Impact of inherited bleeding disorders on maternal bleeding and other pregnancy outcomes: A population-based cohort study.

INTRODUCTION: Increasing rate of postpartum haemorrhage (PPH) has been observed between 2003 and 2010 in Canada. Inherited bleeding disorders contribute to the risk of PPH. AIM: To identify the trend in PPH in the last decade, assess the impact of bleeding disorders on pregnancy outcomes and evaluate their coagulation workup during pregnancy. METHODS: We conducted a population-based retrospective cohort study using the Alberta Pregnancy Birth Cohort from 2010 to 2018. We included women with von Willebrand disease (VWD) and haemophilia, identified by previously validated algorithm and matched with controls. Logistic regression was used to compute odds of PPH and other pregnancy outcomes. RESULTS: We identified 311,330 women with a total of 454,400 pregnancies with live births. The rate of PPH did not change significantly from 10.13 per 100 deliveries (95% CI 10.10-10.16) in 2010-10.72 (95% CI 10.69-10.75) in 2018 (p for trend = .35). Women with bleeding disorders were significantly more likely to experience PPH (odds ratio [OR] 2.3; 95% CI 1.5-3.6), antepartum haemorrhage (OR 2.9; 95% CI 1.5-5.9) and red cell transfusion (OR 2.8; 95% CI 1.1-7.0). We observed a nonsignificant rise in the rate of PPH in women with VWD and haemophilia. Only 49.5% pregnancies with bleeding disorders had third trimester coagulation factor levels checked. Higher odds of PPH and antepartum haemorrhage were observed even with factor levels ≥0.50 IU/mL in third trimester. CONCLUSION: Despite comprehensive care in women with bleeding disorders, they are still at higher risk of adverse pregnancy outcomes compared to population controls.

CETARS/CAR Practice Guideline on Imaging the Pregnant Trauma Patient.

Imaging of pregnant patients who sustained trauma often causes fear and confusion among patients, their families, and health care professionals regarding the potential for detrimental effects from radiation exposure to the fetus. Unnecessary delays or potentially harmful avoidance of the justified imaging studies may result from this understandable anxiety. This guideline was developed by the Canadian Emergency, Trauma and Acute Care Radiology Society (CETARS) and the Canadian Association of Radiologists (CAR) Working Group on Imaging the Pregnant Trauma Patient, informed by a literature review as well as multidisciplinary expert panel opinions and discussions. The working group included academic subspecialty radiologists, a trauma team leader, an emergency physician, and an obstetriciangynaecologist/maternal fetal medicine specialist, who were brought together to provide updated, evidence-based recommendations for the imaging of pregnant trauma patients, including patient safety aspects (eg, radiation and contrast concerns) and counselling, initial imaging in maternal trauma, specific considerations for the use of fluoroscopy, angiography, and magnetic resonance imaging. The guideline strives to achieve clarity and prevent added anxiety in an already stressful situation of injury to a pregnant patient, who should not be imaged differently.

Directive clinique no 439 : Diagnostic et prise en charge du vasa prævia.

OBJECTIF: Résumer les données probantes actuelles et énoncer des recommandations pour le diagnostic et la classification du vasa prævia et pour la prise en charge des femmes ayant reçu ce diagnostic. POPULATION CIBLE: Femmes enceintes présentant un vasa prævia ou des vaisseaux ombilicaux péricervicaux. OPTIONS: En cas de diagnostic soupçonné ou confirmé de vasa prævia ou de vaisseaux ombilicaux péricervicaux, prendre en charge la patiente à l'hôpital ou à domicile, puis pratiquer une césarienne avant terme ou à terme ou entreprendre une épreuve de travail. RéSULTATS: Hospitalisation prolongée, accouchement prématuré, césarienne et morbidité et mortalité néonatales. BéNéFICES, RISQUES ET COûTS: Les femmes ayant un vasa prævia ou des vaisseaux ombilicaux péricervicaux présentent un risque accru d'issues défavorables maternelles, fœtales ou postnatales, à savoir un diagnostic potentiellement erroné, un besoin d'hospitalisation, une restriction inutile des activités, un accouchement précoce et une césarienne inutile. L'optimisation des protocoles de diagnostic et de prise en charge peut améliorer les issues maternelles, fœtales et postnatales. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à mars 2022, à partir de termes MeSH et de mots clés liés à la grossesse, au vasa prævia, aux vaisseaux prævia, à l'hémorragie ante partum, au col court, au travail prématuré et à la césarienne. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Fournisseurs de soins obstétricaux, y compris obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle et radiologistes. RéSUMé POUR TWITTER: En cas de cordon et de vaisseaux ombilicaux non protégés dans les membranes près du col (vasa prævia y compris), une caractérisation échographique et une prise en charge avisée s'imposent pour réduire les risques pour le bébé et la mère pendant la grossesse et l'accouchement. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guideline No. 439: Diagnosis and Management of Vasa Previa.

