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ObjectiveHuman papillomavirus (HPV) has been associated with adverse pregnancy outcomes but placental HPV infection has been rarely studied. The objective was to determine the proportion of HPV-positive placentas and the associated risk factors among HPV-positive women during pregnancy.MethodsWe analysed data from pregnant women enrolled in HERITAGE cohort study between 2010 and 2016 with positive vaginal HPV infection during the first trimester of pregnancy (n=354). Placental swabs and biopsies were collected. HPV genotyping was performed using Linear Array. The predictors of placental HPV detection were identified by generalised estimating equations models.ResultsHPV was detected in 78 placentas (22.0%) (one among 96 caesarean sections and 77 among 258 vaginal deliveries). Overall, 91% of HPV-positive placentas were positive for a genotype that was detected in vaginal samples during pregnancy. Among women who delivered vaginally, abnormal cytology (adjusted OR (aOR) 1.78 (95% CI 1.02 to 3.10)), other genitourinary infection (aOR 2.41 (95% CI 1.31 to 4.44)), presence of multiple HPV genotypes in the first trimester (aOR 2.69 (95% CI 1.76 to 4.12)) and persistence of high-risk HPV infections during pregnancy (HPV-16/18: aOR 3.94 (95% CI 2.06 to 7.55) and other than HPV-16/18: aOR 2.06 (95% CI 1.05 to 4.02)) were independently associated with placental HPV.ConclusionsHPV was frequently detected in the placenta of women who delivered vaginally and may be associated with host immune response characteristics.

Key Points Question Is human papillomavirus (HPV) infection during pregnancy associated with preterm delivery? Findings In this multicenter cohort study of 899 pregnant women, persistent HPV-16/18 infection during pregnancy was significantly associated with preterm birth. Meaning If the identified association between HPV infection during pregnancy and preterm delivery is causal, HPV vaccination may reduce preterm birth and the associated burden., Importance Preterm birth remains a leading cause of perinatal mortality and lifelong morbidity worldwide. The cause of most preterm births is unknown, although several infectious processes have been implicated. Objective To assess whether human papillomavirus (HPV) infection, a frequent infection among women of childbearing age, is associated with preterm birth. Design, Setting, and Participants The prospective HERITAGE cohort study was conducted at 3 academic hospitals in Montreal, Québec, Canada, among 899 pregnant women recruited between November 8, 2010, and October 16, 2016. Follow-up was completed on June 15, 2017. Statistical analysis was conducted from February 6, 2020, to January 21, 2021. Exposures Vaginal HPV DNA detection in the first and third trimesters of pregnancy and placental HPV infection. Main Outcomes and Measures The main outcome was preterm birth (defined as a live birth or stillbirth between 20 weeks and 0 days and 36 weeks and 6 days of gestation). The association between HPV DNA detection and preterm birth was measured using logistic regression. Odds ratios (ORs) and 95% CIs were adjusted by inverse probability of treatment weights of the propensity score. Results The study included 899 women (mean [SD] age, 31.3 [4.6] years [range, 19-47 years]) with singleton pregnancies. A total of 378 women (42.0%) had HPV DNA detected in vaginal samples collected during the first trimester, and it was detected in 91 of 819 placentas (11.1%) at delivery. Fifty-five participants experienced preterm birth (38 spontaneous and 17 medically indicated). Persistent vaginal HPV-16/18 detection was significantly associated with all preterm births (adjusted OR [aOR], 3.72; 95% CI, 1.47-9.39) and spontaneous preterm births (aOR, 3.32; 95% CI, 1.13-9.80), as was placental HPV infection (all preterm births: aOR, 2.53; 95% CI, 1.06-6.03; spontaneous preterm births: aOR, 2.92; 95% CI, 1.09-7.81). Results were similar when restricting the analysis to participants without a history of cervical intraepithelial neoplasia treatment. Conclusions and Relevance The study’s results suggest that persistent HPV-16/18 infection is associated with an increased risk of preterm birth, independent of cervical treatment. Future studies should investigate the association of HPV vaccination and vaccination programs with the risk of preterm birth., This cohort study assesses whether human papillomavirus infection, a frequent infection among women of childbearing age, is associated with preterm birth.

