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Cesarean delivery (CD) is a surgical delivery of a neonate with surgical access through the maternal abdominal and uterine structures. The Enhanced Recovery After Surgery (ERAS) protocol is a standardized perioperative care program and surgery quality improvement process that has had global spread across numerous surgical disciplines. The medical and surgical use of opioids for pain management and the nonmedical opioid use, over the last three decades, have significantly increased the prevalence of abuse and addiction to opioids. This review summarizes pain, pregnancy substance use, and ERAS-directed analgesia and anesthesia for opioid use reduction or elimination in the operative and postoperative periods. Enhanced recovery (quality and safety) in the surgical CD context requires collaboration, consensus, and appropriate clinical prioritization to allow for the identification of 'the right patient, in the right clinical situation, with the right informed consent, and the right clinical care team and health system'.

Background: Pregnancies that are prenatally identified to have fetal anomalies are complex and require expert multidisciplinary care. As many conditions can impact the fetus prenatally and require intervention, an enhanced recovery after surgery (ERAS) for lower urinary tract obstruction (LUTO) is being evaluated to determine the level of evidenced-based data available. Problem: The percutaneous ultrasound-guided fetal surgery procedure for bladder neck obstruction is the focus for elements of preoperative counseling, intraoperative procedure/risk complications, and postoperative management. Methods: A quality improvement review Squire 2.0 (2000–2020) was undertaken for the percutaneous LUTO fetal surgery shunting (lower urinary tract obstruction), process and procedure which require 2 process pathways, one to evaluate the fetal candidate and a second to treat. This structured review is focused on identifying the process elements to allow the determination of the number of evidenced-based elements that would allow for audit and measurement of the clinical element variance for comparative feedback to the individual surgical provider or surgery center. Interventions: Titles and abstracts were screened to identify potentially relevant articles with priority given to meta-analyses, systematic reviews, randomized controlled studies, nonrandomized controlled studies, reviews, and case series. Results: A series of potential clinical elements for the diagnostic fetal evaluation and for the 3 protocol areas of surgical care for the procedures (pre-, intra-, and postoperative care) are identified using an ERAS-like process. Conclusions: The identified clinical elements have the potential for ERAS-LUTO fetal therapy guideline. Multidisciplinary collaboration (surgeon, anesthesia, nursing, imaging, and laboratory) is required for ERAS quality improvement in the pre-, intra-, and postoperative processes. Process elements in each of the operative areas can be audited, evaluated, compared, and modified/improved.

To focus on the evidence-based screening test options and timing as part of the overall "pregnant-woman-centered" preconception and prenatal care journey. The requirement and need for a focused "pregnant-woman-centered" prenatal care process with time for informed consent and shared decision making are important for optimal prenatal care.A structured quality improvement (QI) review (Squire 2.0) was undertaken to examine the appropriate reproductive screening process in the periods of preconception and during pregnancy.First, the broader prenatal care structure was evaluated which, second, enabled the directed reproductive risk screening processes to be offered within an informed consent process. Four international preconception and prenatal evidence-based guidance consensus would routinely offer specific gestational age reproductive risk screening elements: totaling 21 screening elements (three preconception; nine first trimester; three second trimester; four third trimester; one intrapartum; and one postpartum).The best evidence-based opportunity for comprehensive and collaborative prenatal care with appropriate screening elements requires: a single national access healthcare system; expert evidence-based guideline creation; collaborative maternity care providers based for risk assessment, triage, and management; a pregnant-woman-centered care model of maternity care; clearly identified evidence-based gestational age directed screening elements; international preconception and prenatal guideline consensus.

Objective This revised guideline provides updated information for the care of women with chronic viral infections who require intrauterine fetal diagnostic testing. Target Population Women with chronic viral infections who are pregnant or planning a pregnancy. Options Non-invasive screening tests for diagnosis: maternal serum placental analytes with or without nuchal translucency, sonography, maternal serum cell-free placental DNA; and intrauterine fetal diagnostic testing: amniocentesis, chorionic villus sampling, cordocentesis. Outcomes The recommendations in this guideline have the potential to decrease or eliminate morbidity and mortality in women with chronic viral infections and their infants, which is associated with significant health and economic outcomes. Evidence Published literature was retrieved through searches of PubMed, guidelines of national societies (Society of Obstetricians and Gynaecologists of Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, other international societies), and the Cochrane Library using appropriate controlled vocabulary (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) and keywords (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus). Results were restricted to systematic reviews, randomized controlled trials or controlled clinical trials (if available), and observational case-control studies or case series from 2012 to 2019 published in English or French. Studies from 1966 to 2002 were previously reviewed in the SOGC guideline No. 123: Amniocentesis and Women with Hepatitis B, Hepatitis C, or Human Immunodeficiency Virus, and those from 2002 to 2012 were previously reviewed in the SOGC guideline No. 309: Prenatal Invasive Procedures in Women With Hepatitis B, Hepatitis C, and/or Human Immunodeficiency Virus Infections. Updated literature searches were completed regularly through August 2019 and were incorporated into this guideline. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience The intended users are maternity care providers and women with chronic viral infections. This guideline provides information to educate and counsel these women, and to offer them reproductive options. RECOMMENDATIONS (GRADE ratings in parentheses) 1For women with a chronic infection with hepatitis B, hepatitis C, and/or human immunodeficiency virus (HIV), the use of non-invasive methods of fetal aneuploidy risk assessment is recommended, using screening tests with high sensitivity and low false-positive rates (maternal serum placental analytes with or without nuchal translucency, detailed sonography [dating crown-rump length, first- and second-trimester anatomic] and maternal serum cell-free placental DNA as first- or second-tier screening test) (strong, moderate). 2When counselling pregnant women with a chronic infection that can pose a risk of perinatal morbidity regarding intrauterine fetal diagnostic genetic and/or infectious testing: •The pregnancy loss rate (spontaneous loss rate and rate due to the procedure) discussed should be based on the gestational age at the time of the procedure (strong, high). •The first trimester (when chorionic villus sampling is performed) has an estimated spontaneous pregnancy loss rate of 1.40% (based on a population cohort of maternal age >36 years with normal first-trimester sonographic screening); the second trimester (when amniocentesis is performed) has an estimated spontaneous pregnancy loss rate of 0.65% (based on a population cohort of maternal age >36 years with normal second-trimester sonographic screening) (strong, high). •The estimated risk of pregnancy loss due to amniocentesis is 0.35% to 1.00%, based on systematic reviews or meta-analyses, cohort studies with control groups, and randomized controlled trials; the risk varies depending on provider expertise (strong, high). 3When performing sonography-guided amniocentesis for women with a chronic hepatitis B, hepatitis C, and/or HIV infection, every effort should be made to avoid the amniocentesis needle going through the placenta or within 1 to 2 cm of the implantation placental edge (strong, moderate). Hepatitis B 4Hepatitis B virus DNA load should be evaluated in women with positive hepatitis B surface antigen status who require intrauterine fetal diagnostic testing. A viral DNA load >200 000 IU/mL or >106 copies/mL and positive hepatitis B e antigen status increase the risk of vertical transmission (strong, moderate). 5In women with chronic hepatitis B infection and a significant viral load (>200 000 IU/mL or >106 copies/mL), maternal antiviral therapy should be considered in order to decrease the vertical transmission risk. The first-line antenatal antiretroviral agent tenofovir is recommended (strong, moderate). Hepatitis C 6In women with chronic hepatitis C infection, amniocentesis is recommended over chorionic villus sampling due to the limited data available on chorionic villus sampling (conditional, low). 7Amniocentesis in women with a chronic hepatitis C infection does not appear to significantly increase the risk of vertical transmission of the virus; however, there is limited published cohort data, and this information should be shared with the patient during the informed consent process (conditional, low). HIV 8Pregnant women with HIV have reported pregnancy loss rates after amniocentesis of 2.6% to 22% (although only small cohorts have been reported) and vertical transmission rates of 0% to 2.3%. Data evaluating the clinical use of amniocentesis among women with HIV is increasing but still limited, and this information should be shared with women during the informed consent process (conditional, low). 9Amniocentesis in women with HIV who are treated with combination antiretroviral therapy appears to pose no increased risk of vertical transmission of HIV, especially if the antiviral therapy reduces the maternal viral load to undetectable levels (strong, high).

