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To investigate the current practices of maternal-fetal medicine (MFM) specialists regarding the prevention and management of preterm birth (PTB) in twin pregnancies.This was a cross-sectional study of Canadian MFM specialists. Participants responded to an anonymous survey regarding the prevention and management of PTB in twins, including lifestyle and gestational weight gain recommendations, cervical length screening, PTB prevention, and labour and delivery practices.Of 137 MFM specialists surveyed, 95 (69%) responded. Most MFM specialists recommend against activity restriction (77.9%), avoidance of sexual activity (96.7%), routine progesterone (97.8%), routine prophylactic cerclage (98.9%), and routine administration of antenatal corticosteroids (95.6%). There were considerable inconsistencies with respect to gestational weight gain management. Despite lack of support by guidelines, most MFM specialists reported using routine cervical length screening (97.8%) and progesterone for short cervix (92.3%). Over half (52.7%) of MFM specialists recommend cervical cerclage when the cervix is15mm. In cases of PTB, most MFM specialists recommend vaginal delivery when twins are in vertex presentation (63%-75%). MFM specialists are less likely to recommend vaginal delivery when twin B is non-vertex (35%-41%).There is a considerable variation among MFM specialists regarding the prevention and management of PTB in twins, and the practice of many MFM specialists differs from that recommended by professional societies' guidelines. These findings underscore the necessity for high-quality studies and up-to-date recommendations.

The objective of this review was to identify the most significant studies reporting on COVID-19 during pregnancy and to provide an overview of SARS-CoV-2 infection in pregnant women and perinatal outcomes. Eligibility criteria included all reports, reviews; case series with more than 100 individuals and that reported at least three of the following: maternal characteristics, maternal COVID-19 clinical presentation, pregnancy outcomes, maternal outcomes and/or neonatal/perinatal outcomes. We included eight studies that met the inclusion criteria, representing 10,966 cases distributed in 15 countries around the world until July 20, 2020. The results of our review demonstrate that the maternal characteristics, clinical symptoms, maternal and neonatal outcomes almost 11,000 cases of COVID-19 and pregnancy described in 15 different countries are not worse or different from the general population. We suggest that pregnant women are not more affected by the respiratory complications of COVID-19, when compared to the outcomes described in the general population. We also suggest that the important gestational shift Th1-Th2 immune response, known as a potential contributor to the severity in cases of viral infections during pregnancy, are counter-regulated by the enhanced-pregnancy-induced ACE2-Ang-(1–7) axis. Moreover, the relatively small number of reported cases during pregnancy does not allow us to affirm that COVID-19 is more aggressive during pregnancy. Conversely, we also suggest, that down-regulation of ACE2 receptors induced by SARS-CoV-2 cell entry might have been detrimental in subjects with pre-existing ACE2 deficiency associated with pregnancy. This association might explain the worse perinatal outcomes described in the literature.