Objectives: COVID-19 has forced a transformation in continuing professional development (CPD), shifting to virtual platforms. We report the results of a rapidly-implemented COVID-19 online interdisciplinary CPD webinar series. We aimed to determine if this virtual approach for large-scale CPD was relevant, appreciated, and effective for specialist physicians in Quebec.Methods and Analysis: This was a retrospective descriptive online survey-based study. The weekly virtual educational webinars took place between March 3, 2020 to June 15, 2020, resulting in a total of 26 webinars over 16 weeks. The study included all individuals who attended any of the webinar sessions, namely specialist physicians and department chiefs. Number of participants and overall appreciation of webinar sessions were data points collected.Results: Across all webinars, there were 8,500 unique specialist physicians which comprises 80.7% of the entire specialist practicing population in Quebec. Of note, every medical and surgical specialty was represented by attendance in at least one session. In total, 27,504 evaluation forms were completed out of all the sessions, meaning a 78.4% response rate. In post-webinar surveys, 97.6% of respondents agreed or strongly agreed that the webinars were pertinent to their practice and 94.6% agreed or strongly agreed that the presentation met their continuing professional needs.Conclusions: This novel interdisciplinary COVID-19 webinar series is a successful and appreciated strategy to maintain CPD amidst a global pandemic. One year later, it has become a mainstay in our toolbox and we trust this unique model of large-scale interdisciplinary CPD via webinar sessions is useful in normal times as well as in times of crisis.

Perinatal route of transmission of human papillomavirus (HPV) has been demonstrated in several small studies. We designed a large prospective cohort study (HERITAGE) to better understand perinatal HPV. The objective of this article is to present the study design and preliminary data. In the first phase of the study, we recruited 167 women in Montreal, Canada, during the first trimester of pregnancy. An additional 850 are currently being recruited in the ongoing phase. Cervicovaginal samples were obtained from mothers in the first trimester and tested for HPV DNA from 36 mucosal genotypes (and repeated in the third trimester for HPV-positive mothers). Placental samples were also taken for HPV DNA testing. Conjunctival, oral, pharyngeal and genital samples were collected for HPV DNA testing in children of HPV-positive mothers at every 3–6 months from birth until 2 years of age. Blood samples were collected in mother and children for HPV serology testing. We found a high prevalence of HPV in pregnant women (45%[95%CI:37–53%]) and in placentas (14%[8–21%]). The proportion of HPV positivity (any site) among children at birth/3-months was 11%[5–22%]. HPV was detected in children in multiple sites including the conjunctiva (5%[10–14%]). The ongoing HERITAGE cohort will help provide a better understanding of perinatal HPV. Keywords: Human papillomavirus (HPV), Perinatal transmission, Pregnancy, Placenta, Children, Persistence

Objective To analyze the clinical, hormonal, anatomical, and molecular characteristics of Leydig cell tumors, a very rare cause of progressive hyperandrogenism in children. Study design Description of a 9-year-old boy with isosexual precocious pseudopuberty, and of a 12-year-old girl with rapidly progressive virilization, both due to a pure Leydig cell tumor. Review of all cases of pediatric Leydig cell tumors published since 1999 (when the first somatic mutations of the luteinizing hormone receptor were described) and reporting hormonal and/or molecular data. Results Boys (n = 24) are younger than girls (n = 12) at diagnosis (median 6.5 vs 13.0 years, P = .04). Plasma gonadotrophins are more often completely suppressed in boys (6 cases) than in girls (2 cases). Pure Leydig cell tumors are exceedingly rare in girls (2 cases), who most often have Sertoli-Leydig tumors. These tumors affect either testis equally (11 left, 13 right) but occur more often in the left ovary (8 left, 3 right). Activating mutations of the alpha-subunit of the G s stimulatory protein have not been found in either boys or girls and activating mutations of the luteinizing hormone receptor have only been found in boys. Conclusions Leydig cell tumors in children display clinical, hormonal, anatomical, and molecular sexual dimorphism.

