Showing papers in "Journal of obstetrics and gynaecology Canada in 2021"

Guideline No. 410: Prevention, Screening, Diagnosis, and Pregnancy Management for Fetal Neural Tube Defects.

Abstract: 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).

Clinical Profile, Viral Load, Maternal-Fetal Outcomes of Pregnancy With COVID-19: 4-Week Retrospective, Tertiary Care Single-Centre Descriptive Study.

Abstract: Objective The COVID-19 pandemic raises a major concern about its severity in pregnancy, maternal-fetal outcomes, and risk of vertical transmission. We report a retrospective descriptive study of the clinical course and maternal-fetal outcomes of pregnant women with COVID-19. Methods This is a single-centre, retrospective study performed in a tertiary care hospital for pregnant women with COVID-19 in India. The medical records of all women who delivered in the COVID19 facility from May 5, 2020, to June 5, 2020, were reviewed independently. Data extracted from the records included demographic characteristics, obstetric details, comorbidities, disease severity, investigations, management, and information on neonates (birthweight, Apgar score, and perinatal complications). Results Among 348 women tested for SARS-CoV-2, 57 women (16.3%) were confirmed as positive based on quantitative reverse transcriptase polymerase chain reaction of the nasopharyngeal specimen. Most women (45; 78.9%) had a mild infection with favourable maternal-fetal outcomes. Three maternal deaths were associated with comorbidities. Five neonates tested positive for SARS-CoV-2, remained hemodynamically stable, and were subsequently discharged. Conclusions A majority of pregnant women with COVID-19 had mild disease and recovered with good perinatal outcomes. Women with comorbidities may have an increased risk of severe morbidity and mortality. The cycle threshold signifying the viral load and degree of infectivity can modify management during pregnancy. Long-term outcomes and the potential mother-to-child vertical/horizontal transmission need further study.

Impact of Endometriosis on Fatigue and Productivity Impairment in a Cross-Sectional Survey of Canadian Women

Abstract: Objective To evaluate fatigue burden and productivity impairments in Canadian women with a self-reported diagnosis of endometriosis (DxE). Methods From December 2018 to January 2019, Canadian women aged 18−49 years completed an online survey assessing fatigue via the Patient-Reported Outcomes Measurement Information System (PROMIS) Fatigue Short Form 6a questionnaire. Fatigue T-scores were compared between women with and without a DxE, by age and endometriosis symptom severity, using t tests. Women with a DxE completed the Work Productivity and Activity Impairment – Specific Health Problem (WPAI-SHP) questionnaire. The effects of age and hallmark endometriosis symptoms on productivity impairments were assessed via analysis of variance. Results Survey data included 2004 women with and 26 528 women without a DxE. Mean fatigue T-scores were 58.5 ± 10.1 in women with a DxE and 59.2 ± 10.1 in women with hallmark endometriosis symptoms (i.e., menstrual or non-menstrual pelvic pain/cramping, dyspareunia) versus 55.2 ± 9.4 in women without a DxE (both P Conclusions Canadian women with a DxE experience a substantial fatigue burden and significant productivity impairments.

Cannabis Use During the Pre-Conception Period and Pregnancy After Legalization.

Abstract: Objective There is limited evidence of the impact of cannabis legalization on the prevalence of cannabis use and use of other substances. The aim of this exploratory observational study was to compare rates of cannabis use, cigarette smoking, alcohol consumption, and the use of any street drugs during the preconception period and in pregnancy in two convenience samples of pregnant persons in British Columbia, Canada, before and after the legalization of cannabis. Methods Any pregnant person residing in British Columbia, aged >19 years, at any gestational age was eligible to participate. Pre- and post-legalization study participants were recruited between May and October 2018 and July 2019 and May 2020, respectively. Multivariate models were constructed to examine the effect of legalization on cigarette smoking and the use of cannabis, alcohol, and street drugs, adjusting for demographic, pre-pregnancy, and pregnancy confounders. Results From pre- to post-legalization, the prevalence of self-reported cannabis use during the preconception period increased significantly, from 11.74% (95% CI 9.19%–14.88%) to 19.38% (95% CI 15.45%–24.03%). Rates of cannabis use during pregnancy also increased from 3.64% (95% CI 2.32%–5.69%) before legalization to 4.62% (95% CI 2.82%–7.47%) after; however, this difference was not statistically significant. Adjusting for potential confounders, the post-legalization group had significantly higher odds of cannabis use during the preconception period (adjusted odds ratio 1.71; 95% CI 1.14–2.58) but not during pregnancy (adjusted odds ratio 1.66; 95% CI 0.75–3.65). Legalization was also not associated with significant changes in cigarette smoking, alcohol consumption, or the use of street drugs during the preconception period and pregnancy, after adjusting for potential confounders. Conclusion The preliminary evidence presented in this study shows that the legalization of cannabis was associated with 71% higher odds of cannabis use during the preconception period. Studies examining the effects of cannabis use on perinatal outcomes, as well as public health interventions and educational programs related to cannabis use, should include the preconception period as an area of focus.

Pregnancy Outcomes During the COVID-19 Pandemic in Canada, March to August 2020.

Abstract: Objective Several studies have documented changes in the rates preterm birth and stillbirth during the COVID-19 pandemic. We carried out a study to examine obstetric intervention, preterm birth, and stillbirth rates in Canada from March to August 2020. Methods The study included all singleton hospital deliveries in Canada (excluding Quebec) from March to August 2020 (and March to August for the years 2015–2019) with information obtained from the Canadian Institute for Health Information. Data for Ontario were examined separately because this province had the highest rates of COVID-19 in the study population. Rates and odds ratios with 95% confidence intervals (CIs) were used to quantify pregnancy-related outcomes. Results There were 136,445 and 717,905 singleton hospital deliveries in Canada (excluding Quebec) in from March to August 2020 and between March and August 2015–2019, respectively. Rates of obstetric intervention declined in early gestation in 2020. Odds ratios for labour induction and cesarean delivery at Conclusion Changes in labour induction and cesarean delivery at early gestation and other perinatal outcomes during the period of March to August 2020 highlight the need to reconsider the use and impact of obstetric services in pandemics as well as the need for timely perinatal surveillance.

