Showing papers in "Journal of obstetrics and gynaecology Canada in 2014"
TL;DR: The current evidence assessed in the clinical practice guideline prepared by the Canadian Hypertensive Disorders of Pregnancy Working Group and published by Pregnancy Hypertension to provide a reasonable approach to the diagnosis, evaluation, and treatment of the hypertensive disorders of pregnancy is presented.
Abstract: Objective: This executive summary presents in brief the current evidence assessed in the clinical practice guideline prepared by the Canadian Hypertensive Disorders of Pregnancy Working Group and published by Pregnancy Hypertension (http://www.pregnancyhypertension.org/article/S22107789(14)00004-X/fulltext) to provide a reasonable approach to the diagnosis, evaluation, and treatment of the hypertensive disorders of pregnancy.
367 citations
TL;DR: This document presents an approach, based on current evidence, for the diagnosis, treatment, and thromboprophylaxis of venous thromboembolism in pregnancy and postpartum.
Abstract: Objective To present an approach, based on current evidence, for the diagnosis, treatment, and thromboprophylaxis of venous thromboembolism in pregnancy and postpartum. Evidence Published literature was retrieved through searches of PubMed, Medline, CINAHL, and The Cochrane Library from November 2011 to July 2013 using appropriate controlled vocabulary (e.g. pregnancy, venous thromboembolism, deep vein thrombosis, pulmonary embolism, pulmonary thrombosis) and key words (e.g., maternal morbidity, pregnancy complications, thromboprophylaxis, antithrombotic therapy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English or French. There were no date restrictions. Grey (unpublished) literature was identified through searching the websites of clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1).
230 citations
TL;DR: In this article, the authors present evidence-based guidelines for the assignment of gestational age based on ultrasound biometrics, including ultrasound biometry and ultrasound dating, for women.
Abstract: Objective To assist clinicians in assigning gestational age based on ultrasound biometry. Outcomes To determine whether ultrasound dating provides more accurate gestational age assessment than menstrual dating with or without the use of ultrasound. To provide maternity health care providers and researchers with evidence-based guidelines for the assignment of gestational age. To determine which ultrasound biometric parameters are superior when gestational age is uncertain. To determine whether ultrasound gestational age assessment is cost effective. Evidence Published literature was retrieved through searches of PubMed or MEDLINE and The Cochrane Library in 2013 using appropriate controlled vocabulary and key words (gestational age, ultrasound biometry, ultrasound dating). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies written in English. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 31, 2013. 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 specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Benefits, harms, and costs Accurate assignment of gestational age may reduce post-dates labour induction and may improve obstetric care through allowing the optimal timing of necessary interventions and the avoidance of unnecessary ones. More accurate dating allows for optimal performance of prenatal screening tests for aneuploidy. A national algorithm for the assignment of gestational age may reduce practice variations across Canada for clinicians and researchers. Potential harms include the possible reassignment of dates when significant fetal pathology (such as fetal growth restriction or macrosomia) result in a discrepancy between ultrasound biometric and clinical gestational age. Such reassignment may lead to the omission of appropriate—or the performance of inappropriate—fetal interventions.
178 citations
TL;DR: This article is intended to reassure obstetric care providers that if used in an appropriate manner without the use of contrast agents, MRI in the obstetrical patient is safe for mother and fetus in the second and third trimesters.
Abstract: Objective To review the biological effects and safety of magnetic resonance imaging (MRI) in the obstetric patient and to review procedural issues, indications, and contraindications for obstetrical MRI. Outcomes This guideline is intended to reassure patients and clinicians of the safety of MRI in pregnancy and to provide a framework for its use. Evidence Published literature was retrieved through searches of PubMed or Medline in 2013 using controlled vocabulary and key words (e.g., MRI, safety, pregnancy). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English and in French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to July 2013. 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 specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Benefits, harms, and costs This article is intended to reassure obstetric care providers that if used in an appropriate manner without the use of contrast agents, MRI in the obstetrical patient is safe for mother and fetus in the second and third trimesters. Because obstetrical MRI is expensive and has limited availability in Canada, this clinical guideline is intended to encourage the judicious use of this resource.
159 citations
TL;DR: The effect of assisted human reproduction (AHR) on perinatal outcomes is reviewed, areas requiring further research with regard to birth outcomes and AHR are identified, and guidelines to optimize obstetrical management and counselling of prospective Canadian parents are provided.
