Search

For several years, climate change in Luxembourg has increasingly resulted, among other things, in precipitation deficits, which causes damage linked to the phenomenon of shrinkage–swelling of clays, affecting both buildings and infrastructures. The south of Luxembourg, with its predominantly marly and clayey Triassic and Jurassic rocks, is particularly at risk. While the usual stabilisation methods are often used, such as underpinning or injecting under the foundations, they have several drawbacks. As an alternative, innovative rainwater reinjection methods have been tested by our office, with encouraging results, and could help to prevent the occurrence of damage to structures. At the same time, the establishment of a hazard map and the development of technical regulations specifying the parameters to be determined and the tests to be carried out would allow better management of the risk by all stakeholders, as well as the limitation of related costs.

Women who develop preeclampsia (PE) are at high risk for cardiovascular disease (CVD). Early identification of women with PE who may benefit the most from early cardiovascular risk screening and interventions remains challenging. Our objective was to assess whether cytokine and immune cell profiles after PE are helpful in distinguishing women at low and high CVD risk at 6-months postpartum. Individuals who developed PE were followed for immune cell phenotyping and plasma cytokine quantification at delivery, at 3-months, and at 6-months postpartum. Lifetime CVD risk was assessed at 6-months postpartum, and the immune cell and cytokine profiles were compared between risk groups at each time point. Among 31 participants, 18 (58.1%) exhibited high CVD-risk profiles at 6-months postpartum. The proportion of circulating NK-cells was significantly lower in high-risk participants at delivery (p = 0.04). At 3-months postpartum, high-risk participants exhibited a lower proportion of FoxP3+ regulatory T-cells (p = 0.01), a greater proportion of CD8+ T cells (p = 0.02) and a lower CD4+:CD8+ ratio (p = 0.02). There were no differences in immune cell populations at 6-months postpartum. There were no differences in plasma cytokines levels between risk groups at any time point. Subtle differences in immune cell profiles may help distinguish individuals at low and high CVD risk in the early postpartum period and warrants further investigation.

Assessment of donor suitability and criteria development for tissue donation evaluation which appropriately addresses the risk factors for disease transmission, especially high risk for Hepatitis B or C, HIV or other transmissible diseases as defined by the Food and Drug Administration, FDA, is a continuing concern for tissue banks. The relationship of drug use, especially IV drugs, has been determined to be associated with an increased possibility of reactive serology (Centers for Disease Control and Prevention (USCDC) in Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Hepatitis C questions and answers for health professionals. https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm; Centers for Disease Control and Prevention (USCDC) in infectious diseases, opioids and injection drug use, 2018. https://www.cdc.gov/pwid/opioid-use.html; HIH National Institute on Drug Abuse in Health Consequences of Drug Misuse, 2017. https://www.drugabuse.gov/related-topics/health-consequences-drug-misuse). Therefore, prior drug use determined by medical social history screening frequently results in deferral of a potential donor even when the route of drug administration has not been determined to be intravenous. Because of the association of drug use in numerous cases, which come under Medical Examiner jurisdiction, a possible rule out of a number of otherwise suitable medical examiner cases could occur. This retrospective review of medical examiner cases, tissue bank referrals and tissue donors in a 3-year period examines the relationship, if any, between reactive serology and positive toxicology results. These results would appear to indicate assessment of donor medical social history screening is effective in reducing recovery of high-risk donors.

Background Previous studies have shown that older people can experience a considerable change in their physical performance (PP) over time. Objectives To identify PP trajectories and their association with mortality among nursing home residents who were followed up for 3 years. Design Three-year longitudinal observational study. Setting Subjects of the SENIOR cohort. Subjects Six hundred and four nursing home residents with a mean age of 82.9 ± 9.1 years. Methods Baseline characteristics and the date of death were collected from the medical records. PP was assessed annually by the short physical performance battery (SPPB) test. Multiple imputations were performed to manage the missing data. PP trajectory groups were estimated using latent growth curve analysis. Cox proportional hazard regression models were applied to examine the risk of mortality according to the PP trajectory groups. Results Three PP trajectory groups were identified: slow decline (N = 96), moderate decline (N = 234) and fast decline (N = 274). After adjustments for potential confounding variables and the baseline SPPB scores, the residents in the fast decline and moderate decline trajectory groups had an increased risk of mortality compared to those in the slow decline trajectory group, with hazard ratio values of 1.78 (95% confidence interval [CI] = 1.34–2.26) and 1.37 (95% CI = 1.10–1.66), respectively. Conclusions PP trajectories provide value-added information to baseline geriatric assessments and could be used for predicting 3-year mortality among nursing home residents. It may be important to regularly monitor the SPPB score and signal an alert when a fast decline in PP is detected in older people.

Background This study aimed to evaluate the predictive value of the domains of intrinsic capacity (ie, cognition, locomotion, sensory, vitality, and psychosocial) proposed by the World Health Organization (WHO) on the 3-year adverse health outcomes of nursing home residents. Methods A 3-year incidence of mortality, falls, repeated falls, and autonomy decline (ie, a one-unit increase in the Katz score) was assessed in a cohort of Belgian nursing home residents. Cognition was assessed using the Mini-Mental State Examination (MMSE). For locomotion, balance, gait speed and chair stand performance were evaluated by the Short Physical Performance Battery test. The sensory domain was measured using the Strawbridge questionnaire for audition and vision. For vitality, abdominal circumference, body mass index, nutritional status (by Mini Nutritional Assessment [MNA]) and handgrip strength were assessed. Psychosocial status was evaluated by the EQ-5D and the Center for Epidemiological Studies Depression scale. Missing data were handled by multiple imputations. Cox proportional hazard models, logistic regressions, and analysis of variance were used for the analyses. Results In the multivariable model, a one-unit increase in balance performance and in the nutrition score decreased the probability of death by 12% (Hazard ratio [HR] = 0.88; 95% confidence interval [CI] 0.78–0.99) and 4% (HR = 0.96; 95% CI 0.93–0.99), respectively. The risk of falling decreased when there was a one-unit increase in balance performance (HR = 0.87, 95% CI 0.79–0.96) and in the nutrition score (HR = 0.96, 95% CI 0.93–0.98). No association was found for intrinsic capacity and repeated falls. Low scores in nutrition (odds ratio = 0.86, 95% CI 0.77–0.96) were associated with a higher probability of autonomy decline. Conclusion Some domains of intrinsic capacity predicted health outcomes among nursing home residents. Nutrition and balance should be regularly checked among this population.

Perturbations to extravillous trophoblast (EVT) cell migration and invasion are associated with the development of placenta-mediated diseases. Phytochemicals found in the lowbush blueberry plant (Vaccinium angustifolium) have been shown to influence cell migration and invasion in models of tumorigenesis and noncancerous, healthy cells, however never in EVT cells. We hypothesized that the phenolic compounds present in V. angustifolium leaf extract promote trophoblast migration and invasion. Using the HTR-8/SVneo human EVT cell line and Boyden chamber assays, the influence of V. angustifolium leaf extract (0 to 2 × 104 ng/ml) on trophoblast cell migration (n = 4) and invasion (n = 4) was determined. Cellular proliferation and viability were assessed using immunoreactivity to Ki67 (n = 3) and trypan blue exclusion assays (n = 3), respectively. At 20 ng/ml, V. angustifolium leaf extract increased HTR-8/SVneo cell migration and invasion (p