Guideline No. 414: Management of Pregnancy of Unknown Location and Tubal and Nontubal Ectopic Pregnancies

Abstract: Objective To provide an evidence-based algorithm to guide the diagnosis and management of pregnancy of unknown location and tubal and nontubal ectopic pregnancy. Target Population All patients of reproductive age. Benefits, Harms, and Costs The implementation of this guideline aims to benefit patients with positive β-human chorionic gonadotropin results and provide physicians with a standard algorithm for expectant, medical, and surgical treatment of pregnancy of unknown location and tubal pregnancy and nontubal ectopic pregnancies. Evidence The following search terms were entered into PubMed/Medline and Cochrane in 2018: cesarean section, chorionic gonadotropin, beta subunit, human/blood, fallopian tubes/surgery, female, fertility, humans, infertility, laparoscopy, methotrexate, methotrexate/administration & dosage, methotrexate/therapeutic use, pregnancy (abdominal, angular, cervix, cornual, ectopic, ectopic/diagnosis, ectopic/diagnostic imaging, ectopic/drug therapy, ectopic/epidemiology, ectopic/mortality, ectopic/surgery, heterotopic, interstitial, isthmo-cervical, ovarian, tubal, unknown location), recurrence, risk factors, salpingectomy, salpingostomy, tubal pregnancy, ultrasonography, doppler ultrasonography, and prenatal. Articles included were randomized controlled trials, meta-analyses, systematic reviews, observational studies, and case reports. Additional publications were identified from the bibliographies of these articles. Only English-language articles were reviewed. 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 Obstetrician–gynaecologists, family physicians, emergency physicians, midwives, registered nurses, nurse practitioners, medical students, and residents and fellows. SUMMARY STATEMENTS (GRADE ratings in parentheses) 1Ectopic pregnancies account for the majority of first-trimester maternal deaths (high). 2Tubal pregnancies account for the majority of ectopic pregnancies (high). 3Pregnancy of unknown location is a transient state in the diagnostic process, leading to a final diagnosis of viable or nonviable intrauterine pregnancy, ectopic pregnancy, or persistent pregnancy of unknown location (high). 4Management protocols for pregnancy of unknown location are predictive and not diagnostic. They are formulated to risk stratify pregnancy of unknown location as either high or low risk for ectopic pregnancy (high). 5Methotrexate is a safe and effective treatment for carefully selected tubal and nontubal ectopic pregnancies (high). 6Expectant management of a tubal pregnancy can eliminate medication-related and surgical risks in carefully selected patients. However, expectant management can result in serious morbidity if it fails (low). 7There is no evidence to recommend conservative, tube-sparing salpingotomy over salpingectomy in the surgical management of the majority of tubal pregnancies (moderate). 8Ultrasound diagnosis of nontubal ectopic pregnancy requires experienced sonographers and radiologists (moderate). 9Providers should have a high index of suspicion for cervical ectopic pregnancy because severe outcomes often occur with delayed diagnosis and management (low). 10Women who will be undergoing treatment for a cervical pregnancy should be counselled about the risk of hemorrhage and the possible need for hysterectomy (low). 11The terms interstitial and cornual pregnancy are used interchangeably in the literature (low). 12Abdominal pregnancies are associated with high rates of maternal mortality owing to the high risk of catastrophic hemorrhage (low). 13Laparoscopy is often required for definitive diagnosis of ovarian pregnancy (very low). 14Spontaneous heterotopic pregnancies are rare (low). RECOMMENDATIONS (GRADE ratings in parentheses) 1We recommend the use of risk models (e.g., the M6 model) to stratify pregnancy of unknown location as either high or low risk for ectopic pregnancy to guide treatment decisions (strong, moderate). Tubal Pregnancies 2Clinicians can consider expectant management and very close follow-up in carefully selected patients with early, asymptomatic tubal pregnancies (conditional, low). 3If a patient meets the criteria for medical management of a tubal pregnancy, we suggest the single- or double-dose methotrexate protocol (conditional, moderate). 4If feasible, clinicians should use a minimally invasive approach in the surgical management of tubal pregnancy (strong, high). 5Consider both patient and surgeon factors when deciding between salpingectomy and salpingotomy; there is no evidence to recommend conservative, tube-sparing salpingotomy over salpingectomy when the contralateral fallopian tube is normal (conditional, low). Cesarean Scar Pregnancies 6Clinicians should consider medical management with multidose and/or local methotrexate as a safe and effective treatment in appropriately selected women with a cesarean scar pregnancy (conditional, moderate). 7Clinicians should consider treating type I cesarean scar pregnancies surgically with hysteroscopy (conditional, low). 8Clinicians should consider treating type II cesarean scar pregnancies surgically with laparoscopy (conditional, low). Cervical Pregnancies 9In appropriately selected cervical pregnancies, clinicians should offer medical management over surgical management with dilatation and curettage (conditional, low). Interstitial/Cornual Pregnancies 10Clinicians should offer conservative medical management with multidose and/or local methotrexate for interstitial or cornual pregnancies in appropriately selected patients (conditional, moderate). 11If surgery is required, clinicians may perform either laparoscopic cornuotomy or cornual wedge resection because both procedures have comparable results (conditional, low). Abdominal Pregnancies 12Clinicians may choose either laparotomy or laparoscopy to excise an abdominal pregnancy (conditional, low). Ovarian Pregnancies 13Clinicians may offer conservative medical management of ovarian pregnancies with methotrexate in appropriately selected patients (conditional, low). 14Clinicians can perform laparoscopic ovarian wedge resection rather than oophorectomy for ovarian ectopic pregnancies, if clinically appropriate (conditional, low). Heterotopic Pregnancies 15Clinicians should not offer systemic methotrexate in the presence of a desired intrauterine pregnancy (conditional, moderate). 16We suggest surgical excision of the ectopic pregnancy in cases of heterotopic pregnancy. If the intrauterine pregnancy is not desired, we conditionally recommend adding dilatation and curettage to the surgical procedure to evacuate the uterine cavity (conditional, moderate).