Familial recurrence risks are poorly understood in cases of de novo mutations. In the event of parental germ line mosaicism, recurrence risks can be higher than generally appreciated, with implications for genetic counseling and clinical practice. In the course of treating a female with pubertal delay and hypergonadotropic hypogonadism, we identified a new missense mutation in the SRY gene, leading to somatic feminization of this karyotypically normal XY individual. We tested a younger sister despite a normal onset of puberty, who also possessed an XY karyotype and the same SRY mutation. Imaging studies in the sister revealed an ovarian tumor, which was removed. DNA from the father's blood possessed the wild type SRY sequence, and paternity testing was consistent with the given family structure. A brother was 46, XY with a wild type SRY sequence strongly suggesting paternal Y-chromosome germline mosaicism for the mutation. In disorders of sexual development (DSDs), early diagnosis is critical for optimal psychological development of the affected patients. In this case, preventive karyotypic screening allowed early diagnosis of a gonadal tumor in the sibling prior to the age of normal puberty. Our results suggest that cytological or molecular diagnosis should be applied for siblings of an affected DSD individual.

Hypothyroidism was documented by cordocentesis at 19 weeks in a fetus with non-immune goiter. Intra-amniotic thyroxine was injected at 25 weeks when amniotic fluid volume increased. Psychomotor outcome was normal. We argue that intra-amniotic thyroxine should not be used to treat the hypothyroidism but only to correct the development of polyhydramnios.

Background In the fall of 2007, the controversy about the contraceptive use of depot-medroxyprogesterone acetate (DMPA) and its potential impact on skeletal health reached the media in the province of Quebec, Canada, thereby becoming a matter of concern for the lay public and physicians. In order to discuss this subject openly, the National Institute of Public Health of Quebec (INSPQ) organized a scientific meeting on February 15, 2008, with targeted physicians delegated by their medical associations in the fields of general practice, obstetrics and gynaecology, rheumatology, orthopaedic surgery, physiatry and endocrinology. Study Design Participants reviewed the scientific literature using the study classification method according to the level of evidence, reviewed published guidelines of medical societies and organizations on the subject and reached a consensus position. This manuscript presents a review of the literature and describes the consensus position of the targeted medical associations. Results The consensus position adopted by all the targeted medical associations determined that DMPA was a cost-effective contraceptive option that must be considered in the light of the clinical situation and preference of each woman. Candidates for injectable contraception should be informed that the use of DMPA is associated with a slight decrease in bone mineral density (BMD), which is largely, if not completely, reversible. There should not be an absolute limit to the length of time that the DMPA contraceptive is used, regardless of the woman's age. Monitoring BMD is not recommended among users of DMPA for contraceptive purposes. Finally, the consensus statement declared that, although supplements of calcium and vitamin D are beneficial for skeletal health for women in general, such supplementation should not be recommended solely based on a woman's use of DMPA. Conclusion Given the scientific evidences, DMPA use remains a valid contraceptive option for women. Its potential impact on BMD must be balanced against the significant individual, familial and social consequences of unintended pregnancy.

OBJECTIVES. Our goals were to (a) describe neonatal behavioral signs in a group of newborns exposed in utero to selective serotonin reuptake inhibitors or venlafaxine at the time of delivery, (b) compare the rate of neonatal behavioral signs, prematurity, and admission to specialized neonatal care between a group of exposed and unexposed newborns, and (c) compare the effects in exposed preterm and term newborns. PATIENTS AND METHODS. This was a retrospective cohort study including mothers taking selective serotonin reuptake inhibitors or venlafaxine during the third trimester and mothers who were not taking any antidepressants, psychotropic agents, or benzodiazepines at the time of delivery of their newborns. Neonatal behavioral signs included central nervous, respiratory, and digestive systems, as well as hypoglycemia and the need for phototherapy. RESULTS. Seventy-six mothers taking antidepressants and 90 untreated mothers and their newborns were analyzed. Smoking, alcohol intake, and substance abuse were more frequent among treated mothers. In infants in the exposed group, signs involving the central nervous and the respiratory systems were often observed (63.2% and 40.8%, respectively). These signs appeared during the first day of life, with a median duration of 3 days for exposed newborns. The signs resolved in 75% of cases within 3 to 5 days for term and premature newborns, respectively. All exposed premature newborns presented behavioral manifestations compared with 69.1% of term exposed newborns. Median length of stay was almost 4 times longer for exposed premature newborns than for those who were unexposed (14.5 vs 3.7 days). CONCLUSIONS. Neonatal behavioral signs were frequently found in exposed newborns, but symptoms were transient and self-limited. Premature infants could be more susceptible to the effects of selective serotonin reuptake inhibitors and venlafaxine.