IMPORTANCE Early exposure to complex dietary proteins may increase the risk of type 1 diabetes in children with genetic disease susceptibility. There are no intact proteins in extensively hydrolyzed formulas. OBJECTIVE To test the hypothesis that weaning to an extensively hydrolyzed formula decreases the cumulative incidence of type 1 diabetes in young children. DESIGN, SETTING, AND PARTICIPANTS An international double-blind randomized clinical trial of 2159 infants with human leukocyte antigen-conferred disease susceptibility and a first-degree relative with type 1 diabetes recruited from May 2002 to January 2007 in 78 study centers in 15 countries; 1081 were randomized to be weaned to the extensively hydrolyzed casein formula and 1078 to a conventional formula. The follow-up of the participants ended on February 28, 2017. INTERVENTIONS The participants received either a casein hydrolysate or a conventional adapted cows milk formula supplemented with 20% of the casein hydrolysate. The minimum duration of study formula exposure was 60 days by 6 to 8 months of age. MAIN OUTCOMES AND MEASURES Primary outcome was type 1 diabetes diagnosed according to World Health Organization criteria. Secondary outcomes included age at diabetes diagnosis and safety (adverse events). RESULTS Among 2159 newborn infants (1021 female [47.3%]) who were randomized, 1744 (80.8%) completed the trial. The participants were observed for a median of 11.5 years (quartile [Q] 1-Q3, 10.2-12.8). The absolute risk of type 1 diabetes was 8.4% among those randomized to the casein hydrolysate (n = 91) vs 7.6% among those randomized to the conventional formula (n = 82) (difference, 0.8%[95% CI, -1.6% to 3.2%]). The hazard ratio for type 1 diabetes adjusted for human leukocyte antigen risk group, duration of breastfeeding, duration of study formula consumption, sex, and region while treating study center as a random effect was 1.1 (95% CI, 0.8 to 1.5; P = .46). The median age at diagnosis of type 1 diabetes was similar in the 2 groups (6.0 years [Q1-Q3, 3.1-8.9] vs 5.8 years [Q1-Q3, 2.6-9.1]; difference, 0.2 years [95% CI, -0.9 to 1.2]). Upper respiratory infections were the most common adverse event reported (frequency, 0.48 events/year in the hydrolysate group and 0.50 events/year in the control group). CONCLUSIONS AND RELEVANCE Among infants at risk for type 1 diabetes, weaning to a hydrolyzed formula compared with a conventional formula did not reduce the cumulative incidence of type 1 diabetes after median follow-up for 11.5 years. These findings do not support a need to revise the dietary recommendations for infants at risk for type 1 diabetes. Funding Agencies|Eunice Kennedy Shriver National Institute of Child Health and Development (NICHD); National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health [HD040364, HD042444, HD051997]; Canadian Institutes of Health Research; Commission of the European Communities [QLK1-2002-00372]; European Foundation for the Study of Diabates/JDRF/Novo Nordisk; Academy of Finland (Centre of Excellence in Molecular Systems Immunology and Physiology Research) [250114]; Dutch Diabetes Research Foundation; Finnish Diabetes Research Foundation; JDRF

I. Resume Objectif le virus de l'hepatite C (VHC) pose une menace de plus en plus serieuse a la sante publique a l'echelle mondiale. Les travailleurs de la sante qui s'occupent des femmes en âge de procreer sont particulierement bien places pour identifier un nombre important de femmes a risque et fournir les services de depistage et de counseling appropries. Le principal objectif de ces lignes directrices est de fournir une information exacte et a jour a tous ceux et celles qui prodiguent des soins de sante en reproduction aux femmes vivant avec le VHC. Ce document vise aussi a sensibiliser le monde medical et le grand public au probleme de l'hepatite C. Options ces lignes directrices ont ete elaborees en tenant compte des domaines suivants de la pratique clinique : la prevention des maladies, le depistage cible des individus a risque d'infection par le VHC, la prise en charge des patientes identifiees dans le contexte des soins de sante en reproduction et la bonne maniere de les diriger vers les soins specialises appropries. Resultats attendus la mise en pratique de ces lignes directrices devrait permettre de mieux identifier les femmes infectees et contribuer au mieux-etre physique et mental des patientes et de leur famille ainsi qu'a la reduction des taux de transmission. Evidence en utilisant MEDLINE, on a mene une recherche approfondie de la litterature medicale, publiee entre 1966 et 2000, en anglais aussi bien qu'en d'autres langues. En fevrier 2000, a Montreal, eut lieu une rencontre d'un groupe pluridisciplinaire compose d'experts dans les domaines de l'obstetrique et de la gynecologie, des maladies infectieuses, de l'hepatologie et de la sante publique. Ce groupe de travail comprenait aussi une patiente et un representant de la Societe de l'hepatite C du Canada. Le niveau d'evidence accompagnant chaque recommandation est base sur les criteres definis par le Groupe de travail canadien sur l'examen medical periodique. Avantages, desavantages et couts du point de vue de la sante publique, il y a des avantages importants a tirer d'une meilleure identification des individus a risque, du diagnostic, du traitement, de la mise en œuvre de pratiques reduisant le risque et les taux de transmission, a la fois au niveau de l'individu et de la collectivite. Cependant, il faut se rappeler que le diagnostic d'une maladie chronique peut entrainer des consequences tres serieuses pour les patientes et leur famille. Recommandations a)Depistage : le depistage universel du VHC n'est pas recommande. Cependant, un depistage selectif devrait etre offert a toutes les femmes qui appartiennent a une categorie quelconque de risque. Les tests devraient n'etre administres qu'apres un counseling approprie et le consentement eclaire de la patiente (III B). b)Soins precedant la conception et au stade precoce de la grossesse : •Idealement, une evaluation precedant la conception ou au stade precoce de la grossesse devrait comprendre le diagnostic du risque d'infection par l'hepatite C, le counseling et les tests necessaires (III B). •Les patientes qui sont conscientes d'un diagnostic positif de VHC devraient etre evaluees avant de devenir enceintes de maniere a identifier les complications qui pourraient compromettre la sante maternelle durant la grossesse (III B). •A elle seule, l'hepatite C ne constitue pas une contreindication de grossesse (Elle est toutefois contre-indiquee en cas de traitement a la ribavirine.) (III B). c)Soins durant la grossesse : •Le risque de transmission verticale est plus grand si la patiente est aussi infectee du virus de l'immunodeficience humaine (VIH) (II-2). •Les soins prenataux doivent satisfaire aux besoins particuliers selon la condition medicale et obstetricale de la patiente, y compris la surveillance de la fonction hepatique (II-2 A). •Les boissons alcooliques doivent etre evitees (II-2 A). •L'immunisation contre l'hepatite A et B selon le besoin (II-2 A). •La cesarienne systematique n'est pas recommandee comme moyen specifique de reduire le risque de transmission verticale de l'hepatite C au moment de la naissance (II-2 D). •L'allaitement n'est pas contre-indique (II-3 B). d)Soins des nouveau-nes : •Tous les enfants nes de meres porteuses du VHC doivent etre examines pour depister la presence de l'hepatite C (III A). e)Contraception et hormonotherapie substitutive : •Il faut recommander aux femmes qui ont des partenaires sexuels multiples d'utiliser des methodes contraceptives de type barriere (II-3 B). •Avant d'envisager la possibilite d'utiliser un contraceptif hormonal ou de suivre une hormonotherapie substitutive, il faut evaluer soigneusement l'etendue de la maladie du foie (III B). f)Precautions universelles : •De maniere a proteger les travailleurs de la sante aussi bien que les patientes, on recommande le recours a certaines precautions universelles/pratiques systematiques et autres precautions pour toutes les patientes (II-2 A). Validation Les references bibliographiques ont ete recueillies a partir de MEDLINE et on a compare les presentes directives a celles en vigueur afin d'en assurer la coherence. Des examinateurs externes, experts dans leurs domaines respectifs, ont aussi ete consultes.

Los problemas de salud mental en niños y adolescentes presentan una elevada incidencia en el Perú y en el mundo, sin embargo, aún no es considerada como prioridad por parte de los gobiernos. Es por ello, que las condiciones de salud mental aún no son óptimas para dicha población, generándose una gran necesidad de que los servicios de salud mental se centren en la detección temprana y la integren como parte esencial de la atención primaria de la salud (Instituto Nacional de Salud Mental Honorio Delgado- Hideyo Noguchi [INSM], 2012). Añadido a esto, diversas estadísticas sustentan la importancia de una intervención recuperativa o preventiva en el campo de la salud mental infantil, pues se ha demostrado que mientras más temprano se realice una intervención, mayor será la efectividad de esta (Ministerio de Salud del Perú [MINSA], 2018). Es así que, desde la disciplina de la psicología, se considera de suma importancia, prevenir e intervenir a tiempo en esta etapa mediante actividades como la evaluación, diagnóstico, intervención y prevención. Bajo este panorama, el presente reporte detallará las labores profesionales realizadas, así como los resultados observados, en un centro especializado en brindar servicios relacionados a la psicología infantil. Específicamente se centrará en las actividades de evaluación y diagnóstico, capacitación a cuidadores y acompañamiento a niños adoptados.