Guideline No. 420: Cytomegalovirus Infection in Pregnancy.

Abstract: Objective To provide an update on current recommendations for cytomegalovirus (CMV) infection during pregnancy. The objectives of this guideline are: •To improve perinatal care providers' awareness of the consequences of maternal CMV infection for the fetus and the infant; •To emphasize the importance of educating patients about how to prevent CMV acquisition during pregnancy •To raise perinatal care providers' awareness of new developments in CMV screening and treatment •To highlight that a substantial proportion of disability due to congenital CMV (cCMV) can be modified to some extent Target Population Patients of child-bearing age, pregnant patients, and patients planning a pregnancy. Benefits, Harms, and Costs The patient partners urged us to make awareness of preventive strategies a high priority, despite concern that discussing CMV with patients could cause unnecessary anxiety. CMV educational interventions have shown benefits from increased awareness of cCMV prevalence and preventive strategies among providers, patients, and families. Evidence We searched MEDLINE, EMBASE, and CENTRAL databases for CMV in pregnancy. The search terms were developed using MeSH terms and keywords (Appendix). The results were filtered for articles published between January 2010 and October 2020 and systematic reviews, meta-analyses, clinical trials, and observational studies. The main inclusion criteria were pregnant patients and infants, as the target population, and CMV infection, as the diagnosis of interest. Recommendations are graded according to the U.S. Preventive Services Task Force grade of recommendations and level of certainty. Validation Methods We collaborated with patient partners, including members of CMV Canada (cmvcanada.com). In formulating our recommendations, we included patients' voices to add a unique and valuable perspective, thus ensuring that our recommendations are relevant to the patient–provider partnership. Intended Audience All perinatal health care providers. RECOMMENDATIONS (grade and level of certainty in parentheses) 1Pregnant patients with a mononucleosis-like illness or undifferentiated hepatitis should be investigated for cytomegalovirus infection (C, low). 2To diagnose maternal cytomegalovirus infections and to differentiate primary from non-primary infections, this guideline recommends a combination of seroconversion (defined as documentation of a change from cytomegalovirus immunoglobulin G negative to positive), cytomegalovirus immunoglobulin M, and cytomegalovirus immunoglobulin G avidity testing (B, moderate). 3A positive immunoglobulin M result alone should be interpreted with caution when determining when a CMV infection was acquired (C, moderate). 4Breastfeeding is considered safe in patients who had CMV infection during pregnancy (B, high). 5If primary maternal CMV infection is diagnosed during pregnancy, or abnormal sonographic findings suggest congenital CMV infection, pregnant patients should be offered an amniocentesis for confirmation of fetal congenital infection (cCMV) at least 8 weeks after the estimated time of maternal infection (B, high). 6This guideline recommends discussing education and hygiene measures to prevent CMV acquisition with all patients, regardless of serologic status, before conception and through pregnancy, especially early in the antepartum period (B, high). 7CMV hyperimmune globulin should not be used to prevent congenital CMV if a primary CVM infection is diagnosed during pregnancy (B, low). 8In the case of documented primary CMV infection in the first trimester, early treatment with valacyclovir can be considered (B, moderate). 9For established congenital CMV infections during pregnancy, decisions concerning treatment options should be made in a shared process involving patients and experienced teams (C, low). 10In provinces where CMV IgG avidity testing is available, screening for CMV primary infection in the first trimester (using IgG and IgM antibodies followed by IgG avidity testing if the patient is IgM-positive) can be offered, especially in women at high risk (those who have a child under 3 years at home). CMV screening in pregnancy is not recommended in provinces where CMV IgG avidity testing is unavailable (C, low).

Guideline No. 413: Surgical Management of Apical Pelvic Organ Prolapse in Women.

Abstract: Objective To compare success and complication rates of apical suspension procedures for the surgical management of symptomatic uterine or vaginal vault prolapse Target population Women with symptomatic uterine or vaginal vault prolapse seeking surgical correction Options Interventions included abdominal apical reconstructive repairs (sacrocolpopexy, sacrohysteropexy, or uterosacral hysteropexy) via open, laparoscopic, or robotic approaches; vaginal apical reconstructive repairs (vault suspensions or hysteropexy, sacrospinous, uterosacral, iliococcygeus, McCall's, or Manchester types); and vaginal obliterative procedures (with or without uterus in situ) Individual procedures or broad categories of procedures were compared: (1) vaginal versus abdominal routes for reconstruction, (2) abdominal procedures for reconstruction, (3) vaginal procedures for reconstruction, (4) hysterectomy and suspension versus hysteropexy for reconstruction, and (5) reconstructive versus obliterative options Outcomes The Urogynaecology Committee selected outcomes of interest: objective failure (obtained via validated pelvic organ prolapse [POP] quantification systems and defined as overall objective failure as well as failure rate by compartment); subjective failure (recurrence of bulge symptoms determined subjectively, with or without use of a validated questionnaire); reoperation for POP recurrence; complications of postoperative lower urinary tract symptoms (de novo or postoperative stress urinary incontinence; reoperation for persistent, recurrent, or de novo stress urinary incontinence; urge urinary incontinence; and voiding dysfunction); perioperatively recognized urinary tract injury (bladder or ureter); other complications (mesh exposure, defined as mesh being visible and exposed in the vagina, and non-sexual pelvic pain); and sexual function (de novo dyspareunia and sexual function score according to a validated questionnaire) Benefits, harms, and costs This guideline will benefit patients seeking surgical correction of apical POP by improving counselling on surgical treatment options and possible outcomes It will also benefit surgical providers by improving their knowledge of various surgical approaches Data presented could be used to develop frameworks and tools for shared decision-making Evidence We searched Medline, the Cochrane Central Register of Controlled Trials (CENTRAL), and Embase from 2002 to 2019 The search included multiple terms for apical POP surgical procedures, approaches, and complications We excluded POP repairs using transvaginal mesh and studies that compared procedures without apical suspension We included randomized controlled trials and prospective or retrospective comparative studies We limited language of publication to English and French and accessibility to full text A systematic review and meta-analysis was performed 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 users Gynaecologists, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with POP Summary statements All statements refer to correction of apical vaginal prolapse in the short and medium term (up to 5 years), except when otherwise specified

Database Autopsy: An Efficient and Effective Confidential Enquiry into Maternal Deaths in Canada.

