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INTRODUCTION: The aim of this study was to pilot test a question prompt list (QPL) about cardiovascular disease (CVD) risk reduction after hypertensive pregnancy (HDP). METHODS: In a prospective cohort study of adult women who had HDP given the QPL before and surveyed after a physician visit, we assessed perceived person-centred care, self-efficacy for self-management, perceived self-management and QPL feasibility. RESULTS: Twenty-three women participated: 57% of diverse ethno-cultural groups, 65% < 40 years of age and 48% immigrants. Most scored high for person-centred care (mean 4.1 ± 0.2/5); and moderately for self-efficacy (mean 7.4 ± 0.6/10) and self-management (mean 3.1 ± 0.3/5). Most appreciated QPL design and reported QPL benefits: helped them to prepare for the visit and know what to ask; increased confidence to ask questions, knowledge of the link between HDP and CVD and lifestyle behaviours to reduce CVD risk. Most reported that physicians were receptive to discussing QPL questions. CONCLUSION: Women appreciated the QPL and knowledge about self-management was high but self-efficacy for or perceived self-management was moderate. It appears feasible to share a QPL with ethno-culturally diverse women who can share it with physicians to facilitate discussions about post-pregnancy HDP-related CVD risk. PATIENT OR PUBLIC CONTRIBUTION: This study involved women who experienced HDP and engaged ethno-culturally diverse women with lived experience of HDP as study advisors in all stages of the research.
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Doenças Cardiovasculares , Humanos , Feminino , Projetos Piloto , Adulto , Gravidez , Estudos Prospectivos , Doenças Cardiovasculares/prevenção & controle , Autoeficácia , Hipertensão Induzida pela Gravidez/prevenção & controle , Inquéritos e Questionários , Comportamento de Redução do Risco , Pessoa de Meia-Idade , AutogestãoRESUMO
BACKGROUND: Severe maternal morbidity is a composite indicator of maternal health and obstetrical care. Little is known about the risk of recurrent severe maternal morbidity in a subsequent delivery. OBJECTIVE: This study aimed to estimate the risk of recurrent severe maternal morbidity in the next delivery after a complicated first delivery. STUDY DESIGN: We analyzed a population-based cohort study of women with at least 2 singleton hospital deliveries between 1989 and 2021 in Quebec, Canada. The exposure was severe maternal morbidity in the first hospital-recorded delivery. The study outcome was severe maternal morbidity at the second delivery. Log-binomial regression models adjusted for maternal and pregnancy characteristics were used to generate relative risks and 95% confidence intervals comparing women with and without severe maternal morbidity at first delivery. RESULTS: Among 819,375 women, 43,501 (3.2%) experienced severe maternal morbidity in the first delivery. The rate of severe maternal morbidity recurrence at second delivery was 65.2 vs 20.3 per 1000 in women with and without previous severe maternal morbidity (adjusted relative risk, 3.11; 95% confidence interval, 2.96-3.27). The adjusted relative risk for recurrence of severe maternal morbidity was greatest among women who had ≥3 different types of severe maternal morbidity at their first delivery, relative to those with none (adjusted relative risk, 5.50; 95% confidence interval, 4.26-7.10). Women with cardiac complication at first delivery had the highest risk of severe maternal morbidity in the next delivery. CONCLUSION: Women who experience severe maternal morbidity have a relatively high risk of recurrent morbidity in the subsequent pregnancy. In women with severe maternal morbidity, these study findings have implications for prepregnancy counseling and maternity care in the next pregnancy.
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Serviços de Saúde Materna , Obstetrícia , Gravidez , Feminino , Humanos , Estudos de Coortes , Risco , CanadáRESUMO
BACKGROUND: We examined the risk of severe life-threatening morbidity in pregnant patients with Covid-19 infection. METHODS: We conducted a population-based study of 162,576 pregnancies between March 2020 and March 2022 in Quebec, Canada. The main exposure was Covid-19 infection, including the severity, period of infection (antepartum, peripartum), and circulating variant (wildtype, alpha, delta, omicron). The outcome was severe maternal morbidity during pregnancy up to 42 days postpartum. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between Covid-19 infection and severe maternal morbidity using adjusted log-binomial regression models. RESULTS: Covid-19 infection was associated with twice the risk of severe maternal morbidity compared with no infection (RR 2.02, 95% CI 1.76-2.31). Risks were elevated for acute renal failure (RR 3.01, 95% CI 1.79-5.06), embolism, shock, sepsis, and disseminated intravascular coagulation (RR 1.35, 95% CI 0.95-1.93), and severe hemorrhage (RR 1.49, 95% CI 1.09-2.04). Severe antepartum (RR 13.60, 95% CI 10.72-17.26) and peripartum infections (RR 20.93, 95% CI 17.11-25.60) were strongly associated with severe maternal morbidity. Mild antepartum infections also increased the risk, but to a lesser magnitude (RR 3.43, 95% CI 2.42-4.86). Risk of severe maternal morbidity was around 3 times greater during circulation of wildtype and the alpha and delta variants, but only 1.2 times greater during omicron. CONCLUSIONS: Covid-19 infection during pregnancy increases risk of life-threatening maternal morbidity, including renal, embolic, and hemorrhagic complications. Severe Covid-19 infection with any variant in the antepartum or peripartum periods all increase the risk of severe maternal morbidity.
