Delay of Fetal Anatomy Ultrasound Assessment Based on Maternal Body Mass Index Does Not Reduce the Rate of Inadequate Visualization.

OBJECTIVES: To determine whether delay of initial anatomy ultrasound based on the maternal body mass index (BMI) reduces the rate of inadequate visualization compared to standard timing at 180/7 to 196/7 weeks. METHODS: A retrospective study of singleton anatomy assessments was conducted at a tertiary care center in the 2-year period before (A, 2012-2014) and after (B, 2014-2016) protocol initiation. Assessments in period B were scheduled on the basis of the BMI in the first trimester: lower than 25 kg/m2 , 180/7 to 196/7 weeks; 25 to 29.9 kg/m2 , 190/7 to 206/7 weeks; 30 to 34.9 kg/m2 , 200/7 to 216/7 weeks; 35 to 39.9 kg/m2 , 210/7 to 226/7 weeks; and 40 kg/m2 or higher, 220/7 to 236/7 weeks. In period A, assessments were scheduled between 180/7 and 196/7 weeks. The rate of inadequate visualization and repeated assessments in periods A and B were compared. Multivariable logistic regression, per-protocol, and BMI subgroup analyses were completed. RESULTS: In total, 3491 pregnancies in period A and 3672 in period B were included. In period B, 74% were scheduled per protocol; however, this rate decreased for higher-BMI categories (52% for BMI ≥40 kg/m2 ). The inadequate visualization rate was slightly higher in period B versus A (16.9% versus 15.0%; P = .03) and exceeded 35% for a BMI of 40 kg/m2 or higher, with or without delay. After adjusting for maternal age and fetal presentation, period B had small increased odds of inadequate visualization versus period A (adjusted odds ratio, 1.2; 95% confidence interval, 1.02-1.38). Repeated assessment rates were similar in periods B and A (14.0% versus 13.1%; P = .25). CONCLUSIONS: In pregnancies with obesity, a protocol delaying the initial assessment beyond 196/7 weeks based on the maternal BMI does not reduce the rate of inadequate visualization.

No. 239-Obesity in Pregnancy.

OBJECTIVE: To review the evidence and provide recommendations for the counselling and management of obese parturients. OUTCOMES: Outcomes evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. EVIDENCE: Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. 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 evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible.

No 129-L'exercice physique pendant la grossesse et le postpartum.

OBJECTIF: Énoncer une directive canadienne visant à informer les fournisseurs de soins obstétricaux des répercussions, pour la mère, le fœtus et le nouveau-né, des exercices de conditionnement aerobique et musculaire pendant la grossesse. RéSULTATS ATTENDUS: Effets sur la morbidité maternelle, fœtale et néonatale et mesures de la forme physique maternelle. PREUVES: Une recherche sur MEDLINE des articles, publiés en anglais de 1966 à 2002, appartenant aux catégories suivantes : études sur le conditionnement aérobique et musculaire chez des femmes ne faisant pas jusque-là d'exercice et chez des femmes actives avant leur grossesse, ainsi que des études sur les répercussions du conditionnement aérobique et musculaire sur les issues précoces et tardives de la grossesse ou sur les issues néonatales; rapports de synthèse et méta-analyses portant sur l'exercice pendant la grossesse. VALEURS: Les résultats recueillis ont été revus par la Société des obstétriciens et gynécologues du Canada (Comité de la pratique clinique - obstétrique), avec la participation de la Société canadienne de physiologie de l'exercice, et ils ont été classés suivant les critères d'évaluation des preuves établis par le Groupe de travail canadien sur l'examen de santé périodique. RECOMMANDATIONS: VALIDATION: Cette directive a été approuvée par le Comité de pratique clinique - obstétrique de la SOGC, par le Comité exécutif et par le Conseil de la SOGC, ainsi que par le Conseil d'administration de la Société canadienne de physiologie de l'exercice. PARRAINé PAR: la Société des obstétriciens et gynécologues du Canada et par la Société canadienne de physiologie de l'exercice.

No. 129-Exercise in Pregnancy and the Postpartum Period.