Abstract: Background Maternal death surveillance in Canada relies on hospitalization data, which lacks information on the underlying cause of death. We developed a method for identifying underlying causes of maternal death, and quantified the frequency of maternal death by cause. Methods We used data from the Discharge Abstract Database for fiscal years 2013 to 2017 to identify women who died in Canadian hospitals (excluding Quebec) while pregnant or within 1 year of the end of pregnancy. A sequential narrative based on hospital admission(s) during and after pregnancy was constituted and reviewed to assign the underlying cause of death (based on the World Health Organization's framework). Maternal deaths (i.e., while pregnant or within 42 days after the end of pregnancy) and late maternal deaths (i.e., more than 42 days to a year after the end of pregnancy) were examined separately. Results We identified 85 maternal deaths. Direct obstetric causes included 8 deaths (9%) related to complications of spontaneous or induced abortion; 9 (11%), to hypertensive disorders of pregnancy; 15 (18%), to obstetric hemorrhage; 11 (13%), to pregnancy-related infection; 16 (19%), to other obstetric complications; and Conclusions The majority of maternal deaths in Canada have direct obstetric causes, whereas most late maternal deaths have indirect obstetric causes. Suicide is an important direct cause of late maternal death.

Opioid and Cannabis Use During Pregnancy and Breastfeeding in Relation to Sociodemographics and Mental Health Status: A Descriptive Study.

Abstract: Objective This study of Canadian women estimates the prevalence of opioid and cannabis use during pregnancy and cannabis use during the breastfeeding period and explores the sociodemographic and mental health characteristics associated with use. Methods A total of 13 000 women who gave birth between January and June 2018 were invited to participate in the Survey on Maternal Health by Statistics Canada; 7111 women participated for a response rate of 54.7%. Participants were asked about their mental health, supports during pregnancy, and substance use. Multivariable logistic regression was used to describe the relationship between sociodemographic and mental health characteristics and substance use during pregnancy and while breastfeeding. Results The prevalence of self-reported opioid use during pregnancy was 1.4% (95% confidence interval [CI] 1.1%–1.8%). A higher proportion of women reported using cannabis during pregnancy and while breastfeeding, at 3.1% (95% CI 2.5%–3.6%) and 2.6% (95% CI 2.1%–3.1%), respectively. Younger age, not being in a relationship, lower level of education, and thoughts of self-harm were significantly associated with cannabis use during pregnancy. Lower level of education and thoughts of self-harm were also significantly associated with cannabis use while breastfeeding, as were symptoms of postpartum depression and/or generalized anxiety. Lower level of education and symptoms of postpartum depression and/or generalized anxiety were also significantly associated with opioid use during pregnancy. Conclusion The results of this survey show relatively low levels of opioid and cannabis use during pregnancy and cannabis use while breastfeeding in Canada. Different sociodemographic and mental health characteristics are associated with the use of these substances, and public health interventions and policies should take into account these factors.

Perinatal Mental Healthcare Needs Among Women at a Community Hospital.

Abstract: Objective Mental health problems affect up to 20% of women during pregnancy and the postpartum period. This study aimed to describe the mental health services and resources accessed by women with perinatal mental health problems (PMH) and to identify their unmet mental health care needs and preferences for support, as well as the barriers to accessing this support. Methods Participants were 18 years of age or older and spoke English or French. Consent was obtained 24 hours after delivery (T0) to screen for symptoms of depression and anxiety at 2 weeks postpartum (T1) using the Edinburgh Postnatal Depression Scale (EPDS) and the Generalized Anxiety Disorder Scale (GAD-7). Women with a positive screen (EPDS ≥10 or GAD-7 ≥10) were sent informational resources and were followed-up by telephone at 4 months postpartum (T2) to determine their use of these and other resources, their unmet needs, and their preferences for other resources or services. Results Seventy-three out of 344 participants (21.2%) screened positive, of whom 57 (78%) completed the T2 interview. Of those interviewed, 28% had used the informational resources provided by the study. Although 25% had consulted a health professional for mental health care, 37% had unmet mental health care needs. Preferences for additional support included web-based resources (30%), telephone support (28%), and booklets (25%). Lack of time (38%) and lack of childcare (23%) were the main barriers to seeking help. Conclusions Web- and telephone-based approaches have the potential to address the most common barriers to access support for women experiencing perinatal mental health problems.

Guideline No. 408: Management of Gestational Trophoblastic Diseases.

