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Background: Evaluating the effect of restricted activity on the development of preeclampsia under experimental clinical settings has been compromised by inherent selection bias and differential misclassification. The aim of our study was to overcome such limitations by using hospitalized bedrest for preterm labor/birth-related indications as an unbiased measure of restricted activity and evaluate its effect on the development of hypertensive diseases of pregnancy., Methods: We conducted a retrospective cohort study using data from the McGill Obstetrical and Neonatal Database on all pregnancies that took place between 1991 and 2001. We defined "exposure" as hospitalized bed rest for preterm labor/birth related indications and used unconditional logistic regression models to estimate its adjusted effect on the development of hypertensive diseases of pregnancy., Results: Data were available on 36,140 pregnancies. 677 women were hospitalized and prescribed bedrest for either preterm contractions (71%), preterm premature rupture of membranes (18%), an incompetent cervix (8%), or other indications. Among all women, bedrest was associated with a significant reduced risk for developing preeclampsia, 0.27 (0.16-0.48). In a stratified analysis, women delivering prior to 34 weeks of gestation had an even more pronounced reduced risk for developing preeclampsia 0.12 (0.03-0.50) as well as a reduced risk for developing intrauterine growth restriction 0.38 (0.18-0.84)., Conclusion: When strictly adhered to, bedrest may be an effective measure in the prevention of preeclampsia and early intrauterine growth restriction.

Objectives: To examine the relationship between physicians' instrument preference and obstetrical and neonatal outcomes., Study Design: A retrospective cohort study comparing obstetrical and neonatal outcomes of second stage deliveries between obstetricians who prefer forceps (forceps >/=90%) with obstetricians with no preference to forceps (either instrument <90%) was completed using the McGill Obstetrical and Neonatal Database. Logistic regression analysis was used to obtain an adjusted odds ratio controlling for maternal, intrapartum and neonatal confounders., Results: Two thousand and three hundred thirteen infants were delivered by 5 obstetricians who preferred forceps, and 9261 infants were delivered by 15 obstetricians with no instrument preference. Baseline characteristics were similar between the two groups. As compared to obstetricians who preferred forceps, obstetricians with no instrument preference had a higher rate of operative vaginal deliveries 1.5 (1.1-2.0), a higher cesarean section rate 2.5 (1.3-4.9) and a higher episiotomy rate in non-operative vaginal deliveries 3.4 (2.7-4.3). Infants delivered by obstetricians with no instrument preference were less likely to have significant bruising 0.3 (0.2-0.6) but more likely to have a cephalohematoma 3.0 (1.1-8.3)., Conclusion: Physician instrument preference is an important determinant of outcomes that should be considered in studies evaluating instrumental deliveries.

Background: The question "will you be delivering my baby?" is one that pregnant women frequently ask their physicians. We sought to determine whether obstetric outcomes differed between women whose babies were delivered by their own obstetrician (regular-care obstetrician) and those attended by an on-call obstetrician who did not provide antenatal care., Methods: We performed a cohort study of all live singleton term births between 1991 and 2001 at the Royal Victoria Hospital in Montréal. We excluded breech deliveries, elective cesarean sections and deliveries with placenta previa or prolapse of the umbilical cord. Logistic regression analysis was used to compare obstetric outcomes (e.g., cesarean delivery, instrumental vaginal delivery and episiotomy) between the regular-care and on-call obstetricians after adjustment for potential confounders., Results: A total of 28,332 eligible deliveries were attended by 26 obstetricians: 21,779 (76.9%) by the patient's own obstetrician and 6553 (23.1%) by the on-call obstetrician. Compared with women attended by their regular-care obstetrician, those attended by an on-call obstetrician had higher rates of cesarean delivery (11.9% v. 11.4%, adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.03-1.24, p < 0.01) and of third-or fourth-degree tears (7.9% v. 6.4%, adjusted OR 1.21, 95% CI 1.07-1.36, p < 0.01) but lower rates of episiotomy (38.5% v. 42.9%, OR 0.77, 95% CI 0.72-0.82, p < 0.001). No differences were observed between the groups in the rate of instrumental vaginal delivery. The increase in the overall rate of cesarean delivery among women attended by an on-call obstetrician was due mainly to an increase in cesarean deliveries during the first stage of labour because of nonreassuring fetal heart tracing (2.9% v. 1.7%, adjusted OR 1.79, 95% CI 1.49-2.15, p < 0.001). The time of day of delivery did not modify the observed effects., Interpretation: The type of attending obstetrician (regular care v. on call) had a minor effect on obstetric outcomes.

