Guideline No. 450: Care of Pregnant Women Living with HIV and Interventions to Reduce Perinatal Transmission.

OBJECTIVE: This guideline provides an update on the care of pregnant women living with HIV and the prevention of perinatal HIV transmission. This guideline is a revision of the previous guideline, No. 310 Guidelines for the Care of Pregnant Women Living With HIV and Interventions to Reduce Perinatal Transmission, and includes an updated review of the literature with contemporary recommendations. TARGET POPULATION: Pregnant women newly diagnosed with HIV during antenatal screening and women living with HIV who become pregnant. This guideline does not include specific guidance for girls/women of reproductive age living with HIV who are not pregnant. OUTCOMES: Prevention of perinatal HIV transmission is a key indicator of the success of a health care system and requires multidisciplinary care of pregnant women living with HIV. Intended outcomes include guidance on best practice in perinatal management for Canadian health care providers for pregnant women living with HIV; reduction of perinatal transmission of HIV toward a target of eradication of perinatal transmission; provision of optimal antenatal care for pregnant women to ensure the best maternal health outcomes and HIV suppression; and evidence-based support and recommendations for pregnant women living with HIV, maintaining awareness and consideration of the complex psychosocial impacts of living with HIV. BENEFITS, HARMS, AND COSTS: The perinatal transmission of HIV has significant morbidity and mortality implications for the child, with associated lifelong health care costs. Pregnancy presents an emotionally and physically vulnerable time for pregnant women as well as an opportunity to engage them in health promotion. This guidance does not include recommendations with additional costs to health care facilities compared with the previous guideline. Application of the recommendations is aimed at health benefits to both mother and child by optimizing maternal health and preventing perinatal HIV transmission. EVIDENCE: Published and unpublished literature was reviewed with a focus on publications post-2013. OVID-Medline, Embase, PubMed and the Cochrane Library databases were searched for relevant publications available in English or French for each section of this guideline. Results included systematic reviews, randomized controlled trials, and observational studies published from 2012 to 2022. Searches were updated on a regular basis and incorporated in the guideline until May 2023. Unpublished literature, protocols, and international guidelines were identified by accessing the websites of health-related agencies, clinical practice guideline collections, and national and international medical specialty societies. 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 Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations). INTENDED AUDIENCE: The intended users of this guideline include obstetric care providers and infectious disease clinicians who provide care for pregnant women living with HIV. SOCIAL MEDIA SUMMARY: Updated Canadian HIV in pregnancy guideline informed by global research and tailored to Canadian healthcare needs and goals for pregnant women living with HIV and their families. SUMMARY STATEMENTS: RECOMMENDATIONS.

Systematic review of randomized control trials into effective preoperative weight loss interventions and impact on surgical outcomes for major benign gynecological surgery.

AIMS: Limited information exists on what preoperative weight loss interventions (lifestyle, pharmacological, surgical) are effective in improving outcomes of elective, nononcological, gynecological surgery. Obesity rates are increasing and associated with poorer operative outcomes. We aimed to identify high quality studies into preoperative weight loss interventions and perform a systematic review of the literature to guide recommendations for reducing gynecological surgical complications and guide future research. Primary outcomes were mortality and surgical complications including conversion to open surgery, duration of surgery, and recovery. METHODS: The review was pre-registered with PROPSERO. A systematic search was undertaken of the major electronic bibliographic databases. Search results were compiled and abstracts of studies identified before application of the Cochrane highly sensitive search strategy (CHSSS) were reviewed. Full text of studies after application of the CHSSS were evaluated for suitability. For data collection and analysis, a minimum three high-quality randomized control trials were required to synthesize data in relation to the primary outcome. RESULTS: No trials met the inclusion criteria. No randomized control trials in gynecological cohorts were identified. Studies in gynecology-oncology were excluded due to the confounding nature of weight loss as a feature of illness as opposed to health optimization. CONCLUSION: There is limited evidence regarding preoperative weight loss interventions in gynecology. Further research is needed as the prevalence of obesity among women is increasing and definitive surgical management options in gynecology remain essential. PROSPERO registration ID: 165643.