Abstract: Objective This guideline reviews the clinical evaluation and management of gestational trophoblastic diseases, including surgical and medical management of benign, premalignant, and malignant entities. The objective of this guideline is to assist health care providers in promptly diagnosing gestational trophoblastic diseases, to standardize treatment and follow-up, and to ensure early specialized care of patients with malignant or metastatic disease. Intended users General gynaecologists, obstetricians, family physicians, midwives, emergency department physicians, anaesthesiologists, radiologists, pathologists, registered nurses, nurse practitioners, residents, gynaecologic oncologists, medical oncologists, radiation oncologists, surgeons, general practitioners in oncology, oncology nurses, pharmacists, physician assistants, and other health care providers who treat patients with gestational trophoblastic diseases. This guideline is also intended to provide information for interested parties who provide follow-up care for these patients following treatment. Target population Women of reproductive age with gestational trophoblastic diseases. Options Women diagnosed with a gestational trophoblastic disease should be referred to a gynaecologist for initial evaluation and consideration for primary surgery (uterine evacuation or hysterectomy) and follow-up. Women diagnosed with gestational trophoblastic neoplasia should be referred to a gynaecologic oncologist for staging, risk scoring, and consideration for primary surgery or systemic therapy (single- or multi-agent chemotherapy) with the potential need for additional therapies. All cases of gestational trophoblastic neoplasia should be discussed at a multidisciplinary cancer case conference and registered in a centralized (regional and/or national) database. Evidence Relevant studies from 2002 onwards were searched in Embase, MEDLINE, the Cochrane Central Register of Controlled Trials, and Cochrane Systematic Reviews using the following terms, either alone or in combination: trophoblastic neoplasms, choriocarcinoma, trophoblastic tumor, placental site, gestational trophoblastic disease, hydatidiform mole, drug therapy, surgical therapy, radiotherapy, cure, complications, recurrence, survival, prognosis, pregnancy outcome, disease outcome, treatment outcome, and remission. The initial search was performed in April 2017 and updated in May 2019. Relevant evidence was selected for inclusion in the following order: meta-analyses, systematic reviews, guidelines, randomized controlled trials, prospective cohort studies, observational studies, non-systematic reviews, case series, and reports. Additional significant articles were identified through cross-referencing the identified reviews. The total number of studies identified was 673, with 79 studies cited in this review. Validation methods The content and recommendations were drafted and agreed upon by the authors. The Executive and Board of Directors of the Society of Gynecologic Oncology of Canada reviewed the content and submitted comments for consideration, and the Board of Directors for the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology framework. See the online appendix tables for key to grading and interpretation of recommendations. Benefits These guidelines will assist physicians in promptly diagnosing gestational trophoblastic diseases and urgently referring patients diagnosed with gestational trophoblastic neoplasia to gynaecologic oncology for specialized management. Treating gestational trophoblastic neoplasia in specialized centres with the use of centralized databases allows for capturing and comparing data on treatment outcomes of patients with these rare tumours and for optimizing patient care. Summary statements (grade ratings in parentheses) RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Guideline No. 422a: Menopause: Vasomotor Symptoms, Prescription Therapeutic Agents, Complementary and Alternative Medicine, Nutrition, and Lifestyle.

Abstract: Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. 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 physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1 The vast majority of women in mid-life experience menopausal symptoms, the hallmark being vasomotor symptoms. A significant portion of these women have severe symptoms that greatly affect their quality of life (high). 2 For the management of vasomotor symptoms, menopausal hormone therapy is the most effective option and can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (high). 3 Options for menopausal hormone therapy for vasomotor symptoms in women with a uterus include estrogen-progestogen therapy, a tissue-selective estrogen complex, or tibolone. Estrogen alone can be used in women who have had a hysterectomy (high). 4 The safety and efficacy of compounded bioidentical hormone therapy have not been assessed with the same rigour as those of menopausal hormone therapy products approved by Health Canada (moderate). 5 Non-hormonal prescription therapies, including certain antidepressant agents, gabapentinoids, clonidine, and oxybutynin, may offer some relief from hot flashes but have their own adverse effects (moderate). 6 There is emerging evidence that cognitive behavioural therapy may have positive effects on vasomotor symptoms (high). 7 There is insufficient evidence to support the effectiveness of any one natural health product for the management of moderate to severe hot flashes (low). 8 A healthy diet during menopause can reduce the risk of future chronic conditions, aid in weight management, and improve energy levels (high). RECOMMENDATIONS 1 Health care providers should offer menopausal hormone therapy as the most effective option for managing vasomotor symptoms (strong, high). 2 Menopausal hormone therapy can be safely initiated in women without contraindications who are younger than 60 years of age or less than 10 years post-menopause (strong, high). 3 Menopausal hormone therapy should be individualized after careful consideration of symptoms, medical conditions, health risks, family history, treatment goals, patient preferences, and timing of last menstrual period (strong, high). 4 Duration of menopausal hormone therapy should be individualized to the patient, based on ongoing symptoms, benefits, and personal risks. Periodic re-evaluation of menopausal hormone therapy is recommended (strong, high). 5 Women who have experienced loss of ovarian function or with decreased ovarian function before the age of 45 years should consider replacement hormone therapy until the average age of menopause (strong, high). 6 Estrogen-progestogen regimens can be continuous (i.e., estrogen-progestogen taken every day) or follow a cyclic regimen, with estrogen taken every day and progestogen taken for 12–14 days every month. In women with hysterectomy, estrogen alone can be taken every day (strong, high). 7 Options for perimenopausal women include progestogen alone, low-dose combined hormonal contraceptives, menopausal hormone therapy, or estrogen in combination with a levonorgestrel-releasing intrauterine system. (strong, moderate) 8 Non-hormonal prescription therapies can be considered when hormone therapy is contraindicated or not desired (strong, moderate). 9 For cultural traditional therapies, women should be offered the opportunity to work with a cultural leader; health care providers can discuss this option in partnership with women, in order to ensure cultural humility and cultural safety (strong, moderate).

Family History of Hypertension, Cardiovascular Disease, or Diabetes and Risk of Developing Preeclampsia: A Systematic Review.

Abstract: Preeclampsia is a severe pregnancy complication with high potential for adverse effects on maternal and fetal health during the perinatal period. It is also associated with an increased risk of maternal cardiovascular disease later in life. Development of preeclampsia can be decreased by prescribing low-dose aspirin to high-risk women. At present, maternal and pregnancy factors are used to assess the risk of preeclampsia. One additional factor that could add to the assessment of risk is a family history of hypertension, cardiovascular disease, or diabetes, especially for nulliparous women who do not have a pregnancy history to inform treatment decisions. Therefore, we conducted a systematic review to assess the association between family history of the aforementioned conditions and preeclampsia. Four databases including MEDLINE, EMBASE, the Cochrane Library, and CINAHL/pre-CINAHL were searched for observational studies that examined a family history of hypertension, cardiovascular disease, or diabetes in women with preeclampsia and in a control population. Studies were evaluated for quality using the Newcastle-Ottawa Scale. A total of 84 relevant studies were identified. A meta-analysis was not conducted due to suspected heterogeneity in the included studies. Most studies reported a positive association between a family history of hypertension or cardiovascular disease and the development of preeclampsia. The majority of studies examining family history of diabetes reported non-significant associations. Overall, family history of hypertension or cardiovascular disease is associated with a higher risk for developing preeclampsia and should be considered when assessing women in the first trimester for low-dose aspirin.