Resume Objectifs Evaluer les bienfaits et les risques du traitement a la progesterone en cas de grossesse susceptible d'accouchement premature spontane (APS) et emettre des recommandations sur l'utilisation de la progesterone afin de reduire les risques d'APS et d'ameliorer les issues postnatales. Options Administrer ou suspendre le traitement a la progesterone chez les femmes dont la grossesse est jugee a risque eleve d'APS. Resultats Accouchement premature, morbidite et mortalite neonatales et issues postnatales, y compris le devenir neurodeveloppemental. Professionnels concernes Fournisseurs de soins de maternite, notamment les sages-femmes, les medecins de famille et les obstetriciens. Population cible Femmes dont la grossesse presente un risque eleve d'APS. Donnees probantes Des recherches ont ete effectuees dans les bases de donnees Medline, PubMed, Embase et Cochrane Library, de leur creation jusqu'a octobre 2018, pour les termes MeSH (medical subject headings) et les mots cles relatifs a la grossesse, a l'accouchement premature, aux antecedents d'accouchement premature, au col court, aux anomalies uterines, a la conisation du col, a la morbidite et a la mortalite neonatales et aux issues postnatales. Le present document est un resume des donnees probantes et non pas une revue methodologique. Methodes de validation La presente directive clinique a ete revue par le comite de medecine fœto-maternelle de la Societe des obstetriciens et gynecologues du Canada (SOGC) puis approuvee par le conseil d'administration de la SOGC. Benefices, risques, et couts Le traitement a la progesterone reduit significativement les risques d'APS chez une population de femmes qui presentent un risque accru. Meme si ce traitement entraine des couts pour la femme en plus d'un certain inconfort associe a son utilisation, on n'observe aucun autre effet indesirable ou defavorable pour la mere ou le bebe. DECLARATIONS SOMMAIRES (classement GRADE entre parentheses) 1Le traitement a la progesterone reduit le risque d'accouchement premature spontane chez les femmes qui presentent un risque accru en raison d'antecedents d'accouchement premature spontane ou d'un col court (moyenne). 2Les donnees probantes sont insuffisantes pour appuyer l'utilisation de la progesterone en prevention de l'accouchement premature spontane en cas de grossesse gemellaire ou multiple sans raccourcissement du col (moyenne). 3Les donnees probantes sont insuffisantes pour appuyer l'utilisation de la progesterone en prevention de l'accouchement premature spontane chez les femmes qui presentent une longueur normale du col et qui ont des antecedents de conisation du col ou une anatomie uterine anormale (basse). 4L'utilisation de la progesterone chez les femmes dont le travail premature a ete interrompu n'est pas liee a une reduction du risque d'accouchement premature spontane ni a une amelioration des issues postnatales (moyenne). 5Aucun lien n'a ete fait entre l'utilisation de la progesterone par voie vaginale en prevention de l'accouchement premature spontane et l'augmentation des risques de malformations congenitales ou l'alteration du devenir neurodeveloppemental postnatal (moyenne). RECOMMANDATIONS (classement GRADE entre parentheses) 1Le traitement a la progesterone par voie vaginale en prevention de l'accouchement premature spontane est recommande en cas de grossesse monofœtale avec col court (≤ 25 mm, par echographie transvaginale entre 16 et 24 SA) (forte/moyenne). 2Le traitement a la progesterone par voie vaginale en prevention de l'accouchement premature spontane est recommande chez les femmes ayant des antecedents d'accouchement premature spontane (forte/moyenne). 3Le traitement a la progesterone par voie vaginale en prevention de l'accouchement premature spontane est recommande en cas de grossesse gemellaire (et par extrapolation des donnees, en cas de grossesse multiple) avec col court (≤ 25 mm, par echographie transvaginale entre 16 et 24 SA) (forte/moyenne). 4En cas de grossesse monofœtale chez une femme ayant des antecedents d'accouchement premature spontane ou une longueur du col de moins de 25 mm mesuree entre 16 et 24 SA lors de la grossesse en cours, si le cerclage est envisage, il convient d'offrir la progesterone par voie vaginale comme traitement de rechange efficace et potentiellement superieur (forte/moyenne). 5Chez les patientes qui utilisent la progesterone en prevention de l'accouchement premature spontane, les traitements supplementaires tels que le cerclage du col (a l'exception d'un cerclage d'urgence indique en fonction de l'examen du col) ou un pessaire ne sont pas recommandes (forte/moyenne). 6Chez les patientes qui presentent un risque accru d'accouchement premature spontane en raison d'antecedents d'accouchement premature, d'un col court ou d'une grossesse gemellaire ou multiple, l'alitement ou la reduction des activites ne sont pas recommandes (forte/moyenne). 7Lorsque le traitement est indique en prevention de l'accouchement premature spontane en cas de grossesse monofœtale, la progesterone micronisee par voie vaginale a une dose quotidienne de 200 mg est recommandee (forte/moyenne). 8Lorsque le traitement est indique en prevention de l'accouchement premature spontane en cas de grossesse gemellaire ou multiple, la progesterone micronisee par voie vaginale a une dose quotidienne de 400 mg est recommandee (conditionnelle [faible]/basse). 9Il y a lieu d'amorcer le traitement a la progesterone par voie vaginale entre 16 et 24 SA, en fonction du moment de detection du facteur de risque, lorsqu'il est indique (forte/moyenne). 10Il est possible de poursuivre le traitement a la progesterone par voie vaginale jusqu'a 34 a 36 SA en tenant compte des facteurs individuels de la patiente (forte/moyenne).