OBJECTIVE: To summarize the current evidence and to make recommendations for diagnosis and classification of vasa previa and for management of women with this diagnosis. TARGET POPULATION: Pregnant women with vasa previa or low-lying fetal vessels. OPTIONS: To manage vasa previa in hospital or at home, and to perform a cesarean delivery preterm or at term, or to allow a trial of labour when a diagnosis of vasa previa or low-lying fetal vessels is suspected or confirmed. OUTCOMES: Prolonged hospitalization, preterm birth, rate of cesarean delivery, and neonatal morbidity and mortality. BENEFITS, HARMS, AND COSTS: Women with vasa previa or low-lying fetal vessels are at an increased risk of maternal and fetal or postnatal adverse outcomes. These outcomes include a potentially incorrect diagnosis, need for hospitalization, unnecessary restriction of activities, an early delivery, and an unnecessary cesarean delivery. Optimization of diagnostic and management protocols can improve maternal and fetal or postnatal outcomes. EVIDENCE: Medline, Pubmed, Embase, and the Cochrane Library were searched from inception to March 2022, using medical subject headings (MeSH) and keywords related to pregnancy, vasa previa, low-lying fetal vessels, antepartum hemorrhage, short cervix, preterm labour, and cesarean delivery. This document presents 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: Obstetric care providers, including obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, and radiologists. TWEETABLE ABSTRACT: Unprotected fetal vessels in placental membranes and cord that are close to the cervix, including vasa previa, need careful characterization by sonographic examination and evidence-based management to reduce risks to the baby and the mother during pregnancy and delivery. SUMMARY STATEMENTS: RECOMMENDATIONS.

Technical Update No. 439: Antenatal Corticosteroids at Late Preterm Gestation.

OBJECTIVE: To update recommendations for administration of antenatal corticosteroids in the late preterm period. TARGET POPULATION: Pregnant individuals at risk of preterm birth from 340 to 366 weeks gestation. OPTIONS: Administration or non-administration of a single course of antenatal corticosteroids at 340 to 366 weeks gestation. OUTCOMES: Neonatal morbidity (respiratory distress, hypoglycemia), long-term neurodevelopment, and other long-term outcomes (growth, cardiac/metabolic, respiratory). BENEFITS, HARMS, AND COSTS: Administration of antenatal corticosteroids from 340 to 366 weeks gestation decreases the risk of neonatal respiratory distress but increases the risk of neonatal hypoglycemia. The long-term impacts of antenatal corticosteroid administration from 340 to 366 weeks gestation are uncertain. EVIDENCE: For evidence on the neonatal effects of antenatal corticosteroid administration at late preterm gestation, we summarized evidence from the 2020 Cochrane review of antenatal corticosteroids and combined this with evidence from published randomized trials identified by searching Ovid MEDLINE from January 1, 2020, to May 11, 2022. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on neurodevelopmental outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on neurodevelopmental outcomes using the following sources: (1) the 2020 Cochrane review; and (2) evidence obtained by searching Ovid MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to January 5, 2022. We did not apply date or language restrictions. Given the absence of direct evidence on the impact of late preterm antenatal corticosteroid administration on other long-term outcomes, we summarized evidence on the impact of antenatal corticosteroids across gestational ages on other long-term outcomes by combining findings from the 2020 Cochrane review with evidence obtained by searching Ovid MEDLINE for observational studies related to long-term cardiometabolic, respiratory, and growth effects of antenatal corticosteroids from inception to October 22, 2021. We reviewed reference lists of included studies and relevant systematic reviews for additional references. See Appendix A for search terms and summaries. 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 B (Tables B1 for definitions and B2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE: Maternity care providers, including midwives, family physicians, and obstetricians. SUMMARY STATEMENTS: RECOMMENDATIONS.