Retrospective Cohort Study on the Impact of the COVID-19 Pandemic on Pregnancy Outcomes for Women Living With HIV in British Columbia.

BACKGROUND: For pregnant women living with HIV (WLWH), engagement in care is crucial to maternal health and reducing the risk of perinatal transmission. To date, there have been no studies in Canada examining the impact of the COVID-19 pandemic on pregnant WLWH. METHODS: This was a retrospective cohort study assessing the impact of the pandemic on perinatal outcomes for pregnant WLWH using data from the Perinatal HIV Surveillance Program in British Columbia, Canada. We compared maternal characteristics, pregnancy outcomes, and clinical indicators related to engagement with care between a prepandemic (January 2017-March 2020) and pandemic cohort (March 2020-December 2022). We investigated preterm birth rates with explanatory variables using logistic regression analysis. RESULTS: The prepandemic cohort (n = 87) had a significantly (P < 0.05) lower gestational age at the first antenatal encounter (9.0 vs 11.8) and lower rates of preterm births compared with the pandemic cohort (n = 56; 15% vs 37%). Adjusted odds of preterm birth increased with the presence of substance use in pregnancy (aOR = 10.45, 95% confidence interval: 2.19 to 49.94) in WLWH. There were 2 cases of perinatal transmission of HIV in the pandemic cohort, whereas the prepandemic cohort had none. CONCLUSIONS: The pandemic had pronounced effects on pregnant WLWH and their infants in British Columbia including higher rates of preterm birth and higher gestational age at the first antenatal encounter. The nonstatistically significant increase in perinatal transmission rates is of high clinical importance.

Learnings from nursing bridging education programs: A scoping review.

AIM: The aim of this scoping review is to summarize and critically evaluate research focused on nursing bridging education programs internationally. Specifically, this review addresses bridging from a: (1) Personal Support Worker (or similar) to a Registered Practical Nurse (or similar); and (2) Registered Practical Nurse (or similar) to a Registered Nurse. BACKGROUND: Nursing bridging education programs support learners to move from one level of educational preparation or practice to another. These programs can therefore increase nursing workforce capacity. Global healthcare systems have faced nursing shortages for decades. Moreover, the presently insufficient nursing workforce is confronting an ever-increasing volume of needed healthcare that is rising with the global ageing demographic shift. DESIGN: The Joanna Briggs Institute methods for scoping reviews, combined with Arksey and O'Malley's (2005) guidelines, were used with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR). METHODS: MEDLINE (Ovid), CINAHL, EMBASE and SCOPUS databases were searched. Articles published in English that included Personal Support Workers, Registered Practical Nurses, Registered Nurses and/or nurses in similar categories who were studied through the process of a nursing bridging education program were included in the review. The study search was limited to papers published after 2005 (i.e., the beginning of nurse workload "overload" according to the Canadian Nurses Association). Braun and Clarke's (2006) thematic analysis was used in a content analysis of the included studies. RESULTS: A total of 15 articles published between 2005 and 2022 were included. Four themes were generated: (1) participating in bridging education programs fuels both professional and personal development; (2) nursing bridging education programs enhance diversity in the nursing workforce; (3) student nurses do not anticipate the challenges associated with participating in a bridging program; and (4) mentor-mentee connection promotes academic learning and successful completion of nursing bridging education programs. CONCLUSIONS: Despite experiencing challenges, participation in/completion of nursing bridging education programs leads to successful role transitioning and self-reported fulfillment of personal and professional aspirations. This review revealed the need for bridging programs to accommodate the unique needs of student nurses. Incorporation of support services, mentorship and faculty familiarity with varying nursing educational backgrounds facilitates role transitions by reducing the perceived challenges of bridging and promoting connection to foster learning. Nursing bridging education programs allow greater numbers of nurses to be trained to build workforce capacity and enable care for the world's rapidly ageing population.

Canadian SARS-CoV-2 serological survey using antenatal serum samples: a retrospective seroprevalence study.