Guideline No. 422b: Menopause and Genitourinary Health.

Abstract: Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. 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 physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population.

A Systematic Review of the Cost of Chronic Pelvic Pain in Women.

Abstract: Objective To systematically summarize the evidence on costs related to chronic pelvic pain (CPP) for women. Data sources Electronic databases (MEDLINE, EMBASE, PubMed, and Cochrane Library) were searched for English and French articles published from 1990 to January 2021 Study selection Of 1304 articles screened, 67 were screened in full-text form, and a total of 13 articles were included in the final analysis. Articles included involved cost studies that estimated hospital or health system costs for pelvic pain, dysmenorrhea, dyspareunia, endometriosis with pain, interstitial cystitis, or painful bladder syndrome. Data extraction and synthesis A standardized form was created to extract study setting, design, and population; patient demographics; study duration; and reported costs of CPP components and amounts. Two independent reviewers completed the data extraction, and discrepancies were resolved through discussion with a third reviewer. Conclusion Estimated health care costs ranged from US$1367 to US$7043 per woman per year. Prescription costs ranged from US$193 to US$2457 per woman per year. Indirect costs ranged from US$4216 to US$12 789 per woman per year. Combined costs ranged from US$1820 to US$20 898 per woman per year. The yearly costs of CPP varied according to country; yearly costs were estimated to be $2.8 billion, ¥191,680 to ¥246,488, and $16 970 to $20 898 per woman per year in the United Sates, Japan, and Australia, respectively. The literature suggests that CPP represents a considerable economic burden on women and health care systems internationally, with indirect costs contributing a significant portion of total costs.

Guideline No. 421: Point of Care Ultrasound in Obstetrics and Gynaecology

Abstract: Objective To provide an opinion regarding the usefulness of point of care ultrasound in obstetrics and gynaecology. Target Population Women with pregnancy-related complications or issues who could benefit from an urgent bedside sonographic evaluation. Options Point of care ultrasound is a readily accessible option, requiring few resources. Benefits, Harms, and Costs This low-cost imaging option can expedite appropriate patient management, enhance provider confidence, and allay the patient's anxiety in a timely fashion. However, there is potential for error in imaging or interpretation, resulting in incorrect and potentially harmful patient management. Evidence MEDLINE, PubMed, Embase, and the Cochrane Library weres earched from 2009 to 2019. Medical Subject Headings (MeSH) and keywords were related to pregnancy, PoCUS, point of care ultrasound, and bedside ultrasound. This document represents an abstraction of the evidence rather than a methodological review. 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 Providers of urgent care for pregnant women (obstetricians and gynaecologists, family physicians, emergency room physicians, midwives, nurse practitioners, nurses). SUMMARY STATEMENT (GRADE ratings in parentheses) 1 Point of care ultrasound can provide timely and valuable information for management of several complications or issues that arise during pregnancy, labour and delivery, and the postpartum period (low). RECOMMENDATIONS (GRADE ratings in parentheses) 1 All units providing urgent care to pregnant women (including labour and delivery services) should strive to provide 24-hour access to point of care ultrasound (conditional, low). 2 Training, accreditation, and quality assurance for point of care ultrasound should be guided by standards established by regional or local health authorities or local regulatory or credentialing bodies (conditional, low).

Endometriosis in Canada: It Is Time for Collaboration to Advance Patient-Oriented, Evidence-Based Policy, Care, and Research.

Abstract: Endometriosis is an enigmatic, painful, complex disease that affects approximately 1 million people in Canada. The disease can involve multiple organ systems, often resulting in debilitating chronic pain and infertility. Social, medical, geographic, and other factors are implicated in years-long diagnostic delays and may limit access to care. An integrated approach from bench to bedside to community is urgently required. A pan-Canadian collaboration among patients, clinicians and researchers will improve endometriosis awareness, provide best practices, and link research across Canada.

Guideline No. 411: Vaginal Pessary Use

Abstract: Objective To review the use, care, and fitting of pessaries. Target population Women requiring the use of vaginal pessaries for pelvic organ prolapse and/or stress urinary incontinence. Use may also be indicated for women with certain pregnancy-related clinical scenarios, including incarcerated uterus. Options Pessaries are an option for women presenting with prolapse and/or stress urinary incontinence. In addition, certain types of pessaries can be considered for patients with cervical insufficiency or incarcerated uterus. Outcomes Most women with prolapse or stress urinary incontinence can be successfully fitted with a pessary and experience excellent symptom relief, high satisfaction rates, and minimal complications. Benefits, harms, and costs Women with pelvic organ prolapse and/or stress urinary incontinence may choose to use a pessary to manage their symptoms rather than surgery or while waiting for surgery. Major complications have been seen only when pessaries are neglected. Minor complications such as vaginal discharge, odour, and erosions can usually be successfully treated. Evidence Medline was searched for relevant articles up to December 2018. This is an update of the SOGC technical update published in 2013, which was the first internationally published guidance on pessary use. Subsequently, an Australian guideline on the use of pessaries for the treatment of prolapse was published later in 2013. Validation methods The authors rated the quality of evidence and strength of recommendations using the approach of the Canadian Task Force on Preventive Health Care (Appendix A). Intended audience Gynaecologists, obstetricians, family physicians, physiotherapists, residents, and fellows. SUMMARY STATEMENTS 1Most women can be successfully fitted with a pessary to treat the symptoms of pelvic organ prolapse or stress urinary incontinence (II-2). 2Satisfaction rates for pessary use are very high (I). 3Some vaginal pessaries may prevent recurrence of incarcerated uterus (III). 4The role of pessaries specifically designed to prevent preterm labour is not yet elucidated (I). 5Complications associated with pessary use are usually minor, with vaginal discharge being the most common problem (II-3). 6Vaginal erosions can be treated with removal of the pessary and optional vaginal estrogen supplementation (II-2). RECOMMENDATION 1Pessaries should be considered in all women presenting with bothersome pelvic organ prolapse and/or stress urinary incontinence (I, A).