Objectives: To examine the association between body mass index (BMI) and obstetrical and neonatal outcomes., Methods: We conducted a cohort study comparing prepregnant BMI categories with obstetrical and neonatal outcomes using the McGill Obstetrical and Neonatal Database on all deliveries in 10 year period (1987-1997). Prepregnant BMI was categorized into underweight (<20), normal (20-24.9), overweight (25-29.9), obese (30-39.9), and morbidly obese (40+). Logistic regression analysis was used to adjust for age, smoking, parity, and preexisting diabetes using normal BMI as the reference., Results: The population consisted of underweight 4,312 (23.1%), normal weight 10,021 (53.8%), overweight 3,069 (16.5%), obese 1,137 (6.1%), and morbidly obese 104 (0.6%). As compared to women with normal BMIs, overweight, obese, and morbidly obese women had an increased risk of preeclampsia 2.28 (1.88-2.77), 4.65 (3.71-5.83), 6.26 (3.48-11.26); gestational hypertension 1.56 (1.35-1.81), 2.01 (1.64-2.45), 2.77 (1.60-4.78); gestational diabetes 1.89 (1.63-2.19), 3.22 (2.68-3.87), 4.71 (2.89-7.67); preterm birth 1.20 (1.04-1.38), 1.60 (1.32-1.94), 2.43 (1.46-4.05); cesarean section 1.48 (1.35-1.62), 1.85 (1.62-2.11), 2.92 (1.97-4.34); and macrosomia 1.66 (1.23-2.24), 2.32 (1.58-3.41), 2.10 (0.64-6.86). Underweight women were less likely to have: preeclampsia 0.67 (0.52-0.86), gestational hypertension 0.71 (0.60-0.83), gestational diabetes 0.82 (0.69-0.97), cesarean section 0.89 (0.81-0.97), shoulder dystocia 0.88 (0.80-0.96), birth injuries 0.40 (0.21-0.77), and macrosomia 0.43 (0.28-0.68) but more likely to have small for gestational age infants 1.54 (1.37-1.72) and intrauterine growth restricted infants 1.33 (1.07-1.67)., Conclusion: In a large Canadian teaching hospital, increasing prepregnancy BMI category was associated with an increasing risk of adverse pregnancy outcomes. Underweight prepregnancy BMI was associated with a reduced risk of adverse pregnancy outcomes.

In Canada, maternal mortality reporting is based on information contained on death certificates. To examine the extent to which maternal deaths are under-reported in Canada and whether this is likely to change under the 10th revision of the International Classification of Diseases (ICD), we linked live birth and stillbirth registrations to In Canada death registrations of women aged 10 to 50 for 1988 through 1992. We reviewed the death certificates of women found to have died while pregnant or within a year of the termination of pregnancy. The officially reported maternal mortality ratio for the study years was 3.7 deaths per 100,000 live births. Depending on whether we included deaths not certified as maternal deaths at the time the deaths occurred, revised ratios under ICD-9 ranged from 4.9 to 5.1 per 100,000 live births for deaths from direct obstetric causes and from 0.5 to 1.2 per 100,000 live births for deaths from indirect obstetric causes. Reflecting changes in classification criteria, revised ratios under ICD-10 were lower than those under ICD-9 for deaths from direct obstetric causes - ranging from 3.9 to 4.1 per 100,000 live births - and higher for deaths from indirect obstetric causes ranging from 2.0 to 3.0 per 100,000 live births. Of deaths from direct obstetric causes, those from cerebrovascular disease were the most numerous and also the most likely to be underreported. Deaths from pulmonary embolism and indirect obstetric causes were the next most likely to be underreported. In a companion article we report an investigation of whether deaths from causes not directly related to pregnancy -such as injury, infectious disease and epilepsy - are more or less likely to occur among pregnant and recently pregnant women.