To correlate peak expiratory flow (PEF) with the incidence of frailty, deaths and falls among nursing home residents.This is a 1-year longitudinal analysis performed on the clinical data of the SENIOR cohort. PEF, measured by peak flow meter, was considered as "low" when the observed value was ≤80% of the theoretical value. Physical capacity was evaluated using Short Physical Performance Battery, balance and gait using Tinetti test and muscle strength using a dynamometer. The incidence of frailty was defined as the transition from a "robust" or "prefrail" status to a "frail" status following Fried's criteria. Deaths and falls were also collected.Among 646 subjects included at baseline (83.2 ± 9 years and 72.1% women), 297 (45.7%) displayed a low PEF. In this subgroup, physical capacity (p-values from 0.01 to0.001), muscle strength (p 0.001), balance and gait score (p 0.001) were significantly lower compared to subjects displaying normal PEF. Subjects who became frail after one year displayed a lower % of the theoretical PEF value compared to those that did not (88.52 ± 45.06 vs 102.78 ± 50.29, respectively, p = 0.03). After adjustment for potential confounding variables (calf circumference, Tinetti test, SPPB test and handgrip strength), PEF was no longer associated with the occurrence of frailty. There was no association between PEF and mortality and falls.In a nursing home setting, PEF is not an independent factor associated with the incidence of frailty, deaths and falls.

Introduction: Discriminating between placentally-mediated fetal growth restriction and constitutionally-small fetuses is a challenge in obstetric practice. Placental growth factor (PlGF), measurable in the maternal circulation, may have this discriminatory capacity. Methods: Plasma PlGF was measured in women presenting with suspected fetal growth restriction (FGR; ultrasound fetal abdominal circumference

Background Non-elective cervical cerclages are associated with significant perinatal complications. There is scant available information about what the predictors of these outcomes are, thus making counselling difficult. Objective To identify which factors predict delivery at or beyond 28, 34, and 37 weeks' gestation in women with emergency/rescue cervical cerclage. Methods We conducted a retrospective cohort study of nonelective cerclages over 10 years in our centre. We included women with singleton pregnancies, morphologically normal fetuses, and a cervix dilated to at least 1 cm. Our primary outcome was delivery at or beyond 28 weeks' gestation, and secondary outcomes consisted of delivery at or beyond 34 and 37 weeks' gestation. Descriptive statistical and logistic regression analyses were performed. Results We identified a total of 69 cases, and 47 met the inclusion criteria; 44.6% of these women delivered at or beyond 28 weeks' gestation. Membranes seen in the vagina on ultrasound and postcerclage preterm premature rupture of membranes decreased the chance of delivery at or beyond 28 weeks by 81.7% (OR 0.183; 95% CI 0.048 to 0.703) and 95% (OR 0.050; 95% CI 0.006 to 0.429), respectively. The same factors were predictive of deliveries at or beyond 34 and 37 weeks' gestation. Conclusion Membranes seen in the vagina on ultrasound and postcerclage pre-labour premature rupture of membranes were the strongest predictors of failure to reach 28 weeks' gestation. This information is of critical importance when counselling patients about non-elective cervical cerclage.

Placenta-mediated diseases (PMDs) including preeclampsia and fetal growth restriction are often characterized by shallow trophoblast invasion and incomplete spiral artery remodeling leading to impaired placental perfusion. In this context, umbilical artery (UA) Doppler can be used to detect high resistance to flow characteristic of very late-stage placental disease. We propose that evaluation of intraplacental villous artery (IPVA) resistance can provide earlier detection of increased resistance in placental flow. Seventy-five patients were recruited from the Ottawa Hospital. All had scans at 18 to 20, 28 and 34 weeks of gestation. IPVAs arising perpendicular to the chorionic plate in three regions (placental tips 4 cm away from cord insertion and within 1 cm from cord insertion) were sampled at each gestational age for resistance index (RI) and pulsatility index (PI). UA Doppler was also obtained from a free loop of cord. Pregnancy outcomes were collected from a chart review. Data were analyzed using SAS version 9.4 and standard statistic tests (mean±s.d., Student's t-test, mixed-effects modeling). A total of 53 patients completed the study. Of these, 38 had normal pregnancy outcomes (controls) and 15 (cases) developed PMD (preeclampsia, n=8 and low birth weight/intrauterine growth restriction, n=7). Mean birth weight in the study group was 2482.1±518.85 g. At 18 to 20, 28 and 34 weeks gestation, the mean IPVA resistance indices in the control group were 0.86±0.16, 0.81±0.12 and 0.71±0.12 for PI and 0.57±0.07, 0.55±0.06 and 0.49±0.06 for RI, respectively. However, in the cases developing PMDs, the PIs were 1.09±0.17, 0.95±0.21 and 0.78±0.07 and RIs 0.66±0.07, 0.60±0.07 and 0.54±0.04, respectively (P

Hypertensive disorders are the most common medical complication of pregnancy. As such, a large part of antenatal care is dedicated to the detection of pre-eclampsia, the most dangerous of the hypertensive disorders. The highlights of this chapter include progress in the use of out-of-office blood pressure measurement as an adjunct to office blood pressure measurement, pre-eclampsia defined as proteinuria or relevant end-organ dysfunction, antihypertensive therapy for severe and non-severe hypertension and post-partum follow-up to mitigate the increased cardiovascular risk associated with any of the hypertensive disorders of pregnancy.

Background Immunization of pregnant women with tetanus-diphtheria-acellular pertussis vaccine (Tdap) provides protection against pertussis to the newborn infant. Methods In a randomized, controlled, observer-blind, multicenter clinical trial, we measured the safety and immunogenicity of Tdap during pregnancy and the effect on the infant's immune response to primary vaccination at 2, 4, and 6 months and booster vaccination at 12 months of age. A total of 273 women received either Tdap or tetanus-diphtheria (Td) vaccine in the third trimester and provided information for the safety analysis and samples for the immunogenicity analyses; 261 infants provided serum for the immunogenicity analyses. Results Rates of adverse events were similar in both groups. Infants of Tdap recipients had cord blood levels that were 21% higher than maternal levels for pertussis toxoid (PT), 13% higher for filamentous hemagglutinin (FHA), 4% higher for pertactin (PRN), and 7% higher for fimbriae (FIM). These infants had significantly higher PT antibody levels at birth and at 2 months and significantly higher FHA, PRN, and FIM antibodies at birth and 2 and 4 months, but significantly lower PT and FHA antibody levels at 6 and 7 months and significantly lower PRN and FIM antibody levels at 7 months than infants whose mothers received Td. Differences persisted prebooster at 12 months for all antigens and postbooster 1 month later for PT, FHA, and FIM. Conclusions This study demonstrated that Tdap during pregnancy results in higher levels of antibodies early in infancy but lower levels after the primary vaccine series. Clinical trials registration NCT00553228.