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COVID-19 , Coagulação Intravascular Disseminada , Complicações Infecciosas na Gravidez , Feminino , Gravidez , Humanos , SARS-CoV-2 , CanadáRESUMO
BACKGROUND: Individuals with hypertensive disorders of pregnancy (HDP) have an elevated lifetime risk of chronic hypertension, metabolic syndrome, and premature cardiovascular disease. Because breastfeeding duration and exclusivity have been associated in observational studies with improved cardiovascular health, optimizing breastfeeding in those with HDP might be an unrealized cardio-prevention approach, in particular because individuals with HDP have more breastfeeding challenges. Breastfeeding supportive interventions targeting one's breastfeeding self-efficacy have been shown to improve breastfeeding rates. METHODS: We designed an open-label, multi-center 1:1 randomized behavioral trial to test whether a previously validated self-efficacy enhancing breastfeeding intervention can improve breastfeeding duration and/or exclusivity, and lower postpartum blood pressure at 12 months. Randomization is computer-generated and stratified by site (four hospitals in Montreal, Quebec and one hospital in Kingston, Ontario; all in Canada). Included are breastfeeding participants with HDP (chronic/gestational hypertension or preeclampsia) who delivered a live singleton infant at > 34 weeks, speak English or French, and have no contraindications to breastfeeding. Informed and written consent is obtained at hospitalization for delivery or a re-admission with hypertension within 1 week of discharge. Participants assigned to the intervention group receive a breastfeeding self-efficacy-based intervention delivered by a trained lactation consultant in hospital, with continued reactive/proactive support by phone or text message for up to 6 months postpartum. Regardless of group assignment, participants are followed for self-reported outcomes, automated office blood pressure, and home blood pressure at several time points with end of follow-up at 12 months. DISCUSSION: This study will assess whether an intensive nurse-led behavioral intervention can improve breastfeeding rates and, in turn, postpartum blood pressure - an early marker for atherosclerotic cardiovascular disease. If effective, this form of enhanced breastfeeding support, along with closer BP and metabolic surveillance, can be implemented broadly in individuals lactating after HDP. TRIAL REGISTRATION: ClinicalTrials.gov, # NCT04580927 , registered on Oct 9, 2020.
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Doenças Cardiovasculares , Hipertensão Induzida pela Gravidez , Pré-Eclâmpsia , Lactente , Gravidez , Feminino , Humanos , Aleitamento Materno , Pressão Sanguínea , Lactação , Autoeficácia , Período Pós-Parto , Ontário , Ensaios Clínicos Controlados Aleatórios como Assunto , Estudos Multicêntricos como AssuntoRESUMO
OBJECTIVES: To quantify the risk of severe maternal morbidity (SMM) in fresh versus frozen-thawed embryo transfers (ETs) among pregnancies conceived by in vitro fertilization (IVF) and to assess SMM risk according to the number of fresh ETs prior to the index pregnancy. METHODS: Retrospective cohort study using the provincial birth registry in Ontario, Canada. We included 13 929 individuals aged 18-55 years who conceived via IVF between January 1, 2013, and March 5, 2018, and delivered a live or stillborn infant ≥20 weeks gestation. We compared the primary outcome, a composite of SMM or death, between fresh and frozen ETs. RESULTS: A total of 174 individuals who conceived via fresh ETs had SMM (30.7 per 1000), compared with 280 among individuals who received frozen ETs (33.9 per 1000); adjusted risk ratio (aRR) 0.85 (95% CI 0.70-1.04). Compared with frozen ET, fresh ET was associated with a lower risk of severe hemorrhage (aRR 0.63; 95% CI 0.48-0.82) but no difference in risk of preeclampsia. Among individuals with 1 (n = 211) or ≥2 (n = 88) prior fresh cycles, the risk of SMM was not increased compared with having no prior cycles; aRR 0.96 (95% CI 0.78-1.18) and 0.91 (95% CI 0.67-1.25), respectively. CONCLUSION: Fresh ET was associated with a lower risk of severe hemorrhage compared with frozen ET. These findings may be partly explained by the increased popularity of a freeze-all strategy, reserving fresh ETs for patients with fewer comorbidities.