Objectives To assess the benefits and risks of progesterone therapy for women at increased risk of spontaneous preterm birth (SPB) and to make recommendations for the use of progesterone to reduce the risk of SPB and improve postnatal outcomes. Options To administer or withhold progesterone therapy for women deemed to be at high risk of SPB. Outcomes Preterm birth, neonatal morbidity and mortality, and postnatal outcomes including neurodevelopmental outcomes. Intended Users Maternity care providers, including midwives, family physicians, and obstetricians. Target Population Pregnant women at increased risk of SPB. Evidence Medline, PubMed, EMBASE, and the Cochrane Library were searched from inception to October 2018 for medical subject heading (MeSH) terms and keywords related to pregnancy, preterm birth, previous preterm birth, short cervix, uterine anomalies, cervical conization, neonatal morbidity and mortality, and postnatal outcomes. This document represents an abstraction of the evidence rather than a methodological review. Validation Methods This guideline was reviewed by the Maternal–Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors. Benefits, Harms, and/or Costs Therapy with progesterone significantly reduces the risk of SPB in a subpopulation of women at increased risk. Although this therapy entails a cost to the woman in addition to the discomfort associated with its use, no other adverse effects to the mother or the baby have been identified. SUMMARY STATEMENTS (GRADE ratings in parentheses) 1Progesterone therapy reduces the risk of spontaneous preterm birth in women at an increased risk based on history of previous spontaneous preterm birth or in women with a short cervical length (moderate). 2There is insufficient evidence to support the use of progesterone for prevention of spontaneous preterm birth in women with a pregnancy in the absence of cervical shortening (moderate). 3There is insufficient evidence to support the use of progesterone for prevention of spontaneous preterm birth in women with a normal cervical length and a prior conization procedure on the cervix or abnormal uterine anatomy (low). 4Use of progesterone in women with arrested preterm labour is not associated with a reduced risk of spontaneous preterm birth or with improved postnatal outcomes (moderate). 5Use of vaginal progesterone for prevention of spontaneous preterm birth has not been associated with an increase in congenital malformations or with a worsening of postnatal neurodevelopmental outcomes (moderate). RECOMMENDATIONS (GRADE ratings in parentheses) 1In women with a singleton pregnancy and a short cervical length (≤25 mm by transvaginal ultrasound between 16 and 24 weeks), vaginal progesterone therapy for prevention of spontaneous preterm birth is recommended (strong/moderate). 2In women with a previous spontaneous preterm birth, vaginal progesterone therapy for prevention of spontaneous preterm birth is recommended (strong/moderate). 3In women with a twin pregnancy (and by extrapolation of data, with a higher-order multiple pregnancy) and with a short cervical length (≤25 mm by transvaginal ultrasound between 16 and 24 weeks), vaginal progesterone therapy for prevention of spontaneous preterm birth is recommended (strong/moderate). 4In patients with a singleton pregnancy and a previous spontaneous preterm birth or a cervical length ≤25 mm between 16 and 24 weeks in the current pregnancy, if a cerclage is being considered, vaginal progesterone should be offered as an effective and potentially superior alternate therapy (strong/moderate). 5In patients using progesterone for prevention of spontaneous preterm birth, additional therapies such as a cervical cerclage (with exception of a rescue cerclage for an examination-based diagnosis) or a pessary are not recommended (strong/moderate). 6In patients at increased risk of spontaneous preterm birth due to a previous preterm birth, a short cervical length in the current pregnancy, or a multiple pregnancy, bed rest or reduced activity is not recommended (strong/moderate). 7When indicated for prevention of spontaneous preterm birth in a singleton pregnancy, vaginal micronized progesterone in a daily dose of 200 mg is recommended (strong/moderate). 8When indicated for prevention of spontaneous preterm birth in a multiple pregnancy, vaginal micronized progesterone in a daily dose of 400 mg is recommended (conditional [weak]/low). 9When indicated, vaginal progesterone therapy should be initiated between 16 and 24 weeks gestation, depending on when the risked factor is identified (strong/moderate). 10With consideration of individual patient risk factors, vaginal progesterone therapy can be continued up to 34–36 weeks gestation (strong/moderate).

Obesity is one of the most prevalent diseases in the developed world. Recent studies estimate as many as one in two pregnant women have a BMI ≥ 25. Special considerations with respect to assessing and caring for these patients are essential. While advances in ultrasound have expanded its intrapartum utility, its use in obstetrical patients with obesity can similarily facilitate care while also providing clinical challenges.

Obesity has become a new epidemic, affecting all ethnic and racial groups. In the developed world its incidence is persistently increasing, resulting in higher rates of overweight and obesity than normal body mass index in some countries. Pregnancies in women with obesity are at increased risk for adverse maternal and neonatal outcomes. Fetal risks include preterm birth, large for gestational age, macrosomia, shoulder dystocia, congenital anomalies, birth injury, stillbirth, cerebral palsy, and neonatal and infant death. Maternal risks include hypertensive disorders of pregnancy, gestational diabetes, cesarean delivery, anesthetic and surgical complications, endometritis, thromboembolic diseases, and postpartum hemorrhage. These increased risks could be mitigated by careful surveillance during pregnancy. This chapter will address the antenatal care of women with obesity. We will review different published guidelines and compare between them while focusing on preconception, antenatal, and intrapartum care. Our recommendations will follow a proposed checklist for obstetric care planning that we find useful to ensure that all aspects of care are addressed in a timely fashion.

Uterine tachysystole (TS) is a potentially significant intrapartum complication seen most commonly in induced or augmented labors but may also occur in women with spontaneous labor. When it occurs, maternal and perinatal complications can arise if not identified and managed promptly by obstetric care providers. Over recent years, new definitions of the condition have facilitated further research into the field, which has been synthesized to inform clinical management guidelines and protocols. We propose a set of recommendations pertaining to TS in line with contemporary evidence and obstetric practice.

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 pres la 21e 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).

