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Objective To compare maternal and perinatal risk factors associated with complete uterine rupture and uterine dehiscence. Methods Cross-sectional study of patients with uterine rupture/dehiscence from January 1998 to December 2017 (30 years) admitted at the Labor and Delivery Unit of a tertiary teaching hospital in Canada. Results There were 174 (0.1%) cases of uterine disruption (29 ruptures and 145 cases of dehiscence) out of 169,356 deliveries. There were associations between dehiscence and multiparity (odds ratio [OR]: 3.2; p=0.02), elevated maternal body mass index (BMI; OR: 3.4; p=0.02), attempt of vaginal birth after a cesarian section (OR: 2.9; p=0.05) and 5-minute low Apgar score (OR: 5.9; p

While previous viral pandemics showed that pregnancy was a risk factor for susceptibility and adverse outcomes, current evidence is conflicting whether SARS-CoV-2 infection during pregnancy is more severe than in the general population, with relatively low maternal and fetal/neonatal mortality rates. SARS-CoV-2 is known to enter host cells via the ACE-2 receptors, competitively occupying their binding sites. In theory, viral invasion can lead to a reduction in available ACE-2 receptors and consequently an unbalanced regulation between the ACE-AngII-AT1 axis and the ACE-2-Ang-(1-7)-MAS axis, thus enhancing pathological vasoconstriction, fibrosis, inflammation and thrombotic processes. We hypothesize that the normal pregnant state of highly expressed ACE-2 receptors leads to higher Ang-(1-7) levels and consequently more vasodilation and anti-inflammatory response to SARS-COV-2 infection. We suggest that this up-regulation of ACE-2 receptors in human gestation may actually be clinically protective and propose a potential research line to investigate this hypothesis, which may lead to future novel therapeutics.

Venous thromboembolism (VTE) remains among the leading causes of maternal mortality in the developed world, presenting variably as deep vein thrombosis (DVT), pulmonary embolism (PE) or cerebral vein thrombosis (CVT), among others. Obesity in particular has been recognized as the principal contributing factor to the risk of VTE in pregnancy and with the global increase in the rates of obesity affecting reproductive age women, heightened awareness of the risk and consequences of VTE in this population are vital. Thus, prophylaxis, diagnosis and treatment of VTE in the obese gravida are discussed.

Resume Objectif Une femme enceinte sur 12 en vient a subir des traumatismes physiques et ceux-ci exercent des effets importants sur la mortalite et la morbidite maternelles, ainsi que sur l'issue de la grossesse. La mise en oeuvre d'une approche multidisciplinaire s'avere justifiee pour assurer l'optimisation des issues, et ce, tant pour la mere que pour son foetus. Le present document a pour but d'offrir, aux fournisseurs de soins obstetricaux, une approche systematique factuelle qu'ils pourront utiliser pour assurer la prise en charge des patientes enceintes ayant subi un traumatisme. Issues Issues sanitaires et economiques considerables, par comparaison avec les pratiques de rechange. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans Medline, CINAHL et The Cochrane Library entre octobre 2007 et septembre 2013 au moyen d'un vocabulaire controle (« pregnancy », « Cesarean section », « hypotension », « domestic violence », « shock ») et de mots cles (« trauma », « perimortem Cesarean », « Kleihauer-Betke », « supine hypotension », « electrical shock ») appropries. Les resultats ont ete restreints aux analyses systematiques, aux etudes observationnelles et aux essais comparatifs randomises / essais cliniques comparatifs publies en anglais entre janvier 1968 et septembre 2013. Les recherches ont ete mises a jour de facon reguliere et integrees a la directive clinique jusqu'en fevrier 2014. 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 La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau). Avantages, desavantages et couts Nous nous attendons a ce que la presente directive clinique facilite l'offre de soins optimaux et uniformes dans les cas de grossesse compliquee par un traumatisme.

This paper presents the main results of a study about the influence of the web on decision-making processes of women during pregnancy. It aims to understand how search practices, peer influence and opinion sharing are carried out and specifically focusing on the decisions concerning “prenatal screening” and “type of birth”. Data was collected using a questionnaire filled by 178 Portuguese pregnant women that focused on baseline demographics, Internet use and its comparison to traditional forms of information (medical personnel and family). The results are mainly descriptive and show that, although internet information was often sought and used, face to face contact, especially with the medical doctor, is most influential in decision making. Contact with other pregnant women, relatives and friends were relevant but less influential. The main conclusions point out that currently the physician's opinion is still the primary factor in decision making. The importance of Internet data is secondary when compared to direct interaction with the physicians and care givers.

Introduction Cesarean section rates are increasing with a decrease in the rate of trial of labor after cesarean section. The objective of this study was to systematically review the predictive characteristics of sonographic measurement of lower uterine segment thickness for uterine rupture during labor. Material and methods The review was carried out in agreement with PRISMA and SEDATE guidelines. MEDLINE, EMBASE, ClinicalTrials.gov and Cochrane Library were searched from 1990 until November 2018. Quality of included studies was assessed using the QUADAS-2 tool. Data were extracted to construct 2 × 2 tables from each study comparing ultrasound measurement with uterine defect at time of delivery. The data were plotted as a summary receiver-operating characteristic (SROC) curve using the hierarchical SROC model. Results Twenty-eight observational cohort studies met the selection criteria for inclusion. Sonographic lower uterine segment thickness was measured at a gestational age of 36-40 weeks in women with a previous cesarean section. The risk of bias and concerns regarding applicability were low among most studies. The sonographic measurement was correlated with either delivery outcome or lower uterine segment thickness at the time of repeat cesarean section. The cut-off value for lower uterine segment thickness ranged from 1.5 to 4.05 mm across all studies. An association between thin lower uterine segment measurement and uterine dehiscence and uterine rupture was shown in 27 and four studies, respectively. Nineteen studies were included in a meta-analysis with a subgroup analysis by ultrasound methodology. In the subgroup using the ultrasound methodology associated with uterine rupture, the cut-off value is more precise (2.0-3.65 mm) among these 12 studies. There were 18 cases (1.0%) of uterine rupture, 120 (6.6%) of uterine dehiscence and 1674 (92.4%) women with no uterine defect. The SROC curve showed a sensitivity of 0.88 (95% CI 0.83-0.92) and specificity of 0.77 (95% CI 0.70-0.83). The negative likelihood ratio was 0.11 (95% CI 0.08-0.16) and the diagnostic odds ratio was 34.0 (95% CI 18.2-63.5). Conclusions Lower uterine segment thickness >3.65 mm, measured using a standardized ultrasound technique, is associated with a lower likelihood of uterine rupture.

Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient.Significant health and economic outcomes considered in comparing alternative practices.Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Objective To determine whether obstetrical patients in a large tertiary-care centre receive counselling, are aware of the proper actions in relation to fetal movement (on the basis of discussion with caregivers, educational pamphlet, or access to any information), have an understanding similar to that prescribed in the SOGC guidelines, and seek timely assessment in the event of decreased fetal movement. Methods We surveyed a convenience sample of pregnant women (N = 206) at term between July and October 2011. After collecting demographic and provider information, we assessed patient familiarity with fetal movement counting, including sources, timeliness, counting protocols, and response to decreased fetal movement. We calculated incidence rates, measures of association, and statistical significance by chi-square testing. Results The majority of patients (147/206 = 71.4%) relied on their care provider for information, and 44.1% of patients were very familiar with fetal movement counting. A majority, 57.8% (119), received timely information, although 8.1% (27) received information late in pregnancy or not at all. Quite consistently amongst subgroups (low vs. high-risk pregnancy, nullipara vs. multipara, patients of varied providers), one third (34.7%, 70/202) of patients had no knowledge or incorrect knowledge of the SOGC guidelines, 35.1% (71/202) had knowledge of fetal movement counting and what to do, while 30.2% (61/202) who knew how to monitor fetal movements did not know how to respond to decreased movement. Conclusion Timely intervention for decreased fetal movement results in a substantial reduction in the rate of stillbirth. Only one third of our patients were both informed and would have sought further investigation for decreased movement. Reinforcing the significance of fetal movement counting in scholarly publications can remind care providers about the importance of informing all patients about this simple, inexpensive, and successful monitoring protocol.

To advocate for the use of a common classification system for Caesarean section across Canada.A variety of clinical parameters for classification were considered.Consideration of a common system for classifying Caesarean section.Studies published in English from 1976 to December 2011 were retrieved through searches of Medline and PubMed, using appropriate controlled vocabulary and key words (Caesarean section, vaginal birth after Caesarean, classification). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Grey (unpublished) literature was identified through searching the web sites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and the web sites of national and international medical specialty societies.The studies reviewed were classified according to criteria described by the Canadian Task Force on Preventive Health Care, and the recommendation for practice ranked according to this classification (Table 1).The Society of Obstetricians and Gynaecologists of Canada. Recommendation Modified Robson criteria should be used to enable comparison of Caesarean section rates and indications. (III-B).

Assisted reproductive technologies have been widely used over the past 30 years, and 1% to 4% of births worldwide are products of these technologies. However, adverse health outcomes related to assisted reproductive technologies, including cerebral palsy, have been reported. We extracted and reviewed all relevant studies cited by Medline from 1996 to 2010 evaluating the role of assisted reproductive technologies as a causative factor for cerebral palsy and poor long-term neurologic outcome. The research suggests that multiple pregnancy, preterm delivery, and babies small for gestational age are factors in the development of cerebral palsy. The vanishing embryo syndrome may also play a role. We review the evidence for these potentially causative factors, as well as their implications for embryo transfer policies.

