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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.

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 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.

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.

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.

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).

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.

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 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.

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).

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.

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)

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

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).

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 objective of this study was to evaluate associations between adverse outcomes in twin pregnancies and preterm prelabour rupture of membranes (PPROM). A chart review of 246 consecutive twin pregnancies with confirmed PPROM was conducted. Regression analysis (beta [natural log of the odds ratio] and odds ratio [OR]) was performed to identify independent predictors. Two hundred and forty-six twin pregnancies, 492 liveborns, and 20 neonatal deaths. Mean (SD) PPROM gestational age (GA): 31.3 (3.8) wk; delivery GA: 32.0 (3.3) wk. PPROM < 30 wk was associated with increased parity (OR: 2.66), and log (admission leukocyte count) (OR: 9.99). Shortened latency was associated with PPROM GA (beta = -0.17) and chorioamnionitis (beta = 0.95). Neonatal sepsis was predicted by lower delivery GA (OR: 2.04). Adverse perinatal outcomes were protected against by older GA at PPROM (OR 0.53) and shortened latency (OR 0.73). It was concluded that increased leukocytosis and parity implies an infectious aetiology in earlier PPROM. Increased risk for neonatal sepsis at earlier delivery GA is consistent with gestation-dependent fetal immunocompetence. Early PPROM and long latencies were associated with increased adverse perinatal outcomes.

Objective We sought to determine the interventions utilized by maternal-fetal medicine specialists in the prediction and prevention of preterm labor in higher-order multiple (HOM) gestations. Study Design Online questionnaires and email surveys were sent to all the maternal-fetal medicine specialists in Canada (n = 122). Questionnaire items included interventions physicians routinely recommended for HOM gestations including: (1) bed rest; (2) cervical length measurement on transvaginal ultrasound; (3) corticosteroids use; (4) cerclage; and (5) tocolytic therapy. Results Response rate was 66% (81/122), with 68% of respondents in practice for >10 years. Of physicians, 91% did not routinely recommend bed rest (95% confidence interval [CI], 84.7–97.2). In all, 82% (95% CI, 73.63–90.4%) recommended routine cervical length assessment with 32.3% (95% CI, 20.7–43.2) and 37.1% (95% CI, 25.3–48.6) of this group suggesting assessment at 16-18 and 19-21 weeks, respectively. Frequency of assessment varied from biweekly (53.3%; 95% CI, 40.9–65.0), to monthly (23.3%; 95% CI, 12.8–33.1), to a single measurement repeated only if abnormal (12.5%; 95% CI, 4.5–20.8). In all, 28% (95% CI, 18.2–37.8) recommended routine administration of corticosteroids for lung maturation. Timing of administration varied, with 24% initiating steroids between 24-26 weeks, 59% between 27-28 weeks, and 17% after 28 weeks. None reported routine cerclage placement. However, 71% (95% CI, 61.1–80.8) would perform cerclage based on history or ultrasound. Of respondents, 81% (95% CI, 72.4–89.5) would consider using tocolytic agents for threatened preterm labor including calcium channel blockers (94%), nonsteroidal antiinflammatory drugs (5%), and nitroglycerin transdermal patch (24%). Conclusion The variable practice guidelines and paucity of data for management of HOM pregnancy places the onus on individual practitioners to develop their own management schemes. This results in heterogeneous management, which is based on conflicting international guidelines, studies, expert opinion, or past experience.

Purpose We evaluated the role of umbilical artery Doppler velocimetry in the surveillance of pregnancies complicated by systemic lupus erythematosus (SLE). Methods We retrospectively studied 56 women with SLE whose pregnancies were managed at our perinatal center between 1988 and 1995. Results Absent or reversed end-diastolic flow velocity was detected in 6 (11%) of 56 patients. This subgroup of patients had an increased risk of pre-eclampsia, intrauterine growth restriction, cesarean section, and preterm delivery. Conclusions A high incidence (11%) of abnormal umbilical artery waveforms was detected. This finding was associated with an increased risk of maternal and fetal complications. © 1998 John Wiley & Sons, Inc. J Clin Ultrasound 26:379–382, 1998.