Abstract: Objective To review the effect of assisted human reproduction (AHR) on perinatal outcomes, to identify areas requiring further research with regard to birth outcomes and AHR, and to provide guidelines to optimize obstetrical management and counselling of prospective Canadian parents. Outcomes This document compares perinatal outcomes of different types of AHR pregnancies with each other and with those of spontaneously conceived pregnancies. Clinicians will be better informed about the adverse outcomes that have been documented in association with AHR, including obstetrical complications, adverse perinatal outcomes, multiple gestations, structural congenital abnormalities, chromosomal abnormalities, and imprinting disorders. Evidence Published literature was retrieved through searches of MEDLINE and the Cochrane Library from January 2005 to December 2012 using appropriate controlled vocabulary and key words (assisted reproduction, assisted reproductive technology, ovulation induction, intracytoplasmic sperm injection, embryo transfer, and in vitro fertilization). Results were not restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies; studies of all designs published in English from January 2005 to December 2012 were reviewed, and additional publications were identified from the bibliographies of these articles. Searches were updated on a regular basis and incorporated in the guideline to August 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).
125 citations
TL;DR: Rates of postpartum hemorrhage and severe postpartums hemorrhage continued to increase in Canada between 2003 and 2010, and could not be explained by changes in maternal, fetal, and obstetric factors.
Abstract: Objective Increases in postpartum hemorrhage have been reported from several countries. We assessed temporal trends in postpartum hemorrhage and severe postpartum hemorrhage in Canada between 2003 and 2010. Methods We carried out a population-based cohort study of all hospital deliveries in Canada (excluding Quebec) from 2003 to 2010 (n=2 193 425), using data from the Canadian Institute for Health Information. Postpartum hemorrhage was defined as a blood loss of ≥ 500mL following vaginal delivery or ≥ 1000mL following Caesarean section, or as noted by the care provider. Severe postpartum hemorrhage was defined as postpartum hemorrhage plus blood transfusion, hysterectomy, or other procedures to control bleeding (including uterine suturing or ligation/embolization of pelvic arteries). Temporal trends were assessed using the chi-square test for trend, relative risks, and logistic regression. Results Postpartum hemorrhage increased by 22% (95% CI 20% to 25%) from 5.1% in 2003 to 6.2% in 2010 ( P P P P P Conclusion Rates of postpartum hemorrhage and severe postpartum hemorrhage continued to increase in Canada between 2003 and 2010.
94 citations
TL;DR: This guideline reviews the evidence relating to the effects of parvovirus B19 on the pregnant woman and fetus, and discusses the management of women who are exposed to, who are at risk of developing, or who developParvov virus B19 infection in pregnancy.
Abstract: Objectives This guideline reviews the evidence relating to the effects of parvovirus B19 on the pregnant woman and fetus, and discusses the management of women who are exposed to, who are at risk of developing, or who develop parvovirus B19 infection in pregnancy. Outcomes The outcomes evaluated were maternal outcomes including erythema infectiosum, arthropathy, anemia, and myocarditis, and fetal outcomes including spontaneous abortion, congenital anomalies, hydrops fetalis, stillbirth, and long-term effects. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library on July 8, 2013, using appropriate controlled vocabulary (MeSH terms "parvovirus" and "pregnancy") and key words (parvovirus, infection, pregnancy, hydrops). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date restrictions but results were limited to English or French language materials. 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. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). Recommendations 1.Investigation for parvovirus B19 infection is recommended as part of the standard workup for fetal hydrops or intrauterine fetal death. (II-2A) 2.Routine screening for parvovirus immunity in low-risk pregnancies is not recommended. (II-2E) 3.Pregnant women who are exposed to, or who develop symptoms of, parvovirus B19 infection should be assessed to determine whether they are susceptible to infection (non-immune) or have a current infection by determining their parvovirus B19 immunoglobulin G and immunoglobulin M status. (II-2A) 4.If parvovirus B19 immunoglobulin G is present and immunoglobulin M is negative, the woman is immune and should be reassured that she will not develop infection and that the virus will not adversely affect her pregnancy. (II-2A) 5.If both parvovirus B19 immunoglobulin G and immunoglobulin M are negative (and the incubation period has passed), the woman is not immune and has not developed the infection. She should be advised to minimize exposure at work and at home. Absence from work should be considered on a case-by-case basis. (II-2C) Further studies are recommended to address ways to lessen exposure including the risk of occupational exposure. (III-A) 6.If a recent parvovirus B19 infection has been diagnosed in the woman, referral to an obstetrician or a maternal–fetal medicine specialist should be considered. (III-B) The woman should be counselled regarding risks of fetal transmission, fetal loss, and hydrops and serial ultrasounds should be performed every 1 to 2weeks, up to 12weeks after infection, to detect the development of anemia (using Doppler measurement of the middle cerebral artery peak systolic velocity) and hydrops. (III-B) If hydrops or evidence of fetal anemia develops, referral should be made to a specialist capable of fetal blood sampling and intravascular transfusion. (II-2B)
91 citations
TL;DR: The evidence supporting the tubal origin hypothesis for HGSC is examined, the clinical implications of improved understanding of the pathogenesis of ovarian cancer are discussed, and pre-invasive changes within the fimbriated end of the fallopian tube appear in association with early HGSC.