I. Abstract Objective hepatitis C virus (HCV) is an increasingly important public health problem worldwide. Health care workers providing care to women of childbearing age are uniquely placed in their practices to identify a significant proportion of at-risk patients and to provide appropriate screening and counselling. The primary objective of this guideline is to provide accurate, current information to those offering reproductive care to women living with HCV. This document is also intended to raise awareness of HCV in both the medical and general populations. Options the areas of clinical practice considered in formulating this guideline are disease prevention, targeted screening of individuals at risk of contracting HCV, management of identified patients in the context of reproductive care, and the appropriate referral of patients to those with particular expertise. Outcomes implementation of these guidelines should facilitate identification of infected individuals. It should also result in improved physical and mental well-being for patients and their families and reduction in transmission rates. Evidence the literature between 1966 and 2000, including non- English language publications, was extensively searched utilizing Medline. A multidisciplinary group consisting of experts within the fields of obstetrics and gynaecology, infectious diseases, hepatology, and public health convened in Montreal in February 2000. The working group also included a patient and a representative from the Hepatitis C Society of Canada. The level of evidence for the recommendations has been determined using the criteria described by the Canadian Task Force on Periodic Health Examination. Benefits, harms and costs the public health benefits of increased identification of at-risk individuals, diagnosis, treatment, implementation of risk reduction behaviours, and reduced transmission rates, both on an individual and at the community level, are significant. However, it must be remembered that the diagnosis of a chronic disease may have far reaching effects for the individual patient and her family. Recommendations a)Screening •Universal screening for HCV is not recommended, although targeted screening should be offered to all women falling into any at-risk category. Testing should take place following adequate counselling and informed consent of the patient (III B). b)Preconception and early pregnancy care •Ideally, preconception or early pregnancy evaluation should include determination of risk of infection with hepatitis C, counselling, and testing as appropriate (III B). •Patients aware of their HCV positive diagnosis should be evaluated before embarking on pregnancy for complications that may compromise maternal health during pregnancy (III B). •Pregnancy is not generally contraindicated on grounds of HCV infection alone (Although it is contraindicated in the context of ribavirin therapy.) (III B). c)Care during pregnancy •There is a risk of vertical transmission which is greater if the woman is also infected with human immunodeficiency virus (HIV) (II-2 A). •Antenatal care will need to be tailored individually to meet the specific needs of the woman's medical and obstetrical condition, including the monitoring of liver function (II-2 A). •Alcohol should be avoided (II-2 A). •Immunization against hepatitis A and B should be provided as required (II-2 A). •Routine Caesarean section is not recommended as a specific intrapartum measure to reduce the risk of vertical transmission of hepatitis C (II-2 D). •Breastfeeding is not contraindicated (II-3 B). d)Care of infant •All infants born to HCV positive mothers should be evaluated for evidence of hepatitis C infection (III A). e)Contraception and hormone replacement therapy •Barrier methods should be recommended to those with multiple sexual partners (II-3 B). •The extent of liver disease should be carefully evaluated before considering the use of hormonal contraception or hormone replacement therapy (III B). f)Universal precautions •Universal precautions/routine practices and additional precautions are recommended in dealing with all patients for the protection of both health care worker and patient (II-2 A). Validation references were collected through Medline searches and comparison made to existing current guidelines for assessment of consistency. External reviewers expert in their field were also consulted.

Background Massive perivillous fibrin deposition (MPVFD) and chronic intervillositis (CI) are related rare pathological correlates of severe intrauterine growth restriction (IUGR) and fetal loss with high recurrence rates. No standard management has been established. Case A patient underwent termination of pregnancy at 21 weeks for severe early onset IUGR. Placental histology showed mixed CI with MPVFD. Several months later, the patient became pregnant and was managed with prednisone and aspirin (ASA) but miscarried at 16 weeks. Placental pathology showed MPVFD and focal CI. For two subsequent pregnancies, she was treated with intravenous immunoglobulin (IVIG), heparin, and ASA. Both pregnancies resulted in healthy near-term deliveries with normal placentas. Conclusion IVIG, heparin, and ASA can be an option in patients with recurrent pregnancy loss due to MPVFD and CI.

Background Emerging evidence from clinical and epidemiological studies suggests that dietary polyphenols play an important role in the prevention of chronic diseases, including cancer, cardiovascular disease, diabetes and neurodegenerative disorders. Although these beneficial health claims are supported by experimental data for many subpopulation groups, some studies purport that excessive polyphenol consumption may have negative health effects in other subpopulations. The ever-growing interest and public awareness surrounding the potential benefits of natural health products and polyphenols, in addition to their widespread availability and accessibility through nutritional supplements and fortified foods, has led to increased consumption throughout gestation. Therefore, understanding the implications of polyphenol intake on obstetrical health outcomes is of utmost importance with respect to safe consumption during pregnancy. Methods Using relevant keywords, a literature search was performed to gather information regarding polyphenol pharmacology and the molecular mechanisms by which polyphenols exert their biological effects. The primary focus of this paper is to understand the relevance of these findings in the context of reproductive physiology and medicine. Results Evidence from both in vitro experiments and in vivo studies using animals and humans demonstrates that polyphenols regulate key targets related to oxidative stress, inflammation and advanced glycation end products. Although the majority of these studies have been conducted in the context of chronic diseases, such as cancer and diabetes, several of the key targets influenced by polyphenols are also related to a variety of obstetrical complications, including pre-eclampsia, intrauterine growth restriction and preterm birth. Polyphenols have also been shown to influence fertility and sexual development, fetal health and the bioavailability of nutrients. Conclusions Further research leading to a thorough understanding of the physiological roles and potential clinical value that polyphenol consumption may play in pregnancy is urgently needed to help inform patient safety.

The quality of the intrauterine environment influences maternal-fetal health and also offspring predisposition to obesity and cardiometabolic disease later in life. Several determinants, including but not limited to pregravid obesity and excessive gestational weight gain, alter the developmental milieu, fetal growth, and child obesity risk. However, the role of sleep and its relationship to healthy pregnancy is not fully established. Given the host of psychosocial and physiological complications associated with childhood obesity, targeting the gestational period is purported to be an opportune time for preventive intervention. Many longitudinal studies suggest that short sleep duration is a risk factor for the development of impaired glycemia and obesity. However, there is a dearth of information concerning the role of sleep hygiene and its role in a healthy pregnancy. Reports note disrupted and poorer quality of sleep during gestation and highlight an association between reduced sleep and risk of gestational diabetes mellitus. Given the lack of well-designed human trials assessing the value of sleep and healthy pregnancy outcomes, this review summarizes current evidence which suggests that incorporating sleep recommendations and utilizing time management strategies that encourage a healthful night ’s sleep may improve the health of the mom and the baby.

Background: Over the past decade, the Ste20-like kinase SLK, has been implicated in several signaling processes. SLK repression has been shown to impair cell cycle kinetics and inhibit FAK-mediated cell migration. Here, using a gene trapped allele, we have generated mice expressing a truncated form of the SLK kinase. Results: Our results show that an SLK-LacZ fusion protein is expressed in embryonic stem cells and in embryos throughout development. We find that the SLK-LacZ fusion protein is less efficient at phosphorylating substrates resulting in reduced cell proliferation within the embryos and angiogenic defects in the placentae of the homozygous mutant animals at embryonic day (E) 12.5. This results in marked developmental defects and apoptotic lesions in the embryos by E14.5. Conclusions: Homozygotes expressing the SLK-LacZ fusion protein present with an embryonic lethal phenotype occurring between E12.5 and E14.5. Overall, we demonstrate a requirement for SLK kinase activity in the developing embryo and placenta. Developmental Dynamics 243:640–651, 2014. © 2013 Wiley Periodicals, Inc.

Maternal floor infarction is a relatively rare condition characterized clinically by severe early onset fetal growth restriction with features of uteroplacental insufficiency. It has a very high recurrence rate and carries a significant risk or fetal demise. Pathological characteristics include massive and diffuse fibrin deposition along the decidua basalis and the perivillous space of the basal plate. We present a case of recurrent maternal floor infarction and propose diagnostic clues as well as potential therapeutic options.

Objectives Health advocacy (HA) is a core competency in Canadian obstetrics and gynaecology postgraduate programs. Our objectives were to assess awareness and understanding of the health advocate role among trainees, their current HA training and exposure, and the desire and needs for future HA training. Methods An anonymous, cross-sectional, Internet-based, selfreported health advocacy questionnaire was distributed to Canadian obstetrics and gynaecology trainees. Descriptive analysis was conducted for all study variables. Chi-square tests, Cochran-Armitage trend test, and Fisher exact test were performed where appropriate. Results Most trainees (93.9% of respondents) were aware of the CanMEDS HA role and that it is a training objective (92.9%). Only 52.4% had clear objectives while 58.4% understood the role requirements. Most trainees (95.1% of respondents) felt HA was important to address during training. Only 30.4% had HA training, and just 36.3% felt their training needs were addressed. Training included teaching sessions (11.9%), clinical teaching (4.7%), and role modelling (4.7%). Although 82.9% of respondents had HA opportunities with patients, there were fewer opportunities at community (45.1%) and societal (30.0%) levels. Awareness of community groups and activities was low (28.6%), and few (20.0%) had participated in community advocacy programs during their residency. Incorporating advocacy activities into training was valued (80.0%). Many residents supported mandatory HA training (60.0%), more training time on HA experiences (66.3%), and HA experiences during protected time (71.3%). Conclusion Awareness of and interest in the HA role is high, but clear objectives and training are lacking or inadequate. A standardized curriculum would ensure health advocacy exposure and emphasize active participation in community and societal activities. Trainees support this training during protected time.