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Transferência Embrionária , Fertilização in vitro , Feminino , Gravidez , Humanos , Ontário/epidemiologia , Estudos Retrospectivos , Fertilização in vitro/efeitos adversos , Hemorragia , CriopreservaçãoRESUMO
BACKGROUND: To synthesize existing evidence on Black-White disparities in the prevalence of severe cardiovascular maternal morbidity. METHODS: We searched MEDLINE, EMBASE, and CINAHL for observational studies published before July 31, 2021 that compared the risk of severe cardiovascular maternal morbidity between Black and White women. The outcome was severe cardiovascular maternal morbidity, including acute myocardial infarction, peripartum cardiomyopathy, and stroke during pregnancy, delivery, or postpartum. We extracted relevant information including adjusted and unadjusted effect estimates. We used random-effects models to estimate the pooled association between race and severe cardiovascular maternal morbidity, presented as odds ratios with 95% confidence intervals for the comparison of Black women relative to White women. RESULTS: We included 18 studies that met the eligibility criteria for systematic review and meta-analysis. All studies were conducted in the United States and included a total of 7,656,876 Black women and 26,412,600 White women. Compared with White women, Black women had an increased risk of any severe cardiovascular maternal morbidity (adjusted odds ratio, 1.90; 95% confidence interval, 1.54-2.33). Black women were at risk of acute myocardial infarction (adjusted odds ratio, 1.38; 95% confidence interval, 1.14-1.68), peripartum cardiomyopathy (adjusted odds ratio, 1.71; 95% confidence interval, 1.51-1.94), and stroke (adjusted odds ratio, 2.13; 95% confidence interval, 1.39-3.26). CONCLUSIONS: Black women have a considerably higher risk of severe cardiovascular maternal morbidity than White women, including acute myocardial infarction, peripartum cardiomyopathy, and stroke. Reducing inequality in adverse cardiovascular outcomes of pregnancy between Black and White women should be prioritized.
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Cardiomiopatias , Infarto do Miocárdio , Transtornos Puerperais , Acidente Vascular Cerebral , Feminino , Humanos , Gravidez , Infarto do Miocárdio/epidemiologia , Transtornos Puerperais/epidemiologia , Estados Unidos/epidemiologia , Brancos , Negro ou Afro-AmericanoRESUMO
STUDY QUESTION: Is the risk of attention-deficit hyperactivity disorder (ADHD) increased in children born to mothers with infertility, or after receipt of fertility treatment, compared to mothers with unassisted conception? SUMMARY ANSWER: Infertility itself may be associated with ADHD in the offspring, which is not amplified by the use of fertility treatment. WHAT IS KNOWN ALREADY: Infertility, and use of fertility treatment, is common. The long-term neurodevelopmental outcome of a child born to a mother with infertility, including the risk of ADHD, remains unclear. STUDY DESIGN, SIZE, DURATION: This population-based cohort study comprised all singleton and multiple hospital births in Ontario, Canada, 2006-2014. Outcomes were assessed up to June 2020. PARTICIPANTS/MATERIALS, SETTING, METHODS: Linked administrative datasets were used to capture all hospital births in Ontario, maternal health and pregnancy measures, fertility treatment and child outcomes. Included were all children born at ≥24 weeks gestation between 2006 and 2014, and who were alive at age 4 years. The main exposure was mode of conception, namely (i) unassisted conception (reference group), (ii) infertility without fertility treatment (history of an infertility consultation with a physician within 2 years prior to conception but no fertility treatment), (iii) ovulation induction (OI) or intrauterine insemination (IUI) and (iv) IVF or intracytoplasmic sperm injection (ICSI). The main outcome was a diagnosis of ADHD after age 4 years and assessed up to June 2020. Hazard ratios (HRs) were adjusted for maternal age, income quintile, rurality, immigration status, smoking, obesity, parity, any drug or alcohol use, maternal history of mental illness including ADHD, pre-pregnancy diabetes mellitus or chronic hypertension and infant sex. In addition, we performed pre-planned stratified analyses by mode of delivery (vaginal or caesarean delivery), infant sex, multiplicity (singleton or multiple), timing of birth (term or preterm <37 weeks) and neonatal adverse morbidity (absent or present). MAIN RESULTS AND THE ROLE OF CHANCE: The study included 925 488 children born to 663 144 mothers, of whom 805 748 (87%) were from an unassisted conception, 94 206 (10.2%) followed infertility but no fertility treatment, 11 777 (1.3%) followed OI/IUI and 13 757 (1.5%) followed IVF/ICSI. Starting at age 4 years, children were followed for a median (interquartile range) of 6 (4-8) years. ADHD occurred among 7.0% of offspring in the unassisted conception group, 7.5% in the infertility without fertility treatment group, 6.8% in the OI/IUI group and 6.3% in the IVF/ICSI group. The incidence rate (per 1000 person-years) of ADHD was 12.0 among children in the unassisted conception group, 12.8 in the infertility without fertility treatment group, 12.9 in the OI/IUI group and 12.2 in the IVF/ICSI group. Relative to the unassisted conception group, the adjusted HR for ADHD was 1.19 (95% CI 1.16-1.22) in the infertility without fertility treatment group, 1.09 (95% CI 1.01-1.17) in the OI/IUI group and 1.12 (95% CI 1.04-1.20) in the IVF/ICSI group. In the stratified analyses, these patterns of risk for ADHD were largely preserved. An exception was seen in the sex-stratified analyses, wherein females had lower absolute rates of ADHD but relatively higher HRs compared with that seen among males. LIMITATIONS, REASONS FOR CAUTION: Some mothers in the isolated infertility group may have received undocumented OI oral therapy, thereby leading to possible misclassification of their exposure status. Parenting behaviour, schooling and paternal mental health measures were not known, leading to potential residual confounding. WIDER IMPLICATIONS OF THE FINDINGS: Infertility, even without treatment, is a modest risk factor for the development of ADHD in childhood. The reason underlying this finding warrants further study. STUDY FUNDING/COMPETING INTEREST(S): This study was made possible with funding from the Canadian Institutes of Health Research, Grant number PJT 165840. The authors report no conflict of interest. TRIAL REGISTRATION NUMBER: N/A.