Screening and Testing Pregnant Patients for SARS-CoV-2: First-Wave Experience of a Designated COVID-19 Hospitalization Centre in Montreal.

Abstract: Objective Coronavirus disease 2019 (COVID-19) may present asymptomatically in a large proportion of cases in endemic areas. Accordingly, universal testing has been suggested as a potential strategy for reducing transmission in the obstetrical setting. We describe the clinical characteristics of patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during pregnancy at a designated COVID-19 hospitalization centre in Montreal, Quebec. Methods A single-centre retrospective cohort was constructed to include all pregnant patients who tested positive for SARS-CoV-2 between March 22 and July 31, 2020, and received care at the Jewish General Hospital. Initially, testing was restricted to at-risk patients, identified through the use of a screening questionnaire. Beginning on May 15, 2020, universal testing was implemented, and all pregnant patients admitted to the hospital were tested. Data were collected through chart review. Results Of 803 patients tested for SARS-CoV-2 during the study period, 41 (5%) tested positive. Among those patients who were symptomatic, the most commonly reported symptoms were cough (53%), fever (37%), dyspnea (30%), and anosmia and/or ageusia (20%). Before the implementation of universal testing, 13% (3 of 24) of patients with SARS-CoV-2 were asymptomatic. After implementation of universal testing, 80% (8 of 10) of patients with SARS-CoV-2 were asymptomatic. Conclusion Our findings suggest that most pregnant patients with SARS-CoV-2 are asymptomatic or have mild symptoms of COVID-19. Particularly in endemic areas, universal testing of pregnant patients presenting to the hospital should be strongly considered as an important measure to prevent in-hospital and community transmission of COVID-19.

Guideline No. 416: labour, delivery, and postpartum care for people with physical disabilities

Abstract: 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).

Preeclampsia-Like Syndrome in a Pregnant Patient With Coronavirus Disease 2019 (COVID-19).

Abstract: Background Hypertension, proteinuria, and hepatic dysfunction have been described as manifestations of coronavirus disease 2019 (COVID-19) and are generally accepted as poor prognostic factors. However, these same findings can also occur in pregnant women with preeclampsia, thus creating a diagnostic challenge. Case We report a case of COVID-19 infection in an otherwise healthy pregnant patient with secondary hypertension, proteinuria, and significant hepatic dysfunction. Maternal placental growth factor (PlGF) testing was used to rule out preeclampsia. The patient received supportive care and improved significantly. She went on to have a spontaneous vaginal term delivery of a healthy male baby. Conclusion COVID-19 infection in pregnancy may present as preeclampsia-like syndrome. PlGF testing can be used to differentiate preeclampsia from COVID-19 and facilitate appropriate management.

Prevalence of endometriosis and peritoneal pockets in women with infertility and/or pelvic pain

Abstract: Objective To evaluate the prevalence of endometriosis and peritoneal pockets and to analyze whether these pockets are associated with pain. Methods Analysis of prospectively registered data of all women undergoing laparoscopy for infertility or pelvic pain between 1988 and 2011 at KU Leuven University Hospital. Results Of 4497 women, 191 had 238 pockets, with a prevalence of 4.7% in women with infertility only, 4.9% in women with infertility and pelvic pain, and 3.5% in women with pelvic pain only (P = 0.045 for all infertility vs. pelvic pain only). Prevalence did not vary by age. Pockets were associated with endometriosis (P Conclusions The prevalence of pockets was low, at between 3.5% and 5%. Women with infertility only and pockets had more endometriosis than women without. Severe pelvic pain and pelvic pain as an indication for surgery were associated with the presence of pockets as well as the presence and severity of endometriosis.

Association Between Bowel Obstruction or Intussusception and Endometriosis.

Abstract: Objective To evaluate the association between endometriosis and bowel obstruction or intussusception using a large population database. Methods This was a population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP‐NIS) from 2005 to 2014. We studied women aged 18 to 55 years without inflammatory bowel disease or cancer. Multivariate logistic regression was used to examine the association between endometriosis and bowel obstruction. Results Of the 18 427 520 women who met the criteria for inclusion, 96 539 had experienced bowel obstruction, for an overall prevalence of 52 per 10 000, and 3825 had experienced intussusception, for an overall prevalence of 2 per 10 000. When adjusted for sociodemographic characteristics, women with pelvic endometriosis had a consistently higher likelihood of bowel obstruction (odds ratio [OR] 2.6; 95% confidendence interval [CI] 2.3–3.00, P Conclusions Pelvic endometriosis, in particular rectovaginal and intestinal endometriosis is strongly associated with bowel obstruction, independent of the presence of intra-abdominal adhesions. We did not find any association between pelvic endometriosis and intussusception.

Idiopathic Intracranial Hypertension in Pregnancy.

Abstract: Idiopathic intracranial hypertension (IIH) is a syndrome characterized by elevated intracranial pressure without an identifiable underlying cause. Pregnancy has unique and important diagnostic and therapeutic implications for patients with IIH. Despite these implications, there are no guidelines to assist clinicians in managing IIH during pregnancy. Our review aims to summarize the key considerations related to the diagnosis and management of IIH during pregnancy, to optimize the care of these patients and mitigate the risk of disease-related complications. The optimal management of IIH in pregnancy should include a multidisciplinary team, including an obstetrician (or maternal-fetal medicine specialist), a neurologist, and an ophthalmologist (or neuro-ophthalmologist).