Maternal obesity is associated with increased risks of pregnancy complications. Excessive fat mass, common to obese women, has the potential to influence production and secretion of adipose tissue derived proteins called adipokines. The adipokine leptin is involved in the regulation of multiple aspects of maternal metabolic homeostasis. In addition, leptin has been shown to be important for placentation and maternal-fetal exchanges processes regulating growth and development. In later stages of a healthy pregnancy, central leptin resistance occurs to allow increased nutrient availability for the fetus. Disruption of the signaling capacity of leptin associated with obesity is emerging as a potential risk factor leading to pregnancy complications as a result of aberrant fuel partitioning in utero. In this review we discuss the influence of obesity on the roles of leptin and leptin resistance at the central and placental level.

PC4 or PCSK4 belongs to the 9-member superfamily of mammalian subtilases collectively called Proprotein Convertases or Proprotein Convertase Subtilisin/Kexins that convert inactive precursor proteins into their active mature forms by endoproteolytic cleavage. PC4-activity plays a crucial role in mammalian fertilization via activation of sperm surface proteins. PC4 knockout mice exhibit severely impaired male fertility due to premature sperm acrosome reaction. Regulation of sperm-PC4 activity during its storage and transport through epididymis is an important determinant for ultimate egg-binding and fertilizing capacities of sperms. Herein we show that epididymal serpin CRES (cystatin related epididymal spermatogenic) recombinant protein inhibits PC4 activity in vitro in a differential manner when measured against the fluorogenic substrate Boc- RVRR-MCA depending on its oligomeric state. Thus while CRES-dimer exhibits K(i) ∼8 μM, the corresponding monomer showed K(i)100 μM. Both forms also blocked PC4-mediated processing of human proIGF-2 in human placenta tropoblast cell line with dimer being more efficient. Using specific inhibitors and substrates, we also demonstrated the presence of PC4-like activity and CRES protein in varying levels in the fluids of various epididymal compartments. Our observations suggest a potential function of CRES as a regulator of PC4 in sperm-egg interaction and fertilization.

Sildenafil citrate therapy for severe early-onset intrauterine growth restriction. BJOG 2011;118:624-628. Currently, there is no effective therapy for severe early-onset intrauterine growth restriction (IUGR). Sildenafil citrate vasodilates the myometrial arteries isolated from women with IUGR-complicated pregnancies. Women were offered Sildenafil (25 mg three times daily until delivery) if their pregnancy was complicated by early-onset IUGR [abdominal circumference (AC)< 5th percentile] and either the gestational age was

Objective Misclassification of body mass index (BMI) by pregnant women could be a significant barrier to minimizing weight-related adverse pregnancy outcomes and improving the short- and long-term health of mother and child. The primary objective in this study was to determine the proportion of a group of pregnant women who were able to correctly classify BMI. Secondary objectives included assessing the direction of BMI misclassification and maternal knowledge of target gestational weight gain and obesity-associated pregnancy complications. Methods We designed a cross-sectional survey to assess misclassification of BMI and knowledge of obesity and pregnancy outcomes, and to provide information regarding the participants' sources of knowledge, their perception of appropriate weight gain in pregnancy, and basic demographic information. The questionnaire was completed by participants awaiting routine ultrasound assessment at between 11 and 24 weeks' gestation. Results Of 117 respondents, 30 (25.6%) were overweight (BMI 25 to 29.9) or obese (BMI ≥ 30.0). Obese or overweight women were significantly more likely to misclassify their BMI. Furthermore, they were significantly more likely to overestimate the minimum and maximum target gestational weight gains for their respective BMI classes. There were no differences between women in the various BMI categories with regard to their awareness of several common obesity-related pregnancy complications. Conclusion Misclassification of pre-pregnancy BMI is common, particularly among women carrying excess weight. Evaluation of pre-pregnancy BMI and education regarding appropriate gestational weight gain are logical initial steps for optimizing weight-related pregnancy outcomes.

Resume Objectif Analyser les resultats et formuler des recommandations sur le recours a l'antibioprophylaxie dans le cadre d'interventions obstetricales. Issues Parmi les issues evaluees, on trouve la necessite et l'efficacite du recours a des antibiotiques aux fins de la prevention des infections dans le cadre d'interventions obstetricales. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans Medline et The Cochrane Library au moyen de la rubrique « antibioprophylaxie dans le cadre d'interventions obstetricales ». Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete mises a jour de facon reguliere et les articles publies entre janvier 1978 et juin 2009 ont ete incorpores a la directive clinique. Les lignes directrices actuellement publiees par le American College of Obstetrics and Gynecology ont egalement ete incorporees a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Les resultats obtenus ont ete analyses et evalues par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada sous la gouverne des auteures principales, et les recommandations ont ete formulees conformement aux lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Avantages, desavantages et couts La mise en œuvre de la presente directive clinique devrait reduire les couts et les torts attribuables a l'administration d'antibiotiques lorsque celle-ci ne s'avere pas requise, ainsi que les torts attribuables a la non-administration d'antibiotiques lorsque ceux-ci pourraient s'averer benefiques. Declarations sommaires 1.Les donnees disponibles ne soutiennent pas le recours a l'antibioprophylaxie en vue d'attenuer la morbidite infectieuse a la suite d'un accouchement vaginal operatoire. (II-1) 2.Nous ne disposons pas de donnees suffisantes pour soutenir ou deconseiller le recours a l'antibioprophylaxie en vue d'attenuer la morbidite infectieuse dans les cas de retrait manuel du placenta. (III) 3.Nous ne disposons pas de donnees suffisantes pour soutenir ou deconseiller le recours a l'antibioprophylaxie au moment de la dilatation-curetage postpartum visant des produits de conception en retention. (III) 4.Les donnees disponibles ne soutiennent pas le recours a l'antibioprophylaxie en vue d'attenuer la morbidite infectieuse a la suite d'un cerclage planifie ou d'urgence. (II-3) Recommandations 1.Toutes les femmes qui subissent une cesarienne planifiee ou d'urgence devraient se voir administrer une antibioprophylaxie. (I-A) 2.Une dose unique d'une cephalosporine de premiere generation devrait constituer l'antibiotique a privilegier pour ce qui est des cesariennes. Lorsque la patiente presente une allergie a la penicilline, on peut avoir recours a la clindamycine ou a l'erythromycine. (I-A) 3.Dans le cas de la cesarienne, l'antibioprophylaxie devrait etre administree de 15 a 60 minutes avant l'incision de la peau. Aucune dose additionnelle n'est recommandee. (I-A) 4.Lorsqu'une intervention a abdomen ouvert est de longue duree (>3 heures) ou que la perte sanguine estimee est superieure a 1 500 ml, une dose additionnelle d'antibiotique prophylactique peut etre administree de 3 a 4 heures a la suite de la dose initiale. (III-L) 5.L'administration d'une antibioprophylaxie peut etre envisagee pour attenuer la morbidite infectieuse associee a la reparation d'une lesion perineale du troisieme ou du quatrieme degre. (I-B) 6.Chez les patientes massivement obeses (IMC > 35), il est possible d'envisager le doublement de la dose d'antibiotiques. (III-B) 7.L'administration d'antibiotiques aux seules fins de prevenir l'endocardite ne devrait pas etre mise en œuvre chez les patientes qui doivent subir une intervention obstetricale, quelle qu'en soit la nature. (III-E)

Intrauterine growth restriction (IUGR) and preeclampsia (PE) are leading causes of perinatal and maternal morbidity and mortality. Many studies have found association between low levels of insulin-like growth factor binding protein (IGFBP) proteases in the first trimester maternal circulation and the risk of subsequent development of PE and/or IUGR. These results are generally interpreted to reflect decreased production of the proteases by the placenta, leading to reduced proteolysis of IGFBPs and lower free levels of insulin-like growth factor (IGF), resulting in diminished feto-placental development. However, the association between low circulating levels of placental proteins early in pregnancy and the subsequent development of IUGR and/or PE could be due to low exchange in the placenta and not due to reduced production. In contrast, late in pregnancy, the circulating levels of these proteins and their expression in the placenta are often elevated in PE, which may reflect upregulation to compensate for abnormal placental development, that is an adaptive mechanism to increase IGFBP proteolysis, increase local IGF levels and promote feto-placental growth. Further research into the biological mechanisms underlying these associations will aid the identification of high-risk pregnancies and the development of therapeutic targets for diseases for which there are presently no preventative measures.