BACKGROUND: Insufficient data on the rate and distribution of SARS-CoV-2 infection in Canada has presented a substantial challenge to the public health response to the COVID-19 pandemic. Our objective was to assess SARS-CoV-2 seroprevalence in a representative sample of pregnant people throughout Canada, across multiple time points over 2 years of the pandemic, to describe the seroprevalence and show the ability of this process to provide prevalence estimates. METHODS: This Canadian retrospective serological surveillance study used existing serological prenatal samples across 10 provinces over multiple time periods: Feb. 3-21, 2020; Aug. 24-Sept. 11, 2020; Nov. 16-Dec. 4, 2020; Nov. 15-Dec. 3, 2021; and results from the province of British Columbia during a period in which the SARS-CoV-2 B.1.1.529 (Omicron) variant was predominant, from Nov. 15, 2021, to June 11, 2022. Age and postal code administrative data allowed for comparison with concurrent polymerase chain reactivity (PCR)-positive results collected by Statistics Canada and the Canadian Surveillance of COVID-19 in Pregnancy (CANCOVID-Preg) project. RESULTS: Seropositivity in antenatal serum as early as February 2020 indicates SARS-CoV-2 transmission before the World Health Organization's declaration of the pandemic. Seroprevalence in our sample of pregnant people was 1.84 to 8.90 times higher than the recorded concurrent PCR-positive prevalence recorded among females aged 20-49 years in November-December 2020. Overall seropositivity in our sample of pregnant people was low at the end of 2020, increasing to 15% in 1 province by the end of 2021. Seroprevalence among pregnant people in BC during the Omicron period increased from 5.8% to 43% from November 2021 to June 2022. INTERPRETATION: These results indicate widespread vulnerability to SARS-CoV-2 infection before vaccine availability in Canada. During the time periods sampled, public health tracking systems were under-reporting infections, and seroprevalence results during the Omicron period indicate extensive community spread of SARS-CoV-2 infection.

Maternal and Neonatal Health Outcomes Associated with the Use of Gliclazide and Metformin for the Treatment of Diabetes in Pregnancy: A Record Linkage Study.

Background: Gliclazide is commonly used in the treatment of diabetes mellitus; however, very little is known regarding the safety of its use in pregnancy. The aims of this study was to examine the rate of maternal hospitalizations, congenital anomalies, and adverse neonatal outcomes in pregnant women treated with gliclazide compared with pregnant women treated with metformin. Methods: Women who used gliclazide during pregnancy (n = 108) between 2003 and 2012 were identified by linking national medication dispensing data with the New South Wales perinatal data collection. A comparison group of women treated with only metformin during pregnancy (n = 108) were selected using propensity score matching. Data on hospital admissions, mortality, and congenital anomalies were extracted to examine the health of mothers and their children across groups. Results: Rates of maternal hospitalizations during pregnancy were not significantly different between women in the two groups (incident rate ratio: 1.10, 95% CI: 0.90-1.34, P = 0.339). There was no significant difference in average birth weight (3402 g compared with 3572 g, P = 0.072), incidence of neonatal hypoglycemia (<4.6% compared with <4.6%, P = 0.684), or congenital anomalies (7.4% compared with 5.6%, P = 0.582) in neonates exposed to gliclazide compared with metformin. Conclusions: The use of gliclazide during pregnancy was not associated with increased maternal hospitalization or neonatal adverse outcomes in comparison with the use of metformin in pregnancy; however, the limited number of exposed pregnancies is a key limitation.

An unexpected presentation of haemoperitoneum in a pregnant woman.

In the majority of tertiary centres the Emergency Room or Assessment Unit is the gateway to the rest of the hospital. It is the location where critical decisions are formulated depending on whether a patient's condition is serious enough to warrant admission and, at times, emergency surgery. On occasion this decision can be straightforward based solely on the patient's presentation, observations, and basic investigations. This case highlights that although the decision and initial management may be apparent, often the diagnosis can be unexpected and that the diagnostic challenge is often outside the scope of a brief Emergency Room assessment. Corpus luteal cyst rupture is a common phenomenon but often not the cause of significant morbidity as it was in this case, especially in the absence of any associated risk factors.