Objectives Invasive placentation (placenta accreta, increta, or percreta) presents significant challenges at Caesarean section. Caesarean hysterectomy in such circumstances may result in massive blood loss despite surgical expertise. We reviewed two divergent surgical approaches: planned Caesarean hysterectomy versus a “conserving surgery” in which the placenta is left in situ after Caesarean section. Methods We conducted a single-centre retrospective review of all patients who delivered with invasive placentation between 2000 and 2009. We included only patients with antenatally diagnosed invasive placentation and planned mode of delivery. Results Twenty-six patients met the inclusion criteria. Caesarean hysterectomy was planned in 16 patients and conserving surgery in 10. Intraoperative and postoperative complications were comparable in the two groups. Four of 10 patients initially treated by conservative surgery required a subsequent hysterectomy for severe vaginal bleeding, coagulopathy, or sepsis. No pregnancies were subsequently reported in the conserving surgery group. Conclusion An initial conserving surgical procedure is an option in patients with extensive invasive placentation, but it requires further monitoring for potential complications and carries a high subsequent hysterectomy rate.

Objective To elucidate factors pertinent to the course and outcome of H1N1 infection in pregnancy. Methods We conducted a retrospective chart review of H1N1-affected pregnant patients at Mount Sinai Hospital in Toronto, Ontario. All women who tested positive for H1N1 from June 1, 2009, to December 5, 2009, were identified. Records were reviewed to determine pregnancy status. Information from clinic and hospital charts of pregnant patients was gathered using data collection forms previously approved by the Mount Sinai Hospital Research Ethics Board. Results Of 42 patients, 12 were inpatients and 30 were outpatients. Sixty percent of patients (25/42) presented in the third trimester, 33% (14/42) had comorbidities, and 69% were afebrile and therefore did not have a condition that met the United States Centers for Disease Control and Prevention’s definition of influenza-like illness. Antiviral agents were administered promptly in most patients, but delays resulted in one third of patients being treated more than 48 hours from the onset of symptoms. Seventyone percent (30/42) did not require hospitalization, and 58% of hospitalized patients (7/12) were admitted for reasons unrelated to H1N1. Although one quarter of hospitalized patients (3/12) had delivered at the time of discharge, no deliveries occurred because of H1N1. Most patients (91%) delivered at term. One half of the deliveries (51%) were by Caesarean section, but none of these were because of H1N1 infection. Most of the infants (88%) were appropriately grown, and none were admitted to the NICU because of H1N1. Conclusion Infection with H1N1 in pregnant women has the propensity to result in significant maternal and fetal morbidity and mortality, and requires vigilance in assessment and prompt treatment. In contrast to reports published to date, our cohort experienced a largely uncomplicated course of illness, with minimal fetal and maternal impact in most instances.

The recent SOGC guidelines allow for selective vaginal delivery of breech presentations, following an eight-year period during which vaginal breech delivery was discouraged based on the results of the Term Breech Trial (TBT). We sought to determine the effect of publication of this guideline on the acceptance of vaginal breech delivery by obstetricians and to correlate obstetricians' attitudes with actual practice.A survey was sent to all obstetricians practising in five teaching hospitals in Toronto exploring their attitudes towards, and comfort with, vaginal breech delivery in various clinical situations. We correlated these with their graduation year in relation to the publication of the TBT. We also reviewed the obstetrical database of the largest teaching hospital in Toronto to see if these attitudes correlated with actual practice.The vaginal breech delivery rate, which was declining prior to publication of the TBT, plummeted after it. Our survey found that most practitioners (50% to 80%) would be willing to provide vaginal breech delivery in defined conditions, with more experienced obstetricians being more comfortable with offering vaginal breech delivery. However, despite these attitudes, the vaginal breech delivery rate during the period surveyed was only 3% (6/195).In the eight years between publication of the TBT and the new guidelines, very few vaginal breech deliveries were performed. Our survey indicates that most obstetricians have accepted the new guidelines; however, it seems that actual practice is lagging behind. The recent SOGC guidelines seem to have changed attitudes, but without changes in training and practical support, it seems unlikely that the trend for very few vaginal breech deliveries to be performed will be reversed.

Objective To improve awareness and knowledge of problematic substance use in pregnancy and to provide evidence-based recommendations for the management of this challenging clinical issue for all health care providers Options This guideline reviews the use of screening tools, general approach to care, and recommendations for clinical management of problematic substance use in pregnancy. Outcomes Evidence-based recommendations for screening and management of problematic substance use during pregnancy and lactation. Evidence Medline, PubMed, CINAHL, and The Cochrane Library were searched for articles published from 1950 using the following key words: substance-related disorders, mass screening, pregnancy complications, pregnancy, prenatal care, cocaine, cannabis, methadone, opioid, tobacco, nicotine, solvents, hallucinogens, and amphetamines. Results were initially restricted to systematic reviews and randomized control trials/controlled clinical trials. A subsequent search for observational studies was also conducted because there are few RCTs in this field of study. Articles were restricted to human studies published in English Additional articles were located by hand searching through article reference lists. Searches were updated on a regular basis and incorporated in the guideline up to December 2009. Grey (unpublished) literature was also 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 quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on the Preventive Health Care Recommendations for practice were ranked according to the method described in that report (Table 1) Benefits, harms, and costs This guideline is intended to increase the knowledge and comfort level of health care providers caring for pregnant women who have substance use disorders Improved access to health care and assistance with appropriate addiction care leads to reduced health care costs and decreased maternal and neonatal morbidity and mortality. Recommendations 1. All pregnant women and women of childbearing age should be screened periodically for alcohol, tobacco, and prescription and illicit drug use. (III-A) 2. When testing for substance use is clinically indicated, urine drug screening is the preferred method. (II-2A) Informed consent should be obtained from the woman before maternal drug toxicology testing is ordered. (III-B) 3. Policies and legal requirements with respect to drug testing of newborns may vary by jurisdiction, and caregivers should be familiar with the regulations in their region. (III-A) 4. Health care providers should employ a flexible approach to the care of women who have substance use problems, and they should encourage the use of all available community resources. (II-2B) 5. Women should be counselled about the risks of periconception, antepartum, and postpartum drug use. (III-B) 6. Smoking cessation counselling should be considered as a first-line intervention for pregnant smokers. (I-A) Nicotine replacement therapy and/or pharmacotherapy can be considered if counselling is not successful. (I-A) 7. Methadone maintenance treatment should be standard of care for opioid-dependent women during pregnancy. (II-IA) Other slow-release opioid preparations may be considered if methadone is not available. (II-2B) 8. Opioid detoxification should be reserved for selected women because of the high risk of relapse to opioids. (II-2B) 9. Opiate-dependent women should be informed that neonates exposed to heroin, prescription opioids, methadone, or buprenorphine during pregnancy are monitored closely for symptoms and signs of neonatal withdrawal (neonatal abstinence syndrome). (II-2B) Hospitals providing obstetric care should develop a protocol for assessment and management of neonates exposed to opiates during pregnancy. (III-B) 10. Antenatal planning for intrapartum and postpartum analgesia may be offered for all women in consultation with appropriate health care providers. (III-B) 11. The risks and benefits of breastfeeding should be weighed on an individual basis because methadone maintenance therapy is not a contraindication to breastfeeding. (II-3B)