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Transtorno do Deficit de Atenção com Hiperatividade , Infertilidade , Transtorno do Deficit de Atenção com Hiperatividade/complicações , Transtorno do Deficit de Atenção com Hiperatividade/epidemiologia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Fertilização in vitro/efeitos adversos , Fertilização in vitro/métodos , Humanos , Lactente , Recém-Nascido , Infertilidade/etiologia , Infertilidade/terapia , Masculino , Mães , Ontário/epidemiologia , Gravidez , SêmenRESUMO
BACKGROUND: Time-related biases, such as immortal time and time-window bias, frequently occur in pharmacoepidemiologic research. However, the prevalence of these biases in perinatal pharmacoepidemiology is not well understood. OBJECTIVE: To describe the frequency of time-related biases in observational studies of medications commonly used during pregnancy (antibiotic, antifungal, and antiemetic drugs) via systematic review. METHOD: We searched Medline and EMBASE for observational studies published between January 2013 and September 2020 and examining the association between antibiotic, antifungal, or antiemetic drugs and adverse pregnancy outcomes, including spontaneous abortion, stillbirth, preterm delivery, small-for-gestational age, pre-eclampsia, and gestational diabetes. The proportion of studies with time-related biases was estimated overall and by type (immortal time bias, time-window bias). RESULTS: Our systematic review included 20 studies (16 cohort studies, 3 nested case-control studies, and 1 case-control study), of which 12 examined antibiotic, 6 antiemetic, and 2 anti-fungal drugs. Eleven studies (55%) had immortal time bias due to the misclassification of unexposed, event-free person-time between cohort entry and exposure initiation as exposed. No included study had time-window bias. The direction of effect varied for both studies with and without time-related bias, with many studies reporting very wide confidence intervals around the effect estimates, thus making the direction of effect less interpretable. However, studies with time-related bias were more likely to show protective or null associations compared with studies without time-related bias. CONCLUSION: Time-related biases occur frequently in observational studies of drug effects during pregnancy. The use of appropriate study design and analytical approaches is needed to prevent time-related biases and ensure study validity.
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Antieméticos , Gravidez , Recém-Nascido , Feminino , Humanos , Estudos de Casos e Controles , Antifúngicos , Viés , AntibacterianosRESUMO
INTRODUCTION: Hypertensive disorders of pregnancy occur in approximately 7%-10% of pregnancies and are associated with adverse maternal cardiovascular health outcomes across the lifespan. In contrast, breastfeeding has been associated with a reduction in cardiovascular risk factors in a dose-dependent manner. Despite the potential protective effects of lactation on cardiovascular risk, how hypertensive disorders of pregnancy relate to breastfeeding practices and experiences is not well understood. The aim of this study was to investigate the association between hypertensive disorders of pregnancy and breastfeeding outcomes in the first year postpartum. MATERIAL AND METHODS: We conducted a secondary analysis of prospective data from the All Our Families Cohort, a population-based study conducted in Calgary, Alberta, Canada. Women with a singleton pregnancy (n = 1418) who completed self-report questionnaires at <25 weeks and 34-36 weeks of gestation, and 4 months and 12 months postpartum, and provided consent to link to electronic medical records that identified diagnoses of hypertensive disorders of pregnancy (n = 122). Logistic and multiple linear regression analyses were used to model associations between hypertensive disorders of pregnancy and breastfeeding outcomes. Outcomes included breastfeeding intention, intended duration, exclusive breastfeeding at 4 months, breastfeeding duration at 12 months and breastfeeding difficulties. RESULTS: Hypertensive disorders of pregnancy were not associated with breastfeeding intention (odds ration [OR] 1.30, 95% confidence interval [CI] 0.47-3.03, P = 0.57), intended breastfeeding duration (b = -3.28, 95% CI -7.04 to 0.48, P = 0.09), or initiation (OR = 0.64, 95% CI 0.29- 1.65, P = 0.32), but were associated with an increase in the odds of non-exclusive breastfeeding at 4 months postpartum (OR = 2.11, 95% CI 1.39-3.22, P < 0.001). Women with hypertensive disorders breastfed for 6.26 (95% CI -10.00 to -2.51, P < 0.001) weeks less over 12 months postpartum, had significantly higher odds of reporting insufficient milk supply (OR = 1.75, 95% CI 1.19-2.46, P < 0.05) and had lower odds of breast and/or nipple pain (OR = 0.66, 95% CI 0.44-0.92, P < 0.05) compared with those without hypertensive disorders of pregnancy. CONCLUSIONS: Hypertensive disorders of pregnancy are associated with altered breastfeeding practices and experiences during the first year postpartum. Further research is needed to examine biopsychosocial mechanisms through which hypertensive disorders associate with shorter breastfeeding duration, and to examine whether greater breastfeeding duration, intensity or exclusivity reduces short- or long-term maternal cardiovascular risk.
