19+1 - 23+3 weeks' gestation. This visit included recording of maternal demographic characteristics and medical history, assessment of maternal E/A, E/e', myocardial performance index, global longitudinal systolic strain, left ventricular ejection fraction, peripheral vascular resistance, left ventricular cardiac output and left ventricular mass indexed for body surface area, and measurement of MAP, UtA-PI, serum PlGF and serum sFLT-1. The measurements of the eight maternal cardiac indices were standardized to remove the effects of maternal characteristics and elements from the medical history. The competing risks model was used to estimate the individual patient-specific risks of delivery with PE and determine the detection rate (DR), at 10% false positive rate (FPR), in screening by a combination of maternal demographic characteristics and medical history with biomarkers.

The study population of 2,853 pregnancies contained 76 (2.7%) that developed PE. The main findings of the study were: first, in pregnancies that subsequently developed PE there was evidence of altered cardiac geometry, impaired myocardial function and increased peripheral vascular resistance; second, all maternal cardiovascular indices were significantly affected by maternal demographic characteristics and elements of medical history known to be associated with increased risk for subsequent development of PE; third, after adjustment for maternal demographic characteristics and medical history the only cardiovascular index that was significantly affected by subsequent development of PE was peripheral vascular resistance; fourth, peripheral vascular resistance MoM was correlated with MAP MoM, which is not surprising because blood pressure is involved in the estimation of both; fifth, there were small correlations between several cardiovascular indices with MAP MoM, but none with MoM values of UtA-PI, PlGF or sFLT-1; sixth, the performance of screening of delivery with PE at <37 weeks' gestation or delivery with PE at any gestational age in screening by maternal demographic characteristics and medical history or combinations of maternal factors with MAP, UtA-PI, PlGF and sFLT-1 were not improved by the addition of peripheral vascular resistance.

Assessment of maternal cardiovascular function provides information on the pathophysiology of PE but is not useful in the prediction of PE. This article is protected by copyright. All rights reserved.

The hypoplastic left heart complex: fetal predictors of growth and surgical repair.

Ultrasound in Obstetrics and Gynecology

The terms "hypoplastic left heart complex" (HLHC) or borderline left heart have been used to describe fetuses with ventricular discrepancy involving small left heart structures but no overt valvar stenosis. Little evidence exists regarding predictors of successful biventricular (BV) repair in patients with HLHC.

Fetal echocardiograms performed between 2004-2017 with HLHC were included. Studies at 18-26 weeks and 27-37 weeks were analyzed. The primary outcome was a successful BV circulation (Group 1). Group 2 included patients with single ventricle palliation, death or transplant. Univariate analysis was performed on studies at 18-26 weeks and 27-37 weeks. Multivariate logistic regression was performed on studies between 27-37 weeks.

Of 51 included cases, 44 achieved a successful BV circulation (Group 1) and 7 did not (Group 2). On univariate analysis, right to left foramen ovale (FO) flow and a larger mitral valve (MV) annulus z score were associated with successful BV circulation. On multivariate analysis right to left FO flow and a higher MV z score were found in Group 1. Bidirectional or left to right FO flow, LV length (LVL) z score of < -2.4 and a MV z score of < -4.5 correctly predicted 80% of Group 2 outcomes. Late follow-up was available for 41 patients. There were two late deaths in Group 2. Thirteen patients in Group 1 required re-intervention, 12 developed mitral stenosis and 5 developed isolated subaortic stenosis.

A successful BV circulation is common in fetuses with HLHC. The size of the MV annulus, direction of FO flow and LVL z score are important predictors of a successful BV circulation. Long term sequelae in those with a BV circulation may include mitral and subaortic stenosis This article is protected by copyright. All rights reserved.

Foley catheter vs oral misoprostol for the induction of labor: an individual participant data meta-analysis.

Ultrasound in Obstetrics and Gynecology

To compare the effectiveness and safety of Foley catheter and oral misoprostol use in induction of labor (IOL).

We searched the Cochrane Review on Mechanical Methods for Induction of Labour, Ovid MEDLINE, Embase via Ovid, Ovid Emcare, CINAHL Plus, ClinicalTrials.gov and Scopus from inception to April 2019, for randomized controlled trials comparing Foley catheter to oral misoprostol for IOL in viable singleton gestations. Co-primary outcomes were vaginal birth, a composite of adverse perinatal outcome, and a composite of adverse maternal outcome. The quality of included RCTs was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence was evaluated using the GRADE approach. We used two-stage random-effects model for the meta-analysis according to the intention-to-treat principle and assessed interactions between treatment and baseline characteristics.

From seven eligible studies, four shared individual participant data for a total of 2815 participants, of which 1399 women were assigned to Foley catheter and 1416 to oral misoprostol. Compared with oral misoprostol, Foley catheter recipients had a slightly decreased chance of having a vaginal birth (4 trials, 2815 women, RR 0.95, 95% CI 0.91-0.99, I2 2.0%, moderate-certainty evidence). Foley catheter may lead to fewer adverse perinatal outcomes in comparison with oral misoprostol (4 trials, 2815 women, risk ratio [RR] 0.71, 95% CI 0.48-1.05, I2 14.9%, low-certainty evidence). Adverse maternal outcome did not differ (4 trials, 2815 women, RR 1.00, 95% CI 0.97-1.03, I2 0%, moderate-certainty evidence). Meta-analyses of effect-modifications did not show significant interactions between interventions, parity and gestational age on primary outcomes.

For women undergoing IOL Foley catheter is less effective than oral misoprostol as it was associated with fewer vaginal births. However, while we found no significant difference in maternal safety, Foley catheter induction may reduce adverse perinatal outcomes. This article is protected by copyright. All rights reserved.