OBJECTIVE: To design Canadian guidelines advising obstetric care providers of the maternal, fetal, and neonatal implications of aerobic and strength-conditioning exercises in pregnancy. OUTCOMES: Knowledge of the impact of exercise on maternal, fetal, and neonatal morbidity, and of the maternal measures of fitness. EVIDENCE: MEDLINE search from 1966 to 2002 for English language articles related to studies of maternal aerobic and strength conditioning in a previously sedentary population, maternal aerobic and strength conditioning in a previouslyactive population, impact of aerobic and strength conditioning on early and late pregnancy outcomes, and impact of aerobic and strength conditioning on neonatal outcomes, as well as for review articles and meta-analyses related to exercise in pregnancy. VALUES: The evidence collected was reviewed by the Society of Obstetricians and Gynaecologists of Canada (SOGC Clinical Practice Obstetrics Committee) with representation from the Canadian Society for Exercise Physiology, and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on the Periodic Health Exam. RECOMMENDATIONS: VALIDATION: This guideline has been approved by the SOGC Clinical Practice Obstetrics Committee, the Executive and Council of SOGC, and the Board of Directors of the Canadian Society for Exercise Physiology. SPONSORS: This guideline has been jointly sponsored by The Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology.

We Should Proceed With Caution When It Comes to Antenatal Corticosteroids After 34 Weeks.

The Society for Maternal-Fetal Medicine recently released a statement supporting the use of antenatal corticosteroids for women at high risk of late preterm birth. This followed a trend of increasing use of antenatal corticosteroids after 34 weeks' gestation, based on evidence for decreased respiratory morbidity. The absolute benefits, however, are relatively small. We should balance this against the possible long-term harms of corticosteroids after 34 weeks before expanding the indications for their antenatal use.

Exercise and pregnancy in recreational and elite athletes: 2016 evidence summary from the IOC expert group meeting, Lausanne. Part 2-the effect of exercise on the fetus, labour and birth.

This is Part 2 of 5 in the series of evidence statements from the IOC expert committee on exercise and pregnancy in recreational and elite athletes. Part 1 focused on the effects of training during pregnancy and on the management of common pregnancy-related symptoms experienced by athletes. In Part 2, we focus on maternal and fetal perinatal outcomes.

Emergency Caesarean Section in Obese Parturients: Is a 30-Minute Decision-to-Incision Interval Feasible?

OBJECTIVE: To determine the effect of obesity on decision-to-incision and decision-to-delivery time intervals in emergency Caesarean section. METHODS: We performed a retrospective study of emergency Caesarean sections performed between 2005 and 2009. Indications for emergency Caesarean section were defined as those posing an immediate threat to the life of the mother or fetus. The primary outcomes were the time intervals from decision for emergency delivery to skin incision, and decision to delivery of the infant. The secondary outcome was a composite of poor neonatal outcomes comprising umbilical cord artery pH lt; 7.20, Apgar score lt; 7 at five minutes, admission to NICU, or neonatal death. RESULTS: A total of 232 women underwent emergency Caesarean section, and 140 of these met the inclusion criteria. At the time of delivery, 78/140 (55.7%) patients were categorized as obese (BMI ≥ 30kg/m2). The median decision-to-incision and decision-to-delivery intervals were significantly longer in the obese group, with a median delay of 4.5 minutes in both time intervals. Time-to-event analysis demonstrated prolongation of the decision-to-incision interval in the obese group (hazard ratio 0.71, P lt; 0.05). There was no difference in the neonatal composite outcome, but there was a significant reduction in median five-minute Apgar score in the obese group (P = 0.02). CONCLUSION: Obesity is associated with prolonged decision-to-incision and decision-to-delivery intervals, without associated neonatal morbidity, in a tertiary hospital setting. Further studies are required to assess the specific factors limiting expedient delivery in this population.