Abstract: Research published over the past 10 years has suggested that most "ovarian cancer," and specifically the high-grade serous carcinoma (HGSC) subtype of ovarian cancer, actually originates in the fallopian tube. In this review, we examine the evidence supporting the tubal origin hypothesis for HGSC, and discuss the clinical implications of our improved understanding of the pathogenesis of ovarian cancer. We searched Medline R and Medline in-process and non-indexed citations from inception to December 15, 2012, to identify all English or French language articles discussing the origins of HGSC. Articles and findings were summarized descriptively. A step-wise transformation from normal epithelium to a lesion with the ability to invade and metastasize has been demonstrated within the fallopian tube. Intraepithelial or early invasive carcinoma of the fallopian tube is frequently identified in BRCA mutation carriers who undergo prophylactic risk-reducing salpingo-oophorectomy. In both BRCA mutation carriers and women from the general population, pre-invasive changes within the fimbriated end of the fallopian tube appear in association with early HGSC. Molecular and genetic studies, as well as in vitro and animal models, have also supported a tubal origin for HGSC. Whether the removal of fallopian tubes (salpingectomy) at the time of pelvic surgery for other reasons will lead to reductions in mortality from ovarian cancer is currently unknown, but it is an important area for future clinical research.
80 citations
TL;DR: This review will provide health care practitioners with a better understanding of the available prenatal screening methods for OCNTd and the benefits and risks associated with each technique to allow evidenced-based decisions on OCNTD screening, diagnosis, and obstetrical management.
Abstract: Objective To provide obstetrical and genetic health care practitioners with guidelines and recommendations for prenatal screening, diagnosis, and obstetrical management of fetal open and closed neural tube defects (OCNTD). Options This review includes prenatal screening and diagnostic techniques currently being used for the detection of OCNTD including maternal serum alpha fetoprotein screening, ultrasound, fetal magnetic resonance imaging, and amniocentesis. Outcomes To improve prenatal screening, diagnosis, and obstetrical management of OCNTD while taking into consideration patient care, efficacy, cost, and care procedures. Evidence Published literature was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library in November, 2013, using appropriate controlled vocabulary and key words (e.g., prenatal screening, congenital anomalies, neural tube defects, alpha fetoprotein, ultrasound scan, magnetic resonance imaging). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from 1977 to 2012. Searches were updated on a regular basis and incorporated in the guideline to November 30, 2013. 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 specialty societies. An online survey of health care practitioners was also reviewed. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table). Benefits, harms, and costs This review will provide health care practitioners with a better understanding of the available prenatal screening methods for OCNTD and the benefits and risks associated with each technique to allow evidenced-based decisions on OCNTD screening, diagnosis, and obstetrical management.
70 citations
TL;DR: A large number of potentially beneficial uses of statins in pregnant women have prompted a new evaluation of the risk-benefit ratio of these agents in pregnancy, and a meta-analysis of controlled observational studies has failed to corroborate this.
Abstract: Although an initial case series suggested that use of statins in pregnancy carried teratogenic risk, a recent meta-analysis of controlled observational studies has failed to corroborate this. A large number of potentially beneficial uses of statins in pregnant women have prompted a new evaluation of the risk-benefit ratio of these agents in pregnancy.
65 citations
TL;DR: Preliminary data provide preliminary data to guide targeted public health interventions towards meeting the needs for obstetric care of this vulnerable population and significantly increased rates of prior Caesarean section, HIV-positive status, homelessness, social isolation, and delays in accessing prenatal care.
Abstract: Objectives Women who are refugees during pregnancy may be exposed to homelessness, poor nutrition, and limited access to health care, yet the pregnancy outcomes of this vulnerable population have not been systematically evaluated. We undertook a study to determine the risk of adverse obstetric and perinatal outcomes among refugee women in Toronto. Methods Using a retrospective cohort design, we examined pregnancy outcomes for refugee and non-refugee women delivering at St. Michael's Hospital in Toronto, between January 1, 2008, and December 31, 2010. The primary outcome measures were preterm delivery ( Results Multiparous refugee women had a significantly higher rate of delivery by Caesarean section (36.4%), and a 1.5-fold increase in rate of low birth weight infants when compared with non-refugee women. In subgroup analysis by region of origin, women from Sub-Saharan Africa had significantly higher rates of low birth weight infants and Caesarean section than non-refugee control subjects. Further, compared with non-refugee control subjects, refugee women had significantly increased rates of prior Caesarean section, HIV-positive status, homelessness, social isolation, and delays in accessing prenatal care. Conclusions Refugee women constitute a higher-risk population with increased rates of adverse obstetric and perinatal outcomes. These findings provide preliminary data to guide targeted public health interventions towards meeting the needs for obstetric care of this vulnerable population. Recent changes to the Interim Federal Health Program have highlighted the importance of identifying and diminishing disparities in health outcomes between refugee and non-refugee populations.
TL;DR: This guideline provides guidelines for the health care provider on the prevention, diagnosis, and clinical management of postmenopausal osteoporosis and contains recommendations regarding nutrition, physical activity, and the selection of pharmacologic therapy to prevent and manage osteoporeosis.