Goldfarb: I think this discussion has pointed out several things when it comes to the management of adolescent gynecology and the problems that might exist from an infectious standpoint in the vulvovaginal canal and the cervix. Every young lady that has HPV must be tested for other STIs. We would also discuss serum screening for sexually transmitted infections and arrange a follow-up visit to discuss the results. I have found that the older adolescent age 16 to 18 is comfortable with this discussion and is willing to understand the boundaries of confidentiality. I also get down on my knees and beg them not to have an unintended pregnancy and discuss contraception and in the future to avoid sexually transmitted infections. I tell them to make sure the man is wearing a condom every time you make love and be comfortable looking at his penis to be sure there are no warts or lesions on the foreskin or penis itself. Breech: I guess in closing the point that I would think of most for health care providers of adolescents would be to use the interaction you have with the adolescent to employ as much education as possible. Certainly obtaining Pap smears and discussing abnormal Paps. (excerpt)

To determine whether similar odds of cesarean delivery (C/S), preterm birth (PTB), and low birth weight (LBW) are observed among adolescents compared with body mass index (BMI)-equivalent adults in cases of adequate gestational weight gain.We conducted a retrospective, population-based, cohort study using the Center for Disease Control and Prevention's birth data files from the United States for 2012. We selected from the cohort all singleton, cephalic pregnancies and stratified them according to maternal age, prepregnancy BMI, and gestational weight gain following the 2009 Institute of Medicine (IOM) recommendations. The effect of adequate gestational weight gain among adolescents relative to adults of equivalent BMI on the risk of C/S, PTB, and LBW was estimated using logistic regression analysis, adjusting for relevant confounders.We analyzed a total of 3,960,796 births, of which 1,036,646 (26.1%) met the inclusion criteria. In adolescents and adults, likelihood of achieving ideal gestational weight gain decreased with greater prepregnancy BMI. Relative to adults, the overall odds of C/S in all adolescents were (adjusted odds ratio [95% confidence interval]) 0.61 (0.58 to 0.63). When comparing equivalent BMI categories, these odds were unchanged (P.0001). The overall adjusted odds ratio of LBW was 1.15 (1.13 to 1.16). These odds were significantly higher when BMI stratification took place, decreasing with advancing BMI categories, from 1.23 (1.14 to 1.33) among the underweight, to nonsignificant differences in the obese classes (P.05). Finally, when including only those achieving ideal weight gain, the overall odds of premature delivery (1.17 [1.14 to 1.20]) were higher among nonobese adolescents, while they were not found among the obese.When ideal gestational weight gain is attained, only nonobese adolescents exhibit a greater risk of LBW and preterm birth relative to adults of similar BMI, whereas the risk of C/S remains lower for all adolescents, independent of BMI. This information may be useful in the counseling of adolescent pregnancies.

Each year, the president of the SOGC selects a specific theme that he or she will advocate throughout the year. In choosing the focus of my presidential term, I decided to share with SOGC members my passion for the issue of hemostasis problems among women. Bleeding disorders, and the consequences, can affect all of our patients, whether our work is in obstetrics, gynaecology, nursing, or midwifery. I believe that in looking at this particular issue we will find many commonalities that will bring us together and exemplify the benefits of multidisciplinary collaboration, as well as the importance of providing quality care.