Guideline No. 441: Antenatal Fetal Health Surveillance.

OBJECTIVE: To summarize the current evidence and to make recommendations for antenatal fetal health surveillance (FHS) to detect perinatal risk factors and potential fetal decompensation in the antenatal period and to allow for timely intervention to prevent perinatal morbidity and/or mortality. TARGET POPULATION: Pregnant individuals with or without maternal, fetal, or pregnancy-associated perinatal risk factors for antenatal fetal decompensation. OPTIONS: To use basic and/or advanced antenatal testing modalities, based on risk factors for potential fetal decompensation. OUTCOMES: Early identification of potential fetal decompensation allows for interventions that may support fetal adaptation to maintain well-being or expedite delivery. BENEFITS, HARMS, AND COSTS: Antenatal FHS in pregnant individuals with identified perinatal risk factors may reduce the chance of adverse outcomes. Given the high false-positive rate, FHS may increase unnecessary interventions, which may result in harm, including parental anxiety, premature or operative birth, and increased use of health care resources. Optimization of surveillance protocols based on evidence-informed practice may improve perinatal outcomes and reduce harm. EVIDENCE: Medline, PubMed, Embase, and the Cochrane Library were searched from inception to January 2022, using medical subject headings (MeSH) and key words related to pregnancy, fetal monitoring, fetal movement, stillbirth, pregnancy complications, and fetal sonography. 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: All health care team members who provide care for or education to obstetrical patients, including maternal fetal medicine specialists, obstetricians, family physicians, midwives, nurses, nurse practitioners, and radiologists. SUMMARY STATEMENTS: RECOMMENDATIONS.

Directive clinique no 441 : Surveillance prénatale du bien-être fœtal.

OBJECTIF: Résumer les données probantes actuelles et formuler des recommandations pour la surveillance prénatale du bien-être fœtal afin de détecter les facteurs de risque périnatal et toute potentielle décompensation fœtale et de permettre une intervention rapide en prévention de la morbidité et la mortalité périnatales. POPULATION CIBLE: Personnes enceintes avec ou sans facteurs maternels, fœtaux ou gravidiques associés à des risques périnataux et à la décompensation fœtale. OPTIONS: Utiliser des examens prénataux par technologie de base et/ou avancée en fonction des facteurs de risque de décompensation fœtale. RéSULTATS: La reconnaissance précoce de toute décompensation fœtale potentielle permet d'intervenir de façon à favoriser l'adaptation fœtale pour maintenir le bien-être ou à accélérer l'accouchement. BéNéFICES, RISQUES ET COûTS: Chez les personnes enceintes ayant des facteurs de risque périnatal confirmés, la surveillance du bien-être fœtal contribue à réduire le risque d'issue défavorable. Compte tenu du taux élevé de faux positifs, la surveillance du bien-être fœtal peut augmenter le risque d'interventions inutiles, ce qui peut avoir des effets nuisibles, dont l'anxiété parentale, l'accouchement prématuré ou assisté et l'utilisation accrue des ressources de soins de santé. L'optimisation des protocoles de surveillance d'après des pratiques fondées sur des données probantes peut améliorer les issues périnatales et réduire les effets nuisibles. DONNéES PROBANTES: Des recherches ont été effectuées dans les bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à janvier 2022, à partir de termes MeSH et de mots clés liés à la grossesse, à la surveillance fœtale, aux mouvements fœtaux, à la mortinaissance, aux complications de grossesse et à l'échographie fœtale. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Tous les membres de l'équipe de soins qui prodiguent des soins ou donnent de l'information aux patientes en obstétrique, notamment les spécialistes en médecine fœto-maternelle, les obstétriciens, les médecins de famille, les sages-femmes, les infirmières, les infirmières praticiennes et les radiologistes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Prenatal Nutrition Care in Alberta: The Perspectives of Pregnant Women and Registered Dietitians.