Abstract: Objective To provide guidelines for the health care provider on the prevention, diagnosis, and clinical management of postmenopausal osteoporosis. Outcomes Strategies for identifying and evaluating high-risk individuals, the use of bone mineral density (BMD) and bone turnover markers in assessing diagnosis and response to management, and recommendations regarding nutrition, physical activity, and the selection of pharmacologic therapy to prevent and manage osteoporosis. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library on August 30 and September 18, 2012, respectively. The strategy included the use of appropriate controlled vocabulary (e.g., oteoporosis, bone density, menopause) and key words (e.g., bone health, bone loss, BMD). Results were restricted to systematic reviews, practice guidelines, randomized and controlled clinical trials, and observational studies published in English or French. The search was limited to the publication years 2009 and following, and updates were incorporated into the guideline to March 2013. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Values The quality of the evidence was rated using the criteria described by the Canadian Task Force on Preventive Health Care (Table). Sponsors The Society of Obstetricians and Gynaecologists of Canada.
TL;DR: Reproductive-aged women who have undergone treatment of fibroids with UAE may have lower ovarian reserve over the long term than women with fibroid treated with LM, which could have an adverse impact on future response to fertility treatment and/or fecundity.
Abstract: Objective To compare the relative long-term effects on ovarian reserve of treating fibroids in reproductive-aged women with uterine artery embolization (UAE) versus laparoscopic myomectomy (LM), using sensitive measures including antral follicle count (AFC) and serum anti-Mullerian hormone (AMH). Methods We undertook a retrospective cohort pilot study to evaluate the utility and feasibility of carrying out a larger prospective trial. Thirteen women were evaluated in this study, including eight in the UAE group and five in the LM group. They were identified from a larger group of 125 women who had undergone LM and 200 women who had undergone UAE at a participating institution at least 12 months previously; of these, 32 who had UAE and 27 who had LM were of reproductive age and eligible to participate. Participants had an assessment of ovarian reserve including measurements of serum AMH, estradiol, and FSH, and ultrasound assessment of AFC and ovarian volume. Results Median serum AMH levels were significantly lower in women who had undergone UAE at least 12 months previously than in women who had undergone LM (0.78 ng/mL [range 0.67 to 1.28] vs. 2.17 ng/mL [range 1.17 to 2.38], P = 0.01). Median AFC per ovary was also significantly lower in women who had UAE than in those who had LM (3.5 [range 2 to 7] vs. 7 [range 6 to 11], P = 0.03). Median levels of FSH and E 2 and of ovarian volume were not significantly different between the two groups. Conclusion Reproductive-aged women who have undergone treatment of fibroids with UAE may have lower ovarian reserve over the long term (> 12 months) than women with fibroids treated with LM. This could have an adverse impact on future response to fertility treatment and/or fecundity. This finding may inform the choice of minimally invasive treatment for fibroids in reproductive-aged women who have not completed childbearing. It suggests that further study in this area is warranted before the application of UAE is expanded to young reproductive-aged women.
TL;DR: Women of advanced maternal age have significantly higher rates of depression than younger women, and research is required to determine if a program of targeted depression screening and prevention will help reduce the burden of illness among older mothers.
Abstract: Objective Postpartum depression is a relatively common and potentially debilitating condition but its relationship with advanced maternal age has not been adequately studied. We evaluated the relationship between age and depression in a population-based sample of Canadian women. Methods Data on women aged 20 to 44 years were obtained from the Canadian Community Health Survey, 2007 to 2008. Depression was defined using the Short-Form score from the Composite International Diagnostic Interview (depression defined as a score of≥5). Women were stratified according to whether they had a live birth within five years preceding the interview. Logistic regression was used to compare the prevalence of depression among women of advanced maternal age versus younger women after adjusting for education, marital status, and chronic disease. Results Among women who had delivered recently, 8.0% (207 of 2326) were depressed compared with 10% (597 of 5610) of women who had not recently delivered. The prevalence of depression in women who had recently delivered was significantly higher in women aged 40 to 44 years than in women aged 30 to 35 years (adjusted OR 3.72; 95% CI 2.15 to 6.41). Depression rates were not higher among older women who had not had a recent delivery (adjusted OR among women 40 to 44 years 0.75; 95% CI 0.56 to 1.01). Conclusion Women of advanced maternal age have significantly higher rates of depression than younger women. Research is required to determine if a program of targeted depression screening and prevention will help reduce the burden of illness among older mothers.
TL;DR: The clinical aspects of ovarian hyperstimulation syndrome are reviewed and recommendations on its prevention are provided to assist in the prevention of the condition when it occurs, and provision of appropriate supportive measures in the correct setting.