Resume Objectif Accroitre la sensibilisation a la consommation problematique de substances psychoactives pendant la grossesse et les connaissances a ce sujet, et formuler des recommandations factuelles pour la prise en charge de ce difficile probleme clinique a l'intention de tous les fournisseurs de soins de sante Options La presente directive clinique analyse l'utilisation d'outils de depistage, l'approche generale envers les soins et les recommandations pour la prise en charge clinique de la consommation problematique de substances psychoactives pendant la grossesse Issues Recommandations factuelles pour le depistage et la prise en charge de la consommation problematique de substances psychoactives pendant la grossesse et la lactation Resultats Des recherches ont ete menees dans Medline, PubMed, CINAHL et The Cochrane Library en vue d'en tirer les articles publies depuis 1950 au moyen des mots cles suivants : « substance-related disorders », « mass screening », « pregnancy complications », « pregnancy », « prenatal care », « cocaine », « cannabis », « methadone », « opioid », « tobacco », « nicotine », « solvents », « hallucinogens » et « amphetamines ».Les resultats ont ete restreints aux analyses systematiques et aux essais comparatifs randomises / essais cliniques comparatifs.Des recherches subsequentes visant les etudes observationnelles ont egalement ete menees en raison de la rarete des ECR dans ce domaine d'etude.Les articles ont ete restreints aux etudes menees chez l'homme publiees en anglais.Des articles additionnels ont ete identifies manuellement par l'analyse des listes de references des articles selectionnes.Les recherches ont ete mises a jour de facon reguliere et leurs resultats ont ete incorpores a la directive clinique jusqu'en decembre 2009.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 La qualite des resultats a ete evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs.Les recommandations visant la pratique ont ete classees conformement a la methode decrite dans ce rapport (Tableau 1). Avantages, desavantages et couts La presente directive clinique a pour but d'accroitre les connaissances et le degre d'aisance des fournisseurs de soins de sante aux femmes enceintes qui presentent des troubles lies a la consommation de substances psychoactives L'amelioration de l'acces aux soins de sante et a une aide pour l'obtention d'un traitement adequat de l'assuetude mene a une baisse des couts de sante et des taux maternels et neonatals de morbidite et de mortalite. Recommendations 1. Toutes les femmes enceintes et les femmes en âge de procreer devraient periodiquement faire l'objet d'un depistage de la consommation d'alcool, de tabac, de medicaments d'ordonnance et de drogues illicites. (III-A) 2. Lorsque le depistage de la consommation de substances psychoactives s'avere cliniquement indique, le depistage de drogue dans l'urine constitue la methode a privilegier. (II-2A) Le consentement eclaire de la patiente devrait etre obtenu avant que la tenue d'un depistage toxicologique maternel ne soit demandee. (III-B) 3. Les politiques et les obligations juridiques liees au depistage toxicologique chez les nouveau-nes peuvent varier d'un territoire de competence a l'autre, et les fournisseurs de soins devraient se familiariser avec les reglements en vigueur dans leur region. (III-A) 4. Les fournisseurs de soins de sante devraient utiliser une approche flexible envers les soins a offrir aux femmes qui connaissent des problemes de consommation de substances psychoactives. De plus, ils devraient favoriser l'utilisation de toutes les ressources communautaires disponibles. (II-2B) 5. Les femmes devraient se voir offrir des conseils au sujet des risques qu'occasionne la consommation de drogues pendant les periodes periconceptionnelle, antepartum et postpartum. (III-B) 6. Le counseling visant l'abandon du tabagisme devrait etre considere comme etant l'intervention de premiere intention pour ce qui est des femmes enceintes qui fument. (I-A) Le recours a la therapie de remplacement de la nicotine et/ou a la pharmacotherapie peut etre envisage lorsque le counseling echoue. (I-A) 7. Le traitement de substitution a la methadone devrait constituer la norme de diligence pour ce qui est des femmes qui presentent une dependance aux opioides pendant la grossesse. (II-IA) L'utilisation d'autres preparations opioides a liberation prolongee peut etre envisagee lorsque la methadone n'est pas disponible. (II-2B) 8. La desintoxication visant les opioides ne devrait etre mise en oeuvre qu'aupres de certaines femmes, et ce, en raison du risque eleve de rechute. (II-2B) 9. Les femmes qui presentent une dependance aux opiaces devraient etre avisees que les nouveau-nes exposes a l'heroine, aux opioides d'ordonnance, a la methadone ou a la buprenorphine pendant la grossesse font l'objet d'une etroite surveillance visant a deceler les symptomes du sevrage neonatal (syndrome d'abstinence neonatale). (II-2B) Les hopitaux offrant des soins obstetricaux devraient elaborer un protocole pour l'evaluation et la prise en charge des nouveau-nes exposes aux opiaces pendant la grossesse. (III-B) 10. La planification prenatale de l'analgesie intrapartum et postpartum peut etre offerte a toutes les femmes, en consultation avec les fournisseurs de soins appropries. (III-B) 11. Les risques et les avantages de l'allaitement devraient etre ponderes de facon personnalisee, puisque le traitement de substitution a la methadone ne constitue pas une contre-indication a l'allaitement. (II-3B)

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)

Resume Objectif Analyser les donnees et formuler des recommandations en ce qui concerne le counseling et la prise en charge des parturientes obeses. Issues Parmi les issues evaluees, on trouve les effets de l’obesite maternelle sur l’offre de soins prenatals et intrapartum, ainsi que sur la morbidite et la mortalite maternelles et perinatales. Resultats Des recherches ont ete menees aupres de Statistique Canada, de Medline et de The Cochrane Library en vue d’en tirer la litterature portant sur les effets de l’obesite pendant la grossesse sur les soins prenatals et intrapartum, la morbidite et la mortalite maternelles, l’anesthesie obstetricale, et la morbidite et la mortalite perinatales. Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles. Aucune restriction en fonction de la date ou de la langue n’a ete mise en œuvre. Les recherches ont ete regulierement mises a jour et leurs resultats ont ete incorpores a la directive clinique jusqu’en avril 2009. 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 cumules ont ete analyses et evalues par le comite de medecine fœto-maternelle et le comite de pratique clinique-obstetrique de la SOGC, sous la gouverne des auteurs principaux, et les recommandations ont ete formulees conformement aux lignes directrices elaborees par le Groupe d’etude canadien sur les soins de sante preventifs. Avantages, desavantages et couts :La mise en œuvre des recommandations formulees dans la presente directive clinique devraient sensibiliser davantage les cliniciens aux aspects qui doivent etre pris en consideration dans le cadre de la prise en charge des femmes obeses pendant la grossesse, ameliorer la communication et la consultation au sein de l’equipe de soins obstetricaux, et inciter les organismes federaux et provinciaux a sensibiliser les Canadiennes aux bienfaits du maintien d’un poids aussi sante que possible avant la grossesse. Recommandations 1. Les examens de sante periodiques et les autres consultations de nature gynecologique se deroulant avant la grossesse constituent des occasions ideales d’aborder le sujet de la perte de poids avant la conception. Les femmes devraient etre incitees a presenter, avant la grossesse, un IMC 2 et, idealement, 2 . (III-B) 2. L’IMC devrait etre calcule en fonction de la taille et du poids pregrossesses. Les femmes qui presentent un IMC pregrossesse > 30 kg/m 2 sont considerees comme etant obeses. Ce renseignement peut s’averer utile dans le cadre du counseling visant les risques pour la grossesse qui sont associes a l’obesite. (II-2B) 3. Les femmes enceintes obeses devraient se voir offrir des services de counseling au sujet du gain ponderal, de la nutrition et des choix alimentaires. (II-2B) 4. Les femmes obeses devraient etre avisees qu’elles sont exposees a des risques de complications medicales telles que les maladies cardiaques, les maladies pulmonaires, l’hypertension gestationnelle, le diabete gestationnel et l’apnee obstructive du sommeil. La pratique reguliere d’exercices pendant la grossesse peut contribuer a attenuer certains de ces risques. (II-2B) 5. Les femmes obeses devraient etre avisees que leur fœtus est expose a un risque accru d’anomalies congenitales; un depistage approprie devrait etre mis en œuvre. (II-2B) 6. Les fournisseurs de soins obstetricaux devraient tenir compte de l’IMC au moment de prendre des dispositions en vue de la tenue d’une evaluation anatomique fœtale au cours du deuxieme trimestre. Une evaluation anatomique menee a 20–22 semaines pourrait s’averer mieux indiquee pour ce qui est des patientes enceintes obeses. (II-2B) 7. Les femmes enceintes obeses courent un risque accru de subir une cesarienne; de plus, leur taux de reussite en ce qui concerne l’accouchement vaginal a la suite d’une cesarienne connait une baisse. (II-2B) 8. Le tenue d’une consultation prenatale aupres d’un anesthesiste devrait etre envisagee, afin de passer en revue les options en matiere d’analgesie et de s’assurer de la mise en place d’un plan de prise en charge lorsque l’option de l’anesthesie regionale est retenue. (III-B) 9. Le risque de thromboembolie veineuse de chaque femme obese devrait etre evalue. Dans certaines situations cliniques, le fait d’envisager une thromboprophylaxie devrait etre personnalise. (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).

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)

Objectives To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa. Outcomes Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality. Evidence Published literature on randomized trials, prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery; studies comparing outcomes when vasa previa is diagnosed antenatally vs. intrapartum) and key words (e.g., vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 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 from national and international medical specialty societies. Values The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Summary Statement A comparison of women who were diagnosed antenatally and those who were not shows respective neonatal survival rates of 97% and 44%, and neonatal blood transfusion rates of 3.4% and 58.5%, respectively. Vasa previa can be diagnosed antenatally, using combined abdominal and transvaginal ultrasound and colour flow mapping; however, many cases are not diagnosed, and not making such a diagnosis is still acceptable. Even under the best circumstances the false positive rate is extremely low. (II-2) Recommendations 1.If the placenta is found to be low lying at the routine second trimester ultrasound examination, further evaluation for placental cord insertion should be performed. (II-2B) 2.Transvaginal ultrasound may be considered for all women at high risk for vasa previa, including those with low or velamentous insertion of the cord, bilobate or succenturiate placenta, or for those having vaginal bleeding, in order to evaluate the internal cervical os. (II-2B) 3.If vasa previa is suspected, transvaginal ultrasound colour Doppler may be used to facilitate the diagnosis. Even with the use of transvaginal ultrasound colour Doppler, vasa previa may be missed. (II-2B) 4.When vasa previa is diagnosed antenatally, an elective Caesarean section should be offered prior to the onset of labour. (II-1A) 5.In cases of vasa previa, premature delivery is most likely; therefore, consideration should be given to administration of corticosteroids at 28 to 32 weeks to promote fetal lung maturation and to hospitalization at about 30 to 32 weeks. (II-2B) 6.In a woman with an antenatal diagnosis of vasa previa, when there has been bleeding or premature rupture of membranes, the woman should be offered delivery in a birthing unit with continuous electronic fetal heart rate monitoring and, if time permits, a rapid biochemical test for fetal hemoglobin, to be done as soon as possible; if any of the above tests are abnormal, an urgent Caesarean section should be performed. (III-B) 7.Women admitted with diagnosed vasa previa should ideally be transferred for delivery in a tertiary facility where a pediatrician and blood for neonatal transfusion are immediately available in case aggressive resuscitation of the neonate is necessary. (II-3B) 8.Women admitted to a tertiary care unit with a diagnosis of vasa previa should have this diagnosis clearly identified on the chart, and all health care providers should be made aware of the potential need for immediate delivery by Caesarean section if vaginal bleeding occurs. (III-B)

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.