Introduction: Optimizing women's diets in pregnancy improves maternal and child health outcomes; however, the best format for supporting women's nutrition goals in pregnancy is not clear, and access to dietetic services is not standard in prenatal care in Alberta. This study explored women's perceptions about access to Registered Dietitians (RDs) throughout pregnancy and RDs experiences providing prenatal nutrition counselling.Methods: Two studies were conducted. Study A: Pregnant women completed a short survey while attending a prenatal appointment in a large prenatal clinic. The survey assessed women's perspectives about accessing dietetic services during pregnancy. Survey data were analyzed using descriptive statistics. Study B: RDs participated in either a semi-structured phone interview or a focus group and described their experiences working with pregnant women. Data were analyzed using thematic analysis.Results: One hundred pregnant women completed the survey. Ninety percent indicated that they had not seen a RD at this time in pregnancy, and 48% reported that they would like to access a RD in pregnancy, if available. Dietitians discussed the diversity of women's concerns and the challenges to providing prenatal nutrition support.Conclusions: Women have nutrition-related questions during pregnancy. Dietitians experience challenges providing services in the current care systems.

Guideline No. 424: Umbilical Cord Management in Preterm and Term Infants.

OBJECTIVE: To assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity. TARGET POPULATION: People who are pregnant with preterm or term singletons or twins. BENEFITS, HARMS, AND COSTS: In preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage. EVIDENCE: Searches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. 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 conditional [weak] recommendations). INTENDED USERS: Maternity and newborn care providers.

Directive clinique no 424 : Prise en charge du cordon ombilical chez le nourrisson prématuré ou à terme.

OBJECTIF: Évaluer l'effet du clampage retardé du cordon et de la traite du cordon ombilical sur les risques de mortalité et de morbidité maternelles et néonatales en contexte de grossesses monofœtale ou gémellaire. POPULATION CIBLE: Femmes enceintes dont la grossesse monofœtale ou gémellaire est à terme ou avant terme. BéNéFICES, RISQUES ET COûTS: Chez les prématurés de grossesse monofœtale, le clampage retardé de 60 à 120 secondes idéalement, mais d'au moins 30 secondes, réduit le risque de mortalité et de morbidité. Chez les jumeaux prématurés, le clampage retardé est associé à certains bénéfices. Chez les nourrissons de grossesse monofœtale à terme, le clampage retardé de 60 secondes améliore les paramètres hématologiques. Chez les grands prématurés, la traite du cordon ombilical augmente le risque d'hémorragie intraventriculaire. DONNéES PROBANTES: Une recherche a été effectuée au moyen des bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à mars 2020, à partir de termes MeSH et de mots clés liés au clampage retardé du cordon et à la traite du cordon ombilical. Le présent document est un résumé des données probantes et non pas une revue méthodologique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CIBLES: Fournisseurs de soins de maternité et néonataux.

Guideline No. 428: Management of Dichorionic Twin Pregnancies.

OBJECTIVE: To review evidence-based recommendations for the management of dichorionic twin pregnancies. TARGET POPULATION: Pregnant women with a dichorionic twin pregnancy. BENEFITS, HARMS, AND COSTS: Implementation of the recommendations in this guideline may improve the management of twin pregnancies and reduce neonatal and maternal morbidity and mortality. EVIDENCE: Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (e.g., twin, preterm birth). Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies. There were no date limits, but results were limited to English- or French-language materials. VALIDATION METHODS: The content and recommendations were drafted and agreed upon by the principal authors. The Board of the SOGC approved the final draft for publication. 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: Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for women with twin pregnancies. SUMMARY STATEMENTS: RECOMMENDATIONS.

Directive clinique no 428 : Prise en charge de la grossesse gémellaire bichoriale.

OBJECTIF: Examiner les recommandations fondées sur des données probantes pour la prise en charge de la grossesse gémellaire bichoriale. POPULATION CIBLE: Femmes enceintes qui mènent une grossesse gémellaire bichoriale. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive pourrait améliorer la prise en charge de la grossesse gémellaire et réduire les risques de morbidité et mortalité néonatales et maternelles. DONNéES PROBANTES: La littérature publiée a été rassemblée par des recherches dans les bases de données PubMed et Cochrane Library au moyen d'un vocabulaire contrôlé approprié (p. ex., twin, preterm birth). Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. Aucune contrainte n'a été appliquée quant à la date de publication, mais les résultats ont été limités aux contenus en anglais ou en français. MéTHODES DE VALIDATION: Le contenu et les recommandations ont été rédigés et acceptés par les auteurs principaux. Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Consulter l'annexe A en ligne (le tableau A1 pour les définitions et le tableau A2 pour les interprétations des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle, radiologistes et autres professionnels de la santé qui prodiguent des soins aux femmes enceintes de jumeaux. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guideline No. 426: Hypertensive Disorders of Pregnancy: Diagnosis, Prediction, Prevention, and Management.