The NOTCH signaling pathway plays important roles in stem cell maintenance, cell-fate determination and differentiation during development. Following ligand binding, the cleaved NOTCH intracellular domain (NICD) interacts directly with the recombinant signal binding protein for immunoglobulin kappa J region (RBPJ) transcription factor and the resulting complex targets gene expression in the nucleus. To date, four human RBPJ isoforms have been described in Entrez Gene, varying in the first 5'coding exons. Using an improved protocol, we were able to further identify all four known and five novel RBPJ transcript variants in human amniotic fluid (AF) cells, a cell type known for its stem cell characteristics. In addition, we used human embryonal carcinoma (EC) NTera2/D1 (NT2) cells and NT2-derived neuron and astrocytes to compare the expression pattern of RBPJ transcripts. Further examination of RBPJ transcripts showed that the novel splice variants contain open reading frames in-frame with the known isoforms, suggesting that they can putatively generate similar function proteins. All known and novel RBPJ transcripts contain the putative nuclear localization signal (NLS), an important component of RBPJ-mediated gene regulation.

Resume Objectifs Analyser les principes du diagnostic prenatal de l'infection congenitale a cytomegalovirus (CMV) et decrire les issues des grossesses affectees. Issues Prise en charge efficace de l'infection fœtale a la suite d'une infection a CMV maternelle primaire et secondaire pendant la grossesse. Parmi les symptomes neonataux, on trouve le retard de croissance intra-uterin (RCIU), la microcephalie, l'hepatosplenomegalie, les petechies, l'ictere, la chorioretinite, la thrombocytopenie et l'anemie; parmi les sequelles a long terme, on trouve la surdite de perception, la deficience mentale, le retard du developpement psychomoteur et la deficience visuelle. La presente directive clinique offre un cadre pour le diagnostic et la prise en charge des infections a CMV soupconnees. Resultats Des recherches ont ete menees dans Medline en vue d'en tirer les articles publies en anglais, entre 1966 et 2009, au moyen d'un vocabulaire controle (infection congenitale a CMV) et de mots cles (retard de croissance intra-uterin, microcephalie) appropries. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Les recherches ont ete regulierement mises a jour et leurs resultats ont ete incorpores a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Recommandations La qualite des resultats signales dans le present document a ete evaluee au moyen des criteres d'evaluation des resultats decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). 1.Le diagnostic de l'infection a cytomegalovirus (CMV) maternelle primaire pendant la grossesse devrait etre fonde sur l'apparition de novo d'IgG propre au virus dans le serum d'une femme enceinte qui etait auparavant seronegative ou sur la detection d'anticorps IgM specifiques associes a de l'IgG de faible avidite. (II-2A) 2.En presence d'une infection maternelle primaire, les parents devraient etre avises du risque (de 30 % a 40 %) de transmission intra-uterine et d'infection fœtale, et du risque (de 20 % a 25 %) de voir apparaitre des sequelles postnatales lorsque le fœtus est infecte. (II-2A) 3.Le diagnostic prenatal de l'infection a CMV fœtale devrait etre fonde sur l'amniocentese, laquelle devrait etre menee au moins sept semaines a la suite du moment presume de l'infection maternelle et apres la 21 e semaine de gestation. Cet intervalle est important puisqu'il faut de cinq a sept semaines a la suite de l'infection fœtale et de la replication subsequente du virus dans le rein pour qu'une quantite detectable de virus soit secretee dans le liquide amniotique. (II-2A) 4.Le diagnostic de l'infection secondaire devrait etre fonde sur une hausse considerable du titre des anticorps IgM avec ou sans la presence d'anticorps IgM specifiques et en presence d'IgG de forte avidite. Dans les cas etablis d'infection secondaire, le recours a l'amniocentese peut etre envisage, mais le rapport risque–avantage est different en raison du faible taux de transmission. (III-C) 5.A la suite d'un diagnostic d'infection a CMV fœtale, des examens echographiques en serie devraient etre menes toutes les deux a quatre semaines afin de demeurer a l'affut des anomalies echographiques qui pourraient contribuer a la determination du pronostic fœtal; cependant, il est important d'etre conscient que l'absence de constatations echographiques ne garantit pas l'obtention d'une issue normale. (II-2B) 6.La determination quantitative de l'ADN de CMV dans le liquide amniotique peut contribuer a la prediction de l'issue fœtale. (II-3B) 7.Le depistage serologique systematique du CMV chez les femmes enceintes n'est actuellement pas recommande. (III-B) 8.Le depistage serologique du CMV peut etre envisage chez les femmes qui en viennent a presenter des symptomes grippaux pendant la grossesse ou a la suite de la detection de signes echographiques semblant indiquer une infection a CMV. (III-B) 9.Les femmes seronegatives œuvrant dans le domaine de la sante et des soins aux enfants peuvent se voir offrir un suivi serologique pendant la grossesse. Un suivi peut egalement etre envisage dans le cas des femmes enceintes seronegatives qui comptent un enfant en bas âge frequentant une garderie. (III-B)

Objective To review the evidence and provide recommendations on the use of antibiotics in preterm premature rupture of the membranes (PPROM). Outcomes Outcomes evaluated include the effect of antibiotic treatment on maternal infection, chorioamnionitis, and neonatal morbidity and mortality. Evidence Published literature was retrieved through searches of Medline, EMBASE, CINAHL, and The Cochrane Library, using appropriate controlled vocabulary and key words (PPROM, infection, and antibiotics). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and new material incorporated in the guideline to July 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Guideline implementation should assist the practitioner in developing an approach to the use of antibiotics in women with PPROM. Patients will benefit from appropriate management of this condition. Validation This guideline has been reviewed and approved by the Infectious Diseases Committee and the Maternal Fetal Medicine Committee of the SOGC, and approved by the Executive and Council of the SOGC. Sponsor The Society of Obstetricians and Gynaecologists of Canada. Recommendations 1.Following PPROM at 32 weeks' gestation, antibiotics should be administered to women who are not in labour in order to prolong pregnancy and to decrease maternal and neonatal morbidity (I-A). 2.The use of antibiotics should be gestational-age dependent. The evidence for benefit is greater at earlier gestational ages ( 3.For women with PPROM at >32 weeks' gestation, administration of antibiotics to prolong pregnancy is recommended if fetal lung maturity cannot be proven and/or delivery is not planned (I-A). 4.Antibiotic regimens may consist of an initial parenteral phase followed by an oral phase, or may consist of only an oral phase (I-A). 5.Antibiotics of choice are penicillins or macrolide antibiotics (erythromycin) in parenteral and/or oral forms. (I-A) In patients allergic to penicillin, macrolide antibiotics should be used alone (III-B). 6.The following two regimens may be used (the two regimens were used in the largest PPROM randomized controlled trials that showed a decrease in both maternal and neonatal morbidity): (1) ampicillin2g IV every 6 hours and erythromycin 250 mg IV every 6 hours for 48 hours followed by amoxicillin 250 mg orally every 8 hours and erythromycin 333 mg orally every 8 hours for 5 days (I-A); (2) erythromycin 250 mg orally every 6 hours for 10 days (I-A). 7.Amoxicillin/clavulanic acid should not be used because of an increased risk of necrotizing enterocolitis in neonates exposed to this antibiotic. Amoxicillin without clavulanic acid is safe (I-A). 8.Women presenting with PPROM should be screened for urinary tract infections, sexually transmitted infections, and group B streptococcus carriage, and treated with appropriate antibiotics if positive (II-2B).

Smoking during pregnancy has been shown to result in an increased risk of low birth weight. However, the mechanisms underlying this association are poorly understood. The insulin-like growth factor (IGF) system plays a critical role in the regulation of feto-placental growth and development, and abnormal processing of proIGF-II may alter its biological function. Our goal was to investigate the effects of exposure to nicotine on maternal, fetal, and neonatal IGF-II processing. Nulliparous female Wistar rats were randomly assigned to receive saline (vehicle) or nicotine bitartrate (1 mg x kg(-1) x d(- 1)). After mating, dams were euthanized at embryonic days 15, 18, and 21, and fetal body weight was recorded. Serum (fetal and maternal) was collected for determination of the IGF-II profile by Western blot analysis. Nicotine exposure prevented the decrease in maternal IGF-II processing seen in controls with advancing gestation. However, there was no influence of nicotine on fetal levels of IGF-II. Postnatally (postnatal day [PND] 21), pups exposed to nicotine in utero had decreased levels of big IGF-II. Our results show, for the first time, that nicotine exposure prevents the decrease of IGF-II processing in the maternal compartment. This may represent a compensatory mechanism allowing the mother to counteract the negative influence of nicotine on fetal growth and development. Our postnatal findings of suppressed IGF-II may help explain some of the long-term health complications seen in individuals exposed to smoking in utero.