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Aleitamento Materno , Hipertensão Induzida pela Gravidez , Alberta/epidemiologia , Aleitamento Materno/psicologia , Feminino , Humanos , Hipertensão Induzida pela Gravidez/epidemiologia , Período Pós-Parto/psicologia , Gravidez , Estudos ProspectivosRESUMO
Background: In the midst of the North American opioid crisis, identifying and intervening on drivers of high-risk opioid prescriptions is an important step towards reducing iatrogenic harm. Objectives: We aimed to identify factors associated with variations in high-risk opioid discharge prescriptions, following select surgical procedures, to guide future quality improvement initiatives. Methods: This retrospective cohort study analyzed 1322 patients who underwent select open pelvic and open abdominal surgeries between January 1 and December 31, 2017, in a tertiary health care centre in Montreal. Results: Patients who underwent open abdominal surgeries were prescribed significantly higher daily doses of morphine milligram equivalents (MME) (45 mg; interquartile range, 30-60), than patients who underwent either a caesarean delivery (20 mg, 20-20) or a hysterectomy (30 mg, 22-30). After adjustment for multiple potential confounders, abdominal surgery was associated with 4 times the odds of receiving more than 50 MME at hospital discharge compared with pelvic surgeries (odds ratio, 3.96; 95% confidence interval, 1.31-11.97). The availability of postoperative preprinted order sets with fixed high doses of opioids was also highly associated with the outcome. Conclusion: In our institution, some surgeries were more likely to receive high-risk opioid prescriptions at discharge. Efforts to optimize safer prescribing practices should address the creation and/or updating of preprinted order sets to reflect current best practice guidelines. This initiative could be overseen by hospital pharmacy and therapeutics committees.
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OBJECTIVE: We assessed whether bariatric surgery before pregnancy lowers the risk of severe maternal morbidity to a level comparable to no obesity. SUMMARY OF BACKGROUND DATA: Obesity is a risk factor for severe maternal morbidity, but the potential for bariatric surgery to reduce the risk has not been studied. METHODS: We analyzed a retrospective cohort of 2,412,075 deliveries between 1989 and 2019 in Quebec, Canada. The main exposure measures were bariatric surgery before pregnancy and obesity without bariatric surgery, compared with no obesity. The outcome was severe maternal morbidity, a composite of life-threatening pregnancy complications. We estimated risk ratios (RR) and 95% confidence intervals (CI) for the association between bariatric surgery and severe maternal morbidity, adjusted for maternal characteristics. RESULTS: A total of 2654 deliveries (0.1%) were in women who had bariatric surgery, and 70,041 (29.0 per 1000) were in women who had severe maternal morbidity. Risk of severe maternal morbidity was not significantly elevated for bariatric surgery (RR 1.20; 95% CI 0.98-1.46), but was greater for obesity compared with no obesity (RR 1.60; 95% CI 1.55-1.64). Bariatric surgery was not associated with morbidities such as severe preeclampsia, sepsis, and cardiac complications compared with no obesity, but obesity was associated with elevated risks of these and other severe morbidities. Bariatric surgery was associated, however, with intensive care unit admission, compared with no obesity. CONCLUSIONS: Pregnant women with prior bariatric surgery have similar risks as nonobese women for most types of severe maternal morbidity, except for intensive care unit admission.
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Cirurgia Bariátrica , Obesidade/cirurgia , Complicações na Gravidez/epidemiologia , Resultado da Gravidez , Adulto , Feminino , Humanos , Gravidez , Quebeque/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
BACKGROUND: Improvement in the prediction and prevention of severe maternal morbidity (SMM) - a range of life-threatening conditions during pregnancy, at delivery or within 42 days postpartum - is a public health priority. Reduction of SMM at a population level would be facilitated by early identification and prediction. We sought to develop and internally validate a model to predict maternal end-organ injury or death using variables routinely collected during pre-pregnancy and the early pregnancy period. METHODS: We performed a population-based cohort study using linked administrative health data in Ontario, Canada, from April 1, 2006 to March 31, 2014. We included women aged 18-60 years with a livebirth or stillbirth, of which one birth was randomly selected per woman. We constructed a clinical prediction model for the primary composite outcome of any maternal end-organ injury or death, arising between 20 weeks' gestation and 42 days after the birth hospital discharge date. Our model included variables collected from 12 months before estimated conception until 19 weeks' gestation. We developed a separate model for parous women to allow for the inclusion of factors from previous pregnancy(ies). RESULTS: Of 634,290 women, 1969 experienced the primary composite outcome (3.1 per 1000). Predictive factors in the main model included maternal world region of origin, chronic medical conditions, parity, and obstetrical/perinatal issues - with moderate model discrimination (C-statistic 0.68, 95% CI 0.66-0.69). Among 333,435 parous women, the C-statistic was 0.71 (0.69-0.73) in the model using variables from the current (index) pregnancy as well as pre-pregnancy predictors and variables from any previous pregnancy. CONCLUSIONS: A combination of factors ascertained early in pregnancy through a basic medical history help to identify women at risk for severe morbidity, who may benefit from targeted preventive and surveillance strategies including appropriate specialty-based antenatal care pathways. Further refinement and external validation of this model are warranted and can support evidence-based improvements in clinical practice.