Objectives To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. Options Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. Outcomes Reduced perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short- and long-term maternal morbidity and mortality. Evidence Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. Values The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. Validation This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery. Sponsors The Society of Obstetricians and Gynaecologists of Canada. Summary Statements 1.Vaginal breech birth can be associated with a higher risk of perinatal mortality and short-term neonatal morbidity than elective Caesarean section. (I) 2.Careful case selection and labour management in a modern obstetrical setting may achieve a level of safety similar to elective Caesarean section. (II-1) 3.Planned vaginal delivery is reasonable in selected women with a term singleton breech fetus. (I) 4.With careful case selection and labour management, perinatal mortality occurs in approximately 2 per 1000 births and serious short-term neonatal morbidity in approximately 2% of breech infants. Many recent retrospective and prospective reports of vaginal breech delivery that follow specific protocols have noted excellent neonatal outcomes. (II-1) 5.Long-term neurological infant outcomes do not differ by planned mode of delivery even in the presence of serious short-term neonatal morbidity. (I) Recommendations Labour Selection Criteria 1.For a woman with suspected breech presentation, pre- or early labour ultrasound should be performed to assess type of breech presentation, fetal growth and estimated weight, and attitude of fetal head. If ultrasound is not available, Caesarean section is recommended. (II-1A) 2.Contraindications to labour include a.Cord presentation (II-3A) b.Fetal growth restriction or macrosomia (I-A) c.Any presentation other than a frank or complete breech with a flexed or neutral head attitude (III-B) d.d. Clinically inadequate maternal pelvis (III-B) e.Fetal anomaly incompatible with vaginal delivery (III-B) 3.Vaginal breech delivery can be offered when the estimated fetal weight is between 2500g and 4000g. (II-2B) Labour Management 4.Clinical pelvic examination should be performed to rule out pathological pelvic contraction. Radiologic pelvimetry is not necessary for a safe trial of labour; good progress in labour is the best indicator of adequate fetal-pelvic proportions. (III-B) 5.Continuous electronic fetal heart monitoring is preferable in the first stage and mandatory in the second stage of labour. (I-A) When membranes rupture, immediate vaginal examination is recommended to rule out prolapsed cord. (III-B) 6.In the absence of adequate progress in labour, Caesarean section is advised. (II-1A) 7.Induction of labour is not recommended for breech presentation. (II-3B) Oxytocin augmentation is acceptable in the presence of uterine dystocia. (II-1A) 8.A passive second stage without active pushing may last up to 90 minutes, allowing the breech to descend well into the pelvis. Once active pushing commences, if delivery is not imminent after 60 minutes, Caesarean section is recommended. (I-A) 9.The active second stage of labour should take place in or near an operating room with equipment and personnel available to perform a timely Caesarean section if necessary. (III-A) 10.A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery. (III-A) Delivery Technique 11.The health care provider for a planned vaginal breech delivery needs to possess the requisite skills and experience. (II-1A) 12.An experienced obstetrician-gynaecologist comfortable in the performance of vaginal breech delivery should be present at the delivery to supervise other health care providers, including a trainee. (I-A) 13.The requirements for emergency Caesarean section, including availability of the hospital operating room team and the approximate 30-minute timeline to commence a laparotomy, must be in accordance with the recommendations of the SOGC Policy Statement, "Attendance at Labour and Delivery" (CPG No. 89; update in press, 2009). (III-A) 14.The health care provider should have rehearsed a plan of action and should be prepared to act promptly in the rare circumstance of a trapped after-coming head or irreducible nuchal arms: symphysiotomy or emergency abdominal rescue can be life saving. (III-B) 15.Total breech extraction is inappropriate for term singleton breech delivery. (II-2A) 16.Effective maternal pushing efforts are essential to safe delivery and should be encouraged. (II-1A) 17.At the time of delivery of the after-coming head, an assistant should be present to apply suprapubic pressure to favour flexion and engagement of the fetal head. (II-3B) 18.Spontaneous or assisted breech delivery is acceptable. Fetal traction should be avoided, and fetal manipulation must be applied only after spontaneous delivery to the level of the umbilicus. (III-A) 19.Nuchal arms may be reduced by the Lovset or Bickenbach manoeuvres. (III-B) 20.The fetal head may deliver spontaneously, with the assistance of suprapubic pressure, by Mauriceau-Smellie-Veit manoeuvre, or with the assistance of Piper forceps. (III-B) Setting and Consent 21.In the absence of a contraindication to vaginal delivery, a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective Caesarean section, and informed consent should be obtained. A woman's choice of delivery mode should be respected. (III-A) 22.The consent discussion and chosen plan should be well documented and communicated to labour-room staff. (III-B) 23.Hospitals offering a trial of labour should have a written protocol for eligibility and intrapartum management. (III-B) 24.Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care. (III-A) 25.The Society of Obstetricians and Gynaecologists of Canada (SOGC), in collaboration with the Association of Professors of Obstetrics and Gynaecology (APOG), The College of Family Physicians of Canada (CFPC), and The Canadian Association of Midwives (CAM) should revise the training requirements at the undergraduate and postgraduate levels. SOGC will continue to promote training of current health care providers through the MOREOB, ALARM (Advances in Labour and Risk Management), and other courses. (III-A) 26.Theoretical and hands-on breech birth training simulation should be part of basic obstetrical skills training programs such as ALARM, ALSO (Advanced Life Support Training in Obstetrics), and MOREOB to prepare health care providers for unexpected vaginal breech births. (III-B)

Objective To introduce new information on the use of progesterone to prevent premature labour and to provide guidance to obstetrical caregivers who counsel women on the merits of this choice Options This discussion is limited to progesterone therapy for prevention of preterm labour (PTL) in women at increased risk of PTL. Evidence A search of both Medline and the Cochrane Library identified the most relevant medical evidence. This document represents an abstraction of the evidence rather than a methodological review. The level of evidence and quality of recommendations are described using the criteria and classifications of the Canadian Task Force on Preventive Health Care (Table 1). Values This update is the consensus of the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC). Benefits, Harms, and Costs Counselling the patient at increased risk for PTL should include consideration of the potential benefits of progesterone use and our lack of/limited knowledge of many neonatal outcomes and optimal dosing. Sponsor Society of Obstetricians and Gynaecologists of Canada. Recommendations 1.Women at risk for PTL should be encouraged to participate in studies on the role of progesterone in reducing the risks of preterm labour. (I-A) 2.Women should be informed about the lack of available data for many neonatal outcome variables and about the lack of comparative data on dosing and route of administration. Women with short cervix should be informed of the single large RCT showing the benefit of progesterone in preventing PTL. (I-A) 3.Women and their caregivers should be aware that a previous preterm labour and/or short cervix ( 4.On the basis of the data from the RCTs and meta-analysis, it is recommended that in cases where the clinician and the patient have opted for the use of progesterone the following dosages should be used: •For prevention of PTL in women with history of previous PTL: 17 alpha- hydroxyprogesterone 250 mg IM weekly (IB) or progesterone 100 mg daily vaginally. (I-A) •For prevention of PTL in women with short cervix of

Resume Objectif Presenter de nouveaux renseignements quant a l'utilisation de progesterone pour prevenir le travail preterme et offrir des lignes directrices aux fournisseurs de soins obstetricaux qui conseillent les femmes quant aux merites de cette option. Options La presente discussion se limite a la progesterotherapie visant la prevention du travail preterme (TPT) chez les femmes qui courent des risques accrus de TPT. Resultats Les recherches menees dans Medline et Cochrane Library ont permis d'identifier les resultats medicaux les plus pertinents. Le present document constitue un resume de ces resultats plutot qu'une analyse methodologique. La qualite des recommandations et le niveau des resultats sont decrits au moyen des categories et des criteres etablis par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau 1). Valeurs La presente mise a jour est issue du consensus atteint par le comite de medecine foeto-maternelle de la Societe des obstetriciens et gynecologues du Canada (SOGC). Avantages, desavantages et couts Les services de counseling offerts aux patientes courant des risques accrus de TPT devraient comprendre la prise en consideration des avantages potentiels du recours a la progesterone et la reconnaissance du caractere limite de nos connaissances en ce qui concerne de nombreuses issues neonatales et la posologie optimale. Commanditaire Societe des obstetriciens et gynecologues du Canada. Recommandations 1.Les femmes courant des risques de TPT devraient etre incitees a participer aux etudes sur le role de la progesterone dans la baisse des risques de travail preterme. (I-A) 2.Les femmes devraient etre avisees de l'absence de donnees en ce qui concerne bon nombre de variables liees aux issues neonatales, ainsi que de l'absence de donnees comparatives en matiere de posologie et de voie d'administration. Les femmes dont le col uterin est court devraient etre avisees des resultats du seul ECR d'envergure demontrant les avantages du recours a la progesterone pour la prevention du TPT. (I-A) 3.Les femmes et leurs fournisseurs de soins devraient etre conscients que le fait d'avoir deja connu un travail preterme spontane et/ou la presence d'un col uterin court ( 4.En fonction des donnees issues des ECR et des meta-analyses, il est recommande d'adopter les posologies suivantes dans les cas ou le medecin et la patiente ont choisi d'avoir recours a la progesterone: •Pour la prevention du TPT chez les femmes qui presentent des antecedents de TPT: 17 alpha-hydroxyprogesterone a raison de 250 mg IM par semaine (I-B) ou progesterone a raison de 100 mg par jour, par voie vaginale. (I-A) •Pour la prevention du TPT chez les femmes pour lesquelles lecaractere « court » du col uterin ( e et la 26 e semaine degestation : progesterone a raison de 200 mg par jour, par voievaginale. (I-A)