Resume Objectif Analyser les resultats et formuler des recommandations quant a l'utilisation d'antibiotiques en presence d'une rupture prematuree des membranes preterme (RPMP). Issues Parmi les issues evaluees, on trouvait l'effet de l'antibiotherapie sur l'infection maternelle, la chorioamnionite et la morbidite et la mortalite neonatales. Resultats La litterature publiee a ete identifiee par l'intermediaire de recherches menees dans PubMed ou Medline, CINAHL et la Cochrane Library, au moyen d'un vocabulaire controle approprie et de mots cles ( PPROM , infection et antibiotics ). Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction quant a la date ou a la langue n'a ete mise en œuvre. Les recherches ont ete regulierement mises a jour et les donnees publiees jusqu'en juillet 2008 ont ete integrees a la directive clinique. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Valeurs Les resultats obtenus ont ete evalues par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada (SOGC), sous la direction des auteurs principaux; les recommandations ont ete formulees en fonction des lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts La mise en œuvre de la presente directive clinique devrait aider les praticiens a elaborer une approche quant au recours a l'antibiotherapie chez les femmes qui presentent une RPMP. Les patientes tireront avantage d'une prise en charge adequate de cette pathologie. Validation La presente directive clinique a ete analysee et approuvee par le comite sur les maladies infectieuses et le comite de medecine fœto-maternelle, et approuvee par le comite executif et le Conseil de la Societe des obstetriciens et gynecologues du Canada. Commanditaire La Societe des obstetriciens et gynecologues du Canada. Recommendations 1.A la suite d'une RPMP a ≤ 32 semaines de gestation, des antibiotiques devraient etre administres aux femmes qui ne sont pas en travail afin de prolonger la grossesse et d'attenuer la morbidite maternelle et neonatale. (I-A) 2.Le recours aux antibiotiques devrait etre fonction de l'âge gestationnel. Les resultats en soutenant les avantages sont plus concluants en ce qui concerne les âges gestationnels moins avances ( 3.En ce qui concerne les femmes qui connaissent une RPMP a > 32 semaines de gestation, l'administration d'antibiotiques visant la prolongation de la grossesse est recommandee lorsque la maturite pulmonaire fœtale ne peut etre prouvee et/ou lorsque l'accouchement n'est pas planifie. (I-A) 4.Les schemas posologiques d'antibiotiques peuvent comprendre une phase parenterale initiale suivie d'une phase orale ou n'etre constitues que d'une phase orale. (I-A) 5.Les antibiotiques a privilegier sont les penicillines ou les antibiotiques macrolides (erythromycine) sous forme parenterale et/ou orale. (I-A) Chez les patientes allergiques a la penicilline, les antibiotiques macrolides devraient etre utilises seuls. (III-B) 6.Les deux schemas posologiques suivants peuvent etre utilises (ils ont tous deux ete utilises par les plus importants essais comparatifs randomises s'etant penches sur la RPMP qui ont indique une baisse de la morbidite maternelle et neonatale) : (1) ampicilline, a raison de 2 g IV toutes les 6 heures, et erythromycine, a raison de 250 mg IV toutes les 6 heures, pendant 48 heures, le tout etant suivi d'amoxicilline, a raison de 250 mg par voie orale toutes les 8 heures, et d'erythromycine, a raison de 333 mg par voie orale toutes les 8 heures, pendant 5 jours (I-A); (2) erythromycine, a raison de 250 mg par voie orale toutes les 6 heures, pendant 10 jours (I-A) 7.L'amoxicilline/acide clavulanique ne devrait pas etre utilisee en raison du risque accru d'enterocolite necrosante que courent les nouveau-nes exposes a cet antibiotique. L'amoxicilline utilisee sans acide clavulanique est sure. (I-A) 8.Les femmes qui connaissent une RPMP devraient faire l'objet d'un depistage visant les infections des voies urinaires, les infections transmissibles sexuellement et le statut de porteuse de streptocoques du groupe B, et elles devraient etre traitees au moyen d'antibiotiques appropries lorsque ce depistage donne des resultats positifs. (II-2B)

Objective This document summarizes the limited experience of SARS in pregnancy and suggests guidelines for management. Outcomes Cases reported from Asia suggest that maternal and fetal outcomes are worsened by SARS during pregnancy. Evidence Medline was searched for relevant articles published in English from 2000 to 2007. Case reports were reviewed and expert opinion sought. Values Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Pregnancy-associated plasma protein-A and -A2 (PAPPA and PAPPA2) are proteases that cleave IGF binding proteins (IGFBPs) and thereby increase the bioavailability of growth factors. PAPPA has long been recognized as a marker of fetal genetic disorders and adverse pregnancy outcomes. In contrast, although PAPPA2 is also highly expressed in human placenta, its physiological importance is not clear. To establish whether mice will be a useful model for the study of PAPPA2, we compared the patterns of expression of PAPPA2 in the placentae of mouse and human. We show, for the first time, that Pappa2 is highly expressed in mouse placenta, as is the case in humans. Specifically, it is expressed at the interface of the maternal and fetal layers of the mouse placenta at all gestational stages studied (10.5–16.5 days post coitum). Similarly, PAPPA2 is expressed in the syncytiotrophoblast layer of human placental villi and is also detected in some invasive extravillous trophoblasts in the first trimester. These results are consistent with a model whereby PAPPA2 cleaves IGFBPs produced in the maternal decidua to promote feto-placental growth, and indicate that this protein may play analogous roles in human and mouse placenta. PAPPA2 protein is detectable in the circulation of pregnant mice and humans during the first trimester and at term, raising the possibility that PAPPA2 may be a useful biomarker of placental dysfunction. Pappa2 expression also shows specific localization within the mouse embryo and therefore may play roles in fetal development, independent of its action in the placenta.

Resume Objectif Analyser les resultats et offrir des recommandations quant a l'immunisation pendant la grossesse. Issues Parmi les issues evaluees, on trouve l'efficacite de l'immunisation, les risques et les avantages pour la mere et le fœtus. Resultats Des recherches ont ete menees dans les bases de donnees Medline et Cochrane en vue d'en tirer les articles, publies avant juillet 2007, portant sur l'immunisation pendant la grossesse. Valeurs Les donnees obtenues ont ete analysees et evaluees par le comite sur les maladies infectieuses de la Societe des obstetriciens et gynecologues du Canada (SOGC), sous la supervision des auteurs principaux, et des recommandations ont ete formulees conformement aux lignes directrices etablies par le Groupe d'etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts La mise en œuvre des recommandations de la presente directive clinique devrait mener a une meilleure immunisation des femmes enceintes et des femmes qui allaitent, a une attenuation du risque d'immunisation contre-indiquee et a une meilleure prevention de la maladie. Recommandations 1.Avant de proceder a l'immunisation de toute femme en âge de procreer, le fournisseur de soins devrait chercher a ecarter la presence possible d'une grossesse chez celle-ci. (III-A) 2.Les fournisseurs de soins devraient obtenir les antecedents quant a l'immunisation de toutes les femmes qui les consultent afin d'obtenir des soins prenatals. (III-A) 3.En general, les vaccins a virus vivant et/ou a virus vivant-attenue sont contre-indiques pendant la grossesse, et ce, en raison de la presence d'un risque (essentiellement theorique) pour le fœtus. (II-3B) 4.Les femmes qui ont recu, par inadvertance, une immunisation au moyen de vaccins vivants ou vivants-attenues pendant la grossesse ne devraient pas etre avisees de proceder a une interruption de grossesse motivee par la presence d'un risque de teratogenicite. (II-2A) 5.Les femmes n'etant pas enceintes qui ont ete immunisees au moyen d'un vaccin vivant ou vivant-attenue devraient etre avisees de reporter la grossesse pendant au moins quatre semaines. (III-B) 6.L'administration de vaccins viraux inactives, de vaccins bacteriens et de toxoides pendant la grossesse est consideree comme etant sure. (II-1A) 7.Les femmes qui allaitent peuvent tout de meme etre immunisees (immunisation passive-active, vaccins vivants ou morts). (II-1A) 8.Les femmes enceintes devraient se voir offrir le vaccin antigrippal lorsque leur grossesse coincide avec la saison de la grippe. (II-1A)