Pregnant adolescents use cigarettes and alcohol, and possibly illicit drugs, at rates similar to those of their non-pregnant peers. Most discontinue use during the first trimester of pregnancy, but use tends to increase after delivery. Substance use is best detected by direct questioning; urine screening is not universally effective. Several therapeutic interventions can be used in helping pregnant adolescents discontinue substance use and establish a drug-free environment.

In the mature adult brain, there are voice selective regions that are especially tuned to familiar voices. Yet, little is known about how the infant's brain treats such information. Here, we investigated, using electrophysiology and source analyses, how newborns process their mother's voice compared with that of a stranger. Results suggest that, shortly after birth, newborns distinctly process their mother's voice at an early preattentional level and at a later presumably cognitive level. Activation sources revealed that exposure to the maternal voice elicited early language-relevant processing, whereas the stranger's voice elicited more voice-specific responses. A central probably motor response was also observed at a later time, which may reflect an innate auditory-articulatory loop. The singularity of left-dominant brain activation pattern together with its ensuing sustained greater central activation in response to the mother's voice may provide the first neurophysiologic index of the preferential mother's role in language acquisition.

The measurement of the lower uterine segment (LUS) seems to be the best technique available to estimate the risk of uterine rupture, but there is a great heterogeneity in the techniques used. It appears necessary to standardize the interventions and their teaching prior to extending the use of the LUS measurement to clinical settings beyond well-defined research purposes.

OBJECTIVE: To investigate obstetricians’ perceptions of clinical practice guidelines targeting management of labour and vaginal birth after previous caesarean birth, and to identify the barriers to, facilitators of and obstetricians’ solutions for implementing these guidelines in practice. METHODS: This qualitative study was conducted in three hospitals in Montreal that represent around 10% of births in Quebec. Data was collected from 10 focus groups, followed by six semi-structured interviews. Two researchers jointly analysed the verbatim transcripts according to A manual for the use of focus groups. FINDINGS: The identified barriers to and facilitators of the implementation of guidelines can be classified into four categories: 1) the hospital level, including management and hospital policies; 2) the departmental level, including local policies, leadership, organizational factors, economic incentive, and availability of equipment and staff; 3) the health professionals’ motivations and attitudes, including medico-legal concerns, skill levels, acceptance of guidelines and strategies used to implement recommendations; and 4) patients’ motivations. CONCLUSION: Identifying the barriers to and facilitators of the adoption of recommendations is an important way to guide the development of efficient strategies. The findings of this study suggest that the adoption of guidelines may be improved if local health professionals’ perceptions are considered to make recommendations more acceptable and useful. Our findings also support the assumption that obstetricians seek to implement best practices, but require evidence tools and support to assess their practices and enhance their performance. In addition, peer review activities championed by opinion leaders have been identified by obstetricians as the most suitable strategy to improve the use of the guidelines in their practices.

OBJECTIVE To provide guidelines for health-care providers on the use of contraceptive methods to prevent pregnancy and sexually transmitted diseases. OUTCOMES Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, risk of infection, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the cost and availability of cited contraceptive methods in Canada. EVIDENCE Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1988 to March 2003, in order to update the Report of the Consensus Committee on Contraception published in May-July 1998. Relevant Canadian Government publications and position papers from appropriate health and family planning organizations were also reviewed. VALUES The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice are ranked according to the method described in this Report.

To provide guidelines for health-care providers on the use of contraceptive methods to prevent pregnancy and sexually transmitted diseases.Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, risk of infection, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the cost and availability of cited contraceptive methods in Canada.Medline and the Cochrane Database were searched for articles in English on subjects related to contraception, sexuality, and sexual health from January 1988 to March 2003, in order to update the Report of the Consensus Committee on Contraception published in May-July 1998. Relevant Canadian Government publications and position papers from appropriate health and family planning organizations were also reviewed.The quality of the evidence is rated using the criteria described in the Report of the Canadian Task Force on the Periodic Health Examination. Recommendations for practice are ranked according to the method described in this Report.