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Mortalidade Materna , Modelos Estatísticos , Morbidade , Complicações na Gravidez/epidemiologia , Complicações na Gravidez/mortalidade , Estudos de Coortes , Feminino , Humanos , Ontário/epidemiologia , Gravidez , Reprodutibilidade dos Testes , Medição de Risco/métodos , Dados de Saúde Coletados RotineiramenteRESUMO
OBJECTIVE: We aimed to describe opioid prescribing practices after obstetric delivery and to evaluate how these practices compare with national opioid prescribing guidelines. METHODS: A closed survey was developed, evaluated for validity and reliability, and distributed by email to obstetrician members of the Society of Obstetricians and Gynaecologists of Canada (SOGC) in December 2018. Descriptive statistics were used to summarize respondent demographics, pharmaceutical pain management strategies, and opioid prescribing practices. Logistic regression was used to measure associations between respondent characteristics and high-risk opioid prescribing practices (e.g., prescribing >50 mg morphine equivalent dose per day, prescribing >5 days, not screening for substance/opioid use disorder before prescribing). RESULTS: Our survey had high content validity (content validity index 0.89; 95% CI 0.78-1.00) and adequate reliability (Kappa 0.70; 95% CI 0.63-0.84 and intraclass correlation coefficient 0.70; 95% CI 0.67-0.81). Of the 1019 SOGC members reached, 243 initiated the survey (response rate, 24%). Among respondents, 235 (92%) completed the survey. Among opioid prescribers, 47% reported at least 1 high-risk opioid prescribing practice, the most frequent being a lack of substance/opioid use disorder screening. In the adjusted logistic regression model, being in practice more than 20 years (adjusted odds ratio [aOR] 0.53; 95% CI 0.29-0.93) and practising in a non-central area of Canada (aOR 0.49; 95% CI 0.28-0.84) reduced the odds of high-risk prescribing. CONCLUSION: Further research on barriers to screening are needed to support and enhance safer opioid prescribing practices among Canadian obstetricians.
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Analgesia , Analgésicos Opioides , Canadá , Feminino , Humanos , Mães , Dor , Manejo da Dor , Período Pós-Parto , Padrões de Prática Médica , Gravidez , Reprodutibilidade dos Testes , Inquéritos e QuestionáriosRESUMO
Women with a history of preeclampsia (PE) have increased risk of cardiovascular disease (CVD) later in life. However, the molecular determinants underlying this risk remain unclear. We sought to understand how circulating miRNA levels are affected by prior PE, and related to biological pathways underpinning cardiovascular disease. RNA sequencing was used to profile plasma levels of 2578 miRNAs in a retrospective study of women with a history of PE or normotensive pregnancy, in two independent cohorts with either acute coronary syndrome (ACS) (n = 17-18/group) or no ACS (n = 20/group). Differential miRNA alterations were assessed in relation to a history of PE (within each cohort) or ACS (across cohorts), and compared with miRNAs previously reported to be altered during PE. A history of PE was associated with altered levels of 30 and 20 miRNAs in the ACS and non-ACS cohorts, respectively, whereas ACS exposure was associated with alterations in 259 miRNAs. MiR-206 was identified at the intersection of all comparisons relating to past/current PE and ACS exposure, and has previously been implicated in atherogenic activities related to hepatocytes, vascular smooth muscle cells and macrophages. Integration of all differentially altered miRNAs with their predicted and experimentally validated targets in silico revealed a number of highly targeted genes with potential atherogenic functions (including NFAT5, CCND2 and SMAD2), and one significantly enriched KEGG biological pathway (Wnt signaling) that was shared between all exposure groups. The present study provides novel insights into miRNAs, target genes and biological pathways that may underlie the long-term cardiovascular sequelae of PE.
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Doenças Cardiovasculares/complicações , Doenças Cardiovasculares/genética , MicroRNA Circulante/sangue , MicroRNAs/sangue , Pré-Eclâmpsia/sangue , Pré-Eclâmpsia/genética , Via de Sinalização Wnt , Síndrome Coronariana Aguda/sangue , Síndrome Coronariana Aguda/complicações , Síndrome Coronariana Aguda/genética , Doenças Cardiovasculares/sangue , Estudos de Coortes , Feminino , Humanos , Pessoa de Meia-Idade , Gravidez , Análise de Componente Principal , Via de Sinalização Wnt/genéticaRESUMO
Pulmonary embolism (PE) complicates 5.4 per 10 000 pregnancies and remains a significant cause of maternal mortality. Prompt diagnosis and treatment of PE are key to ensuring optimal outcomes, but are not without risks associated with over-testing. Given the paucity of evidence informing PE diagnosis in pregnancy, marked heterogeneity exists among different societies in their recommendations. Here we provide an overview of existing recommendations and novel evidence informing the diagnosis of PE in pregnancy, including the use of d-dimers, the choice of diagnostic imaging modality, and the potential for breast cancer risk among women exposed to ionizing radiation from computed tomography pulmonary angiography (CTPA).
