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Objectif: La présente directive clinique aborde les aspects essentiels des soins prénataux chez les femmes atteintes d'obésité. La partie 1 porte sur la préconception et les soins prénataux. La partie 2 porte sur la planification en équipe de l'accouchement et les soins post-partum. UTILISATEURS CONCERNéS: Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières, anesthésiologistes) qui prodiguent des soins relatifs à la grossesse auprès de femmes atteintes d'obésité., Population Cible: Femmes atteintes d'obésité qui sont enceintes ou prévoient le devenir. DONNéES PROBANTES: Des recherches ont été menées en consultant les ressources de Statistique Canada, de Medline et de Cochrane Library en vue d'en tirer la littérature relativement aux effets de l'obésité durant la grossesse sur les soins prénataux et intrapartum, la morbidité et la mortalité maternelles, l'anesthésie obstétricale ainsi que sur la morbidité et la mortalité périnatales. Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. Aucune restriction de date ou de langue n'a été employée. Les recherches ont été mises à jour régulièrement, et les résultats ont été incorporés à la directive clinique jusqu'en septembre 2018. Nous avons également tenu compte de la littérature grise (non publiée) obtenue sur les sites Web d'organismes d'évaluation des technologies de la santé et d'autres organismes pertinents, dans des collections de directives cliniques et des registres d'essais cliniques, et auprès d'associations nationales et internationales de médecins spécialistes. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs. Les membres du comité de médecine fœto-maternelle ont ensuite passé en revue le contenu et formulé des commentaires aux fins d'examen. Enfin, le conseil d'administration de la Société des obstétriciens et gynécologues du Canada (SOGC) a approuvé la publication de la version définitive de la directive. Les points de désaccord ont été abordés lors de réunions pour enfin arriver à un consensus. La qualité des données et des recommandations a été déterminée à l'aide des critères d'évaluation décrits par le Groupe d'étude canadien sur les soins de santé préventifs. AVANTAGES, PRéJUDICE ET COûTS: La mise en place des recommandations des présentes directives peut améliorer la reconnaissance des fournisseurs de soins obstétricaux relativement aux problèmes qui touchent les personnes enceintes atteintes d'obésité, notamment au moyen de stratégies de prévention clinique; de la communication entre l'équipe de soins de santé, la patiente et la famille; et de la planification de l'équipement et des ressources humaines. Il est à espérer que les organismes régionaux, provinciaux et fédéraux participeront à la formation et au soutien en matière de soins coordonnés pour les personnes enceintes atteintes d'obésité. MISE à JOUR DE LA DIRECTIVE CLINIQUE: Les directives de la SOGC sont automatiquement passées en revue 5 ans après leur publication. Les auteurs peuvent toutefois proposer une autre date de réévaluation s'ils croient qu'une période de 5 ans est trop courte ou trop longue en fonction de leurs connaissances du sujet à titre d'experts en la matière., Promoteurs: La présente directive a été élaborée à l'aide de ressources financées par la SOGC. DéCLARATIONS SOMMAIRES: RECOMMANDATIONS., (Copyright © 2019. Published by Elsevier Inc.)

Objective: This guideline will review key aspects in the pregnancy care of women with obesity. Part I will focus on pre-conception and pregnancy care. Part II will focus on team planning for delivery and Postpartum Care., Intended Users: All health care providers (obstetricians, family doctors, midwives, nurses, anaesthesiologists) who provide pregnancy-related care to women with obesity., Target Population: Women with obesity who are pregnant or planning pregnancies., 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 September 2018. Grey (unpublished) literature was identified through searching the websites of health technology assessment and related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies., Validation Methods: The content and recommendations were drafted and agreed upon by the authors. Then the Maternal-Fetal Medicine Committee peer reviewed the content and submitted comments for consideration, and the Board of the Society of Obstetricians and Gynaecologists of Canada (SOGC) approved the final draft for publication. Areas of disagreement were discussed during meetings, at which time consensus was reached. The level of evidence and quality of the recommendation made were described using the Evaluation of Evidence criteria of the Canadian Task Force on Preventive Health Care., Benefits, Harms, and Costs: Implementation of the recommendations in these guidelines may increase obstetrical provider recognition of the issues affected pregnant individuals with obesity, including clinical prevention strategies, communication between the health care team, the patient and family as well as equipment and human resource planning. It is hoped that regional, provincial and federal agencies will assist in the education and support of coordinated care for pregnant individuals with obesity., Guideline Update: SOGC guidelines will be automatically reviewed 5 years after publication. However, authors can propose another review date if they feel that 5 years is too short/long based on their expert knowledge of the subject matter., Sponsors: This guideline was developed with resources funded by the SOGC., Summary Statements: RECOMMENDATIONS., (Copyright © 2019 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Objective: To explore inadequate and excessive gestational weight gain (GWG) among pregnant women of different racial/ethnic backgrounds in Ontario, Canada., Methods: A population-based retrospective cohort study was conducted among women who had prenatal screening and had a singleton birth in an Ontario hospital between April 2016 and March 2017. We estimated adjusted risk ratios (aRR) of racial/ethnic differences for inadequate or excessive GWG using multinomial logistic regression models. Interaction effects were examined to determine whether racial/ethnic difference in GWG varied by pre-pregnancy body mass index (BMI)., Results: Among 74,424 women, the prevalence of inadequate GWG in White, Asian, and Black women was 15.7%, 25.8%, and 25.0%, and excessive GWG was 62.8%, 45.5%, and 54.7%, respectively. There were significant interaction effects between race/ethnicity and pre-pregnancy BMI for inadequate GWG (Wald p < 0.01) and excessive GWG (Wald p < 0.01). Compared with White women, Asian women had higher risk of inadequate GWG and lower risk of excessive GWG in all weight classes, and Black women had higher risk of inadequate GWG and lower risk of excessive GWG if their BMI was normal, overweight, or obese., Conclusion: Variations in unhealthy GWG by pre-pregnancy weight classes among Ontario White, Asian and Black women were observed. Individualized counseling regarding appropriate GWG is universally recommended. Additional consideration of racial/ethnic variations by maternal weight classes may help to promote healthy GWG in Canada.