Background: The use of a 24-hour urine collection to evaluate protein excretion in a woman with suspected pregnancy-induced hypertension (PIH) is cumbersome, time consuming, and subject to improper collection. Our purpose was to determine the correlation of the protein/creatinine ratio of a single voided urine specimen to the 24-hour urine collection for total protein in the range of zero to 1000 mg protein per 24 hours., Methods: Single voided urine specimens and 24-hour total urine protein collections were ordered for 66 consecutive women admitted to an antepartum unit for suspected PIH. The correlation of the protein/creatinine ratio of the single voided specimen with the 24-hour urine protein excretion was calculated., Results: Forty-one sets of data with a 24-hour urine protein less than 1000 mg per 24 hours were obtained. The correlation of the single voided protein/creatinine ratio to the 24-hour total protein was 0.80 (P<.001), with a regression equation of (protein/creatinine)=0.81X(24-hour protein)-0.011. No single protein/creatinine ratio cutoff was ideal to distinguish between significant and insignificant proteinuria; however, a ratio less than .15 efficiently ruled out significant proteinuria [corrected]., Conclusions: We conclude that the protein/creatinine ratio of a single voided urine specimen may have a role in the management of ambulatory women with suspected PIH, although further study is needed. The main potential benefit of this method is that in institutions where women with suspected PIH are hospitalized, women with insignificant proteinuria may be identified within a matter of hours and their follow-up care handled on an outpatient basis.

To establish the seroprevalence of the human immunodeficiency virus (HIV) in our county hospital obstetric patients, and to assess the predictive value of screening questionnaires for high-risk behaviors attributing to HIV infection, we conducted written surveys and blinded HIV testing over a 4-month period ending February 1993. Blinded HIV antibody testing was performed on 1348 patients upon admission to labor and delivery. The coded blood samples were matched to similarly coded surveys of patient demographics and behaviors implicated in HIV transmission. The overall HIV prevalence in our regional population remains virtually unchanged at a rate of 0.22% (2.2 per 1000 patients). Questionnaires regarding health history were not predictive for HIV infection in our patients. Universal screening questionnaires cannot predict HIV infection. Similarly, routine mandatory testing for HIV performed on obstetric patients on the day of delivery are not cost-effective and do not provide clinically meaningful information needed to alter management protocols.

Available evidence shows that the benefits of routine oxytocic administration in the third stage of labor far outweigh the potential risks. In 1990, T.F. Baskett, MD, reviewed the routine use of oxytocic drugs by Canadian obstetricians in the management of the third stage of labor. With Dr Baskett's permission, we sent a similar questionnaire to 1500 obstetricians in Texas: 1000 practiced in urban areas and 500 practiced in rural areas of the state. Ninety-four percent of Texas obstetricians answering the survey used oxytocics routinely in managing the third stage of labor. However, only 14.9% administered the oxytocics before delivery of the placenta, in contrast to 92.1% who gave oxytocics after the delivery of the placenta. Oxytocin was the chosen oxytocic drug for routine third-stage management (95%) as well as for postpartum hemorrhage (73.3%). Of the physicians surveyed, 55.9% used 15-methyl prostaglandin F2a (Hemabate) to treat postpartum hemorrhage refractory to other drugs within the past year. Of the respondents, 14.3% had managed acute uterine inversion during the past year. Thus, Texas obstetricians use Oxytocin routinely in the management of the third stage of labor, but few are converted to active management.

Objective: To examine several variables that may affect the success rate for a trial of labor after previous cesarean delivery, as well as those affecting the rate of uterine rupture., Methods: Between June 1, 1990 and December 31, 1991, we performed a consecutive, prospective study of 593 pregnant women who had had at least one abdominal delivery in the past, and attempted a trial of labor in each. Particular attention was given to the success rate of vaginal delivery, the type of previous uterine incision, use of oxytocin, estimated maternal blood loss, 5-minute Apgar scores, and reason for the previous cesarean operation., Results: Four hundred seventy-eight patients (81%) had a successful vaginal delivery. Oxytocin induction or augmentation was successful in 46 of 67 (69%) and 117 of 167 cases (70%), respectively. Estimated maternal blood loss was less than 500 mL in 453 cases (95%). Five patients (0.8%) experienced true uterine rupture, resulting in severe neurologic sequelae in one infant. The only consistent indication of uterine rupture was an abrupt and prolonged fetal bradycardia. The majority (463; 97%) of infants who were delivered vaginally had 5-minute Apgar scores of 8 or greater., Conclusion: Our success rate of 81% suggests that a trial of labor after previous cesarean delivery is a safe and desirable option, but only after thorough patient counseling. An abrupt and persistent fetal bradycardia may be the only indication that uterine rupture has occurred.

Vaginal delivery was successful in 76% of the 242 women who underwent a trial of labor after cesarean section in a prior pregnancy. Separation of the uterine scar occurred in four women (1.7%). Women whose prior cesarean section was for breech presentation had the highest rate of successful vaginal delivery (86%). The vaginal delivery rates were similar in women who delivered infants with birth weights > or = 4,000 g (73%) and < 4,000 g (76%). The use of epidural anesthesia and oxytocin may enhance the success of vaginal delivery in women undergoing a trial of labor following an earlier cesarean section.