Objective This revised guideline is intended to provide an update on the genetic aspects, prevention, screening, diagnosis, and management of fetal neural tube defects. Target population Women who are pregnant or may become pregnant. Neural tube defect screening should be offered to all pregnant women. Options For prevention: a folate-rich diet, and folic acid and vitamin B12 supplementation, with dosage depending on risk level. For screening: second-trimester anatomical sonography; first-trimester sonographic screening; maternal serum alpha fetoprotein; prenatal magnetic resonance imaging. For genetic testing: diagnostic amniocentesis with chromosomal microarray and amniotic fluid alpha fetoprotein and acetylcholinesterase; fetal exome sequencing. For pregnancy management: prenatal surgical repair; postnatal surgical repair; pregnancy termination with autopsy. For subsequent pregnancies: prevention and screening options and counselling. Outcomes The research on and implementation of fetal surgery for prenatally diagnosed myelomeningocele has added a significant treatment option to the previous options (postnatal repair or pregnancy termination), but this new option carries an increased risk of maternal morbidity. Significant improvements in health and quality of life, both for the mother and the infant, have been shown to result from the prevention, screening, diagnosis, and treatment of fetal neural tube defects. Benefits, harms, and costs The benefits for patient autonomy and decision-making are provided in the guideline. Harms include an unexpected fetal diagnosis and the subsequent management decisions. Harm can also result if the patient declines routine sonographic scans or if counselling and access to care for neural tube defects are delayed. Cost analysis (personal, family, health care) is not within the scope of this clinical practice guideline. Evidence A directed and focused literature review was conducted using the search terms spina bifida, neural tube defect, myelomeningocele, prenatal diagnosis, fetal surgery, neural tube defect prevention, neural tube defect screening, neural tube defect diagnosis, and neural tube defect management in order to update and revise this guideline. A peer review process was used for content validation and clarity, with appropriate ethical considerations. Validation methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended audience Maternity care professionals who provide any part of pre-conception, antenatal, delivery, and neonatal care. This guideline is also appropriate for patient education. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

BACKGROUND Cesarean birth (CB) is the most common inpatient surgical procedure, and until recently, there were no internationally accepted, standardized clinical guidelines available. The Enhanced Recovery After Surgery (ERAS® ) program aims to improve outcomes through the development of international guidelines (IGs). As an ERAS IG for CB was being developed, this qualitative study was conducted to explore and consolidate women's experiences with CB. METHODS Qualitative methods were used to assess the patient experience with current evidence-based CB protocols across operative phases. Twelve women who experienced CB at a single center in Canada were interviewed using an open-ended, semi-structured interview guide at six weeks postpartum. Two researchers coded the emerging themes separately and compared findings. RESULTS Women described feeling informed, but felt they did not have a choice. Presurgery, women wanted more information about the risks of CB. Preoperatively, women expressed confusion with the procedures, but felt informed about local anesthesia and thermoregulation. Post-CB, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about postpartum infant care was not well communicated, as many women were uninformed about delayed cord clamping and infant thermoregulation. CONCLUSIONS This qualitative study provides opportunities to improve communication, the patient-practitioner relationship, and the overall satisfaction throughout the CB process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CB have the potential to deliver significant improvements to patient care and patient satisfaction.

Centres providing maternity care and offering a trial of labour after cesarean must develop and use maternal educational and consent processes that emphasize choice and autonomy related to options for and decisions surrounding vaginal birth after cesarean and elective repeat cesarean delivery. These centres should have administrative systems and processes that take into account local resources for cesarean delivery services, including team-based complex maternity risk support and an urgency consensus on the fetal, maternal, and maternal-fetal indications for a surgical delivery to ensure an appropriate decision-to-delivery interval.

There has been little implementation of enhanced recovery after surgery (ERAS) in obstetrical surgery, but ERAS elements have the potential to be successfully implemented in cesarean delivery (CD). The ERAS CD knowledge transfer and implementation will require multidisciplinary team coordination in the preoperative, intraoperative, and postoperative phases and the development of a formalized ERAS® guideline for ERAS CD. Such a guideline will require pairing with an audit system (e.g., ERAS® Interactive Audit System) to enable teams to review their protocol compliance on a regular basis. The ERAS team (typically comprised of at least a surgeon, anesthesiologist, and nurse) determines where their compliance is low and then is able to focus their efforts on improving compliance, which then translates into improved clinical outcomes.