Background: Hydralazine, labetalol, and nifedipine are the recommended first-line treatments for severe hypertension in pregnancy. While all three are effective, there is a lack of sufficient evidence regarding their comparative safety and efficacy., Objective: To determine the comparative safety and efficacy of the first-line treatment options for severe hypertension in pregnancy., Methods: A systematic search of Medline, Embase, and Cochrane Central Register of Controlled Trials up to May 31, 2018 was conducted. RCTs in pregnancy comparing a first-line antihypertensive agent to another first-line agent for the treatment of severe hypertension in pregnancy. Screening, data abstraction, and quality assessment were done by two independent reviewers. To estimate relative effects from all available evidence, a Bayesian network meta-analysis with vague priors was conducted., Main Results: Of the 1330 publications identified, 17 RCTs comprised of a total of 1591 women met our selection criteria. For successful treatment of severe hypertension, nifedipine was found to be superior to hydralazine (OR 4.13 [95% CrI 1.01-20.75]) but not labetalol (OR 3.43 [95% CrI 0.94-19.95]). This was not associated with an increased risk for caesarean delivery or maternal side effects. There was no significant difference between labetalol and hydralazine., Conclusions: Given the results of this systematic review and network meta-analysis, maternity care providers should feel comfortable initiating management of severe hypertension in pregnancy using oral nifedipine., (Copyright © 2019 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Obesity is common in women of childbearing age, and management of this population around the time of pregnancy involves specific challenges. Weight and medical comorbidities should be optimized both before and during pregnancy. During pregnancy, gestational weight gain should be limited, comorbidities should be appropriately screened for and managed, and fetal health should be monitored. Consideration should be given to the optimal timing of delivery and to reducing surgical and anesthetic complications. In the postpartum period, breastfeeding and weight loss should be promoted. Maternal obesity is associated with adverse metabolic effects in offspring, promoting an intergenerational cycle of obesity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objective: Atonic postpartum hemorrhage rates have increased in many industrialized countries in recent years. We examined the blood loss, risk factors, and management of the third stage of labour associated with atonic postpartum hemorrhage., Methods: We carried out a case-control study of patients in eight tertiary care hospitals in Canada between January 2011 and December 2013. Cases were defined as women with a diagnosis of atonic postpartum hemorrhage, and controls (without postpartum hemorrhage) were matched with cases by hospital and date of delivery. Estimated blood loss, risk factors, and management of the third stage labour were compared between cases and controls. Conditional logistic regression was used to adjust for confounding., Results: The study included 383 cases and 383 controls. Cases had significantly higher mean estimated blood loss than controls. However, 16.7% of cases who delivered vaginally and 34.1% of cases who delivered by Caesarean section (CS) had a blood loss of < 500 mL and < 1000 mL, respectively; 8.2% of controls who delivered vaginally and 6.7% of controls who delivered by CS had blood loss consistent with a diagnosis of postpartum hemorrhage. Factors associated with atonic postpartum hemorrhage included known protective factors (e.g., delivery by CS) and risk factors (e.g., nulliparity, vaginal birth after CS). Uterotonic use was more common in cases than in controls (97.6% vs. 92.9%, P < 0.001). Delayed cord clamping was only used among those who delivered vaginally (7.7% cases vs. 14.6% controls, P = 0.06)., Conclusion: There is substantial misclassification in the diagnosis of atonic postpartum hemorrhage, and this could potentially explain the observed temporal increase in postpartum hemorrhage rates., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the impact of search strategies for a different language on systematic review results, using English index searches versus Chinese index searches for Chinese literature pertaining to cerebral palsy (CP) as an example., Methods: We conducted two parallel searches with the same search strategy. Both searches looked for studies published in the Chinese language that examined risk factors for CP. The first was conducted in standard English indexes and the second was in standard Chinese indexes. We compared the results using the two searches using a Z-test. Egger's test and Begg's test were used to assess the potential publication bias., Results: Using the English indexes, nine studies were identified. Using the identical search and inclusion/exclusion criteria in the Chinese indexes, 17 studies were returned. The association between intracranial hemorrhage and CP was much stronger in the studies found in the search by the English indexes (odds ratio [OR] 61.73, 95% confidence interval (CI) 19.48-195.61) than the results from studies identified by the Chinese indexes (OR 9.57, 95% CI 2.42-37.88). The association between hypertension and CP was not significant in studies found using the English indexes (OR 1.67, 95% CI 