Aspirin for Endometrial Preparation in Patients Undergoing IVF: A Systematic Review and Meta-analysis

Abstract: Objective To investigate the effect of aspirin on IVF success rates when used as an adjuvant treatment for endometrial preparation. Data Sources Relevant publications were comprehensively selected from PubMed, MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) up to November 15, 2020. Study Selection Randomized controlled trials (RCTs) and retrospective cohort studies that used aspirin as an adjuvant treatment for endometrial preparation and reported subsequent pregnancy outcomes were included. Studies were excluded if aspirin was used before and/or during ovarian stimulation. Data Extraction and Synthesis This systematic review and meta-analysis included a total of 7 studies. Risk of bias assessment was based on the methodology and categories listed in the Cochrane Handbook for the RCTs and the Newcastle-Ottawa scale for the retrospective studies. The primary outcome was live birth rate. Summary measures were reported as odds ratios (ORs) with 95% confidence intervals (CIs). There was significant evidence that aspirin for endometrial preparation improved live birth rates (OR 1.52; 95% CI 1.15–2.00). No effect was noted for clinical pregnancy rates (OR 1.37; 95% CI 1.00–1.87); however, aspirin was associated with improved pregnancy rates in a subgroup analysis of patients receiving oocyte donation (OR 2.53; 95% CI 1.30–4.92) and in the sensitivity analysis (OR 1.3; 95% CI 1.02–1.66). No effect of aspirin was found for implantation or miscarriage rates (OR 1.31; 95% CI 0.51–3.36 and OR 0.41; 95% CI 0.02–7.42, respectively). Conclusion These findings support a beneficial effect of aspirin for endometrial preparation on IVF success rates, mainly live birth rates, outside the context of ovarian stimulation. However, this evidence is based on poor quality data and needs to be confirmed with high-quality RCTs.

Sentinel Lymph Node Sampling as an Alternative to Lymphadenectomy in Patients With Endometrial Cancer and Obesity.

Abstract: Objective Although its use in endometrial cancer staging is relatively new, sentinel lymph node (SLN) sampling has been shown to be highly accurate and is associated with few complications. However, some studies report lower rates of detection with SLN sampling among patients with obesity. The aim of the current study is to evaluate the feasibility of SLN sampling in endometrial cancer for patients with obesity, and to determine whether omitting lymph node dissection (LND) in surgical staging using SLN sampling impacts oncologic outcomes. Methods we conducted a retrospective study of patients with obesity (BMI ≥35 kg/m2), diagnosed with endometrial carcinoma between 2007 and 2017, that compared surgical and oncologic outcomes of 2 cohorts: patients who underwent LND and patients who underwent SLN without lymphadenectomy. The primary outcome was operative time. Secondary outcomes included intraoperative bleeding; lymph node assessment information; intraoperative and postoperative adverse events; and oncologic outcomes including progression-free survival (PFS), overall survival (OS), and disease-specific survival (DSS). PFS was defined as the time from surgery to the recurrence or death from any cause. OS was defined as time from diagnosis to death or the last date the patient was known to be alive, and DSS was defined as the time from the surgery to death from the disease. Results Out of 223 patients with a median BMI of 40.6 kg/m2, 140 underwent LND and 83 underwent SLN alone. The median operative time for patients in the SLN group was shorter than that of patients in the LND group (190.5 [range 108–393] vs. 238 [131–440] min; P Conclusions In patients with obesity, omitting LND from surgical staging with SLN sampling was associated with shorter operative times and less bleeding and did not affect survival at 2 years.

Standardized Postpartum Follow-Up for Women with Pregnancy Complications: Barriers to Access and Perceptions of Maternal Cardiovascular Risk.

Abstract: Objective Certain obstetrical complications are known to increase a woman's risk of future cardiovascular disease (CVD). The Maternal Health Clinic (MHC) provides postpartum cardiovascular risk counselling and follow-up; however, half of women referred do not attend. This study aimed to identify barriers to access, as well as whether attendance at the MHC improved the accuracy of patients' CVD risk perception. Methods MHC patients completed a CVD risk perception questionnaire prior to being assessed and 3 months after their appointment ("attendees"). Calculated lifetime CVD risk scores were compared with perceived risk to assess accuracy of risk perception. Patients who did not attend their MHC appointment ("non-attendees") were administered the questionnaire by phone and asked about perceived barriers to access. Results Sixty-seven of 137 eligible attendees (48.9%) completed both the pre- and post-MHC questionnaires. Significantly more participants accurately estimated their absolute CVD risk after their MHC appointment, although the majority continued to underestimate their risk. Among non-attendees, 81 of 130 women (62.3%) completed the questionnaire. The most common barriers to access cited were being too busy with childcare, accessing follow-up with the patient's family doctor instead, and difficulty attending their appointment. Conclusion Lack of time and inconvenience were two common barriers to accessing the MHC. Improved collaboration with primary care providers and use of telemedicine may help to mitigate these issues. Both attendees and non-attendees appeared to have an inadequate perception of CVD risk. Standardized postpartum CVD risk screening and counselling may be an effective method of providing these women with risk education and improving the accuracy of their risk perception.

First-Trimester Preterm Preeclampsia Screening in Nulliparous Women: The Great Obstetrical Syndrome (GOS) Study.

Abstract: Objectives To estimate the ability of a combination of first-trimester markers to predict preterm preeclampsia in nulliparous women. Methods We conducted a prospective cohort study of nulliparous women with singleton gestations, recruited between 110 and 136 weeks gestation. Data on the following were collected: maternal age; ethnicity; chronic diseases; use of fertility treatment; body mass index; mean arterial blood pressure (MAP); serum levels of pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), alpha fetoprotein (AFP), free beta human chorionic gonadotropin (s-hCG); and mean uterine artery pulsatility index (UtA-PI). We constructed a proportional hazard model for the prediction of preterm preeclampsia selected based on the Akaike information criterion. A receiver operating characteristic curve was created with the predicted risk from the final model. Our primary outcome was preterm preeclampsia and our secondary outcome was a composite of preeclampsia, small for gestational age, intrauterine death, and preterm birth. Results Among 4659 nulliparous women with singleton gestations, our final model included 4 variables: MAP MoM, log10PlGF MoM, log10AFP MoM and log10UtA-PI MoM. We obtained an area under the curve of 0.84 (95% CI 0.75–0.93) with a detection rate of preterm preeclampsia of 55% (95% CI 37%–73%) and a false-positive rate of 10%. Using a risk cut-off with a false-positive rate of 10%, the positive predictive value for our composite outcome was 33% (95% CI 29%–37%). Conclusions The combination of MAP, maternal serum PlGF and AFP, and UtA-PI are useful to identify nulliparous women at high risk of preterm preeclampsia but also at high risk of other great obstetrical syndromes.