Resume Objectif Etudier la teratogenicite associee aux diabetes gestationnel et preexistant, fournir des lignes directrices en vue d'optimiser la prevention et le diagnostic des anomalies foetales chez les femmes diabetiques, et identifier les domaines particuliers de l'association entre les anomalies foetales et le diabete qui necessitent la tenue d'autres recherches. Options Counseling preconception, supplementation en acide folique avant la grossesse et pendant le premier trimestre, et maitrise de la glycemie. Issues Sensibilisation accrue aux anomalies foetales associees aux diabetes gestationnel et preexistant. Resultats Des recherches ont ete menees dans Cochrane Library et Medline en vue d'en tirer les articles, rediges en anglais et publies entre 1990 et fevrier 2005, traitant des anomalies foetales et des diabetes gestationnel et preexistant. Parmi les termes de recherche, on trouvait ce qui suit : pregnancy, diabetes mellitus, pre-existing diabetes, type 1 diabetes, type 2 diabetes, insulin dependent diabetes, gestational diabetes, impaired glucose tolerance, congenital anomalies, malformations et stillbirth. Des publications additionnelles ont ete identifiees a partir des bibliographies de ces articles, ainsi qu'a partir du Science Citation Index. L'analyse a porte sur tous les types d'etude. Les essais comparatifs randomises arrivaient en tete de liste en matiere de qualite des resultats; les etudes de cohorte arrivaient au deuxieme rang a ce chapitre. Les etudes cles et les donnees justificatives pour chacune des recommandations sont resumees au moyen de commentaires d'evaluation et font l'objet de references. Valeurs Les donnees recueillies ont ete analysees par les comites sur la genetique et sur la medecine foeto-maternelle de la Societe des obstetriciens et gynecologues du Canada (SOGC), et quantifiees au moyen des classifications et des criteres etablis par le Groupe d'etude canadien sur les soins de sante preventifs. Recommandations 1.Bien que les etudes experimentales laissent entendre que l'hyperglycemie constitue le principal agent teratogene dans le cadre des grossesses diabetiques, d'autres facteurs lies au diabete peuvent egalement affecter les issues foetales. D'autres recherches faisant appel a des modeles animaux s'averent requises pour clarifier les facteurs teratogenes qui sont associes aux diabetes gestationnel et preexistant. (II-3C) 2.Des etudes de cohorte prospectives et retrospectives ont demontre l'existence d'une hausse du risque d'anomalies congenitales en presence d'un diabete preexistant. D'autres etudes incluant les issues des interruptions de grossesse au cours du premier et du deuxieme trimestre, neutralisant l'effet de variables parasites potentielles et utilisant des groupes temoins appropries s'averent requises. (II-2A) 3.Des etudes de cohorte prospectives et retrospectives ont demontre qu'une hausse du risque d'anomalies congenitales etait associee au diabete gestationnel. Cette constatation est probablement associee a l'inclusion des femmes presentant un diabete de type 2 passe inapercu. La clarification de la relation entre le diabete gestationnel et les anomalies congenitales au moyen d'etudes incluant les issues des interruptions de grossesse au cours du premier et du deuxieme trimestre, neutralisant l'effet de variables parasites potentielles et utilisant des groupes temoins appropries s'avere requise. (II-2A) 4.Chez certaines femmes, il est possible que la presence d'un diabete de type 2 soit constatee pour la premiere fois au cours de la grossesse. L'identification preconception des femmes courant des risques eleves de presenter un diabete de type 2 et la mise en oeuvre d'une maitrise glycemique optimale pourraient entrainer la baisse du risque d'anomalies congenitales. (II-2A) 5.Les sulfonylurees de deuxieme generation n'ont pas ete associees a des anomalies congenitales dans le cadre d'etudes menees chez l'homme. L'utilisation de biguanides pourrait etre associee a d'autres issues perinatales indesirables. L'utilisation d'autres agents antihyperglycemiques oraux n'est pas recommandee au cours de la grossesse. (II-2A) 6.Le risque d'anomalies congenitales est accru chez la progeniture des femmes obeses diabetiques. Un regime alimentaire sain et la pratique reguliere d'exercices peuvent contribuer a optimiser le poids pregrossesse et a reduire le risque d'anomaliescongenitales. (II-2A) 7.La determination precise de l'âge gestationnel s'avere requise chez les femmes diabetiques. Compte tenu de la hausse du risque d'anomalies congenitales, ces femmes devraient se voir offrir un depistage biochimique et echographique approprie, ainsi qu'une evaluation detaillee des structures cardiaques foetales. (II-2A) 8.Les femmes diabetiques devraient se voir offrir des services de counseling preconception par une equipe multidisciplinaire, afin d'optimiser leur sante generale et leur maitrise glycemique, et d'analyser leur risque d'anomalies congenitales. (II-2A) 9.Le fournisseur de soins devrait s'assurer de consigner rigoureusement les antecedents de la patiente afin d'identifier d'autres facteurs (tels que des antecedents familiaux positifs ou un âge maternel avance) pouvant aggraver davantage le risque d'anomalies structurelles ou chromosomiques congenitales. (II-2A) 10.Chez les femmes diabetiques, la grossesse devrait faire l'objet d'une planification. L'offre de services adequats de counseling au sujet de la contraception et de la periode preconception s'avere essentielle. L'euglycemie devrait etre maintenue avant et pendant la grossesse. (II-2A) 11.Toutes les femmes diabetiques devraient beneficier de conseils au sujet de la consommation d'aliments a teneur elevee en acide folique et fortifies au folate, et de l'adoption d'une supplementation appropriee en acide folique (de 4 a 5 mg par jour) pendant la periode preconception et pendant les 12 premieres semaines de gestation. (II-2A) 12.Un nombre important de femmes diabetiques ne profitent pas des programmes de soins preconception offerts. Des strategies s'averent requises pour ameliorer l'acces a ces programmes et pour maximiser les interventions associees a l'amelioration des issues de grossesse, telles que l'utilisation d'acide folique. (II-2A) Validation La presente directive clinique a ete examinee par les comites sur la genetique et sur la medecine foeto-maternelle de la SOGC. L'approbation finale a ete accordee 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

Resume Objectif Examiner le recours a l'echographie transvaginale aux fins du diagnostic du placenta praevia et recommander une prise en charge fondee sur une localisation precise du placenta. Options Echographie transvaginale (ETV) ou echographie transabdominale, en ce qui a trait au diagnostic du placenta praevia; voie d'accouchement, en fonction de la distance separant le pourtour du placenta et l'orifice cervical interne; soins prenatals a l'hopital ou en clinique externe; cerclage afin de prevenir l'hemorragie; anesthesie locale ou generale; diagnostic prenatal du placenta accreta. Issue Avantage clinique eprouve en ce qui concerne le recours a l'ETV pour le diagnostic et la planification de la prise en charge du placenta praevia. Resultats Recherche menee dans MEDLINE au moyen du terme placenta previa et analyse bibliographique. Avantages, desavantages et couts L'obtention d'un diagnostic precis du placenta praevia pourrait entrainer une diminution de la duree d'hospitalisation et du nombre d'interventions inutiles. Recommandations 1.L'echographie transvaginale, lorsque disponible, peut etre utilisee pour determiner l'emplacement du placenta en tout temps pendant la grossesse, lorsque l'on soupconne avoir affaire a un placenta bas. Elle est considerablement plus precise que l'echographie transabdominale et son innocuite est bien etablie. (11–2A) 2.On incite les echographistes a signaler, au moment de l'ETV, la distance exacte separant le pourtour placentaire et l'orifice cervical interne en ayant recours a la terminologie standard (millimetres d'ecart par rapport a l'orifice ou millimetres de chevauchement). La situation dans laquelle le pourtour placentaire atteint exactement l'orifice interne est decrite sous forme d'une distance de 0mm. Lorsque, au moment de l'ETV menee entre la 18 e et la 24 e semaine de gestation, le pourtour placentaire atteint l'orifice cervical interne ou empiete sur ce dernier (incidence se situant entre 2 % et 4 %), la tenue d'un examen de suivi visant a determiner l'emplacement du placenta au troisieme trimestre est recommandee. Un chevauchement superieur a 15mm est associe a une hausse de la probabilite d'un placenta praevia a terme. (ll-2A) 3.Lorsque le pourtour placentaire se situe a entre 20mm d'ecart par rapport a l'orifice interne et 20mm de chevauchement apres la 26 e semaine de gestation, l'echographie devrait etre repetee a intervalles reguliers (en fonction de l'âge gestationnel, de la distance par rapport a l'orifice interne et de caracteristiques cliniques telles que l'hemorragie), et ce, puisqu'il est probable que la position du placenta continue d'evoluer. Un chevauchement de 20mm ou plus, a quelque moment que ce soit au cours du troisieme trimestre, est grandement predictif de la necessite d'avoir recours a la CS. (ll-B) 4.La distance orifice-pourtour placentaire, au moment de l'ETV menee apres la 35 e semaine de gestation, s'avere utile pour la planification de la voie d'accouchement. Lorsque le pourtour placentaire se situe a > 20mm d'ecart par rapport a l'orifice cervical interne, les femmes peuvent se voir offrir un essai de travail, lequel presente alors une forte probabilite de reussite. Une distance de 20 a 0mm d'ecart par rapport a l'orifice est associee a un taux accru de CS; cependant, en fonction des circonstances cliniques presentes, l'accouchement vaginal demeure possible. (ll-2A) 5.En general, apres la 35 e semaine de gestation, la presence de quelque degre de chevauchement (> 0mm) que ce soit constitue une indication pour le recours a la cesarienne a titre de voie d'accouchement. (ll-2A) 6.La prise en charge du placenta praevia en clinique externe peut s'averer appropriee dans le cas des femmes stables beneficiant d'un soutien a la maison, demeurant a proximite immediate d'un hopital et pouvant facilement et rapidement avoir acces a des moyens de transport et de communication telephonique. (ll-2C) 7.Nous ne disposons pas de donnees suffisantes pour recommander la pratique du cerclage cervical en vue de reduire les saignements en presence d'un placenta praevia. (ll-D) 8.Lorsque l'on doit effectuer une CS en raison d'un placenta praevia, il est possible d'avoir recours a une anesthesie regionale. (II-2B) 9.Les femmes qui presentent un placenta praevia et qui ont deja subi une CS courent un risque accru de placenta accreta. En presence de resultats d'imagerie indiquant une adherence pathologique du placenta, les fournisseurs de soins devraient faire en sorte de proceder a l'accouchement au sein d'un milieu approprie dote de ressources adequates. (II-2B) Validation Comparaison avec Placenta previa and placenta previa accreta: diagnosis and management , Royal College of Obstetricians and Gynaecologists, directive clinique n° 27, octobre 2005. La qualite des resultats et la classification des recommandations sont decrites au moyen des criteres et des categories etablis par le Groupe d'etude canadien sur les soins de sante preventifs (Tableau).