Objective : Déterminer l'effet de l'obésité sur les intervalles décision-incision et décision-accouchement en ce qui concerne la tenue d'une césarienne d'urgence. Méthodes : Nous avons mené une étude rétrospective portant sur les césariennes d'urgence menées entre 2005 et 2009. Les indications menant à la tenue d'une césarienne d'urgence ont été définies comme étant celles qui constituaient une menace immédiate pour la vie de la mère ou celle du fœtus. Les critères d'évaluation principaux ont été l'intervalle entre la décision de procéder à un accouchement d'urgence et l'exécution de l'incision cutanée, et l'intervalle entre cette décision et la naissance de l'enfant. Le critère d'évaluation secondaire était un composite de diverses mauvaises issues néonatales, dont un pH artériel (cordon ombilical) lt; 7,20, un indice d'Apgar lt; 7 à cinq minutes, l'admission à l'UNSI et le décès néonatal. Résultats : Au total, 232 femmes ont subi une césarienne d'urgence et 140 d'entre elles répondaient aux critères d'inclusion. Au moment de l'accouchement, 78/140 (55,7 %) patientes ont été catégorisées comme étant obèses (IMC ≥ 30kg/m2). Les intervalles décision-incision et décision-accouchement médians étaient considérablement plus longs dans le groupe des femmes obèses (délai médian de 4,5 minutes pour ce qui est de ces deux intervalles). L'analyse du délai avant la survenue de l'événement a démontré la prolongation de l'intervalle décision-incision au sein du groupe des femmes obèses (rapport de risque, 0,71; P lt; 0,05). Bien qu'aucune différence n'ait été constatée en ce qui concerne l'issue composite néonatale, une baisse significative de l'indice d'Apgar médian à cinq minutes a été observée au sein du groupe des femmes obèses (P = 0,02). Conclusion : L'obésité est associée à une prolongation des intervalles décision-incision et décision-accouchement, sans répercussions connexes sur la morbidité néonatale, en milieu hospitalier tertiaire. La tenue d'autres études s'avère requise pour l'évaluation des facteurs particuliers qui limitent la tenue d'un accouchement en temps opportun au sein de cette population.

Creation of plastinated placentas as a novel teaching resource for medical education in obstetrics and gynaecology.

INTRODUCTION: Knowledge of the gross anatomy of the placenta is fundamental in order to help identify potential complications during pregnancy. The placenta is difficult to study without a three-dimensional appreciation of its structure. The aim of this study was to develop a collection of plastinated placenta specimens and accompanying clinical educational materials to provide learning resources for placental abnormalities and their associated pregnancy outcomes. These plastinates and educational modules were used as teaching resources for both undergraduate and post-graduate medical trainees in Obstetrics and Gynaecology. METHODS: Placentas were plastinated by S10 silicone plastination. Clinical education materials were created that included ultrasound images, photographs and information on the associated pregnancy outcomes. Utility of the plastinates was assessed using questionnaires completed by 70 medical students and 33 attendees at the 8th and 9th Annual International Human Placenta Workshop held at Queen's University, Kingston, ON. Attendees included graduate students, post-doctoral fellows, medical residents, research investigators and clinicians. RESULTS: Data collected demonstrated that 76.7% of medical student (n = 60) and 78.1% of Placenta Workshop attendees (n = 32) preferred plastinates as a supplemental learning resource compared to textbooks and images alone (36.7% and 37.5% respectively). All respondents also expressed the desire to have plastinated placentas available for future learning opportunities. DISCUSSION: Plastinated placentas are a valuable addition as teaching resources for many demographic groups with an interest in placental anatomy and pathology. Medical trainees and residents in Obstetrics and Gynaecology would benefit from the availability of plastinates as educational tools.

Thromboembolism in the obese pregnant woman.

We sought to quantify the added risk of thromboembolism in the obese parturient, evaluate risk factors for thromboembolism in the obese parturient, and provide suggestions as to when and in what form thromboembolism prophylaxis should be considered. Although recent guidelines from national colleges and advisory groups have attempted to guide the clinician in thromboprophylaxis in the obese parturient, the lack of adequate prospective series and trials has lead to some contrary recommendations. The arbitrary use of bed rest in the obese patient is a significant risk factor for venous thromboembolism without proven benefit. Despite a paucity of gold standard evidence, the prevalence of obesity and its associated risk of venous thromboembolism warrants careful consideration for the use of thromboprophylaxis in the obese pregnant population. This is especially important in the presence of additional thromboembolism risk factors.

Brachial artery flow-mediated dilation is not affected by pregnancy or regular exercise participation.