Objectives To review the principles of prenatal diagnosis of congenital cytomegalovirus (CMV) infection and to describe the outcomes of the affected pregnancies. Outcomes Effective management of fetal infection following primary and secondary maternal CMV infection during pregnancy. Neonatal signs include intrauterine growth restriction (IUGR), microcephaly, hepatosplenomegaly, petechiae, jaundice, chorioretinitis, thrombocytopenia and anemia, and long-term sequelae consist of sensorineural hearing loss, mental retardation, delay of psychomotor development, and visual impairment. These guidelines provide a framework for diagnosis and management of suspected CMV infections. Evidence Medline was searched for articles published in English from 1966 to 2009, using appropriate controlled vocabulary (congenital CMV infection) and key words (intrauterine growth restriction, microcephaly). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline. 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. Recommendations The quality of evidence reported in this document has been assessed using the evaluation of evidence criteria in the Report of the Canadian Task Force on Preventive Health Care (Table 1). 1.Diagnosis of primary maternal cytomegalovirus (CMV) infection in pregnancy should be based on de-novo appearance of virus-specific IgG in the serum of a pregnant woman who was previously seronegative, or on detection of specific IgM antibody associated with low IgG avidity (II-2A). 2.In case of primary maternal infection, parents should be informed about a 30% to 40% risk for intrauterine transmission and fetal infection, and a risk of 20% to 25% for development of sequelae postnatally if the fetus is infected (II-2A). 3.The prenatal diagnosis of fetal CMV infection should be based on amniocentesis, which should be done at least 7 weeks after presumed time of maternal infection and after 21 weeks of gestation. This interval is important because it takes 5 to 7 weeks following fetal infection and subsequent replication of the virus in the kidney for a detectable quantity of the virus to be secreted to the amniotic fluid (II-2A). 4.The diagnosis of secondary infection should be based on a significant rise of IgG antibody titre with or without the presence of IgM and high IgG avidity. In cases of proven secondary infection, amniocentesis may be considered, but the risk–benefit ratio is different because of the low transmission rate (III-C). 5.Following a diagnosis of fetal CMV infection, serial ultrasound examinations should be performed every 2 to 4 weeks to detect sonographic abnormalities, which may aid in determining the prognosis of the fetus, although it is important to be aware that the absence of sonographic findings does not guarantee a normal outcome (II-2B). 6.Quantitative determination of CMV DNA in the amniotic fluid may assist in predicting the fetal outcome (II-3B). 7.Routine screening of pregnant women for CMV by serology testing is currently not recommended (III-B). 8.Serologic testing for CMV may be considered for women who develop influenza-like illness during pregnancy or following detection of sonographic findings suggestive of CMV infection (III-B). 9.Seronegative health care and child care workers may be offered serologic monitoring during pregnancy. Monitoring may also be considered for seronegative pregnant women who have a young child in day care (III-B).

Objective Traditionally, physiological variation in fetal weight is believed to emerge during the latter half of pregnancy. Although recent evidence suggests that crown-rump length (CRL) and nuchal translucency (NT) measured at 11–14 weeks correlate with abnormal fetal growth, findings have been limited by dating accuracy in spontaneous gestations. Therefore, we sought to determine whether CRL or NT measurements correlated with term birth weight (BW) or BW ratio in a cohort of IVF pregnancies, in which the date of conception is precisely known. Methods This retrospective cohort study included 227 term, singleton IVF pregnancies. Subjects were included if they had an early first-trimester ultrasound examination and subsequent nuchal translucency (NT) screening. The difference between the measured and the expected CRL and the biparietal diameter (BPD) and NT measurement were calculated and correlated with the actual term BW or BW ratio. The BW ratio was calculated using the actual BW and the expected BW for GA. Results The difference between measured and expected mid–first-trimester CRL, and the BPD at NT assessment, correlated with BW ratio at delivery ( r Spearman = 0.15, P = 0.023 and r Spearman = 0.27, P r Spearman = 0.18, r = 0.14, and P = 0.005 and 0.038, respectively). Conclusion In this well-dated IVF population, we report a significant correlation between BW ratio and first-trimester CRL, BPD, and NT measurements. These findings support the hypothesis that physiological variation in BW can be reflected by variation in first-trimester fetal measurements.

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.

Many studies have reported on the association of reduced fetal movements and stillbirth, but little is known about excessive fetal movements and adverse pregnancy outcome. First described in 1977, sudden excessive fetal movement was noted to reflect acute fetal distress and subsequent fetal demise. Subsequently, little was reported regarding this phenomenon until 2012. However, emerging data suggest that 10-30% of the women that subsequently suffer a stillbirth describe a single episode of excessive fetal movement prior to fetal demise. These episodes are poorly understood but may reflect fetal seizure activity secondary to fetal asphyxia, cord entanglement or an adverse intrauterine environment. At present, the challenge in managing women with excessive fetal movements is a timely assessment of the fetus to identify those women at risk of adverse fetal outcomes who may benefit from intervention.