Enhanced Recovery After Surgery (ERAS) is a global surgical quality improvement initiative that has spread across numerous surgical disciplines. The uptake of ERAS in cesarean delivery in Canada is presently unknown. This study surveyed the current practices of Society of Obstetricians and Gynaecologists of Canada (SOGC) members with regards to ERAS guidelines for preoperative, intraoperative, and postoperative cesarean delivery care. Survey responses highlight perioperative practice variations across Canada. Active implementation of ERAS cesarean delivery guidelines could potentially lessen variations in perioperative care, improve patient outcomes, and minimize health care costs.

Background: The prevalence of perinatal infection from maternal exposure is increasing. The prevalence of acute maternal infections identifies cytomegalovirus, parvovirus B19, toxoplasmosis, and varicella as the most common organisms and in the order of frequency. Maternal informed consent and understanding is required before intrauterine testing for fetal infectious and possible genetic risk assessment. Methods: This structured review of the reproductive published literature focuses on the risks of amniocentesis and cordocentesis diagnostic procedure-related fetal loss rates and fetal vertical transmission (VT) rates from published infected pregnant cohorts. Results: The total postprocedure fetal loss rate for diagnostic amniocentesis procedures, in limited infectious cohorts, is 1.5% and does not appear to be increased compared to “noninfected” amniocentesis cohorts using an estimated background spontaneous fetal loss rate (no procedure) of 0.65%. The “pooled” unintended fetal loss rate is from small infected population cohorts, but can be used for counseling purposes. Postcordocentesis fetal loss risk, in an infected cohort, is not possible to estimate due to limited data. The “biological spontaneous fetal loss rate” risk with a perinatal infection (positive or negative fetal anomalies) and no diagnostic procedure before 20 weeks of gestation is reviewed. The risk of VT in acute infection cohorts as a result of the intra-amniotic diagnostic procedure is not found to be increased. Conclusion: The unintended “fetal loss” rate after amniocentesis for perinatal infected cohorts is similar to that of noninfected cohorts, but the estimate is based on limited infected cohorts. There was no procedure-based risk of fetal VT in the infected cohorts, but identification of postprocedure maternal bleeding into the amniotic cavity increases the potential risk. Maternal knowledge translation and an informed consent process with risk-benefit maternal/fetal risk counseling are required prior to any diagnostic amniocentesis procedure.

Background To systematically review the literature on clinical interventions that influence vaginal birth after cesarean (VBAC) rates. Methods We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting VBAC, uterine rupture and uterine dehiscence rates. One reviewer extracted data and a second reviewer verified for accuracy. Meta-analysis was conducted using Mantel-Haenszel (random effects model) relative risks (VBAC rate) and risk differences (uterine rupture and dehiscence). Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). Results Twenty-nine studies (six trials and 23 cohorts) examined different clinical interventions affecting rates of vaginal deliveries among women with a prior cesarean delivery (CD). Methodological quality was good overall for the trials; however, concerns among the cohort studies regarding selection bias, comparability of groups and outcome measurement resulted in higher risk of bias. Interventions for labor induction, with or without cervical ripening, included pharmacologic (oxytocin, prostaglandins, misoprostol, mifepristone, epidural analgesia), non-pharmacologic (membrane sweep, amniotomy, balloon devices), and combined (pharmacologic and non-pharmacologic). Single studies with small sample sizes and event rates contributed to most comparisons, with no clear differences between groups on rates of VBAC, uterine rupture and uterine dehiscence. Conclusions This systematic review evaluated clinical interventions directed at increasing the rate of vaginal delivery among women with a prior CD and found low to very low certainty in the body of evidence for cervical ripening and/or labor induction techniques. There is insufficient high-quality evidence to inform optimal clinical interventions among women attempting a trial of labor after a prior CD.

INTRODUCTION: Cesarean delivery (CD) is the most common inpatient surgical procedure; however, there are no internationally-accepted, standardized clinical guidelines. The Enhanced Recovery After Surgery (ERAS®) program aims to improve outcomes through the development of international guidelines (IG). The purpose of this study is to obtain and consolidate women’s experiences with CD to inform the development of an ERAS international guideline (IG). METHODS: Qualitative methods were used to assess the patient experience with current evidence-based CD protocols across operative phases. Twelve women who experienced CD were interviewed using an open-ended, semi-structured interview guide at six-weeks post-partum. Two researchers coded the emerging themes separately and compared findings. RESULTS: Women described feeling informed, but felt they did not have a choice. Pre-surgery, women wanted more information about the risks of CD. Pre-operatively, women expressed confusion with the procedures, but felt informed about local anaesthesia and thermoregulation. Post-CD, women felt informed about pain and nausea control; however, urinary catheter removal was delayed when compared to the ERAS recommendations. Information about post-partum infant care was not well communicated, as many women were uninformed about delayed cord-clamping and infant thermoregulation. DISCUSSION: This qualitative study provides opportunities to improve communication, the patient-provider relationship, and the overall satisfaction throughout the CD process. The findings support the implementation of patient decision aids and training with the shared decision model. The improved procedures recommended in the ERAS IG for CD have the potential to deliver significant improvements to patient satisfaction, mother-infant bonding and mental wellness.