Abstract: Objective To review the clinical aspects of ovarian hyperstimulation syndrome and provide recommendations on its prevention. Options Preventative measures, early recognition, and prompt systematic supportive care will help avoid poor outcomes. Outcomes Establish guidelines to assist in the prevention of ovarian hyperstimulation syndrome, early recognition of the condition when it occurs, and provision of appropriate supportive measures in the correct setting. Evidence Published literature was retrieved through searches of Medline, Embase, and the Cochrane Library from 2011 to 2013 using appropriate controlled vocabulary ([OHSS] ovarian hyperstimulation syndrome and: agonist IVF, antagonist IVF, metformin, HCG, gonadotropin, coasting, freeze all, agonist trigger, progesterone) and key words (ovarian hyperstimulation syndrome, ovarian stimulation, gonadotropin, human chorionic gonadotropin, prevention). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to February 2013. 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 specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).
TL;DR: Although GHTN is the most common form of hypertension in pregnancy, most researchers have focused their efforts on PE because of its implications for maternal–fetal health, whereas information about the implications of a diagnosis of G HTN is much more limited.
Abstract: P complicating 5% to 8% of pregnancies, has been traditionally defined by an elevated blood pressure (over 140/90 mmHg on at least 2 occasions at least 6 hours apart) and proteinuria, at or beyond 20 weeks’ gestation.1,2 In 2013, the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy recommended that the definition of PE should be extended to include cases without evidence of proteinuria, provided that the hypertension is accompanied by evidence of end-organ involvement.2 PE is associated with an increased risk of adverse pregnancy outcome, including prematurity, placental abruption, and intrauterine growth restriction.3 In contrast, gestational hypertension is defined by an elevated BP at or beyond 20 weeks’ gestation in the absence of proteinuria1,2 and is considered to be a transient condition (Figure 1).1 The development of proteinuria later in pregnancy changes the final diagnosis to preeclampsia. Otherwise, the final diagnosis is determined according to a re-evaluation of BP recordings at approximately three months postpartum. For women who are then normotensive (the most common scenario4), the final diagnosis is transient HTN of pregnancy (Figure 1). Persistence of GHTN for more than three months postpartum is consistent with a diagnosis of chronic hypertension. For clinicians who provide management for women with hypertension in pregnancy, several issues are of interest with respect to the importance of distinguishing between GHTN and PE. The first is the long-standing controversy of whether GHTN is an independent clinical entity or merely a mild or pre-onset form of PE. A second and more practical issue is determining the risk of progression of GHTN to PE. A third issue is quantifying the degree to which GHTN is associated with adverse pregnancy outcomes. Although GHTN is the most common form of hypertension in pregnancy,5 most researchers have focused their efforts on PE because of its implications for maternal–fetal health, whereas information about the implications of a diagnosis of GHTN is much more limited. Herein, we attempt to summarize the most up to date information available to address these important clinical questions.
TL;DR: In this paper, the authors reviewed the evidence relating to the care of pregnant women living with HIV and the prevention of perinatal HIV transmission, and evaluated the impact of HIV on pregnancy outcome and the efficacy and safety of antiretroviral therapy.
Abstract: Objective This guideline reviews the evidence relating to the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. Prenatal care of pregnancies complicated by HIV infection should include monitoring by a multidisciplinary team with experts in this area. Outcomes Outcomes evaluated include the impact of HIV on pregnancy outcome and the efficacy and safety of antiretroviral therapy and other measures to decrease the risk of vertical transmission. Evidence Published literature was retrieved through searches of PubMed and The Cochrane Library in 2012 and 2013 using appropriate controlled vocabulary (HIV, anti-retroviral agents, pregnancy, delivery) and key words (HIV, pregnancy, antiretroviral agents, vertical transmission, perinatal transmission). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English or French. There were no date restrictions. Searches were updated on a regular basis and incorporated in the guideline to June 2013. 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 specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1).
TL;DR: Ethics and policy considerations merge in NIPT with regard to sex selection and support for persons living with disabilities and issues related to offering and promoting a privately available medical strategy in publicly funded institutions are presented.
Abstract: New technologies analyzing fetal DNA in maternal blood have led to the wide commercial availability of non-invasive prenatal testing (NIPT). We present here for clinicians the ethical and policy issues related to an emerging practice option. Although NIPT presents opportunities for pregnant women, particularly women who are at increased risk of having a baby with an abnormality or who are otherwise likely to access invasive prenatal testing, NIPT brings significant ethics and policy challenges. The ethical issues include multiple aspects of informed decision-making, such as access to counselling about the possible results of the test in advance of making a decision about participation in NIPT. Policy considerations include issues related to offering and promoting a privately available medical strategy in publicly funded institutions. Ethics and policy considerations merge in NIPT with regard to sex selection and support for persons living with disabilities.
TL;DR: In women admitted to hospital with preeclampsia, the serum uric acid concentration, corrected for gestational age via a Z score, is clinically useful in predicting adverse perinatal outcomes but not maternal outcomes.