Objective To review the evidence and provide recommendations on immunization in pregnancy. Outcomes Outcomes evaluated include effectiveness of immunization, and risks and benefits for mother and fetus. Evidence The Medline and Cochrane databases were searched for articles published up to June 2007 on the topic of immunization in pregnancy. Values The evidence obtained was reviewed and evaluated by the Infectious Diseases Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Implementation of the recommendations in this guideline should result in more appropriate immunization of pregnant and breastfeeding women, decreased risk of contraindicated immunization, and better disease prevention. Recommendations 1.All women of childbearing age should be evaluated for the possibility of pregnancy before immunization. (III-A) 2.Health care providers should obtain an immunization history from all women accessing prenatal care. (III-A) 3.In general, live and/or live-attenuated virus vaccines are contraindicated during pregnancy, as there is a, largely theoretical, risk to the fetus. (II-3B) 4.Women who have inadvertently received immunization with live or live-attenuated vaccines during pregnancy should not be counselled to terminate the pregnancy because of a teratogenic risk. (II-2A) 5.Non-pregnant women immunized with a live or live-attenuated vaccine should be counselled to delay pregnancy for at least four weeks. (III-B) 6.Inactivated viral vaccines, bacterial vaccines, and toxoids are considered safe in pregnancy. (II-1A) 7.Women who are breastfeeding can still be immunized (passive-active immunization, live or killed vaccines). (II-1A) 8.Pregnant women should be offered the influenza vaccine when pregnant during the influenza season. (II-1A)

To provide recommendations for the management of genital herpes infection in women who want to get pregnant or are pregnant and for the management of genital herpes in pregnancy and strategies to prevent transmission to the infant.More effective management of complications of genital herpes in pregnancy and prevention of transmission of genital herpes from mother to infant.Medline was searched for articles published in French or English related to genital herpes and pregnancy. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed.Recommendations were made according to the guidelines developed by the Canadian Task Force on Preventive Health Care.

Resume Objectif La presente directive clinique a pour but de fournir des recommandations aux fournisseurs de soins gynecologiques quant a la prise en charge optimale de l'herpes genital. Issues Prevention plus efficace des complications et de la transmission de l'herpes genital. Resultats Des recherches ont ete menees dans Medline en vue d'en tirer les articles, publies en francais et en anglais, traitant de l'herpes genital et de la gynecologie. Les references que contenaient ces articles ont permis l'identification d'articles supplementaires. Tous les types d'etude et toutes les recommandations ont ete analyses. Recommandations 1.Jusqu'a 70 % de toutes les infections genitales au VHS-2 sont transmises pendant l'elimination asymptomatique; ainsi, le recours aux condoms est recommande afin d'attenuer la probabilite de transmission de la maladie. (II-A) 2.L'obtention d'un diagnostic d'herpes genital fonde sur des resultats de laboratoire est essentielle pour assurer la mise en oeuvre d'une prise en charge efficace. (II-A) 3.Le traitement suppressif est suggere pour les patientes qui presentent •au moins six recurrences par annee •des complications importantes en presence de moins de six recurrences par annee •des problemes importants en ce qui concerne la qualite de vie liee a la sante •un dysfonctionnement social et sexuel •ou qui doivent reduire le risque de transmission a un partenaire sexuel ou au foetus / nouveau-ne. (II-B) 4.L'utilisation de valacyclovir (antiviral), conjointement avec le port de condoms et l'offre de conseils quant aux pratiques sexuelles sures, est recommandee pour les personnes chez lesquelles la presence d'herpes genital a ete prouvee. (I-B) 5.Le depistage systematique ou cible du VHS n'est pas indique. (III-B)

The purpose of this guideline is to provide recommendations to gynaecology health care providers on optimal management of genital herpes.More effective prevention of complications and transmission of genital herpes.Medline was searched for articles published in French and English related to genital herpes and gynaecology. Additional articles were identified through the references of these articles. All study types and recommendation reports were reviewed.1. Up to 70% of all genital HSV-2 infections are transmitted during asymptomatic shedding; therefore, the use of condoms is recommended to lessen the likelihood of disease transmission. (II-A) 2. A laboratory-based diagnosis of genital herpes is essential for its effective management. (II-A) 3. Suppressive treatment is suggested for patients who have * at least 6 recurrences per year * significant complications, but fewer than 6 recurrences per year * their quality of life significantly affected * social and sexual dysfunction * to lower the risk of transmission to a sexual partner or fetus/neonate. (II-B) 4. The use of the anti-viral valacyclovir, coupled with condoms and safer sex counselling, is recommended for individuals with proven genital herpes. (I-B) 5. Routine or targeted HSV screening is not indicated.

Resume Objectif Fournir une mise a jour sur la teratologie en ce qui a trait aux effets des infections et des medicaments d'ordonnance et en vente libre sur la grossesse. Options Le present consensus se limite aux principes de teratologie et aux expositions possibles courantes pendant la grossesse. Resultats Des recherches ont ete menees dans Medline et dans des manuels afin d'en tirer les donnees, publiees avant juin 2006, portant sur les risques teratologiques associes a l'exposition. Le present document constitue un resume de ces donnees. Avantages, desavantages et couts Le present consensus offre aux praticiens un resume des renseignements portant sur les risques teratologiques associes a l'exposition a des medicaments, a des produits chimiques et a des agents infectieux pendant la grossesse.

BACKGROUND: Women in Canada, as in the rest of the world, represent an increasing proportion of new HIV positive cases.(1) In 2002, women accounted for 25% of all positive HIV tests reported in Canada;(2) with the majority being in their childbearing years (15 to 39 years), perinatal transmission of HIV in Canada is cause for concern.(2) Following the development of interventions that can effectively reduce vertical transmission rate, prenatal screening of HIV has become the first and most pivotal step in the prevention of mother-to-child HIV transmission.(3)–(5) The purpose of this study was to assess how women’s knowledge and attitudes regarding HIV and HIV screening in pregnancy influence screening rates. METHOD: A prospective anonymous survey of 231 women attending antenatal care clinics at a teaching university hospital or in a community clinic was conducted. RESULTS: In general, pregnant women supported universal HIV screening in the prenatal period. Women who previously had been tested for HIV and who did not perceive that they were at risk for contracting HIV were more likely to decline HIV testing in their current pregnancy. Overall knowledge regarding HIV and its transmission is less than optimal, particularly among those women who declined HIV testing. CONCLUSION: Knowledge gaps exist between women accepting and declining prenatal HIV screening, particularly relating to benefits of screening. These results suggest that efforts have to continue to be put into educating the public but also, importantly, into changing current attitudes.

Satisfaction with maternity care is strongly related to the patient-caregiver relationship and involvement in the decision-making process. We sought to compare women's views about their care in a randomized trial of 'less tight' vs. 'tight' control of non-proteinuric pre-existing or gestational hypertension in pregnancy.In the CHIPS Pilot Trial, women completed a postpartum questionnaire to assess their likes and dislikes about their blood pressure (BP) management and trial participation. Comparisons were descriptive.Baseline information was similar for the 'less tight' and 'tight' control groups. Of 132 women, 126 (95.5%) from 17 centers completed a postpartum questionnaire, usually within days of delivery. At least 90% of women in both groups were satisfied with their care, and would be willing to participate again or recommend participation to a friend. Women in both the 'less tight' and 'tight' groups were satisfied with BP management (98.4% vs. 95.1%), and the frequency of tests of maternal and fetal well being. Half of women in both groups perceived that their BP was too high and that caregivers thought that their BP was too high. More women in the 'less tight' (vs. the 'tight') control group took less medication than expected (71.7% vs. 38.2%). More women in the 'tight' (vs. the 'less tight') group took more medication than they expected (60.0% vs. 22.2%). At least 60% of all women used home BP monitoring.In the CHIPS Pilot Trial, while women stated that they were satisfied with their BP management and care, a surprising 50% in both groups thought that their BP was too high. The majority of women used home BP monitoring, the role of which must be further defined in hypertensive pregnancies.