Whether brachial artery FMD (flow-mediated dilation) is altered in pregnancy by 28-35 weeks compared with non-pregnant women remains controversial. The controversy may be due to limitations of previous studies that include failing to: (i) test non-pregnant controls in the mid-late luteal phase, (ii) account for effects of pregnancy on the dilatory shear stimulus, (iii) account for physical activity or (iv) control for inter-individual variation in the time to peak FMD. In the present study, brachial artery FMD was measured in 17 active and eight sedentary pregnant women (34.1±1.6 weeks of gestation), and in 19 active and 11 sedentary non-pregnant women (mid-late luteal phase). Decreased vascular tone secondary to increased shear stress contributes minimally to pregnancy-induced increases in baseline brachial artery diameter, as shear stress removal during distal cuff inflation in pregnant women did not reduce diameter to baseline levels observed in non-pregnant controls. Neither the shear stimulus nor the percentage FMD was affected by pregnancy or regular exercise. Continuous diameter measurements are required to control for delayed peak dilation during pregnancy (57±15 compared with 46±15 s; P=0.012), as post-release diameter measured at 60 or 55-65 s post-release underestimated FMD to a greater extent in non-pregnant than in pregnant women.

SOGC Clinical Practice Guidelines: Obesity in pregnancy. No. 239, February 2010.

OBJECTIVE: To review the evidence and provide recommendations for the counselling and management of obese parturients. OUTCOMES: OUTCOMES evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. EVIDENCE: Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. 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 evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible.

Modification of angiogenic factors by regular and acute exercise during pregnancy.

This cross-sectional study examined mechanisms through which exercise might alter preeclampsia risk by estimating the effects of acute and chronic exercise on angiogenic markers in healthy pregnant women with different amounts of regular exercise participation. Serum-soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), and soluble endoglin (sEng) were measured before and after 20 min of moderate-intensity cycle ergometry in normotensive, nonsmoking pregnant (16 active, 9 inactive, 34.1+/-1.6 wk gestation) and nonpregnant (15 active, 12 inactive, midlate luteal phase) women. Inactive women did not regularly exercise at an intensity that was sufficient to cause sweating. Active women exercised for at least 3 h/wk. Inactive pregnant women had significantly lower PlGF concentrations [median (interquartile range): 268 (159, 290) vs. 278 (221, 647) pg/ml, P=0.014] and higher sFlt-1 [5,180 (4,540, 5,834) vs. 4,217 (2,014, 5,481) pg/ml, P=0.005] and sEng concentrations [9.1 (7.7, 16.7) vs. 7.8 (6.5, 10.1) ng/ml, P=0.025] than active pregnant women. This effect of regular exercise participation was not observed in nonpregnant women. Acute exercise in pregnancy was not associated with antiangiogenic changes that might contribute to preeclampsia; rather, there was a small, but statistically significant, increase in PlGF following acute exercise in active pregnant women [278 (221, 647) vs. 335 (245, 628) pg/ml, P=0.014]. sFlt-1 increased significantly following acute exercise in inactive nonpregnant women [90 (86, 100) vs. 106 (101, 116) pg/ml, P=0.012], but not in active nonpregnant women. Regular exercise during pregnancy is associated with higher serum PlGF and lower sFlt-1 and sEng concentrations in late gestation, a difference that is unlikely to have predated the pregnancy.

Obesity in pregnancy.