Abstract: Objective Elevated serum uric acid is commonly observed in women with preeclampsia, but its utility in predicting adverse outcomes has recently been disputed. Our goal was to analyze data from a large cohort of women with preeclampsia to determine the utility of serum uric acid in predicting adverse maternal and perinatal outcomes. Methods Data were obtained from an ongoing international prospective study of women admitted to hospital with preeclampsia (Pre-eclampsia Integrated Estimate of RiSk). Univariate logistic regression was used to determine the relationship between serum uric acid concentration (both absolute and gestational-age corrected [ Z score]) and adverse outcomes (maternal and perinatal). Analyses were conducted to compare cohorts of women with preeclampsia as defined by hypertension and proteinuria versus hypertension and hyperuricemia. Results Uric acid Z score was associated with adverse perinatal outcome (OR 1.5; 95% CI 1.4 to 1.7) and had a point estimate>0.7 (area under the curve receiver operating characteristic 0.72; 95% CI 0.69 to 0.74). Serum uric acid concentration also showed a significant association with adverse maternal outcomes, but the point estimate was Conclusion In women admitted to hospital with preeclampsia, the serum uric acid concentration, corrected for gestational age via a Z score, is clinically useful in predicting adverse perinatal outcomes but not maternal outcomes.
TL;DR: Many of the recommendations made by study participants show how patient-centred models may address inequities in service delivery for LGBTQ people and for other patients who may have particular AHR service needs.
Abstract: Objective To determine what recommendations lesbian, gay, bisexual, trans, and queer (LGBTQ) people have for provision of assisted human reproduction (AHR) services to their communities. Methods Using a semi-structured guide, we interviewed a purposeful sample of 66 LGBTQ-identified individuals from across the province of Ontario who had used or had considered using AHR services since 2007. Results Participants were predominately cisgender (non-trans), white, same-sex partnered, urban women with relatively high levels of education and income. Participants made recommendations for changes to the following aspects of AHR service provision: (1) access to LGBTQ-relevant information, (2) adoption of patient-centred practices by AHR service providers, (3) training and education of service providers regarding LGBTQ issues and needs, (4) increased visibility of LGBTQ people in clinic environments, and (5) attention to service gaps of particular concern to LGBTQ people. Conclusion Many of the recommendations made by study participants show how patient-centred models may address inequities in service delivery for LGBTQ people and for other patients who may have particular AHR service needs. Our results suggest that service providers need education to enact these patient-centred practices and to deliver equitable care to LGBTQ patients.
TL;DR: UDCA treatment should be recommended for women with ICP to reduce adverse maternal and fetal outcomes.
Abstract: Objective : The benefits of ursodeoxycholic acid (UDCA) use for treating intra-hepatic cholestasis of pregnancy (ICP) remain uncertain. A 2010 Cochrane Review of randomized control trials was unable to recommend either for or against the use of UDCA in treating ICP. We conducted a meta-analysis of the literature, including both non-randomized studies (NRSs) and RCTs. The objective of the study was to determine if patients included in NRSs were comparable to those in RCTs, and to determine whether the inclusion of NRSs could strengthen the available evidence and guide clinical practice on UDCA use in women with ICP. Data sources We searched Medline (Ovid), Embase (Ovid), EMB Reviews, CINAHL (Ebsco), and Web of Knowledge (Thomson Reuters) for articles published from 1966 to June 2012. Study Selection We included all eligible RCTs of UDCA versus placebo or other treatments, and all NRSs comparing UDCA with any other treatment in women with ICP. Data Synthesis We included 11 RCTs (n=625 pregnancies) and six NRSs (n=211 pregnancies). The women included in RCTs and NRSs were comparable, but study quality was poorer for NRSs. Overall, women treated with UDCA had decreased pruritus in 73% of RCTs and in 100% of NRSs with available data. Liver function tests were improved in 82% of RCTs and in 100% of NRSs with available data. UDCA use did not affect the Caesarean section rate, but was associated with less prematurity, less use of neonatal intensive care units (data available in only 3/17 studies), and trends towards increased birth weight and decreased meconium staining. There were 0/356 stillbirths with UDCA and 3/399 stillbirths with comparator. Conclusion : UDCA treatment should be recommended for women with ICP to reduce adverse maternal and fetal outcomes.
TL;DR: The authors provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality.
Abstract: Objective
To provide updated guidelines for health care providers on the management of menopause in asymptomatic healthy women as well as in women presenting with vasomotor or urogenital symptoms and on considerations related to cardiovascular disease, breast cancer, urogynaecology, and sexuality.
TL;DR: Because of the high rates of poor obstetrical outcomes found in this prospective cohort, population-level screening for HCV in pregnancy should be considered.