Objective To review the use of transvaginal ultrasound for the diagnosis of placenta previa and recommend management based on accurate placental localization. Options Transvaginal sonography (TVS) versus transabdominal sonography for the diagnosis of placenta previa; route of delivery, based on placenta edge to internal cervical os distance; in-patient versus out-patient antenatal care; cerclage to prevent bleeding; regional versus general anaesthesia; prenatal diagnosis of placenta accreta. Outcome Proven clinical benefit in the use of TVS for diagnosing and planning management of placenta previa. Evidence MEDLINE search for "placenta previa" and bibliographic review. Benefits, Harms, and Costs Accurate diagnosis of placenta previa may reduce hospital stays and unnecessary interventions.

Objective To determine the frequency of visualization of the ovaries by transvaginal sonography (TVS) in a group of women in early pregnancy and to determine the onset of a decrease in sonographic visualization of the ovaries during this time. Methods The study population included all patients with an intrauterine pregnancy confirmed by the presence of a yolk sac, embryo, or fetus. The biometric data included crown–rump length and/or gestational sac mean diameter corresponding to ≤ 14 weeks’ gestational age (GA). Results The study population included 11 095 women, of whom 1972 (17.8%) had a GA ≤ 6 weeks, 4665 (42.0%) 6.1 to 8 weeks, 2782 (25.1%) 8.1 to 10 weeks, 1208 (10.1%) 10.1 to 12 weeks, and 468 (4.2%) 12.1 to 14 weeks. At least one ovary was identified in 11 043 women (99.5%), and both ovaries were identified in 10 620 women (95.7%). Only the right ovary was identified in 274 women (2.5%), and only the left ovary was identified in 149 women (1.3%). In 52 women (0.5%), neither ovary was identified. Both ovaries were identified in 1929 pregnancies of ≤ 6 weeks’ GA (97.8%), in 4528 between 6.1 and 8 weeks’ GA (97.1%), in 2664 between 8.1 and 10 weeks, GA (95.8%), in 1114 between 10.1 and 12 weeks’ GA (92.2%), and in 385 between 12.1 and 14 weeks’ GA (82.3%). Conclusion Transvaginal sonography achieved an overall visualization of one or both ovaries in 99.5% women with pregnancies of ≤ 14 weeks, GA. Both ovaries were visualized in 95.7% of women. A significant decline in ovarian visualization occurred after 10 weeks’ GA. The results provide reference data on the likelihood of ovarian visualization in early pregnancy.

Objective To review the effect of the number of embryos transferredon the outcome of in vitro fertilization (IVF), to provide guidelineson the number of embryos to transfer in IVF-embryo transfer (ET)in order to optimize healthy live births and minimize multiplepregnancies. Options Rates of live birth, clinical pregnancy, and multiplepregnancy or birth by number of embryos transferred arecompared. Outcomes Clinical pregnancy, multiple pregnancy, and live birthrates. Evidence The Cochrane Library and MEDLINE were searched forEnglish language articles from 1990 to April 2006. Search termsincluded embryo transfer (ET), assisted reproduction, in vitrofertilization (IVF), intracytoplasmic sperm injection (ICSI), multiplepregnancy, and multiple gestation. Additional references wereidentified through hand searches of bibliographies of identifiedarticles. Values Available evidence was reviewed by the ReproductiveEndocrinology and Infertility Committee and the Maternal-FetalMedicine Committee of the Society of Obstetricians andGynaecologists of Canada and the Board of the Canadian Fertilityand Andrology Society, and was qualified using the Evaluation ofEvidence Guidelines developed by the Canadian Task Force onthe Periodic Health Exam. Benefits, Harms, and Costs This guideline is intended to minimizethe occurrence of multifetal gestation, particularly high-ordermultiples (HOM), while maintaining acceptable overall pregnancyand live birth rates following IVF-ET. Recommendations The recommendations made in this guideline were derived mainlyfrom studies of cleavage stage embryos—those cultured for two orthree days. 1.Individual IVF-ET programs should evaluate their own data toidentify patient-specific, embryo-specific, and cycle-specificdeterminants of implantation and live birth in order to developembryo transfer policies that minimize the occurrence of multifetalgestation while maintaining acceptable overall pregnancy and livebirth rates. (III-B) 2.In general, consideration should be given to the transfer of fewerblastocyst stage embryos than cleavage stage embryos,particularly in women with excellent prognoses and high-qualityblastocysts. (I-A) 3.In women under the age of 35 years, no more than two embryosshould be transferred in a fresh IVF-ET cycle. (II-2A) 4.In women under the age of 35 years with excellent prognoses, thetransfer of a single embryo should be considered. Women withexcellent prognoses include those undergoing their first or secondIVF-ET cycle or one immediately following a successful IVF-ETcycle, with at least two high-quality embryos available for transfer.(I-A) 5.In women aged 35 to 37 years, no more than three embryos shouldbe transferred in a fresh IVF-ET cycle. In those with high-qualityembryos and favourable prognoses, consideration should be givento the transfer of one or two embryos in the first or second cycle.(II-2A) 6.In women aged 38 to 39 years, no more than three embryos shouldbe transferred in a fresh IVF-ET cycle. (III-B) In those withhigh-quality embryos and favourable prognoses, considerationshould be given to the transfer of two embryos in the first orsecond cycle. (III-B) 7.In women over the age of 39 years, no more than four embryosshould be transferred in a fresh IVF-ET cycle. (III-B) In those olderwomen with high-quality embryos in excess of the number to betransferred, consideration should be given to the transfer of threeembryos in the first IVF-ET cycle. (III-B) 8.In exceptional cases when women with poor prognoses have hadmultiple failed fresh IVF-ET cycles, consideration may be given tothe transfer of more embryos than recommended above insubsequent fresh IVF-ET cycles. (III-C) 9.In donor–recipient cycles, the age of the oocyte/embryo donorshould be used when determining the number of embryos totransfer. (II-2B) 10.In women with obstetrical or medical contraindication to multifetalgestation, fewer embryos should be transferred to minimize thechance of multifetal gestation. In such cases, pre-treatmentconsultation with a maternal-fetal medicine specialist should be pursued. (III-C) Whenever reasonable, consideration should begiven to the transfer of a single embryo. (II-3B) 11.Couples should be adequately counselled regarding theobstetrical, perinatal, and neonatal risks of multifetal gestation tofacilitate informed decision making regarding the number ofembryos to transfer. (II-3B) Emphasis on healthy singleton livebirth as the measure of success in IVF-ET may be beneficial inpromoting a reduction in the number of embryos transferred. (III-C) 12.A strategy for public funding of IVF-ET must be developed for theeffective implementation of guidelines limiting the number ofembryos transferred. In the context of this strategy, total healthcare costs would be lower as a result of reductions in the incidenceof multifetal pregnancies and births. (III-C) 13.Efforts should be made to limit iatrogenic multiple pregnanciesresulting from non–IVF-ET ovarian stimulation through thedevelopment of suitable guidelines for cycle cancellation and theremoval of financial barriers to IVF-ET. (III-B) Summary Statement The following recommendations are generally intended forcleavage stage embryos transferred on day two or three. Because blastocyst stage embryos have higher implantation rates thancleavage stage embryos, fewer blastocyst stage embryos mayneed to be transferred. (II) Validation This guideline was reviewed by the ReproductiveEndocrinology and Infertility Committee and the Maternal-FetalMedicine Committee and approved by the Executive and Councilof the Society of Obstetricians and Gynaecologists of Canada andthe Board of the Canadian Fertility and Andrology Society. Sponsor Society of Obstetricians and Gynaecologists of Canada.The quality of evidence reported in this document has beendescribed using the Evaluation of Evidence criteria outlined in theReport of the Canadian Task Force on the Periodic Health Exam(Table 1).