OBJECTIVE: To review the evidence and provide recommendations for the counselling and management of obese parturients. OUTCOMES: Outcomes evaluated include the impact of maternal obesity on the provision of antenatal and intrapartum care, maternal morbidity and mortality, and perinatal morbidity and mortality. EVIDENCE: Literature was retrieved through searches of Statistics Canada, Medline, and The Cochrane Library on the impact of obesity in pregnancy on antepartum and intrapartum care, maternal morbidity and mortality, obstetrical anaesthesia, and perinatal morbidity and mortality. Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. There were no date or language restrictions. Searches were updated on a regular basis and incorporated in the guideline to April 2009. 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 evidence obtained was reviewed and evaluated by the Maternal Fetal Medicine and Clinical Practice Obstetric Committees of the SOGC under the leadership of the principal authors, and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: Implementation of the recommendations in this guideline should increase recognition of the issues clinicians need to be aware of when managing obese women in pregnancy, improve communication and consultation amongst the obstetrical care team, and encourage federal and provincial agencies to educate Canadians about the values of entering pregnancy with as healthy a weight as possible. RECOMMENDATIONS: 1. Periodic health examinations and other appointments for gynaecologic care prior to pregnancy offer ideal opportunities to raise the issue of weight loss before conception. Women should be encouraged to enter pregnancy with a BMI < 30 kg/m(2), and ideally < 25 kg/m(2). (III-B). 2. BMI should be calculated from pre-pregnancy height and weight. Those with a pre-pregnancy BMI > 30 kg/m(2) are considered obese. This information can be helpful in counselling women about pregnancy risks associated with obesity. (II-2B). 3. Obese pregnant women should receive counselling about weight gain, nutrition, and food choices. (II-2B). 4. Obese women should be advised that they are at risk for medical complications such as cardiac disease, pulmonary disease, gestational hypertension, gestational diabetes, and obstructive sleep apnea. Regular exercise during pregnancy may help to reduce some of these risks. (II-2B). 5. Obese women should be advised that their fetus is at an increased risk of congenital abnormalities, and appropriate screening should be done. (II-2B). 6. Obstetric care providers should take BMI into consideration when arranging for fetal anatomic assessment in the second trimester. Anatomic assessment at 20 to 22 weeks may be a better choice for the obese pregnant patient. (II-2B). 7. Obese pregnant women have an increased risk of Caesarean section, and the success of vaginal birth after Caesarean section is decreased. (II-2B). 8. Antenatal consultation with an anaesthesiologist should be considered to review analgesic options and to ensure a plan is in place should a regional anaesthetic be chosen. (III-B). 9. The risk of venous thromboembolism for each obese woman should be evaluated. In some clinical situations, consideration for thromboprophylaxis should be individualized. (III-B).

Low flow-mediated constriction occurs in the radial but not the brachial artery in healthy pregnant and nonpregnant women.

Radial artery diameter decreases when a wrist cuff is inflated to stop blood flow to distal tissue. This phenomenon, referred to as low flow-mediated vasoconstriction (L-FMC), was proposed as a vascular function test. Recommendations that L-FMC be measured concurrently with flow-mediated dilation (FMD) were based on radial artery data. However, cardiovascular disease prediction studies traditionally measure brachial artery FMD. Therefore, studies should determine whether L-FMC occurs in the brachial artery. The hypothesis that reduced shear causes L-FMC has not been tested. Brachial and radial artery L-FMC and FMD were assessed in active nonpregnant (n=17), inactive nonpregnant (n=10), active pregnant (n=15, 34.1+/-1.2 wk gestation), and inactive pregnant (n=8, 34.2+/-2.2 wk gestation) women. Radial artery diameter decreased significantly during occlusion in all groups (nonpregnant, -4.4+/-4.2%; pregnant, -6.4+/-3.2%). Brachial artery diameter did not change in active and inactive nonpregnant, and inactive pregnant women; however, the small decrease in active pregnant women was significant. Occlusion decreased shear rate in both arteries, yet L-FMC only occurred in the radial artery. Radial artery L-FMC was not correlated with the reduction in shear rate. L-FMC occurs in the radial but not the brachial artery and is not related to changes in shear rate. Positive correlations between L-FMC (negative values) and FMD (positive values) suggest that radial artery FMD may be reduced among women who experience greater L-FMC. Studies should clarify the underlying stimulus and mechanisms regulating L-FMC, and test the hypothesis that endothelial dysfunction is manifested as enhanced brachial artery L-FMC, but attenuated radial artery L-FMC.

Mechanisms of activity-related breathlessness in healthy human pregnancy.

We examined the contribution of alterations in central ventilatory control, static and dynamic respiratory mechanics and their interaction to exertional breathlessness in healthy human pregnancy. Detailed ventilatory, respiratory mechanical/muscular and perceptual responses to incremental cycle exercise were compared in the third trimester (TM(3)) and again approximately 5 months post-partum (PP) in women with (B, n = 12) and without (NB, n = 15) clinically significant activity-related breathlessness (measured by the baseline dyspnea index). In contrast to NB, breathlessness intensity ratings were significantly higher at any given work rate during exercise in TM(3) versus PP within B. This difference could not be explained by differences in central ventilatory control or respiratory mechanical/muscular factors. When compared with NB, the B group had an exaggerated ventilatory response to exercise in PP and TM(3), and appeared to lack central desensitization to the perceptual effects of maternal hyperventilation that was manifest within the NB group. In conclusion, gestational breathlessness could not be explained by alterations in central ventilatory control or respiratory mechanical/muscular factors, but reflected the normal awareness of increased ventilation.