A direct teratogenic effect of antiepileptic drugs (AEDs) on the fetus has been postulated. However, there may also be a primary effect of AEDs on placenta, with secondary consequences to the fetus. Thirteen carefully medically controlled epileptic women were followed prenatally and perinatally. Placentas from all were investigated morphologically and in two with electronmicroscopy. In nine patients, the placentas were studied with respect to insulin and insulin-like growth factor (IGF-I and IGF-II) receptor activity. In this pilot study of a group of carefully medically controlled epileptic women with low levels of AEDs, the results did not differ from normal controls. The possibility of adverse effects of higher concentrations of AEDs cannot be excluded, however.

Premature ovarian failure remains a multifactorial syndrome in which genetic, immune, and environmental factors may play a role. The possible etiology and pathophysiology of premature ovarian failure is reviewed. A scheme of the management of premature ovarian failure is illustrated. This allows a logical approach in which the final diagnosis has to be made with laparotomy ovarian biopsy. It is hoped that future research can be directed to the solution of the etiology of premature menopause and insensitive ovary syndrome, as well as the management of patients with insensitive ovary syndrome, so that either by estrogen replacement or stimulation with hypothalamic/pituitary hormone these primordial follicles can be induced to develop normally.

The effect of clonidine (0.075 mg given intravenously) on subjectively experienced menopausal flushes, skin temperature and luteinizing hormone (LH) secretion was investigated in eight women in a double-blind, saline-controlled cross over study. Subjects were monitored over a 5-hour period. The number and magnitude of temperature peaks (increment greater than 1 degree C) was unaffected by clonidine. Clonidine significantly decreased the number of subjectively experienced flushes as well as the intensity of the flushes. Clonidine had no effect on the number of LH secretory pulses or on total LH secretion. These results indicate that the therapeutic effect of clonidine is independent of factors responsible for episodic skin temperature changes or factors regulating LH secretion.

The effect of methyldopa (100 mg intravenously), the precursor of the alpha-receptor agonist alpha-methylnorepinephrine, on subjectively experienced menopausal flushes, skin temperature, and luteinizing hormone secretion was investigated in seven women in a double-blind, saline-controlled, crossover study. Subjects were monitored over a 3-hour period. Methyldopa significantly decreased the number of subjective flushes (p less than 0.05) and the number of cutaneous temperature peaks (p less than 0.05) but had no effect on the number of luteinizing hormone secretory pulses, variability of luteinizing hormone secretion, or total luteinizing hormone secretion. These studies indicate that alpha-adrenergic mechanisms (central and/or peripheral) play a role in the pathophysiology of menopausal flushes.

It has been suggested that patients receiving anticonvulsant therapy have depressed thyroid function. Thyroid function was studied in 16 pregnant epileptic women who were receiving various anticonvulsants; 20 nonepileptic pregnant women served as controls. Maternal and umbilical cord blood was collected at delivery and serum thyrotropin, total thyroxine, triiodothyronine, triiodothyronine resin uptake, and free thyroxine levels were measured. The free thyroxine index was calculated from the thyroxine and triiodothyronine resin uptake data. There were no significant differences in any of the maternal parameters. In cord serum, the thyroxine level was significantly lower (p less than 0.001) in the infants of the epileptic mothers. The triiodothyronine resin uptake was slightly increased in the epileptic group (p less than 0.05) so that the free thyroxine index largely compensated for this. The thyrotropin, free thyroxine, and triiodothyronine levels did not differ between the two groups. Thus the low thyroxine values in cord blood of infants of epileptic mothers receiving anticonvulsants probably reflect an alteration in protein binding rather than a true alteration in thyroid function.

Among patients seeking abortion are a group who request concurrent sterilization. This study compared three combinations of abortion and sterilization techniques. Suction termination with laparoscopic tubal ligation appears to be the combination of choice, for the mean hospital stay of patients undergoing this procedure was two days and the operative morbidity was 3.1%. For suction termination with tubal ligation at laparotomy, and hysterotomy with tubal ligation the mean hospital stays were 6 and 5.7 days respectively and the operative morbidity was four to five times greater.