0.34-8.30) but was significant in studies identified by searching the Chinese indexes (OR 2.25, 95% CI 1.06-4.77). Egger's test suggested that, for the risk factor of preterm birth, some small studies with negative results might have been missed by the search using the English indexes (Egger's test: P = 0.00)., Conclusions: Searching Chinese literature using English indexes has the potential to fail to identify a substantial number of publications. This bias can result in significant discrepancies in the pooled estimates of risk factors for CP., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: To examine the combined effect of macrosomia and maternal obesity on adverse pregnancy outcomes using a retrospective cohort., Methods: Infants with a birth weight of ≥ 4000g (macrosomia) were identified from an institutional birth cohort. Demographic characteristics and maternal, fetal, neonatal, and pregnancy outcomes of macrosomic infants whose mothers were obese were compared with those whose mothers were non-obese., Results: Pregnancies in obese women resulting in macrosomic infants are more likely to be complicated by gestational diabetes, gestational hypertension, and smoking than pregnancies in non-obese women with macrosomic infants. Mothers whose infants are macrosomic are significantly more likely to require induction of labour (OR 1.42; 95% CI 1.10 to 1.98) and delivery by Caesarean section (OR 1.45; 95% CI 1.04 to 2.01), particularly for maternal indications (OR 3.7; 95% CI 1.47 to 9.34), if they are obese. Finally, macrosomic infants of obese mothers are significantly more likely to require neonatal resuscitation in the form of free flow oxygen (OR 1.57; 95% CI 1.03 to 2.42) than macrosomic infants of non-obese mothers., Conclusion: When both maternal obesity and macrosomia are present, adverse pregnancy outcomes are more common than when fetal macrosomia occurs in a woman of normal weight.

Objective: Maternity care providers can use pre-pregnancy weight (PPW) and gestational weight gain (GWG) as markers for difficult delivery, and frequently obtain this information directly from the patient. The goal of this study was to determine whether women report their PPW and GWG correctly at the end of pregnancy., Methods: We performed a prospective cohort study of 189 women delivering between June 1, 2011, and July 31, 2011, at the Saint John Regional Hospital or the Moncton Hospital in New Brunswick. Self- reported PPW and GWG were compared with measured weights obtained from the antenatal chart and upon presentation for delivery. Patient characteristics, BMI classification, and accuracy and degree of error in recall were assessed., Results: The majority of respondents were under 30 years of age (63.4%) and were delivering at term (96.3%). Ninety women (47.6%) were having their first baby. A record of weight measured in the first trimester was available for 98 respondents (51.9%); using this information, 44 women (44.9%) were determined to be overweight or obese at delivery. Approximately one third of women with a normal BMI were not able to recall their PPW or GWG accurately (± 1 kg). Among all BMI classes, there was a consistent pattern of under-reporting of PPW (by a mean of 1.52 kg) and over-reporting of GWG (by a mean of 1.61 kg), but several extreme outliers were identified., Conclusion: At the time of delivery, under-reporting of PPW and over-reporting of GWG are common and difficult to predict. Maternity care providers should be aware of this discrepant reporting of PPW and GWG and recognize the implications for intrapartum management and postpartum weight loss.

Objective: Nationally, rates of obesity continue to rise, resulting in increased health concerns for women of reproductive age. Identifying the impact of maternal obesity on obstetrical outcomes is important to enhance patient care., Methods: We conducted a retrospective cohort study of 6674 women who delivered a singleton infant at ≥ 20 weeks' gestation between December 1, 2007, and March 31, 2010, at The Ottawa Hospital. Maternal pre-pregnancy BMI was used to classify women into normal, overweight, and obese (class I/II/III) categories according to WHO classifications. Obstetrical outcomes among obese women were compared with those of women with normal BMI. Multivariable regression models were used to determine adjusted odds ratios and 95% confidence intervals., Results: Compared with women with normal BMI, obese women had significantly higher rates of preeclampsia, gestational hypertension, and gestational diabetes, and these rates increased with increasing BMI (trend-test P < 0.001). There was a significant increase in rates of induction of labour in the obesity categories, from 25.3% in women with normal BMI to 42.9% in women with class III morbid obesity (aOR 1.67; 95% CI 1.43 to 1.93). Rates of primary Caesarean section rose with increasing BMI and were highest in women with class III morbid obesity (36.2% vs. 22.1% in women with normal BMI) (aOR 1.46; 95% CI 1.23 to 1.73)., Conclusion: Increasing BMI is associated with increasing rates of preeclampsia, gestational hypertension, and gestational diabetes. There is a significant increase in rates of induction of labour with increasing obesity class, and a significantly increased Caesarean section rate with higher BMI. Obstetrical care providers should counsel obese patients about the risks they face and the importance of weight loss before pregnancy.