Objective To review the existing data regarding varicella zoster virus infection (chickenpox) in pregnancy, interventions to reduce maternal complications and fetal infection, and antepartum and peripartum management . Methods The maternal and fetal outcomes in varicella zoster infection were reviewed, as well as the benefit of the different treatment modalities in altering maternal and fetal sequelae. Evidence Medline was searched for articles and clinical guidelines published in English between January 1970 and November 2010. Values The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care. Recommendations for practice were ranked according to the method described in that report (Table). Recommendations 1.Varicella immunization is recommended for all non-immune women as part of pre-pregnancy and postpartum care (II-3B). 2.Varicella vaccination should not be administered in pregnancy. However, termination of pregnancy should not be advised because of inadvertent vaccination during pregnancy (II-3D). 3.The antenatal varicella immunity status of all pregnant women should be documented by history of previous infection, varicella vaccination, or varicella zoster immunoglobulin G serology (III-C). 4.All non-immune pregnant women should be informed of the risk of varicella infection to themselves and their fetuses. They should be instructed to seek medical help following any contact with a person who may have been contagious (II-3B). 5.In the case of a possible exposure to varicella in a pregnant woman with unknown immune status, serum testing should be performed. If the serum results are negative or unavailable within 96 hours from exposure, varicella zoster immunoglobulin should be administered (III-C). 6.Women who develop varicella infection in pregnancy need to be made aware of the potential adverse maternal and fetal sequelae, the risk of transmission to the fetus, and the options available for prenatal diagnosis (II-3C). 7.Detailed ultrasound and appropriate follow-up is recommended for all women who develop varicella in pregnancy to screen for fetal consequences of infection (III-B). 8.Women with significant (e.g., pneumonitis) varicella infection in pregnancy should be treated with oral antiviral agents (e.g., acyclovir 800 mg 5 times daily). In cases of progression to varicella pneumonitis, maternal admission to hospital should be seriously considered. Intravenous acyclovir can be considered for severe complications in pregnancy (oral forms have poor bioavailability). The dose is usually 10 to 15 mg/kg of BW or 500 mg/m2 IV every 8 h for 5 to 10 days for varicella pneumonitis, and it should be started within 24 to 72 h of the onset of rash (III-C). 9.Neonatal health care providers should be informed of peripartum varicella exposure in order to optimize early neonatal care with varicella zoster immunoglobulin and immunization (III-C). Varicella zoster immunoglobulin should be administered to neonates whenever the onset of maternal disease is between 5 days before and 2 days after delivery (III-C).

Objective: To determine the incidence and risk factors for recurrent shoulder dystocia in women. Methods: We searched Medline, Pubmed, Embase, and CINAHL for relevant articles in English and French from 1980 to February 2018 that described risks of recurrent shoulder dystocia undergoing a trial of labour in subsequent pregnancies. A total of 684 articles were found, of which 13 were included as they met criteria. We extracted data on study characteristics, incidence of recurrent shoulder dystocia, degree of neonatal injury, and presence of known risk factors. Results: There was a wide variation in the incidence of shoulder dystocia in subsequent pregnancies from 1-25%. The largest cohort reported a risk of 13.5%. The most important risk factor for recurrent shoulder dystocia is an increase in birthweight in the subsequent pregnancy compared to the index pregnancy (OR 7-12). Prolonged second stage, instrumental delivery, maternal diabetes, increased maternal BMI, and severe neonatal morbidity in the index pregnancy were also associated with an increased risk of recurrent shoulder dystocia. However, many of these risk factors were present in women who did not have a recurrent shoulder dystocia. In addition, women with recurrent shoulder dystocia rarely had identifiable risk factors, other than the history of previous shoulder dystocia. Sample sizes were low as most studies are single centre, retrospective cohorts with low rates of subsequent pregnancy and vaginal birth as many women may have elected to have a caesarean section in subsequent pregnancies or were lost to follow up. There was a high rate of reporting bias and heterogeneity, prohibiting formal meta-analyses. Conclusion: Recurrent shoulder dystocia is an unpredictable obstetric complication with potentially devastating consequences. Individual assessment and thorough counselling should be offered to women contemplating a subsequent planned vaginal birth with specific attention paid to those women where the estimated birthweight is >4000 g or greater than in the index pregnancy.