OBJECTIVE: This guideline was developed by maternity care providers from obstetrics and internal medicine. It reviews the diagnosis, evaluation, and management of the hypertensive disorders of pregnancy (HDPs), the prediction and prevention of preeclampsia, and the postpartum care of women with a previous HDP. TARGET POPULATION: Pregnant women. BENEFITS, HARMS, AND COSTS: Implementation of the recommendations in these guidelines may reduce the incidence of the HDPs, particularly preeclampsia, and associated adverse outcomes. EVIDENCE: A comprehensive literature review was updated to December 2020, following the same methods as for previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines, and references were restricted to English or French. To support recommendations for therapies, we prioritized randomized controlled trials and systematic reviews (if available), and evaluated substantive clinical outcomes for mothers and babies. VALIDATION METHODS: The authors agreed on the content and recommendations through consensus and responded to peer review by the SOGC Maternal Fetal Medicine Committee. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, along with the option of designating a recommendation as a "good practice point." See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).The Board of the SOGC approved the final draft for publication. INTENDED USERS: All health care providers (obstetricians, family doctors, midwives, nurses, and anesthesiologists) who provide care to women before, during, or after pregnancy.

Directive clinique no 426 : Troubles hypertensifs de la grossesse : Diagnostic, prédiction, prévention et prise en charge.

OBJECTIF: La présente directive a été élaborée par des fournisseurs de soins de maternité en obstétrique et en médecine interne. Elle aborde le diagnostic, l'évaluation et la prise en charge des troubles hypertensifs de la grossesse, la prédiction et la prévention de la prééclampsie ainsi que les soins post-partum des femmes avec antécédent de trouble hypertensif de la grossesse. POPULATION CIBLE: Femmes enceintes. BéNéFICES, RISQUES ET COûTS: La mise en œuvre des recommandations de la présente directive devrait réduire l'incidence des troubles hypertensifs de la grossesse, en particulier la prééclampsie, et des issues défavorables associées. DONNéES PROBANTES: La revue exhaustive de la littérature a été mise à jour en tenant compte des nouvelles données probantes jusqu'en décembre 2020 et en suivant la même méthodologie que pour la précédente directive de la Société des obstétriciens et gynécologues du Canada (SOGC) sur les troubles hypertensifs de la grossesse. La recherche s'est limitée aux articles publiés en anglais ou en français. Les recommandations relatives aux traitements s'appuient d'abord sur les essais cliniques randomisés et les revues systématiques (lorsque disponibles), ainsi que sur l'évaluation des résultats cliniques substantiels chez les mères et les bébés. MéTHODES DE VALIDATION: Les auteurs se sont entendus sur le contenu et les recommandations par consensus et ont répondu à l'examen par les pairs du comité de médecine fœto-maternelle de la SOGC. Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE) et se sont gardé l'option de désigner certaines recommandations par la mention « bonne pratique ¼. Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). Le conseil d'administration de la SOGC a approuvé la version définitive aux fins de publication. PROFESSIONNELS CIBLES: Tous les fournisseurs de soins de santé (obstétriciens, médecins de famille, sages-femmes, infirmières et anesthésistes) qui prodiguent des soins aux femmes avant, pendant ou après la grossesse.

DIRECTIVE CLINIQUE CONJOINTE DE LA SOGC ET DE LA SCP: Directive clinique no 424 : Prise en charge du cordon ombilical chez le nourrisson prématuré ou à terme.