Abstract: Objectives (1) To describe obstetrical and neonatal outcomes among a cohort of hepatitis C virus (HCV) infected women, comparing HCV RNA positive to HCV RNA negative women; (2) to characterize virologic and hepatic parameters associated with HCV infection during pregnancy; and (3) to describe the rate of HCV vertical transmission. Methods We prospectively enrolled 145 HCV-positive pregnant women across British Columbia between 2000 and 2003. Participating women were monitored during pregnancy and their infants were followed to assess them for HCV infection. Maternal HCV RNA was assessed close to delivery. Results Seventy percent of women reported injection drug use as their primary risk factor for HCV acquisition. Observed rates of intrauterine fetal death, preterm delivery, small for gestational age, and low birth weight infants were 3.4%, 17.9%, 11.3%, and 12.5%, respectively, without a significant association with maternal HCV RNA status. The rate of cholestasis was 5.6% in the HCV RNA-positive group (6/108) and 2.8% in the HCV RNA-negative group (1/37) ( P =0.496). Serum alanine aminotransferase levels decreased significantly through pregnancy, and were significantly higher in HCV RNA-positive women than in HCV RNA-negative women after controlling for cholestasis, co-infections, and alcohol consumption. Among the HCV RNA-positive women, the median FIB-4 score was 0.67 (IQR 0.56 to 0.76) in the first trimester, 0.74 (IQR 0.52 to 1.18) in the second trimester, and 0.89 (IQR 0.52 to 1.09) in the third trimester ( P =0.02). The median HCV viral load at delivery was 424 561 IU/mL. The vertical transmission rate was 4.7% in HCV RNA-positive women, with no cases in HCV RNA-negative women. Conclusion Because of the high rates of poor obstetrical outcomes found in this prospective cohort, population-level screening for HCV in pregnancy should be considered.
TL;DR: Evidence is provided that providing fertility-related information contributes to greater reproductive knowledge and may affect childbearing intentions and future research is warranted to examine the influence of fertility information on reproductive decision-making within a theoretical framework.
Abstract: Objective To examine the impact of providing fertility information on personal levels of fertility knowledge and intentions to delay childbearing. Methods Participants (n=69 young childless women) were randomly assigned to either an experimental (fertility-related) or control (alcohol-related) informational intervention group. Subsequent to the exposure to information, participants completed a questionnaire measuring fertility knowledge and intentions for reproduction. We predicted that the provision of fertility-related information would result in greater fertility knowledge and less intention to delay childbearing among young childless women. Results The young women exposed to the brief fertility information intervention were significantly more likely to respond correctly to questions testing their fertility knowledge, and reported less intention to delay childbearing than the young women in the control group. Conclusion This study provided evidence that providing fertility-related information contributes to greater reproductive knowledge and may affect childbearing intentions. Future research is warranted to examine the influence of fertility information on reproductive decision-making within a theoretical framework in order to ensure that subsequent information interventions maximize their effectiveness.
TL;DR: The risk of in utero infection through prenatal invasive procedures in women with hepatitis B, hepatitis C, and/or human immunodeficiency virus (HIV) infections is reviewed and non-invasive methods of prenatal risk assessment are recommended.
Abstract: Objective To review the risk of in utero infection through prenatal invasive procedures in women with hepatitis B, hepatitis C, and/or human immunodeficiency virus (HIV) infections. Outcomes Fetal and neonatal morbidity and mortality. Evidence Published literature was retrieved through searches of Medline, CINAHL, and the Cochrane Library using appropriate controlled vocabulary (amniocentesis, chorionic villus sampling, cordocentesis, fetal and neonatal infection) and key words (hepatitis B, hepatitis C, HIV). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies from 2002 to 2012 published in English or French. (Studies from 1966 to 2002 were previously reviewed in Clinical Practice Guideline No. 123.) Searches were updated on a regular basis and incorporated in the guideline to February 2014. 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 specialty societies. Values The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table).
TL;DR: Measurement of maternal adipose tissue depth at the time of routine first-trimester ultrasonography may provide additional information about maternal IR, beyond pre-pregnancy BMI.
Abstract: Background High pre-pregnancy body mass index is a known risk factor for gestational diabetes mellitus, but the contribution of abdominal adiposity to insulin resistance (IR) in pregnancy is not well understood We assessed the association between abdominal adiposity in early pregnancy and IR Methods We completed a prospective cohort study of 79 pregnant women Visceral adipose tissue (VAT) depth was measured by ultrasonography at 11 to 14weeks' gestation, at the time of routine fetal nuchal translucency assessment A two-hour 75g oral glucose tolerance test was subsequently completed at 16 to 22weeks' gestation and IR was estimated by the homeostatic model assessment of insulin resistance (HOMA-IR) as well as by the insulin sensitivity index Results After adjusting for maternal age, parity, ethnicity, and pre-pregnancy BMI, VAT depth explained 42% of the variance in HOMA-IR, which was slightly better than the variance in the multivariable model examining HOMA-IR and pre-pregnancy BMI (40%) For the insulin sensitivity index, the model variance values were 36% and 32%, respectively Conclusion Measurement of maternal adipose tissue depth at the time of routine first-trimester ultrasonography may provide additional information about maternal IR, beyond pre-pregnancy BMI
TL;DR: Obese women did not require significantly higher doses of gonadotropins for ovarian stimulation than normal weight individuals, and female obesity did not significantly affect the clinical outcomes of IVF treatment.