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Guias como Assunto , Complicações Cardiovasculares na Gravidez , Embolia Pulmonar/diagnóstico por imagem , Adulto , Tomada de Decisão Clínica , Angiografia por Tomografia Computadorizada , Feminino , Produtos de Degradação da Fibrina e do Fibrinogênio/análise , Humanos , Gravidez , Complicações Cardiovasculares na Gravidez/sangue , Embolia Pulmonar/sangue , Fatores de TempoRESUMO
BACKGROUND: The extent to which infertility treatment predicts severe maternal morbidity is not well known. We examined the association between infertility treatment and severe maternal morbidity in pregnancy and the postpartum period. METHODS: We conducted a cohort study using population-based registries from Ontario between 2006 and 2012. Pregnancies achieved using infertility treatment (ovulation induction, intrauterine insemination or in vitro fertilization with or without intracytoplasmic sperm injection) were compared with unassisted pregnancies using propensity score matching, based on demographic, reproductive and obstetric factors. The primary outcome was a validated composite of severe maternal morbidity or maternal death from 20 weeks' gestation to 42 days postpartum. We also calculated the odds ratio of a woman having 1, 2, or 3 or more severe maternal morbidity indicators in relation to invasive (e.g., in vitro fertilization) or noninvasive (e.g., intrauterine insemination) infertility treatment. RESULTS: We matched 11 546 infertility treatment pregnancies with 47 553 untreated pregnancies. Severe maternal morbidity or maternal death occurred in 356 infertility-treated pregnancies (30.8 per 1000 deliveries) versus 1054 untreated pregnancies (22.2 per 1000 deliveries); relative risk 1.39 (95% confidence interval [CI] 1.23-1.56). The likelihood of a woman having 3 or more severe maternal morbidity indicators was increased in women who received invasive infertility treatment (odds ratio [OR] 2.28, 95% CI 1.56-3.33) but not in those who received noninvasive infertility treatment (OR 0.99, 95% CI 0.57-1.72). INTERPRETATION: Women who undergo infertility treatment, particularly in vitro fertilization, are at somewhat higher risk of severe maternal morbidity or death. Efforts are needed to identify patient- and treatment-specific predictors of severe maternal morbidity that may influence the type of treatment a woman is offered.
Assuntos
Fertilização in vitro , Infertilidade/terapia , Morbidade/tendências , Complicações na Gravidez/epidemiologia , Adulto , Estudos de Coortes , Feminino , Fertilização in vitro/efeitos adversos , Humanos , Infertilidade/complicações , Idade Materna , Mortalidade Materna/tendências , Estudos Observacionais como Assunto , Razão de Chances , Ontário/epidemiologia , Período Pós-Parto , Gravidez , Complicações na Gravidez/etiologia , Pontuação de Propensão , Medição de RiscoRESUMO
OBJECTIVE: To describe current physician practice patterns in Canada with regard to performing in vitro fertilization in high-risk patients. METHODS: All medical directors of IVF clinics registered with the Canadian Fertility and Andrology Society (n=35) were invited to participate in an online survey between January and May 2014. We carried out descriptive analyses of participants' responses regarding implementation of local restrictive policies for access to IVF. Whether practice patterns differed in hospital versus community-based clinics was assessed using chi-square testing with significance set at alpha<0.05. RESULTS: The response rate was 77.1%. More than one half of clinics (55.6%) were university-affiliated, and 29.6% were hospital-based. The majority of respondents (70.4%) used an upper age limit for permitting IVF (median 50 years, IQR 44 to 50), mostly because of lower pregnancy and live birth rates. Approximately one half of respondents limited treatment according to BMI (median upper permitted BMI 38 kg/m2, IQR 35 to 40 kg/m2) to minimize complications during pregnancy. Most respondents (77.8%) believed that routine pre-IVF medical assessment would be useful in their daily practice. There was a non-significant trend towards more restrictive policies in hospital-based clinics compared with community-based clinics. CONCLUSION: Our findings confirm that Canadian reproductive medicine physicians are taking maternal health factors into consideration when assessing patients' suitability for IVF. Nevertheless, there is between-clinic variability in the parameters used to assess eligibility for treatment. In light of the changing maternal demographic, more research is needed on assisted reproductive technology and perinatal outcomes in women who are at risk for pregnancy complications.