Obesity in pregnancy has become one of the most important challenges in obstetrical care given its prevalence and potential adverse impact on both mother and fetus. The primary objective of this descriptive review is to identify common themes and distinctions within the current recommendations for maternal obesity in the most updated version of four published national guidelines.We reviewed the following guidelines for obesity in pregnancy: American College of Obstetricians and Gynecologists (ACOG) 2015, Royal Australian and New Zealand College of Obstetricians and Gynecologists (RANZCOG) 2013, Royal College of Obstetrics and Gynecology (RCOG) 2010, and Society of Obstetrics and Gynecologists of Canada (SOGC) 2010.There were no major contradictions between the guidelines, however, variations did exist. Recognition of overweight and obese populations prenatally was uniformly emphasized, so that appropriate nutrition and exercise counseling could be provided prior to pregnancy. Obesity in pregnancy was consistently defined as a body mass index of 30 kg/mIn general, the guidelines emphasized the importance of counseling women regarding the risks associated with obesity in pregnancy, and stressed the necessity of screening for these adverse outcomes. Initiatives to develop common terminology and reporting of outcomes in women's health are important for the development of cohesive and uniform recommendations for patient care. Disparities existed with respect to management strategies and where the further research and systematic reviews should be targeted, to allow clinicians to provide an appropriate obstetrical care pathway for obese women.

To assess the impact of body mass index (BMI) on the rate of cesarean section (rCS) in induction of labor (IOL).A total of 7,543 singleton term pregnancies undergoing IOL (cervical dilatation at admission, CDA ≤ 3 cm) were divided according to BMI: underweight (n = 325); normal weight (NW) (n = 4,633); overweight (OW) (n = 1,610); and obese (n = 975). Age, parity, macrosomia, gestational age (GA), gestational weight gain (GWG), CDA, and IOL indications were considered.A higher rate of macrosomia (15.0 vs. 11.1%; p 0.0001), earlier induction (GA 39.7 ± 1.3 vs. 40.1 ± 1.3 weeks; p 0.0001) for maternal indications (39.1 vs. 21.1%; p 0.001), and lower CDA (≤1cm; 66.4 vs. 61.4%; p 0.005) were observed in obese versus NW. The rate of weight gain above the recommended range was higher in obese (obese 70.6% vs. NW 43.9%; p 0.001), despite a significantly lower mean GWG compared with NW (14 ± 7.5 vs. 16.5 ± 5.6 kg; p 0.001). Compared with NW, OW and obese demonstrated a significantly higher rCS (OW 31.1% and obese 36.9% vs. NW 24.7%; p 0.001). BMI represented an independent factor affecting the rCS (vs. NW; OW odds ratio [OR] 1.4; confidence interval [CI] 1.2-1.7; p 0.001; obese OR 2.3; CI 1.9-2.7 p 0.001).In the case of IOL, obesity represents an independent factor associated with a significant increase of CS to be considered during induction counselling.

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 review the management and outcome of pregnancies of women presenting to obstetrical triage with decreased fetal movements (DFM). Study Design A retrospective review of women presenting with DFMs to two large Canadian obstetrical centres with a combined 9490 deliveries per year. The charts were reviewed for compliance with the Canadian guidelines for demographics (age, parity, GA, comorbidities, etc.), pregnancy management (admission vs. discharge, need to deliver), and pregnancy outcomes (mortality, morbidity, GA at delivery, Apgar scores, etc.). Patients who did not comply with the Canadian guidelines (requiring the patient to count six movements within two hours) were not excluded. Results The charts of 579 patients who self-reported DFMs between January 2012 and December 2012 were reviewed. The distribution of ages was between 18 and 47 year old. The majority of these patients had no comorbidities (454/579). A significant minority of patients had FM in the triage area (231/579). The Canadian guidelines were interpreted differently in the two centres. In one (level 3), the protocol was to have a biophysical profile (BPP) on all patients prior to discharge, whereas in the other (level 2), only patients with a non-reactive non-stress test (NST) and/or oligohydramnios or intrauterine growth restriction (IUGR) underwent a BPP. All patients had an evaluation by an RN and MD and had a NST on arrival. A combination of NST and BPP was performed on 235/579. The frequency of DFM was 6.1% (level 3 centre: 5.6%, level 2 centre: 7.8%). There were 8 stillbirths on arrival. The 187 patients who had a reactive NST and a normal BPP and were sent home did not have a single stillbirth within 2 weeks. In the level 3 centre, 19 patients were sent home without a BPP and one had a stillbirth within 2 days (5%); in the level 2 hospital, there was only one stillbirth among the NST-only group (0.35%). There were 65 admissions; 46 of them (71%) were delivered, and 50% of them had a Caesarean delivery (baseline around 30%). Conclusions This is the first study looking at the performance of the Canadian guidelines of 2007. We found that the DFM rate was compatible with the literature (6.1% vs. 5%). The frequency of stillbirth on arrival was 1.4% (8/579). Patients discharged after normal NST and BPP did extremely well (no stillbirths), whereas those admitted following DFM had a relatively high Caesarean delivery rate (50%). This study was not designed to address changes in stillbirth rate, but it outlines the patients who experience DFM and their eventual outcomes.