Resume Objectifs Examiner l'effet du nombre d'embryons transferes surl'issue de la fecondation in vitro (FIV). Fournir des lignesdirectrices quant au nombre d'embryons a transferer dans le cadrede la « fecondation in vitro et transfert d'embryon » (FIVETE), afind'optimiser le nombre de naissances vivantes d'un foetus en santeet de minimiser le nombre de grossesses multiples. Options Les taux de naissance vivante, de grossesse clinique et degrossesse ou de naissance multiple par nombre d'embryonstransferes sont compares. Issues Taux de grossesse clinique, de grossesse multiple et denaissance vivante. Resultats Des recherches ont ete menees dans la Cochrane Library et MEDLINE afin d'en tirer les articles de langue anglaise, publiesentre 1990 et avril 2006, comportant les mots cles suivants : embryo transfer (ET), assisted reproduction, in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), multiple pregnancyet multiple gestation . Des references supplementaires ont eteidentifiees au moyen de recherches manuelles menees dans lesbibliographies des articles issus des recherches susmentionnees. Valeurs Les resultats disponibles ont ete analyses par le comited'endocrinologie de la reproduction et infertilite et le comite demedecine fœto-maternelle de la Societe des obstetriciens etgynecologues du Canada, ainsi que par le Conseil de la Societecanadienne de fertilite et d'andrologie, et leur qualite a ete evalueeen fonction des lignes directrices sur l'evaluation des resultatselaborees par le Groupe d'etude canadien sur l'examen medicalperiodique. Avantages, desavantages et couts La presente directive clinique apour but de minimiser la frequence de la gestation multifoetale,particulierement celle des gestations multiples de rang eleve(MRE), tout en assurant le maintien de taux globaux acceptablesde grossesse et de naissance vivante a la suite de la FIVETE. Recommendations Les recommandations formulees dans la presente directiveclinique sont principalement inspirees d'etudes portant sur desembryons qui en etaient au stade de la segmentation (embryonsmis en culture pendant deux ou trois jours). 1.Chacun des programmes de FIVETE devrait evaluer ses propresdonnees afin d'identifier les determinants de l'implantation et de lanaissance vivante propres a la patiente, a l'embryon et au cycle, etce, en vue d'elaborer des politiques de transfert d'embryonspermettant de minimiser la frequence de la gestation multifoetale,tout en assurant le maintien de taux globaux acceptables degrossesse clinique et de naissance vivante. (III-B) 2.En general, il faudrait envisager d'avoir recours au transfert demoins d'embryons en etant au stade du blastocyste qued'embryons en etant au stade de la segmentation, et ce,particulierement chez les femmes qui presentent un excellentpronostic et des blastocystes de grande qualite. (I-A) 3.Chez les femmes de moins de 35 ans, pas plus de deux embryonsdevraient etre transferes dans le cadre d'un cycle frais deFIVETE. (II-2A) 4.Chez les femmes de moins de 35 ans qui presentent un excellentpronostic, le transfert d'un seul embryon devrait etre envisage. Par« femmes qui presentent un excellent pronostic », on entend lesfemmes qui se soumettent a leur premier ou deuxieme cycle deFIVETE, ou qui s'y soumettent immediatement a la suite d'un cyclede FIVETE reussi, et qui presentent au moins deux embryons degrande qualite disponibles aux fins du transfert. (I-A) 5.Chez les femmes dont l'âge se situe entre 35 et 37 ans, pas plusde trois embryons devraient etre transferes dans le cadre d'uncycle frais de FIVETE. Chez celles qui disposent d'embryons degrande qualite et qui presentent un pronostic favorable, le transfertd'un ou de deux embryons au cours du premier ou du secondcycle devrait etre envisage. (II-2A) 6.Chez les femmes de 38 et de 39 ans, pas plus de trois embryonsdevraient etre transferes dans le cadre d'un cycle frais de FIVETE.(III-B) Chez celles qui disposent d'embryons de grande qualite etqui presentent un pronostic favorable, le transfert de deuxembryons au cours du premier ou du second cycle devrait etreenvisage. (III-B) 7.Chez les femmes de plus de 39 ans, pas plus de quatre embryonsdevraient etre transferes dans le cadre d'un cycle frais de FIVETE.(III-B) Chez celles qui disposent d'un plus grand nombred'embryons de grande qualite que ce qui s'avere necessaire pourle transfert, le transfert de trois embryons au cours du premiercycle de FIVETE devrait etre envisage. (III-B) 8.Dans les cas exceptionnels ou des femmes qui presentent unmauvais pronostic ont connu de multiples echecs dans le cadre decycles frais de FIVETE, le transfert d'un plus grand nombred'embryons que ce qui est recommande ci-dessus peut etreenvisage dans le cadre de cycles frais de FIVETEsubsequents. (III-C) 9.Dans le cadre des cycles donneur–receveur, l'âge du donneurd'ovocyte/embryon devrait etre utilise pour determiner le nombred'embryons a transferer. (II-2B) 10.Chez les femmes qui presentent des contre-indicationsobstetricales ou medicales a la gestation multifoetale, un nombremoindre d'embryons devraient etre transferes afin de minimiser lesrisques de gestation multifoetale. Dans de tels cas, uneconsultation pretraitement aupres d'un specialiste en medecinefœto-maternelle devrait etre mise en oeuvre. (III-C) Lorsque celas'avere raisonnable, le transfert d'un seul embryon devrait etreenvisage. (II-3B) 11.Les couples devraient beneficier de services de counselingadequats en ce qui a trait aux risques obstetricaux, perinatals etneonatals associes a la gestation multifoetale, et ce, afin de faciliterla prise d'une decision eclairee en ce qui concerne le nombred'embryons a transferer. (II-3B) La mise d'un accent particulier surla naissance vivante d'un foetus unique en sante a titre de criterede reussite de la FIVETE s'avererait benefique, pour ce qui est dela promotion de la baisse du nombre d'embryons transferes. (III-C) 12.Une strategie visant le financement public de la FIVETE doit etreelaboree, afin d'assurer la mise en oeuvre efficace de lignesdirectrices limitant le nombre d'embryons transferes. Dans lecontexte d'une telle strategie, les couts de sante totauxconnaitraient une baisse attribuable a la diminution de l'incidencedes grossesses et des naissances multifoetales. (III-C) 13.Des efforts devraient etre deployes pour limiter les grossessesmultiples iatrogeniques attribuables a la stimulation ovariennen'etant pas associee a la FIVETE, et ce, par l'intermediaire del'elaboration de lignes directrices convenables visant l'annulationde cycle et l'elimination des obstacles financiers a laFIVETE. (III-B) Declaration sommaire Les recommandations suivantes visent generalement le transfert,au cours de la deuxieme ou de la troisieme journee, d'embryonsen etant au stade de la segmentation. Puisque les embryons enetant au stade du blastocyste presentent des taux d'implantationplus eleves que ceux que presentent les embryons en etant austade de la segmentation, il est possible que l'on ait a transferer unnombre moindre d'embryons en etant au stade du blastocyste. (II) Validation La presente directive clinique a ete examinee par lecomite d'endocrinologie de la reproduction et infertilite et le comitede medecine fœto-maternelle, et a ete approuvee par le comiteexecutif et le Conseil de la Societe des obstetriciens etgynecologues du Canada, ainsi que par le Conseil de la Societecanadienne de fertilite et d'andrologie. Commanditaire Societe des obstetriciens et gynecologues duCanada.La qualite des resultats du present document a ete determinee al'aide des criteres d'evaluation decrits dans le rapport du Groupede travail canadien sur l'examen de sante periodique (Tableau 1).

Resume Objectif Fournir un protocole d'enquete pour aider les fournisseurs de soins de sante a determiner la cause d'une mort fœtale. Options Nous avons pris en consideration les protocoles d'enquete sur les morts fœtales qui sont actuellement disponibles au Canada et dans d'autres pays. Issues dentification des causes possibles de mortinaissance et leur relation avec les futures grossesses. Resultats Des articles associes a l'etiologie de la mort fœtale ont ete recenses au moyen d'une recherche menee dans MEDLINE (de janvier 1993 a decembre 2004), la Cochrane Library et des protocoles d'enquete issus du American College of Obstetricians and Gynecologists , du Alberta Medical Association Committee on Reproductive Care et du Centers for Disease Control and Prevention National Center for Health Statistics . Avantages Offrir de meilleurs conseils aux femmes au sujet des causes possibles de mort fœtale et des implications en ce qui concerne les futures grossesses. Recommandations Un protocole d'enquete devrait etre utilise pour chercher a mettre au jour la cause d'une mort fœtale. (II-B) Validation Les resultats obtenus ont ete analyses et evalues par le comite de medecine fœto-maternelle et le comite de pratique clinique - obstetrique de la Societe des obstetriciens et gynecologues du Canada. Le niveau des resultats et la qualite des recommandations ont ete decrits au moyen des criteres d'evaluation des resultats du Groupe d'etude canadien sur l'examen medical periodique. Commanditaire La Societe des obstetriciens et gynecologues du Canada.

Traditional risk factors for GDM include a family history of diabetes, gestational glycosuria, macrosomia, and polyhydramnios. Screening on the basis of risk factors, however, fails to diagnose 50% of women with GDM.2 Thus, the 1992 SOGC guidelines recommended universal screening for GDM.3 In that same year, the Canadian Task Force on Periodic Health Examination determined that there was no evidence to justify screening of women at low risk for GDM.4

Objectives To provide an investigation protocol to help health care providers determine the cause of a fetal death. Options Consideration has been given to protocols for the investigation of fetal death that are currently available in Canada and in other countries. Outcomes Identification of possible causes of stillbirth and their relationship to future pregnancies. Evidence Articles related to the etiology of fetal death were identified in a search of MEDLINE (January 1993 to December 2004), the Cochrane Library, and investigation protocols from the American College of Obstetricians and Gynecologists, the Alberta Medical Association Committee on Reproductive Care, and the Centers for Disease Control and Prevention National Center for Health Statistics. Benefits To provide better advice for women regarding possible causes of fetal death and implications for future pregnancies. Recommendation A protocol should be used to investigate the possible cause of a fetal death. (Il-B) Validation The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee and the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada. The level of evidence and quality of the recommendation made was described using the Evaluation of Evidence criteria of the Canadian Task Force on the Periodic Health Examination. Sponsor The Society of Obstetricians and Gynaecologists of Canada.