The family physician dealing with gynecologic pelvic pain (acute or chronic) enters at the beginning of the problem as diagnostician, refers the patient to a specialist in the interim, and resumes care in the follow-up period. Patients with chronic pelvic pain (pelvic pain that has lasted for at least six months) can be difficult to treat because they often have a history of dysfunctional family life, sexual and marital problems, and often a hidden history of sexual molestation or incest. The family physician can best care for the patient with empathy, a long ventilated history, complete physical and pelvic examination, and pelvic ultrasonograpy if necessary. Laparoscopy normally shows pelvic adhesions in one third of these patients, minimal endometriosis in one third, and a normal pelvis in the final third. The family physician should specifically reassure patients with normal results that they do not have cancer. The ideal therapy combines both stimulation-produced analgesia and treatment of the psychological, emotional, sociological, and environmental aspects of the disease.

The effect of naloxone (1.4 mg/hr for 3 hours) on subjectively experienced menopausal flushes, skin temperature, and luteinizing hormone secretion was investigated in seven women in a double-blind, saline-controlled, crossover study. Naloxone had no effect on the number of subjective flushes, episodic skin temperature elevation, luteinizing hormone pulses, variability of luteinizing hormone secretion, or total luteinizing hormone secretion. This study suggests that a naloxone-sensitive opioid mechanism is not active in modulating luteinizing hormone secretion in the postmenopausal woman and that opioid receptor blockade is not effective in altering the frequency of menopausal flushes.

Thirty-eight adolescents who underwent an abortion were studied by questionnaire and interview with a psychiatrist and a social worker 2 years after the abortion. Most did not regret their abortion and considered it a positive experience. Most said they would not have another abortion, although adoption was unanimously rejected as a choice for the pregnant teenager. Relations with their parents were generally good and the families were supportive in the decision-making process and in the postabortion period. The girl's father had been absent because of death or separation in 37% of instances. A lengthy relationship with the putative father before the abortion was common, but 37% of the relationships were not able to withstand the pregnancy-abortion crisis. The proportion using contraceptives before the abortion was 2%, and 2 years after the abortion, 84%.

The effect of guanfacine (0.5 mg/day), an alpha-adrenergic agonist, on menopausal flushing, was studied in a double-blind, placebo-controlled crossover study in 11 patients. Both guanfacine and placebo significantly decreased the total number of flushes from baseline values. There was, however, no significant difference between placebo and guanfacine. Larger doses of guanfacine may be required to exert a therapeutic effect similar to that reported in the literature with the alpha-adrenergic agents, clonidine and alpha-methyldopa.

The patient's choice of a contraceptive method is seemingly influenced by six factors: (a) her attitude toward contraception, (b) the physician's choice, (c) her assessment of risk, (d) her motivation and compliance for reliable contraception, (e) her previous experience with contraception and (f) her partner's influence. Recommendations are made for dealing with three groups of patients who present particular problems: (a) the patient who insists on the pill despite the contraindications for her emphasized by the physician; (b) the patient on the pill who is aging; and (c) the patient or couple who chooses tubal ligation at whatever age and regardless of the number of children she has borne.

Labour pain was measured with the McGill Pain Questionnaire in 87 primiparas and 54 multiparas. The average intensity of labour pain ranked among the most intense pains recorded with the questionnaire. However, the pain scores had a wide range and were influenced by several medical and social variables. They were significantly higher for the primiparas than for the multiparas. Moreover, high pain levels were associated with a history of menstrual difficulties and lower socioeconomic status. The primiparas who had received prepared childbirth training had lower pain scores than those who had received no such training. Nevertheless, the effects of prepared childbirth training were relatively small, and most patients (81%) who received it requested epidural anesthesia. Because many women who received training suffered severe pain during labour, prepared childbirth training and epidural anesthesia should be regarded as compatible, complementary procedures.

Therapeutic abortion has been a major potential source of Rh isoimmunization. Popularization of early termination necessitates reconfirmation of established policies. This study involved 75 patients, selected at random, in whom pre- and post-abortion blood smears were studied for fetal-maternal hemorrhage. Results showed that this may occur even in early suction termination. The significance of these findings was discussed in relation to the cost-effectiveness and the dosage of anti-Rho (D) globulin administered to patients.

This article describes the functions of the Pediatric and Adolescent Gynecology Clinic at the Montreal Children's Hospital. Most of the problems treated there are pregnancy in the adolescent, vulvo-vaginitis, dysfunctional bleeding, dysmenorrhea, amenorrhea and lower abdominal pain. Treatment for these complaints is described, stress being laid on reassurance and careful explanation.