Objectif: Évaluer l'effet du clampage retardé du cordon et de la traite du cordon ombilical sur les risques de mortalité et de morbidité maternelles et néonatales en contexte de grossesses monofœtale ou gémellaire. Population cible: Femmes enceintes dont la grossesse monofœtale ou gémellaire est à terme ou avant terme. Bénéfices risques et coûts: Chez les prématurés de grossesse monofœtale, le clampage retardé de 60 à 120 secondes idéalement, mais d'au moins 30 secondes, réduit le risque de mortalité et de morbidité. Chez les jumeaux prématurés, le clampage retardé est associé à certains bénéfices. Chez les nourrissons de grossesse monofœtale à terme, le clampage retardé de 60 secondes améliore les paramètres hématologiques. Chez les grands prématurés, la traite du cordon ombilical augmente le risque d'hémorragie intraventriculaire. Données probantes: Une recherche a été effectuée au moyen des bases de données Medline, PubMed, Embase et Cochrane Library, de leur création jusqu'à mars 2020, à partir de termes MeSH et de mot-clés liés au clampage retardé du cordon et à la traite du cordon ombilical. Le présent document est un résumé des données probantes et non pas une revue méthodologique. Méthodes de validation: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique d'évaluation, de développement et d'évaluation (GRADE). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]).

JOINT SOGC-CPS CLINICAL PRACTICE GUIDELINE: Guideline No. 424: Umbilical cord management in preterm and term infants.

Objective: To assess the impact of deferred (delayed) cord clamping (DCC) and umbilical cord milking in singleton and twin gestations on maternal and infant mortality and morbidity. Target Population: Women who are pregnant with preterm or term singletons or twins. Benefits Harms and Costs: In preterm singletons, DCC for (ideally) 60 to 120 seconds, but at least for 30 seconds, reduces infant risk of mortality and morbidity. DCC in preterm twins is associated with some benefits. In term singletons, DCC for 60 seconds improves hematological parameters. In very preterm infants, umbilical cord milking increases risk for intraventricular hemorrhage. Evidence: Searches of Medline, PubMed, Embase, and the Cochrane Library from inception to March 2020 were undertaken using Medical Subject Heading (MeSH) terms and key words related to deferred cord clamping and umbilical cord milking. 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 conditional [weak] recommendations).

Decreasing Insulin Requirements in Pregnancy With Pre-existing or Gestational Diabetes: Management Practices Across Canada.

Decreasing insulin requirements in pregnant women with preexisting or gestational diabetes has been attributed to placental insufficiency, which results in increased surveillance or early delivery. This practice is not evidence based. A 5-item questionnaire was administered electronically to a convenience sample of Canadian resident and staff obstetrician-gynaecologists and maternal-fetal medicine specialists. Practice patterns varied widely among the 142 survey respondents, and this variation did not correlate to their level of training. There is a paucity of evidence to guide the management of patients with decreasing insulin requirements, which is reflected in varied and possibly unnecessary clinical interventions.

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

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): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Guideline No. 402: Diagnosis and Management of Placenta Previa.

OBJECTIVES: To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis. OPTIONS: To manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed. OUTCOMES: Prolonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality. INTENDED USERS: Family physicians, obstetricians, midwives, and other maternal care providers. TARGET POPULATION: Pregnant women with placenta previa or low-lying placenta. EVIDENCE: Medline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review. VALIDATION METHODS: This guideline has been reviewed by the Maternal-Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors. BENEFITS, HARMS, AND/OR COSTS: Women with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).

Guideline No. 398: Progesterone for Prevention of Spontaneous Preterm Birth.

OBJECTIVES: To assess the benefits and risks of progesterone therapy for women at increased risk of spontaneous preterm birth (SPB) and to make recommendations for the use of progesterone to reduce the risk of SPB and improve postnatal outcomes. OPTIONS: To administer or withhold progesterone therapy for women deemed to be at high risk of SPB. OUTCOMES: Preterm birth, neonatal morbidity and mortality, and postnatal outcomes including neurodevelopmental outcomes. INTENDED USERS: Maternity care providers, including midwives, family physicians, and obstetricians. TARGET POPULATION: Pregnant women at increased risk of SPB. EVIDENCE: Medline, PubMed, EMBASE, and the Cochrane Library were searched from inception to October 2018 for medical subject heading (MeSH) terms and keywords related to pregnancy, preterm birth, previous preterm birth, short cervix, uterine anomalies, cervical conization, neonatal morbidity and mortality, and postnatal outcomes. This document represents an abstraction of the evidence rather than a methodological review. VALIDATION METHODS: This guideline was reviewed by the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors. BENEFITS, HARMS, AND/OR COSTS: Therapy with progesterone significantly reduces the risk of SPB in a subpopulation of women at increased risk. Although this therapy entails a cost to the woman in addition to the discomfort associated with its use, no other adverse effects to the mother or the baby have been identified. SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES): RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).