Resume Objectif Analyser les donnees existantes au sujet de l'infection au virus varicelle-zona pendant la grossesse, des interventions visant a attenuer les complications maternelles et l'infection fœtale, et de la prise en charge antepartum et peripartum. Methodes Les issues maternelles et fœtales de l'infection au virus varicelle-zona ont ete analysees, tout comme les avantages des diverses modalites de traitement pour ce qui est de la modification des sequelles maternelles et fœtales. Issues Des recherches ont ete menees dans Medline pour en tirer les articles et les directives cliniques publiees en anglais entre janvier 1970 et novembre 2010. Valeurs La qualite des resultats a ete etablie 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). Recommendations 1.L'immunisation contre la varicelle est recommandee pour toutes les femmes non immunisees, dans le cadre des soins offerts avant la grossesse et par la suite. (II-3B) 2.La vaccination contre la varicelle ne devrait pas etre administree pendant la grossesse. Toutefois, l'interruption de grossesse ne devrait pas etre recommandee a la suite d'une vaccination par inadvertance au cours de la grossesse. (II-3D) 3.Chez toutes les femmes enceintes, le statut immunitaire prenatal quant a la varicelle devrait etre documente par la determination des antecedents en matiere d'infections, de vaccination contre la varicelle ou de serologie visant l'immunoglobuline G varicelle-zona. (III-C) 4.Toutes les femmes enceintes non immunisees devraient etre avisees du risque que constitue l'infection a la varicelle pour elles et leurs foetus. Elles devraient etre avisees d'obtenir une aide medicale a la suite de tout contact avec une personne qui pourrait avoir ete contagieuse. (II-3B) 5.Dans le cas d'une possible exposition a la varicelle chez une femme enceinte dont le statut immunitaire est inconnu, un depistage serique devrait etre mene. Lorsque les resultats de l'analyse serique sont negatifs ou ne peuvent etre obtenus dans les 96 heures de l'exposition, de l'immunoglobuline varicelle-zona devrait etre administree. (III-C) 6.Les femmes qui en viennent a presenter une infection a la varicelle pendant la grossesse doivent etre avisees des sequelles maternelles et foetales indesirables potentielles, du risque de transmission au foetus et des options disponibles en ce qui concerne le diagnostic prenatal. (II-3C) 7.L'obtention d'une echographie detaillee et la mise en oeuvre d'un suivi approprie sont recommandes pour toutes les femmes qui contractent la varicelle pendant la grossesse, et ce, afin de chercher a depister les consequences foetales de l'infection. (III-B) 8.Les femmes qui presentent une infection significative a la varicelle (p. ex. pneumonite) pendant la grossesse devrait etre traitees au moyen d'antiviraux administres par voie orale (p. ex. acyclovir, a raison de 800 mg cinq fois par jour). Dans les cas ou l'infection en vient a donner lieu a une pneumonite varicelleuse, l'hospitalisation de la mere devrait etre serieusement envisagee. L'administration d'acyclovir par voie intraveineuse peut etre envisagee en presence de complications graves pendant la grossesse (les formes orales presentent une faible biodisponibilite). Pour ce qui est de la pneumonite varicelleuse, la dose est habituellement de 10 a 15 mg/kg de poids corporel ou de 500 mg/m2 par voie IV toutes les 8 h pendant de 5 a 10 jours; ce traitement devrait etre entame dans les 24 a 72 h de l'apparition du rash. (III-C) 9.Les fournisseurs de soins neonataux devraient etre avises de l'exposition peripartum a la varicelle de facon a pouvoir optimiser, au moyen d'immunoglobuline varicelle-zona et d'une immunisation, les soins offerts aux debuts de la periode neonatale. (III-C) De l'immunoglobuline varicelle-zona devrait etre administree aux nouveau-nes lorsque la maladie apparait chez la mere entre 5 jours avant l'accouchement et 2 jours par la suite. (III-C)

Operative vaginal delivery is defined as a procedure performed in the final part of the second stage of labor in which the operator uses either forceps or a vacuum device to promote the extraction of the fetus from the birth canal. The goal of operative vaginal delivery is to facilitate vaginal birth, hence speeding up delivery with a minimum of maternal or neonatal morbidity (Keriakos et al. J Obstet Gynaecol 33(8):781–786, 2013).

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).

