Delays to Surgery in Emergency Department Cases of Ectopic Pregnancy: A Quality Improvement Study.

OBJECTIVE: Create a process map for emergency department (ED) presentations of surgical ectopic pregnancy, and identify areas of management amenable to quality improvement. METHODS: A retrospective chart review of all patients undergoing surgical management of ectopic pregnancy at a large, urban, academic tertiary care centre from 2015 to 2017 was performed. RESULTS: Seventy-three patients were included. There were 6 (8.2%) unstable A cases (recommended time to operating room [OR] 0-2 hours), 23 (31.5%) stable A cases, and 44 (60%) B cases (recommended time to OR 2-8 hours). The percent of patients who were in the OR within the recommended time window were 6 (100%) for unstable A cases, 13 (56%) stable A cases, and 29 (65.9%) stable B cases, respectively (P = 0.139). Notable time delays include the time from gynaecology referral to the time seen by gynaecology (29.7% of total wait time for stable A cases from ED to OR) and the time the OR was booked to the time the patient was brought to the OR (53.2% of total wait time for stable B cases). Of the patients seen by physician at the emergency department first, the time from triage to the OR was significantly shorter for patients that received bedside ultrasound only (0.67 ± 0.5 hours vs. 2.1 ± 1.8 hours [P = 0.007]). CONCLUSION: This is the first study to map the ED presentation of surgical ectopic pregnancy. The management of ectopic pregnancy would benefit from the development of surgical triage decision aids, a surgical care pathway, and increased use of screening bedside ultrasound.

Short Cervix Following Initial Cerclage-Reinforcing Cerclage Versus Expectant Management.

OBJECTIVES: To determine whether reinforcing cerclage following ultrasound evidence of cerclage failure before 24 weeks is an effective method to delay gestational age at delivery, and to decrease the rate of preterm and peri-viable delivery. METHODS: A retrospective review was conducted for all patients who underwent any cervical cerclage procedure at a single tertiary care centre in Toronto, Canada between 1 December 2007 and 31 December 2017. RESULTS: Of 1482 cerclage procedures completed during the study period, 40 pregnant persons who underwent reinforcing cerclage were compared with 40 pregnant persons who were found to have cerclage failure before 24 weeks but were managed expectantly. After adjusting for the shortest cervical length measured prior to 24 weeks, there was no significant difference between the reinforcing cerclage and control group for gestational age at delivery, preterm, or peri-viable birth (P = 0.52, P = 0.54, P = 0.74, respectively). In an unadjusted model, there was a statistically significant increase in placental infection identified on postpartum placenta pathology in the reinforcing cerclage group compared with the expectant management group, 92.9% compared with 66.7% (P = 0.028). CONCLUSION: Reinforcing cerclage is unlikely to successfully delay the gestational age at delivery and reduce rates of preterm and pre-viable birth, especially if irreversible and progressive cervical change has begun. Future work should examine the role of preoperative amniocentesis to explore the impact of pre-existing intra-amniotic infection and reinforcing cerclage success.

Obstetric risks and outcomes of refugee women at a single centre in Toronto.

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 (< 37 weeks' gestational age), low birth weight (< 2500 g), and delivery by Caesarean section. 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.

Objectifs : Pendant la grossesse, les réfugiées pourraient être exposées à l'itinérance, à des carences alimentaires et à un accès limité aux soins de santé, et pourtant, les issues de grossesse que connaît cette population vulnérable n'ont pas fait l'objet d'une évaluation systématique. Nous avons entrepris de mener une étude visant à déterminer le risque de constater des issues obstétricales et périnatales indésirables chez les réfugiées de Toronto. Méthodes : Au moyen d'un devis d'étude de cohorte rétrospective, nous nous sommes penchés sur les issues de grossesse connues par les réfugiées et les non-réfugiées ayant accouché au St. Michael's Hospital de Toronto entre le 1er janvier 2008 et le 31 décembre 2010. Les critères d'évaluation primaires ont été l'accouchement préterme (âge gestationnel < 37 semaines), le faible poids de naissance (< 2 500 g) et l'accouchement par césarienne. Résultats : Les réfugiées multipares présentaient un taux considérablement accru d'accouchement par césarienne (36,4 %) et un taux de nouveau-nés de faible poids de naissance équivalant à une fois et demie celui qui était associé aux non-réfugiées. Dans le cadre d'une analyse de sous-groupe par région d'origine, nous avons constaté que les femmes d'Afrique subsaharienne présentaient des taux considérablement plus élevés de césarienne et de nouveau-nés de faible poids de naissance que ceux des non-réfugiées (groupe témoin). De surcroît, par comparaison avec ces dernières, les réfugiées présentaient des taux considérablement accrus d'antécédents de césarienne, de séropositivité pour le VIH, d'itinérance, d'isolement social et de délais pour ce qui est de l'accès aux soins prénataux. Conclusions : Les réfugiées constituent une population exposée à des risques élevés qui présente des taux accrus d'issues obstétricales et périnatales indésirables. Ces constatations offrent des données préliminaires qui permettent d'orienter la mise en œuvre d'interventions de santé publique ciblées visant à répondre aux besoins de cette population vulnérable en matière de soins obstétricaux. Les récentes modifications qui ont été apportées au Programme fédéral de santé intérimaire ont souligné l'importance de l'identification et de l'atténuation des écarts constatés en matière d'issues de santé entre les populations réfugiées et non réfugiées.