Objective: To determine the effect of extreme macrosomia on perinatal outcome. Methods: We conducted a retrospective review of all deliveries with birth weight ≥ 5000 g in a tertiary centre from 1986 to 2000 and analyzed the method of delivery and perinatal outcome. Results: Extreme macrosomia (birth weight ≥ 5000 g) was coded in 111 deliveries. There were 62 deliveries by Caesarean section (CS) (25 in labour and 37 elective). The 49 vaginal deliveries were complicated by 10 (20%) cases of shoulder dystocia and 3 (6%) of Erb's palsy. Permanent Erb's palsy was noted in only 1 of these 3 cases. Shoulder dystocia was associated with use of oxytocin and instrumental deliveries. Conclusion: Implementing the 2002 guidelines from the American College of Obstetricians and Gynecologists (that is, recommending Caesarean delivery of fetuses with an estimated weight of at least 5000 g) would have a negligible effect on the CS rate while eliminating 10 cases of shoulder dystocia in 49 births. A policy eliminating the use of oxytocin and instrumental deliveries would have prevented most birth traumas in this group. Unfortunately, this high-risk group is difficult to identify in the antepartum period, complicating the implementation of these guidelines and probably leading to higher rates of CS. In addition, the effect of endorsing such a policy on overall neonatal and maternal morbidity is minimal, because most morbidity occurs in newborns weighing less than 4000 g.

The aim of this study was to estimate the effective dose 90% (ED90) of carbetocin to provide adequate uterine tone at Cesarean delivery (CD) for labour arrest. We conducted a double-blind dose-finding study of carbetocin using a biased-coin up-and-down design in women undergoing CD for labour arrest under epidural anesthesia. Forty healthy term pregnant women who had received at least three hours of oxytocin infusion during labour were recruited for the study. Carbetocin was administered intravenously upon delivery of the anterior shoulder of the fetus. The first patient received 20 µg, and the dose for the subsequent patient was determined according to the response of the previous patient as per the biased-coin allocation scheme using increments or decrements of 20 µg (maximum 140 µg). Uterine tone was assessed by the obstetrician and rated as satisfactory or unsatisfactory throughout the intraoperative period. The primary outcome was satisfactory uterine tone with no need for additional uterotonic drugs intraoperatively. Secondary outcomes included use of additional uterotonic drugs postoperatively in the first 24 hr, estimated blood loss, and adverse effects. The ED90 of carbetocin to produce adequate uterine tone was estimated at 121 µg (95% confidence interval [CI]: 111 to 130; 99% CI: 108 to 133) using the truncated Dixon and Mood (DM) method. The isotonic estimator of ED90 was 140 µg; however, the observed response rate across all doses was

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Background — Pregnant women with heart disease (HD) are at increased risk for cardiac (CV) complications. However, the frequency of neonatal (NE) complications in pregnant women with HD relative to pregnant women without HD has not been examined. Methods and Results — Pregnant women with HD were prospectively monitored during 302 pregnancies. The frequency of NE and CV complications was compared with those in a control group without HD during 572 pregnancies. The frequency of NE complications was higher in the HD group (18% versus 7%; HD versus controls). The NE complication rate was lowest in pregnancies of women age 20 to 35 years who did not smoke during pregnancy, did not receive anticoagulants, and had no obstetric risk factors: 4% in control patients, 5% in HD patients with no cardiac risk factors for NE complications (left heart obstruction, poor functional class, or cyanosis), and 7% in HD patients with ≥1 such risk factor. In contrast, the event rate in pregnancies of controls age 35 years who had obstetric risk factors or multiple gestation or who smoked was 11%. In the HD group, women age 35 years who had obstetric risk factors or multiple gestation, who smoked, or who received anticoagulants experienced an even higher NE complication rate (27% with no cardiac risks for NE events and 33% in the presence of ≥1 cardiac risk factors). The frequency of CV complications was higher in the HD group (17% versus 0%; HD versus controls). Conclusion — Pregnant women with HD are at increased risk for both NE and CV complications. The risk for NE adverse events in pregnant women with HD is highest in those with both obstetric and cardiac risk factors for NE complications.

Resume Objectif Fournir aux cliniciens des directives fondees sur les meilleures donnees disponibles quant a l'aspiration au perinee pour les enfants nes en presence de liquide amniotique teinte de meconium. Resultats Des recherches ont ete menees dans la base de donnees Medline afin d'en tirer les articles, publies en anglais entre 2000 et 2008, portant sur la prise en charge du meconium a la naissance. Valeurs La recommandation a ete formulee conformement aux lignes directrices elaborees par le Groupe d'etude canadien sur les soins de sante preventifs. Recommandation Il est recommande que les etablissements adoptent une politique indiquant que le fait de ne pas proceder a l'aspiration est aussi sur que la tenue systematique d'une aspiration au perinee pour les enfants nes en presence de liquide amniotique teinte de meconium. (IA)

L’infection a streptocoques du groupe B (SGB) est une cause importante d’infection maternelle et de morbidite et de mortalite neonatales. Les taux de mortalite associes a l’infection neonatale a SGB a debut precoce se situent entre 5 % et 20 %1. Les approches de depistage et de traitement actuellement recommandees au Canada et aux Etats-Unis ont ete associees a une baisse de l’incidence de la maladie a debut precoce, soit de 2–3 par 1 000 a 0,5 par 1 000, au cours des deux dernieres decennies2,3. La mise en œuvre de ces strategies fait en sorte qu’une proportion elevee de femmes (et leurs nouveau-nes) sont exposees aux antibiotiques; pourtant, nous n’avons constate aucune baisse du taux d’infection a debut tardif, ce qui donne lieu a la question suivante : Faisons-nous appel a la strategie optimale pour la prise en charge de l’infection a SGB au cours de la grossesse?

Background The physiological changes of pregnancy can result in cardiovascular complications in the mother, which in turn may have fetal implications. Prior studies have focused on specific cardiac lesions or identified univariate predictors. There is a need to refine the risk stratification of women with heart disease so they can receive appropriate obstetrical counseling and care. Methods and Results We examined the outcomes of 221 women with heart disease who underwent 276 pregnancies and received their obstetrical care at three Toronto hospitals from 1986 through 1994. Those who underwent therapeutic abortions were excluded. Among the study participants, there were 24 miscarriages and 252 completed pregnancies (pregnancies not ending in miscarriage). Maternal heart failure, arrhythmia, or stroke occurred in 45 completed pregnancies (18%). There were no maternal deaths. Poor maternal functional class or cyanosis, myocardial dysfunction, left heart obstruction, prior arrhythmia, and prior cardiac events were predictive of maternal cardiac complications. These predictors were incorporated into a point score that can be used to estimate the probability of a cardiac complication in the mother. The rate of cardiac complications for a patient with 0, 1, and >1 of the above factors was 3%, 30%, and 66%, respectively. Neonatal complications occurred in 42 completed pregnancies (17%). Neonatal events included death (2), respiratory distress syndrome (16), intraventricular hemorrhage (2), premature birth (35), and small-for-gestational-age birth weight (14). Poor maternal functional class or cyanosis was predictive of neonatal events. Conclusions Despite low maternal and neonatal mortality, pregnancy in women with heart disease is associated with significant cardiac and neonatal morbidity. The probability of maternal cardiac or neonatal events can be predicted from baseline characteristics of the mother.

To review a series of critically ill obstetric patients admitted to a general intensive care unit in a Canadian centre, to assess the spectrum of diseases, interventions required and outcome.A retrospective chart review was performed of obstetric patients admitted to the intensive care unit of an academic hospital with a high-risk obstetric service, during a five-year period. Data obtained included the admission diagnosis, ICU course and outcome. Daily APACHE II and TISS scores were recorded.Sixty-five obstetric patients, representing 0.26% of deliveries in this hospital, were admitted to the ICU during the study period. All had received prenatal care. Admission diagnoses included obstetric (71%) and non-obstetric (29%) complications. The mean APACHE II score was 6.8 +/- 4.2 and mean TISS score was 24 +/- 8.1. Twenty-seven patients (42%) required mechanical ventilation. No maternal mortality occurred and the perinatal mortality rate was 11%.A small proportion of obstetric patients develop complications requiring ICU admission. The outcome in this study was excellent, in contrast to that reported in other published studies with similar ICU admission rates. The universal availability of prenatal care may be an important factor in the outcome of this group of patients. The lack of a specific severity of illness scoring system for the pregnant patient makes comparison of case series difficult.

The aim of this study was to determine the intravenous dose of carbetocin required to produce effective uterine contraction in 95% of women (ED95) undergoing elective Cesarean delivery under spinal anesthesia.One hundred and twenty term pregnant women at low risk for postpartum hemorrhage (PPH) undergoing elective Cesarean delivery under spinal anesthesia were randomly allocated to receive carbetocin in doses of 20, 40, 60, 80, or 100 μg iv upon delivery of the fetus. The obstetrician evaluated the efficacy of uterine tone as satisfactory or unsatisfactory, and in case of unsatisfactory tone, additional uterotonics were administered as per routine institutional practice. The primary outcome measure was satisfactory uterine tone at two minutes after carbetocin administration, and the secondary outcomes were the estimated blood loss, need for additional uterotonic agents within 24 hr, and side effects.Overall satisfactory uterine tone at two minutes was observed in 94.2% (113/120) of the women, and there was no difference across the different study groups. It was not possible to calculate the ED95 of carbetocin due to the even distribution of women with unsatisfactory uterine tone at two minutes across all dose groups (P = 0.60). Additional uterotonics within 24 hr were required in 13% (16/120) of the women. Side effects were similar across all dose groups, with an overall 42.5% incidence of hypotension following the administration of carbetocin.In women at low risk for PPH undergoing elective Cesarean delivery under spinal anesthesia, carbetocin is similarly effective in doses of 20-100 μg. There is a high incidence of hypotension associated with carbetocin in these doses. Further dose-finding studies are warranted, including doses lower than 20 μg. This trial was registered at www.clinicaltrials.gov (NCT01428817).