Objectif : Décrire les profils de pratique actuels des médecins canadiens en ce qui a trait à la tenue d'une fécondation in vitro chez des patientes exposées à des risques élevés. Méthodes : Tous les directeurs médicaux des cliniques de FIV inscrites à la Société canadienne de fertilité et d'andrologie (n = 35) ont été conviés à participer à un sondage en ligne entre janvier et mai 2014. Nous avons mené des analyses descriptives des réponses des participants en ce qui concerne la mise en Åuvre de politiques locales de restriction de l'accès à la FIV. La présence de différences entre les milieux hospitaliers et les cliniques communautaires en ce qui a trait aux profils de pratique a été évaluée au moyen d'un test de chi carré (seuil de signification : alpha < 0,05). Résultats : Le taux de réponse a été de 77,1 %. Plus de la moitié des cliniques (55,6 %) étaient affiliées à une université et 29,6 % des cliniques opéraient en milieu hospitalier. La majorité des répondants (70,4 %) utilisaient une limite supérieure en matière d'âge pour la tenue d'une FIV (médiane : 50 ans, intervalle interquartile : de 44 à 50 ans), principalement en raison des taux moindres de grossesse et de naissance vivante. Près de la moitié des répondants limitaient l'accès au traitement en fonction de l'IMC (IMC supérieur médian permis : 38 kg/m2, intervalle interquartile : de 35 à 40 kg/m2), et ce, afin de minimiser les complications au cours de la grossesse. La plupart des répondants (77,8 %) estimaient que la tenue systématique d'une évaluation médicale pré-FIV serait utile dans le cadre de leur pratique quotidienne. Une tendance non significative envers l'adoption de politiques plus restrictives a été constatée au sein des cliniques hospitalières, par comparaison avec les cliniques communautaires. Conclusion : Nos constatations confirment que les médecins canadiens Åuvrant dans le domaine de la médecine génésique prennent en considération des facteurs de santé maternelle dans le cadre de leur évaluation du caractère adéquat de la FIV pour leurs patientes. Quoi qu'il en soit, les paramètres utilisés pour évaluer l'admissibilité au traitement varient d'une clinique à l'autre. Compte tenu de l'évolution des caractéristiques démographiques maternelles, la tenue d'autres recherches s'avère requise sur le recours à la procréation assistée et les issues périnatales chez les femmes qui sont exposées à des risques de connaître des complications de grossesse.
Assuntos
Fertilização in vitro , Seleção de Pacientes , Diretores Médicos , Padrões de Prática Médica , Adulto , Índice de Massa Corporal , Canadá , Pesquisas sobre Atenção à Saúde , Humanos , Idade Materna , Pessoa de Meia-Idade , Projetos Piloto , Cuidado Pré-Concepcional , Medição de RiscoRESUMO
Background: Advancing maternal age is increasingly prevalent and is associated with severe maternal morbidity often requiring intensive care unit (ICU) admission. Objectives: To describe maternal ICU admissions at a quaternary care hospital in Montreal, Canada, and evaluate the association between maternal age and composite of: need for invasive interventions, ICU stay > 48â h, or maternal death. Methods: Chart review of ICU admissions during pregnancy/postpartum (2006-2016); logistic regressions to evaluate the impact of age on outcomes. Results: With 5.1 ICU admissions per 1000 deliveries, we included 187 women (mean age 32 ± 6.3 years; 20 (10.7%) ≥ 40 years). The composite outcome occurred in 105 (56.2%) patients; there were two maternal deaths. Age ≥ 40 years increased the odds of invasive interventions (OR 4.03; 95% confidence interval [CI] 1.15-14.1) but not of the composite outcome (OR 2.30; 95% CI 0.66-8.02). Conclusion: Peripartum women aged ≥ 40 years had worse outcomes in ICU, with an increased need for invasive interventions.
RESUMO
AIMS: This systematic review aimed to assess the effects of exercise training during pregnancy and the postpartum period on maternal vascular health and blood pressure (BP). METHODS AND RESULTS: The outcome of interest was pulse wave velocity (PWV), flow-mediated dilation (FMD), and BP from pregnancy to 1-year postpartum. Five databases, including Ovid MEDLINE, EMBASE, CINAHL, Web of Science, and Cochrane Library, were systematically searched from inception to August 2023. Studies of randomized controlled trials (RCTs) comparing the effects of prenatal or postpartum exercise to a non-exercise control group were included. The risk of bias and the certainty of evidence were assessed. Random-effects meta-analyses and sensitivity analyses were conducted. In total, 20 RCTs involving 1221 women were included. Exercise training, initiated from Week 8 during gestation or between 6 and 14â weeks after delivery, with the programme lasting for a minimum of 4â weeks up to 6â months, showed no significant impact on PWV and FMD. However, it resulted in a significant reduction in systolic BP (SBP) [mean difference (MD): -4.37â mmHg; 95% confidence interval (CI): -7.48 to -1.26; P = 0.006] and diastolic BP (DBP) (MD: -2.94â mmHg; 95% CI: -5.17 to -0.71; P = 0.01) with very low certainty. Subgroup analyses revealed consistent trends across different gestational stages, types of exercise, weekly exercise times, and training periods. CONCLUSION: Exercise training during pregnancy and the postpartum period demonstrates a favourable effect on reducing maternal BP. However, further investigations with rigorous methodologies and larger sample sizes are needed to strengthen these conclusions.
This systematic review of the literature demonstrates that exercise training during pregnancy and postpartum can reduce blood pressure in women.