Jean-Francois Le Bas MR Spectroscopy of Bilateral Thalamic Gliomas. AJNR Am J Neuroradiol 20:876e881, May 1999 4. Gajjar A, Sanford RA, Heideman R, Jenkins JJ, Walter A, Li Y, Langston JW, Muhlbauer M, Boyett JM, Kun LE. Low-grade astrocytoma: a decade of experience at St. Jude Children’s Research Hospital. St Jude Children’s Research Hospital/Le Bonheur Children’s Medical Center Brain Tumor Team, Memphis, TN 38105-2794, USA. 5. Gulcin Benbir, _ Idris Sayilir, Buge € Oz, Mustafa Uzan, Cengiz YALCinkaya. Bilateral Thalamic Glioma: A Case Report. Journal of Neruological Sciences 2008, Volume 25, Number 4, Page(s) 301-305 6. Francois Este‘ve, Sylvie Grand, Christophe Rubin, Dominique Hoffmann, Basile Pasquier, Danielle Graveron-Demilly, Rachid Mahdjoub, and Jean-Francois Le Bas MR Spectroscopy of Bilateral Thalamic Gliomas. AJNR Am J Neuroradiol 20:876e881, May 1999 7. McKissock W, Paine KWE. Primary tumors of the thalamus. Brain 1958;81:41e63 8. Puget S, Crimmins DW, Garnett MR, Grill J, Oliveira R, Boddaert N, Wray A, Lelouch-Tubiana A, Roujeau T, Di Rocco F, Zerah M, Sainte-Rose C. Thalamic Tumors in Children: A Reappraisal J Neurosurg. 2007 May;106(5 Suppl):354-62. 9. Reardon DA, Gajjar A, Sanford RA, Heideman RL, Walter AW, Thompson SJ, Merchant TE, Li H, Jenkins JJ, Langston J, Boyett JM, Kun LE. Bithalamic involvement predicts poor outcome among children with thalamic glial tumors. Pediatr Neurosurg. 1998 Jul;29(1):29-35. J Neurosurg. 2007 May; 106(5 Suppl):354-62. 10. Smyth EG, Stern K. Tumors of the thalamus: a clinico-pathological study. Brain 1938; 61:339e374

The measurement of the lower uterine segment (LUS) seems to be the best technique available to estimate the risk of uterine rupture, but there is a great heterogeneity in the techniques used. It appears necessary to standardize the interventions and their teaching prior to extending the use of the LUS measurement to clinical settings beyond well-defined research purposes.

OBJECTIVE: The aim of this study is to determine the most effective medical management of acute adolescent menorrhagia. STUDY METHODS: Retrospective chart review taking place at Sainte-Justine Hospital between October 1989 and December 1999. All adolescents admitted with menorrhagia as the primary diagnosis, with hemoglobin RESULTS: 31 adolescents (mean age of 14.4 years) were identified. The mean hemoglobin on admission was 65.2 g/L. Coagulation profiles, bleeding time and von Willebrand's testing were done in 100% (31/31), 45.1% (14/31) and 37.9% (11/29) of patients, respectively. 87.1% (27/31) of patients were found to have anovulatory uterine bleeding (AUB) as a diagnosis of exclusion, while 9.7% (3/31) of patients were found to have a primary hematologic disorder. All 31 patients were treated with supportive measures and high dose estrogen therapy (Premarin®, Wyeth-Ayerst). In addition, 12.9% (4/31) patients received antifibrinolytic therapy (Amicar ®, Wyeth-Ayerst). 45% (14/31) of patients required blood transfusions, of which 11 patients had AUB and 3 patients had a hematologic disorder. Complete cessation of bleeding with medical treatment was achieved in 87.1% (27/31) of patients. 12.9% (4/31) of patients required a dilatation and curretage for ongoing bleeding, with an excellent response. However, 2 of these patients had received suboptimal estrogen therapy. CONCLUSIONS: In addition to the usual supportive treatment, adolescents admitted with acute, severe menorrhagia should continue to be treated medically using high dose estrogen therapy. Consideration should be given to adding an antifibrinolytic therapy in an effort to reduce the need for blood transfusions and surgical interventions.