Objective To inform reproductive and other health care providers about genetic and fetal risk information to consider during a woman/couples' pre-conception evaluation, including considerations for genetic risk assessment, genetic screening, or testing to allow for improved counselling and informed choice. Options This genetic information can be used for patient education, planning, and possible pre-conception and/or prenatal testing. Outcomes This information may allow improved risk assessment for pre-conception counselling for individual patients and their families. Evidence PubMed or Medline and the Cochrane Database were searched in May 2017 using appropriate key words ("pre-conception," "genetic disease," "maternal," "family history," "genetic," "health risk," "genetic health surveillance," "prenatal screening," "prenatal diagnosis," "birth defects," and "teratogen"). Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, and national and international medical specialty societies. Benefits, harms, and costs The benefits for the patient and her family include an increased understanding of relevant genetic risk pre-conception and in early pregnancy, and better pregnancy outcomes as a result of use of the information. The harm includes potential increased anxiety or psychological stress associated with the possibility of identifying genetic risks. Validation The evidence obtained was peer-reviewed by the Genetics Committee of The Society of Obstetricians and Gynaecologists of Canada. Consideration for Care Statements For this review article, the Consideration for Care Statements use the GRADE strength and quality as it is comparable for the clinician and the patient/public user. 1.The provider needs to educate and counsel women regarding the importance of knowing her personal and her partner's family history (if available); and encourage the patients to consider discussing this issue prior to becoming pregnant. The provider should obtain or review a three-generation pedigree for the patient and her partner (Strong; Moderate). 2.The provider needs to educate and counsel women about evaluating their lifestyle activities and their possible reproductive and fetal risks (weight, smoking, alcohol, drugs, medications) if a pregnancy were to occur without some planning (Strong; Moderate). 3.The provider needs to educate and counsel women about the importance of optimizing and then managing the medical or surgical conditions and fetal teratogenic exposures that may require chronic or frequent use of medications or where scheduled surgery is being considered as part of their health care management (Strong; Moderate). 4.The provider should offer relevant investigations for a history of recurrent pregnancy loss and consider how findings might relate to genetic/placental risk during a pregnancy with consideration for the elimination of thrombophilia testing for recurrent loss, intra-uterine growth restriction, pre-eclampsia, and abruption (Strong; Moderate). 5.The provider should not undertake maternal serologic studies for cytomegalovirus and toxoplasmosis as part of routine prenatal laboratory studies (Strong; Moderate). 6.The provider should review whether pregnancy planning or prevention is a primary consideration at each office visit. The provider should offer to educate and counsel the patient about the personal use and options available for using birth control to enhance the patient's reproductive planning and her ability to have a pregnancy when it is desired (Strong; Moderate). 7.The provider should ask or assist the patient to consider or create a personal reproductive plan looking at "how many pregnancies do you (and your partner) want, when do you (and your partner) want to start, and what duration of spacing do you (and your partner) want?" Although this planning may have obstacles such as marital and occupation changes, some effort to plan should be introduced (Strong; Moderate). [GRADE from the Canadian Task Force on Preventive Health Care (www.canadiantaskforce.ca). For clinicians, Strong = The recommendation would apply to most individuals. Formal discussion aids are not likely to be needed to help individuals make decisions consistent with their values and preferences. For patients/public, Strong = We believe most people in this situation would want the recommended course of actions and only a small number would not. Quality of evidence (High, Moderate, Low) based on the confidence that the true effect lies close to that of the estimate of the effect.] Conclusion Pre-conception planning is presently underutilized by both patients and providers. Pre-conception genetic assessment is only a part of the counselling, education, and health management change that can improve perinatal and maternal morbidity and mortality. A published literature review on pre-conception genetic counselling identified mainly clinical cohort studies, surveys, and expert opinion with no RCTs. There is strong support for pre-conception counselling and moderate quality based on the understanding that most individuals would support and use pre-conception counselling when choice, timing, and ease of access is considered.

Background Cell-free DNA (cfDNA) screening has recently acquired tremendous attention, promising patients and healthcare providers a more accurate prenatal screen for aneuploidy than other current screening modalities. It is unclear how much knowledge regarding cfDNA screening obstetrical providers possess which has important implications for the quality and content of the informed consent patients receive. Methods A survey was designed to assess obstetrical provider knowledge and attitudes towards cfDNA screening and distributed online through the Society of Obstetricians & Gynecologists of Canada (SOGC). Chi-squared tests were used to detect differences in knowledge and attitudes between groups. Results 207 respondents completed the survey, composed of 60.6% Obstetricians/Gynecologists (OB/GYN), 15.4% Maternal Fetal Medicine (MFM) specialists, 16.5% General Practitioners (GP), and 7.5% Midwives (MW). MFM demonstrated a significant trend of being most knowledgeable about cfDNA screening followed by OB/GYN, GP, and lastly MW in almost all aspects of cfDNA screening. All groups demonstrated an overall positive attitude towards cfDNA screening; however, OB/GYN and MFM demonstrated a significantly more positive attitude than GP and MW. Despite not yet being a diagnostic test, 19.4% of GP would offer termination of pregnancy immediately following a positive cfDNA screen result compared to none of the MFM and only few OB/GYN or MW. Conclusions We have demonstrated that different types of obstetrical providers possess varying amounts of knowledge regarding cfDNA screening with MFM currently having greater knowledge to all other groups. All obstetrical providers must have adequate prenatal screening understanding so that we can embrace the benefits of this novel and promising technology while protecting the integrity of the informed consent process. Electronic supplementary material The online version of this article (10.1186/s12884-018-1662-z) contains supplementary material, which is available to authorized users.

The broad categories of surgical fetal therapy can be separated into either open surgical techniques or minimally invasive endoscopic/ultrasound-guided techniques that require only puncture of the uterus with single or multiple small ports. Benefits of fetoscopic or ultrasound-guided fetal intervention include decreased uterine irritability, decreased incidence of preterm labor, and avoidance of risks associated with hysterotomy and commitment to cesarean delivery for future pregnancies. Fetal abnormalities potentially amenable to ultrasound-guided drainage techniques include thoracic fluid-filled lesions and lower urinary tract obstruction.

Objective To describe evidence-based practice for managing the labour, delivery, and postpartum care of people with physical disabilities in Canada. Target Population This guideline addresses the needs of people with physical disabilities, with a focus on conditions that affect strength and mobility, as well as those that affect neurological or musculoskeletal function or structure. Although aspects of this guideline may apply to people with solely intellectual, developmental, or sensory disabilities (e.g., hearing and vision loss), the needs of this population are beyond the scope of this guideline. Outcomes Safe and compassionate care for people with physical disabilities who are giving birth. Benefits, Harms, and Costs Implementation of this guideline will improve health care provider awareness of specific complications people with physical disabilities may experience during labour, delivery, and the postpartum period and therefore increase the likelihood of a safe birth. Evidence A literature review was conducted using MEDLINE (474), Embase (36), and the Cochrane Central Register of Controlled Trials (CENTRAL; 28) databases. The results have been filtered for English language, publication date of 2013 to present, observational studies, systematic reviews, meta-analyses, and guidelines and references in these publications were also reviewed. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience Maternal–fetal medicine specialists, obstetricians, family physicians, nurses, midwives, neurologists, physiatrists, and those who care for people with physical disabilities. RECOMMENDATIONS 1In verbal and written communication and documentation, clinicians should use people-first language (e.g., "person with a disability" rather than "disabled person"), which emphasizes the person over the disability (strong, low). 2Clinicians should screen for and mitigate risk factors for preterm birth, such as bladder infection (strong, low). 3Clinicians should teach patients who cannot feel contractions, such as those with spinal cord injuries, how to identify signs of labour (strong, low). 4Clinicians should offer induction of labour to avoid issues associated with transportation and to facilitate neuraxial analgesia for patients at risk of autonomic dysreflexia (strong, low). 5Consultation with an obstetrician or maternal–fetal medicine specialist should occur in the pre-conception period or early in pregnancy to outline a plan of care, including location of birth, taking into consideration the availability of and access to equipment and personnel and the ability to monitor maternal cardiovascular status and fetal status on an individualized basis (strong, low). 6Clinicians should consider the patient's underlying health concerns, obstetrical indications, and wishes and preferences when planning mode of delivery. Consultation with an interdisciplinary team is recommended (strong, low). 7Clinicians should be aware of a patient's risk for autonomic dysreflexia and consider evaluating patients for autonomic dysreflexia and preeclampsia when signs and symptoms of these conditions are present (strong, low). 8Clinicians should treat autonomic dysreflexia in people with spinal cord injury by recognizing and addressing the underlying cause, which may require expediting delivery (strong, low). 9Care providers should create a delivery plan for people with physical disabilities that includes anaesthesia. This planning should include antenatal consultation with the department of anaesthesia when significant obstetrical or anaesthetic risk factors are present (strong, low). 10Patients who wish to breastfeed should be encouraged to do so; this may require access to a lactation consultant. When counselling patients on breastfeeding, clinicians should address the risk of autonomic dysreflexia, the possibility of impaired letdown, difficulties in mobilization that may hinder the patient's ability to exclusively breastfeed, how the patient's required medications might affect breastfeeding, and how breastfeeding might exacerbate fatigue or underlying conditions (weak, very low). 11Clinicians should screen for postpartum depression and make referrals for psychological support when indicated (strong, low).

RESUME Objectif Decrire les pratiques fondees sur des donnees probantes en matiere de prise en charge des soins pendant l'accouchement et la periode post-partum chez les personnes ayant un handicap physique au Canada. Population cible La presente directive clinique aborde les besoins des personnes ayant un handicap physique en mettant l'accent sur les problemes de sante qui affectent la force et la mobilite, ainsi que sur ceux qui touchent les fonctions ou structures neurologiques ou musculosquelettiques. Bien que certains aspects de cette directive puissent s'appliquer aux personnes ayant une deficience intellectuelle, un trouble neurodeveloppemental ou un handicap sensoriel (p. ex., perte auditive ou visuelle) seulement, les besoins de cette population sortent du cadre de la presente directive. Resultats Prestation de soins surs et empathiques aux personnes parturientes ayant un handicap physique. Benefices, risques et couts La mise en œuvre de la presente directive permettra aux fournisseurs de soins de sante de mieux connaitre les complications particulieres que peuvent presenter les personnes ayant un handicap physique pendant l'accouchement et la periode post-partum, ce qui augmentera la probabilite d'un accouchement securitaire. Donnees probantes Une revue de la litterature a ete effectuee a l'aide des bases de donnees MEDLINE (474), Embase(36) et le Cochrane Central Register of Controlled Trials (CENTRAL; 28). Les resultats ont ete filtres pour obtenir des etudes observationnelles, des revues systematiques, des meta-analyses et des directives publiees en anglais depuis 2013. Les references de ces articles ont egalement ete passees en revue. Methodes de validation Les auteurs ont evalue la qualite des donnees probantes et la solidite des recommandations en utilisant la methodologie GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne ( tableau A1 pour les definitions et tableau A2 pour l'interpretation des recommandations fortes et faibles). Public vise Specialistes en medecine fœto-maternelle, obstetriciens, medecins de famille, infirmieres, sages-femmes, neurologues, physiatres et autres professionnels qui donnent des soins aux personnes ayant un handicap physique. RECOMMANDATIONS 1 Dans la documentation et les communications verbales et ecrites, il est recommande aux cliniciens d'utiliser un langage axe sur la personne d'abord (p. ex., « personne handicapee » ou « personne ayant un handicap » plutot que « un handicape » ou « une handicapee ») afin de mettre l'accent sur la personne plutot que sur le handicap (forte, faible). 2 Il y a lieu pour les cliniciens de depister et d'attenuer les facteurs de risque de l'accouchement premature, tels que l'infection urinaire basse (forte, faible). 3 Il est recommande aux cliniciens d'enseigner comment reconnaitre les signes du travail aux personnes qui ne peuvent ressentir les contractions, comme celles qui presentent une lesion medullaire (forte, faible). 4 Il convient aux cliniciens d'offrir un declenchement artificiel du travail afin de prevenir les problemes de transport et de faciliter l'analgesie neuraxiale chez les personnes a risque de dysreflexie autonome (forte, faible). 5 La consultation d'un obstetricien ou d'un specialiste en medecine fœto-maternelle est recommandee en preconception ou en debut de grossesse afin de definir les grandes lignes d'un plan de soins, lequel comprendra notamment le lieu d'accouchement, en fonction de l'acces a l’equipement et au personnel et leur disponibilite et de la capacite de surveiller l’etat cardiovasculaire de la mere et l’etat du fœtus separement (forte, faible). 6 Il y a lieu pour les cliniciens de tenir compte des ennuis de sante sous-jacents, des indications obstetricales, des souhaits et des preferences de la personne lors de la planification du mode d'accouchement. Il est recommande de consulter une equipe interdisciplinaire (forte, faible). 7 Les cliniciens doivent etre conscients du risque de dysreflexie autonome de la personne et envisager la possibilite d'une dysreflexie autonome et d'une pre-eclampsie en presence de signes et symptomes de ces problemes (forte, faible). 8 Il est recommande aux cliniciens de traiter la dysreflexie autonome chez les personnes ayant une lesion medullaire en reconnaissant et en traitant la cause sous-jacente, ce qui peut necessiter d'accelerer le processus d'accouchement (forte, faible). 9 En cas de personne parturiente ayant un handicap physique, il y a lieu pour les fournisseurs de soins de definir un plan d'accouchement integrant l'anesthesie. Il est recommande que ce plan comprenne la consultation prenatale avec le personnel d'anesthesie lorsque d'importants facteurs de risque obstetricaux ou anesthesiques sont presents (forte, faible). 10 Il y a lieu d'encourager l'allaitement chez toute personne souhaitant allaiter, ce qui peut necessiter l'acces a une conseillere en allaitement. Lorsqu'ils donnent des conseils sur l'allaitement, les cliniciens doivent discuter des risques de dysreflexie autonome, de la possibilite d'une montee de lait insuffisante et du fait que les difficultes de mobilisation peuvent nuire a la capacite d'allaitement exclusif, que leur medication necessaire peut nuire a l'allaitement et que l'allaitement peut exacerber la fatigue ou un probleme de sante sous-jacent (faible, tres faible). 11 Il y a lieu pour les cliniciens d'effectuer un depistage de la depression post-partum et de faire une recommandation pour soutien psychologique, lorsqu'indique (forte, faible).

Objective To review the available prenatal screening options in light of the recent technical advances and to provide an update of previous guidelines in the field of prenatal screening. Intended Users Health care providers involved in prenatal screening, including general practitioners, obstetricians, midwives, maternal fetal medicine specialists, geneticists, and radiologists. Target Population All pregnant women receiving counselling and providing informed consent for prenatal screening. Evidence Published literature was retrieved through searches of Medline, PubMed, and the Cochrane Library in and prior to March 2016 using an appropriate controlled vocabulary (prenatal diagnosis, amniocentesis, chorionic villi sampling, non-invasive prenatal screening) and key words (prenatal screening, prenatal genetic counselling). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English and published from January 1985 to May 2016. Searches were updated on a regular basis and incorporated in the guideline. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical speciality societies. Guideline update Evidence will be reviewed 5 years after publication to determine whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

Objective To develop a Canadian consensus document on maternal screening for fetal aneuploidy (e.g., Down syndrome and trisomy 18) in singleton pregnancies.

Elaborer un document de consensus canadien sur le depistage maternel de l'aneuploidie fœtale (p. ex, syndrome de Down et trisomie 18) en ce qui concerne les grossesses monofœtales.

Resume Objectif Fournir, aux professionnels de la sante des domaines de l'obstetrique et de la genetique, des lignes directrices et des recommandations en ce qui a trait au depistage / diagnostic prenatal et a la prise en charge obstetricale du dysraphisme spinal ouvert / ferme (DSOF) chez le fœtus. Options La presente analyse englobe les techniques de depistage / diagnostic prenatal qui sont actuellement utilisees aux fins de la detection du DSOF, y compris le depistage des concentrations seriques en alphafoetoproteines chez la mere, l'echographie, l'imagerie par resonance magnetique visant le fœtus et l'amniocentese. Issues Ameliorer le depistage / diagnostic prenatal et la prise en charge obstetricale du DSOF, tout en prenant en consideration les soins offerts a la patiente, l'efficacite, les couts et les interventions de soins. Resultats La litterature publiee a ete recuperee par l'intermediaire de recherches menees dans PubMed ou MEDLINE, CINAHL et The Cochrane Library en novembre 2013 au moyen d'un vocabulaire controle et de mots cles appropries (p. ex. « prenatal screening », « congenital anomalies », « neural tube defects », « alpha-fetoprotein », « ultrasound scan », « magnetic resonance imaging »). Les resultats ont ete restreints aux analyses systematiques, aux essais comparatifs randomises / essais cliniques comparatifs et aux etudes observationnelles publies en anglais entre 1977 et 2012. Les recherches ont ete mises a jour de facon reguliere et ont ete integrees a la directive clinique jusqu'au 30 novembre 2013. La litterature grise (non publiee) a ete identifiee par l'intermediaire de recherches menees dans les sites Web d'organismes s'interessant a l'evaluation des technologies dans le domaine de la sante et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et aupres de societes de specialite medicale nationales et internationales. Une enquete en ligne menee aupres des praticiens de la sante a egalement fait l'objet d'une analyse. Valeurs La qualite des resultats est evaluee au moyen des criteres decrits dans le rapport du Groupe d'etude canadien sur les soins de sante preventifs (Tableau). Avantages, desavantages et couts La presente analyse permettra aux professionnels de la sante de mieux comprendre les methodes de depistage prenatal du DSOF dont nous disposons a l'heure actuelle, ainsi que les avantages et les risques qui sont associes a chacune de ces methodes, pour assurer la prise de decisions factuelles en ce qui concerne le depistage, le diagnostic et la prise en charge obstetricale du DSOF.

Offrir des renseignements à jour sur l'utilisation pré et postconceptionnelle d'acide folique par voie orale, avec ou sans supplément de multivitamines / micronutriments, aux fins de la prévention des anomalies du tube neural et d'autres anomalies congénitales. Ces renseignements aideront les médecins, les sages-femmes, les infirmières et les autres professionnels de la santé à contribuer aux efforts de sensibilisation des femmes quant à l'utilisation et aux posologies adéquates de la supplémentation en acide folique / multivitamines, avant et pendant la grossesse. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed, Medline, CINAHL et la Cochrane Library en janvier 2011 au moyen d'un vocabulaire contrôlé et de mots clés appropriés (p. ex. « folic acid », « prenatal multivitamins », « folate sensitive birth defects », « congenital anomaly risk reduction », « pre-conception counselling »). Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre 1985 et juin 2014. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en juin 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques, et auprès de sociétés de spécialité médicale nationales et internationales. COûTS, RISQUES ET AVANTAGES: Les coûts financiers sont ceux de la supplémentation quotidienne en vitamines et de la consommation d'un régime alimentaire santé enrichi en folate. Les risques sont ceux qui sont liés à une association signalée entre la supplémentation alimentaire en acide folique et des modifications épigénétiques fœtales / la probabilité accrue d'obtenir une grossesse gémellaire. Ces associations pourraient devoir être prises en considération avant la mise en œuvre d'une supplémentation en acide folique. La supplémentation en acide folique par voie orale (ou l'apport alimentaire en folate combiné à un supplément de multivitamines / micronutriments) a pour avantage de mener à une baisse connexe du taux d'anomalies du tube neural et peut-être même des taux d'autres complications obstétricales et anomalies congénitales particulières.La qualité des résultats est évaluée au moyen des critères décrits par le Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). DéCLARATION SOMMAIRE: RECOMMANDATIONS.

Background Rates of cesarean deliveries have been increasing, and contributes to the rising number of elective cesarean deliveries in subsequent pregnancies with associated maternal and neonatal risks. Multiple guidelines recommend that women be offered a trial of labor after a cesarean (TOLAC). The objective of the study is to systematically review the literature on adjunct clinical interventions that influence vaginal birth after cesarean (VBAC) rates. Methods We searched Ovid Medline, Ovid Embase, Wiley Cochrane Library, CINAHL via EBSCOhost; and Ovid PsycINFO. Additional studies were identified by searching for clinical trial records, conference proceedings and dissertations. Limits were applied for language (English and French) and year of publication (1985 to present). Two reviewers independently screened comparative studies (randomized or non-randomized controlled trials, and observational designs) according to a priori eligibility criteria: women with prior cesarean sections; any adjunct clinical intervention or exposure intended to increase the VBAC rate; any comparator; and, outcomes reporting changes in TOLAC or VBAC rates. One reviewer extracted data and a second reviewer verified for accuracy. Two reviewers independently conducted methodological quality assessments using the Mixed Methods Appraisal Tool (MMAT). Results Twenty-three studies of overall moderate to good methodological quality examined adjunct clinical interventions affecting TOLAC and/or VBAC rates: system-level interventions (three studies), provider-level interventions (three studies), guidelines or information for providers (seven studies), provider characteristics (four studies), and patient-level interventions (six studies). Provider-level interventions (opinion leader education, laborist, and obstetrician second opinion for cesarean sections) and provider characteristics (midwifery antenatal care, physicians on night float call schedules, and deliveries by family physicians) were associated with increased rates of VBAC. Few studies employing heterogeneous designs, sample sizes, interventions and comparators limited confidence in the effects. Studies of system-level and patient-level interventions, and guidelines/information for providers reported mixed findings. Conclusions Limited evidence indicates some provider-level interventions and provider characteristics may increase rates of attempted and successful TOLACs and/or VBACs, whereas other adjunct clinical interventions such as system-level interventions, patient-level interventions, and guidelines/information for healthcare providers show mixed findings. Electronic supplementary material The online version of this article (10.1186/s12884-018-2065-x) contains supplementary material, which is available to authorized users.

OBJECTIF La presente directive clinique revisee vise a fournir une mise a jour sur les aspects genetiques, la prevention, le depistage, le diagnostic et la prise en charge des anomalies du tube neural. POPULATION CIBLE Les femmes enceintes ou qui pourraient le devenir. Il convient d'offrir le depistage des anomalies du tube neural a toutes les femmes enceintes. OPTIONS Pour la prevention : un regime alimentaire riche en acide folique et des supplements d'acide folique et de vitamine B12 selon une posologie d'apres le niveau de risque. Pour le depistage : l'echographie obstetricale du deuxieme trimestre, le depistage echographique du premier trimestre, le dosage de l'alphafœtoproteine serique maternelle et l'imagerie par resonance magnetique prenatale. Pour les tests genetiques : l'amniocentese diagnostique avec analyse chromosomique sur micropuce et le dosage de l'alphafœtoproteine et de l'acetylcholinesterase dans le liquide amniotique et le sequencage de l'exome fœtal. Pour la prise en charge de la grossesse : la reparation chirurgicale prenatale, la reparation chirurgicale postnatale et l'interruption de grossesse avec autopsie. Pour les grossesses subsequentes : les options de prevention et de depistage et les conseils. ReSULTATS: La recherche et la mise en œuvre du traitement chirurgical fœtal en cas de diagnostic prenatal de myelomeningocele ont ajoute une option therapeutique fœtale importante aux options precedentes (reparation postnatale ou interruption de grossesse), mais cette nouvelle option comporte un risque accru de morbidite maternelle. La prevention, le depistage, le diagnostic et le traitement des anomalies du tube neural se revelent entrainer des ameliorations importantes a la mere et au nourrisson en matiere de sante et de qualite de vie. BeNeFICES, RISQUES ET COuTS: Le type et l'ampleur des benefices, risques et couts attendus pour les patientes grâce a la mise en œuvre de la presente directive clinique par un etablissement de soins de sante integrent un canal maternel preconception et prenatal adequat comprenant l'acces des patientes aux soins, les conseils, les analyses et examens, l'imagerie, le diagnostic et l'interpretation. Les benefices relatifs a l'autonomie de la patiente et au processus decisionnel sont enonces dans la presente directive clinique. Les risques comprennent un diagnostic fœtal inattendu et les decisions de prise en charge subsequentes. Le fait que la patiente refuse les echographies habituelles et le retard du conseil ou d'acces aux soins en cas d'anomalie du tube neural comportent egalement des risques. L'analyse des couts (personnels, familiaux, sante publique) ne fait pas partie de la portee de la presente directive clinique. DONNeES PROBANTES: Afin de mettre a jour et reviser la presente directive, une revue de la litterature ciblee et dirigee a ete effectuee a l'aide des termes de recherche suivants : spina bifida, neural tube defect, myelomeningocele, prenatal diagnosis, fetal surgery, neural tube defect prevention, neural tube defect screening, neural tube defect diagnosis et neural tube defect management. Un processus d'examen par les pairs a ete utilise pour la validation et la clarte du contenu, avec des considerations appropriees d'ordre ethique. MeTHODES DE VALIDATION: Les auteurs ont evalue la qualite des donnees probantes et la force des recommandations en utilisant l'approche d'evaluation, de developpement et d'evaluation (GRADE). Consulter l'annexe A en ligne (le tableau A1 pour les definitions et le tableau A2 pour les interpretations des recommandations fortes et faibles). PROFESSIONNELS CONCERNeS: Professionnels des soins de maternite qui offrent des soins preconception, prenataux, obstetricaux ou neonataux. La presente directive clinique convient egalement aux fins d'education des patientes. RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHeSES).

RESUME Objectif La presente directive clinique revisee met a jour les renseignements sur la prestation de soins aux femmes atteintes d'une infection virale chronique devant se soumettre a un test diagnostique fœtal intra-uterin. Population cible Femmes atteintes d'une infection virale chronique qui sont enceintes ou prevoient le devenir. Options Tests de depistage non invasifs a des fins diagnostiques : marqueurs placentaires seriques maternels avec ou sans mesure de la clarte nucale, echographie, ADN fœtal libre circulant dans le sang maternel; et tests diagnostiques fœtaux intra-uterins : amniocentese, biopsie choriale (choriocentese), cordocentese. Issues Les recommandations de la presente directive clinique pourraient reduire ou eliminer la morbi-mortalite chez les femmes atteintes d'une infection virale chronique et leurs nourrissons, ce qui est associe a d'importantes consequences sur les plans de la sante et de l'economie. Donnees probantes La litterature publiee a ete recueillie au moyen de recherches dans les bases de donnees PubMed et Cochrane Library ainsi que dans les directives cliniques de societes medicales nationales et internationales (Societe des obstetriciens et gynecologues du Canada, American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine et d'autres societes internationales) en utilisant un vocabulaire (amniocentesis, chorionic villus sampling, cordocentesis, procedure pregnancy loss risk, viral vertical transmission, fetal and neonatal infection) et des mots cles (maternal infection or exposure, hepatitis B, hepatitis C, human immunodeficiency virus) controles et appropries. Les resultats retenus se limitent aux revues systematiques, aux essais cliniques randomises ou aux essais cliniques comparatifs (si disponibles) et aux etudes cas-temoins observationnelles ou etudes de serie de cas publiees entre 2012 et 2019 en anglais ou en francais. Les etudes publiees entre 1966 et 2002 ont deja ete examinees dans la directive clinique de la SOGC no 123, L'amniocentese chez les femmes infectees par l'hepatite B, l'hepatite C ou le virus de l'immunodeficience humaine; les etudes publiees entre 2002 et 2012 ont quant a elles ete examinees dans la directive clinique de la SOGC no 309, Interventions effractives prenatales chez les femmes qui presentent des infections par le virus de l'hepatite B, le virus de l'hepatite C et/ou le virus de l'immunodeficience humaine. De nouvelles recherches ont ete effectuees dans la litterature jusqu'en aout 2019, puis ont ete integrees a la presente directive clinique. Methodes de validation L'auteur a evalue la qualite des donnees probantes et la solidite des recommandations au moyen du cadre methodologique GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Consulter l'annexe A en ligne (le tableau A1 pour les definitions et le tableau A2 pour les interpretations des recommandations fortes et faibles). Public vise Les utilisateurs prevus sont des fournisseurs de soins de maternite et les femmes atteintes d'une infection virale chronique. Cette directive fournit des renseignements pour renseigner et conseiller ces femmes et leur offrir des options de procreation. RECOMMENDATIONS (GRADE ratings in parentheses) 1Il est recommande d'utiliser des methodes d'evaluation prenatales non invasives des risques d'aneuploidie chez les femmes atteintes d'une infection chronique au virus de l'hepatite B, au virus de l'hepatite C et/ou au virus de l'immunodeficience humaine (VIH) au moyen de tests de depistage ayant une forte sensibilite et un faible taux de faux positifs (marqueurs placentaires seriques maternels avec ou sans mesure de la clarte nucale, echographie detaillee [datation par mesure de la distance vertex-coccyx, echographie morphologique des premier et deuxieme trimestres] et analyse de l'ADN fœtal libre circulant dans le serum maternel comme test de depistage de premiere ou de deuxieme intention) (forte, moyenne). 2Il y a lieu d'aborder les points suivants lors des conseils aupres de femmes enceintes atteintes d'une infection chronique qui peuvent presenter un risque de morbidite perinatale liee aux tests diagnostiques fœtaux intra-uterins pour des indications infectieuses et/ou genetiques : •Les discussions sur le risque de fausse couche (taux de fausses couches spontanees et taux de fausses couches dues a l'intervention) doivent etre abordees en fonction de l'âge gestationnel au moment de l'intervention (forte, elevee). •Au premier trimestre, le taux de fausses couches spontanees (en cas de choriocentese) est estime a 1,40 % (d'apres une cohorte de meres de > 36 ans ayant obtenu des resultats normaux a l'echographie de depistage au premier trimestre); au deuxieme trimestre (en cas d'amniocentese), le taux de fausses couches spontanees est estime a 0,65 % (d'apres une cohorte de meres de > 36 ans ayant obtenu des resultats normaux a l'echographie de depistage au deuxieme trimestre) (forte, elevee). •Le risque estime de fausse couche due a l'amniocentese est de 0,35 a 1,00 % d'apres des revues systematiques ou des meta-analyses, des etudes de cohorte avec groupes temoins et des essais cliniques randomises; le risque varie en fonction de l'expertise du fournisseur (forte, elevee). 3Au moment d'effectuer une amniocentese sous guidage echographique chez une femme atteinte d'une infection chronique au virus de l'hepatite B, au virus de l'hepatite C et/ou au VIH, toutes les precautions doivent etre prises pour eviter que l'aiguille d'amniocentese traverse le placenta ou qu'elle penetre a une distance de 1 a 2 cm du bord de l'implantation placentaire (forte, moyenne). Hepatite B 4La charge d'ADN viral de l'hepatite B doit etre evaluee chez les femmes positives pour l'antigene de surface du virus de l'hepatite B qui doivent subir un test diagnostique fœtal intra-uterin. Une charge d'ADN viral de > 200 000 UI/ml ou de > 106 copies/ml et un statut positif pour l'antigene e de l'hepatite B augmentent le risque de transmission verticale (forte, moyenne). 5Chez les femmes atteintes d'une hepatite B chronique et ayant une charge virale importante (> 200 000 UI/ml ou > 106 copies/ml), il est recommande d'envisager un traitement antiviral maternel afin de reduire le risque de transmission verticale. Le tenofovir, un antiretroviral de premiere intention, est recommande (forte, moyenne). Hepatite C 6Chez les femmes atteintes d'une hepatite C chronique, l'amniocentese est preferable a la biopsie choriale en raison du manque de donnees disponibles sur la choriocentese (conditionnelle, basse). 7L'amniocentese chez les femmes atteintes d'une hepatite C chronique ne semble pas significativement augmenter le risque de transmission verticale; cependant, comme il y a peu de donnees de cohortes publiees a ce sujet, il y a lieu d'en informer la patiente pendant le processus de consentement eclaire (conditionnelle, basse). VIH 8Les femmes enceintes atteintes du VIH signalent un taux de fausses couches de 2,6 a 22 % apres une amniocentese (quoique seules les donnees de petites cohortes aient ete rapportees) ainsi qu'un taux de transmission verticale de 0 a 2,3 %. On accumule de plus en plus de donnees evaluant l'utilisation clinique de l'amniocentese chez les femmes atteintes du VIH, mais elles n'en demeurent pas moins limitees; par consequent, il y a lieu d'en informer la patiente pendant le processus de consentement eclaire (conditionnelle, basse). 9L'amniocentese chez les femmes atteintes du VIH qui recoivent un traitement antiretroviral combine ne semble pas augmenter le risque de transmission verticale du VIH, surtout si le traitement antiviral reduit la charge virale maternelle a un niveau indetectable (forte, elevee).