Abstract: Objective To examine the effect of body mass index on gonadotropin dose requirements for ovarian stimulation, as well as other clinical outcomes in women undergoing in vitro fertilization. Methods We performed a retrospective cohort study involving 752 women undergoing a total of 951 IVF or IVF-ICSI cycles at a private fertility clinic between January 2007 and May 2011. The 951 treatment cycles were divided into three groups according to the weight of the women involved: normal weight (BMI 2 , 461cycles), overweight (25≤BMI 2 , 277cycles), and obese (BMI≥30kg/m 2 , 179cycles). Total gonadotropin dose requirements and clinical IVF cycle outcomes (cycle cancellation, clinical pregnancy, and live birth) were compared between the three BMI groups. We performed multivariable analyses, adjusting for potential confounders such as age at cycle start, day 3 serum FSH level, smoking, presence of polycystic ovary syndrome, and duration of infertility. Results There were no significant differences between the three BMI groups for any of the IVF cycle outcomes measured, including the total FSH dose required for ovarian stimulation. The likelihood of cycle cancellation, clinical pregnancy, and live birth were not significantly different between normal weight, overweight, and obese women. Conclusion Obese women did not require significantly higher doses of gonadotropins for ovarian stimulation than normal weight individuals. At our centre, female obesity did not significantly affect the clinical outcomes of IVF treatment. However, given the conflicting results of existing studies, the effect of maternal obesity on IVF outcomes remains unclear.
TL;DR: A cohort of 15 women with PGAD who presented to a chronic non-cancer pain clinic in a large urban tertiary teaching hospital that provides pelvic and genital pain management found commonalities between cases of PGAD encountered in a chronic pain management clinic.
Abstract: Objective Persistent genital arousal disorder (PGAD) has been identified as a condition of often unprovoked genital arousal associated with a significant level of distress. PGAD is not well understood, and no definitive cause has been determined. The aim of this study was to gain a better understanding of the disorder and to seek commonalities between cases of PGAD encountered in a chronic pain management clinic. Method We reviewed a cohort of 15 women with PGAD who presented to a chronic non-cancer pain clinic in a large urban tertiary teaching hospital that provides pelvic and genital pain management. We conducted a series of interviews to examine medical history, history of presenting illness, and management. Descriptive statistics were used to examine the data. Results Findings were largely consistent with previous research on PGAD regarding symptomatology and aggravating and alleviating factors. Symptoms of genital pain, depression, and interstitial cystitis were found in over one half of the patients in this cohort. Previous antidepressant use, restless legs syndrome, and pudendal neuralgia were found in a number of cases. Pelvic varices and Tarlov cysts have been previously identified as possible contributors to PGAD, but these were not a common finding in our cohort. Conclusion Further research is needed to build on the current understanding of PGAD. Patients should be asked about persistent arousal as part of a sexual and reproductive history, especially in the case of common comorbidities.
TL;DR: The need to educate women of reproductive age and identifies particular patient populations in Canada that would most benefit from further education about infertility are demonstrated.
Abstract: Objective An increasing number of Canadian women are delaying child-bearing, despite a decrease in fertility with age. A longer duration of infertility is associated with a significant decrease in live birth rate, reinforcing the need for prompt access to fertility treatment. This study aimed to assess the fertility awareness of women attending a fertility clinic to determine whether fertility awareness is a factor in accessing treatment. Methods A quantitative cross-sectional survey evaluated fertility awareness and collected information about ethnicity, education level, and the duration of infertility for new patients. Fertility awareness was evaluated with questions about prevalence, causes, and treatment of infertility. Results The mean age of participants in the study was 34years (range 23 to 44; n=140). The duration of infertility before new patients first sought medical advice for infertility was less than one year in 52.9%, one to two years in 28.6%, two to three years in 12.9%, and four or more years in 5.0% of study participants. Fertility awareness was calculated as the percentage of correct responses to the survey questions. The mean fertility awareness for all study participants was 49.9% and this ranged from the lowest score of 9.1% to the highest score of 90.9% correct. Women waiting for longer than two years to seek medical help had lower fertility awareness ( P =0.038). In addition, fertility awareness was greater in women who had previously sought medical help for infertility from a family doctor, a gynaecologist, or another fertility clinic ( P =0.001). Higher fertility awareness correlated with a higher level of education (linear trend P P =0.025), but the age at which women of different ethnicities sought treatment was similar (ANOVA P =0.13). Conclusion Fertility awareness is associated with time to seek treatment, ethnicity, and level of education among new patients seeking medical treatment. This study demonstrates the need to educate women of reproductive age and identifies particular patient populations in Canada that would most benefit from further education about infertility.