Risk factors related to obstetric anal sphincter injuries (OASIS) are known for singleton deliveries. No study to date has described the rate and risk factors involved in twin deliveries. We conducted a retrospective cohort study (1985–2010) of all vaginal twin and singleton deliveries in a single tertiary center. The adjusted odds ratio (OR) for OASIS at delivery was estimated using the logistic regression model. The study comprised 1,538 and 91,312 patients with vaginal twin and singleton delivery, respectively. Twenty twin (1.27 %) and 2,331 (2.55 %) singleton deliveries were complicated with OASIS. The following OASIS-associated risk factors were shared by both populations: nulliparity [twins adjusted OR 5.9, 95 % confidence interval (CI) 1.7–20.9; singletons adjusted OR 3.9, 95 % CI 3.5–4.4), occipitoposterior (OP) position (twins adjusted OR 3.00, 95 % CI 1.1–8.0; singletons adjusted OR 1.6, 95 % CI 1.3–2.00), birthweight (for each 100 g) (twin adjusted OR 1.1, 95 % CI 1.0–1.2; singletons adjusted OR 1.07, 95 % CI 1.06–1.08), and instrumental delivery (twins adjusted OR 4.3, 95 % CI 1.2–15.4, singletons adjusted OR 2.4, 95 % CI 2.2–2.6). Risk factors of nulliparity, OP position, large fetal size, and instrumental delivery were shared by both twin and singleton deliveries. These data will be useful in counselling women carrying twins who intend to deliver vaginally.

Objective: The primary goal of this study was to determine the ultrasonographic signs of asynclitic and transverse head positioning. In addition, we compared the performance of intrapartum ultrasound to vaginal digital examination. Material & Methods: 150 women were evaluated by 2D transabdominal and translabial ultrasound (US) to detect the asynclitic and deep transverse positions. Transvaginal sterile digital examinations were performed immediately after each intrapartum US assessments, the examinations were repeated at intervals of 45–90 minutes. Examiners were blinded to each other’s findings (clinical or sonographic). Data were reviewed and analyzed by an independent reviewer. Results: The efficacy of digital examination was significantly lower than US evaluation for the detection of either transverse position or asynclitism. The most frequent transverse position was the left one, while the most frequent asynclitism was the anterior one. Conclusions: Digital pelvic examination for detection of fetal head transverse position during labor is inferior to US, especially in the deep transverse positioning, where caput succedaneum occurs and reduces the diagnostic accuracy of vaginal digital examination. The US examination leads to early detection of persistent transverse position allowing for earlier timing and optimal technique for the operative vaginal delivery. We describe two signs for diagnosing asynclitism. The “squint sign” and the “sunset of thalamus and cerebellum signs” are two simple US signs allowing detection of anterior and posterior asynclitism.

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.

Please cite this paper as: Sword W, Kurtz Landy C, Thabane L, Watt S, Krueger P, Farine D, Foster G. Is mode of delivery associated with postpartum depression at 6 weeks: a prospective cohort study. BJOG 2011;118:966–977. Objective To examine the relationship between delivery mode and postpartum depression at 6 weeks following hospital discharge. Design A prospective cohort study. Setting Eleven hospitals in Ontario, Canada. Sample A total of 2560 women ≥16 years of age who delivered singleton, live infants at term. Methods Women completed a questionnaire in hospital and 74% (n = 1897) participated in a structured telephone interview 6 weeks after discharge. Additional data were extracted from labour and delivery records. Generalised estimating equations (GEEs) were used to investigate factors associated with postpartum depression. Main outcome measure Women were screened for depression at 6 weeks following hospital discharge using the Edinburgh Postnatal Depression Scale (EPDS). A score of ≥12 on the EPDS was used as a measure of the primary outcome, depression. Results Mode of delivery was not independently associated with postpartum depression, and did not factor into the main-effects model. The multivariable analysis identified 11 predictor variables for depression: young maternal age (OR 5.27; 95% CI 2.73–10.15); maternal hospital readmission (OR 3.02; 95% CI 1.46–6.24); non-initiation of breastfeeding (OR 2.02; 95% CI 0.99–4.11); good, fair, or poor self-reported postpartum health (OR 1.82; 95% CI 1.19–2.80); urinary incontinence (OR 1.79; 95% CI 1.06–3.03); multiparity (OR 1.59; 95% CI 1.22–2.08); low mental health functioning (OR 1.20; 95% CI 1.15–1.25); low subjective social status (OR 1.16; 95% CI 1.02–1.33); high number of unmet learning needs in hospital (OR 1.12; 95% CI 1.03–1.22); low social support (OR 1.06; 95% CI 1.03–1.09); and low physical health functioning (OR 1.03; 95% CI 1.003–1.055). An exploratory interaction model revealed that caesarean section was associated with higher odds of becoming depressed in Canadian-born women, but that in women born outside of Canada it was associated with a lower risk of becoming depressed. Conclusions Delivery mode had no significant impact on the development of postpartum depression in the main-effects model. However, it may interact with place of birth and other unmeasured factors to create a risk for depression.

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)

Objective To review the evidence and provide recommendations for the counselling and management of obese parturients. Outcomes Outcomes evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. Evidence Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. 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 Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Benefits, Harms, and Costs Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible.