Introduction of a Maternal-Fetal Medicine Tele-Ultrasound Program in Rural Alberta.

OBJECTIVES: We established a program of Maternal-Fetal Medicine (MFM) telemedicine that is safe and acceptable. Since December 2019, a multi-disciplinary team has been planning this quality improvement project. METHODS: We performed a pilot study to investigate the feasibility of using telemedicine and tele-ultrasound to enable prompt MFM consultations for patients in remote locations. We began with the training of sonographers followed by implementation in a small pilot. Interim analysis of the acceptability and feasibility of the program was done through patient surveys, images audit, and review of neonatal outcomes. RESULTS: Our background epidemiologic data showed that in Alberta, between 2017 and 2022, 460 patients travelled >6 hours, and 5038 travelled >2 hours from home to reach their site of birth. Patients were appropriately triaged to delivery/consultation at the tertiary level center based on diagnosis/suspicion of anomalies, such as abnormally invasive placenta, intrauterine growth restriction, hydrops, and partial agenesis of the corpus callosum, all of which were confirmed postdelivery. There was no neonatal mortality, and the single stillbirth was related to an unpreventable peri-viable co-twin demise. The patient survey demonstrated that for >85% of respondents the program reduced costs and stress. Ultrasound image audit found improvement and consistency in image quality after 3 months of training combined with supervision. CONCLUSION: MFM telemedicine is feasible and can be safe with adequate supervision. Additional support and resources are needed to scale and spread this quality improvement initiative.

Neonatal Thyrotoxicosis with Tricuspid Valve Regurgitation and Hydrops in a Preterm Infant Born to a Mother with Graves' Disease.

Neonatal hyperthyroidism is rare disorder due to the passage of thyroid receptor antibodies (TRBs) from the mother to the fetus. Neonatal thyrotoxicosis can present in several ways and if unrecognized, can be fatal. We present a preterm neonate who developed fetal hydrops and tricuspid regurgitation in utero. The mother had a history of treated Grave's disease. The infant responded to maternal treatment antenatally and postnatal anti-thyroid treatment, with resolution of both the tricuspid regurgitation and hydrops. To our knowledge, this is the first case report of tricuspid regurgitation associated with fetal and neonatal thyrotoxicosis. Our case also highlights the importance of obtaining a detailed and accurate history in a mother with previous Grave's disease, even if treated.

No. 214-Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks.

OBJECTIVE: To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks. OUTCOMES: Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy. EVIDENCE: The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

Diabetes in Pregnancy.

OBJECTIVE: This guideline reviews the evidence relating to the diagnosis and obstetrical management of diabetes in pregnancy. OUTCOMES: The outcomes evaluated were short- and long-term maternal outcomes, including preeclampsia, Caesarean section, future diabetes, and other cardiovascular complications, and fetal outcomes, including congenital anomalies, stillbirth, macrosomia, birth trauma, hypoglycemia, and long-term effects. EVIDENCE: Published literature was retrieved through searches of PubMed and the Cochrane Library using appropriate controlled vocabulary (MeSH terms "diabetes" and "pregnancy"). Where appropriate, results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. There were no date limits, but results were limited to English or French language materials. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). SUMMARY STATEMENTS: Recommendations It is recognized that the use of different diagnostic thresholds for the "preferred" and "alternative" strategies could cause confusion in certain settings. Despite this, the committee has identified the importance of remaining aligned with the current Canadian Diabetes Association 2013 guidelines as being a priority. It is thus recommended that each care centre strategically align with 1 of the 2 strategies and implement protocols to ensure consistent and uniform reporting of test results.

Le diabète pendant la grossesse.

OBJECTIF: La présente Directive passe en revue les données probantes liées au diagnostic et à la prise en charge obstétricale du diabète durant la grossesse. ISSUES: Les issues évaluées étaient les issues maternelles à court et à long terme, dont la prééclampsie, la césarienne, le diabète éventuel et d'autres complications cardiovasculaires et les issues fœtales, dont les anomalies congénitales, la mortinaissance, la macrosomie, le traumatisme de la naissance, l'hypoglycémie et les effets à long terme. RéSULTATS: La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans PubMed et The Cochrane Library au moyen d'un vocabulaire contrôlé (termes MeSH « diabète ¼ et « grossesse ¼) appropriés. Le cas échéant, les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés / essais cliniques comparatifs et aux études observationnelles. Aucune limite n'a été imposée en matière de date, mais les résultats ont été limités aux articles publiés en anglais ou en français. VALEURS: La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau 1). DéCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Guidelines for the Management of a Pregnant Trauma Patient.

OBJECTIVE: Physical trauma affects 1 in 12 pregnant women and has a major impact on maternal mortality and morbidity and on pregnancy outcome. A multidisciplinary approach is warranted to optimize outcome for both the mother and her fetus. The aim of this document is to provide the obstetric care provider with an evidence-based systematic approach to the pregnant trauma patient. OUTCOMES: Significant health and economic outcomes considered in comparing alternative practices. EVIDENCE: Published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library from October 2007 to September 2013 using appropriate controlled vocabulary (e.g., pregnancy, Cesarean section, hypotension, domestic violence, shock) and key words (e.g., trauma, perimortem Cesarean, Kleihauer-Betke, supine hypotension, electrical shock). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English between January 1968 and September 2013. Searches were updated on a regular basis and incorporated in the guideline to February 2014. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: This guideline is expected to facilitate optimal and uniform care for pregnancies complicated by trauma. Summary Statement Specific traumatic injuries At this time, there is insufficient evidence to support the practice of disabling air bags for pregnant women. (III) Recommendations Primary survey 1. Every female of reproductive age with significant injuries should be considered pregnant until proven otherwise by a definitive pregnancy test or ultrasound scan. (III-C) 2. A nasogastric tube should be inserted in a semiconscious or unconscious injured pregnant woman to prevent aspiration of acidic gastric content. (III-C) 3. Oxygen supplementation should be given to maintain maternal oxygen saturation > 95% to ensure adequate fetal oxygenation. (II-1B) 4. If needed, a thoracostomy tube should be inserted in an injured pregnant woman 1 or 2 intercostal spaces higher than usual. (III-C) 5. Two large bore (14 to 16 gauge) intravenous lines should be placed in a seriously injured pregnant woman. (III-C) 6. Because of their adverse effect on uteroplacental perfusion, vasopressors in pregnant women should be used only for intractable hypotension that is unresponsive to fluid resuscitation. (II-3B) 7. After mid-pregnancy, the gravid uterus should be moved off the inferior vena cava to increase venous return and cardiac output in the acutely injured pregnant woman. This may be achieved by manual displacement of the uterus or left lateral tilt. Care should be taken to secure the spinal cord when using left lateral tilt. (II-1B) 8. To avoid rhesus D (Rh) alloimmunization in Rh-negative mothers, O-negative blood should be transfused when needed until cross-matched blood becomes available. (I-A) 9. The abdominal portion of military anti-shock trousers should not be inflated on a pregnant woman because this may reduce placental perfusion. (II-3B) Transfer to health care facility 10. Transfer or transport to a maternity facility (triage of a labour and delivery unit) is advocated when injuries are neither life- nor limb-threatening and the fetus is viable (≥ 23 weeks), and to the emergency room when the fetus is under 23 weeks' gestational age or considered to be non-viable. When the injury is major, the patient should be transferred or transported to the trauma unit or emergency room, regardless of gestational age. (III-B) 11. When the severity of injury is undetermined or when the gestational age is uncertain, the patient should be evaluated in the trauma unit or emergency room to rule out major injuries. (III-C) Evaluation of a pregnant trauma patient in the emergency room 12. In cases of major trauma, the assessment, stabilization, and care of the pregnant women is the first priority; then, if the fetus is viable (≥ 23 weeks), fetal heart rate auscultation and fetal monitoring can be initiated and an obstetrical consultation obtained as soon as feasible. (II-3B) 13. In pregnant women with a viable fetus (≥ 23 weeks) and suspected uterine contractions, placental abruption, or traumatic uterine rupture, urgent obstetrical consultation is recommended. (II-3B) 14. In cases of vaginal bleeding at or after 23 weeks, speculum or digital vaginal examination should be deferred until placenta previa is excluded by a prior or current ultrasound scan. (III-C) Adjunctive tests for maternal assessment 15. Radiographic studies indicated for maternal evaluation including abdominal computed tomography should not be deferred or delayed due to concerns regarding fetal exposure to radiation. (II-2B) 16. Use of gadolinium-based contrast agents can be considered when maternal benefit outweighs potential fetal risks. (III-C) 17. In addition to the routine blood tests, a pregnant trauma patient should have a coagulation panel including fibrinogen. (III-C) 18. Focused abdominal sonography for trauma should be considered for detection of intraperitoneal bleeding in pregnant trauma patients. (II-3B) 19. Abdominal computed tomography may be considered as an alternative to diagnostic peritoneal lavage or open lavage when intra-abdominal bleeding is suspected. (III-C) Fetal assessment 20. All pregnant trauma patients with a viable pregnancy (≥ 23 weeks) should undergo electronic fetal monitoring for at least 4 hours. (II-3B) 21. Pregnant trauma patients (≥ 23 weeks) with adverse factors including uterine tenderness, significant abdominal pain, vaginal bleeding, sustained contractions (> 1/10 min), rupture of the membranes, atypical or abnormal fetal heart rate pattern, high risk mechanism of injury, or serum fibrinogen < 200 mg/dL should be admitted for observation for 24 hours. (III-B) 22. Anti-D immunoglobulin should be given to all rhesus D-negative pregnant trauma patients. (III-B) 23. In Rh-negative pregnant trauma patients, quantification of maternal-fetal hemorrhage by tests such as Kleihauer-Betke should be done to determine the need for additional doses of anti-D immunoglobulin. (III-B) 24. An urgent obstetrical ultrasound scan should be undertaken when the gestational age is undetermined and need for delivery is anticipated. (III-C) 25. All pregnant trauma patients with a viable pregnancy who are admitted for fetal monitoring for greater than 4 hours should have an obstetrical ultrasound prior to discharge from hospital. (III-C) 26. Fetal well-being should be carefully documented in cases involving violence, especially for legal purposes. (III-C) Obstetrical complications of trauma 27. Management of suspected placental abruption should not be delayed pending confirmation by ultrasonography as ultrasound is not a sensitive tool for its diagnosis. (II-3D) Specific traumatic injuries 28. Tetanus vaccination is safe in pregnancy and should be given when indicated. (II-3B) 29. Every woman who sustains trauma should be questioned specifically about domestic or intimate partner violence. (II-3B) 30. During prenatal visits, the caregiver should emphasize the importance of wearing seatbelts properly at all times. (II-2B) Perimortem Caesarean section 31. A Caesarean section should be performed for viable pregnancies (≥ 23 weeks) no later than 4 minutes (when possible) following maternal cardiac arrest to aid with maternal resuscitation and fetal salvage. (III-B).

Objectif : Une femme enceinte sur 12 en vient à subir des traumatismes physiques et ceux-ci exercent des effets importants sur la mortalité et la morbidité maternelles, ainsi que sur l'issue de la grossesse. La mise en œuvre d'une approche multidisciplinaire s'avère justifiée pour assurer l'optimisation des issues, et ce, tant pour la mère que pour son fœtus. Le présent document a pour but d'offrir, aux fournisseurs de soins obstétricaux, une approche systématique factuelle qu'ils pourront utiliser pour assurer la prise en charge des patientes enceintes ayant subi un traumatisme. Issues : Issues sanitaires et économiques considérables, par comparaison avec les pratiques de rechange. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, CINAHL et The Cochrane Library entre octobre 2007 et septembre 2013 au moyen d'un vocabulaire contrôlé (« pregnancy ¼, « Cesarean section ¼, « hypotension ¼, « domestic violence ¼, « shock ¼) et de mots clés (« trauma ¼, « perimortem Cesarean ¼, « Kleihauer-Betke ¼, « supine hypotension ¼, « electrical shock ¼) appropriés. Les résultats ont été restreints aux analyses systématiques, aux études observationnelles et aux essais comparatifs randomisés / essais cliniques comparatifs publiés en anglais entre janvier 1968 et septembre 2013. Les recherches ont été mises à jour de façon régulière et intégrées à la directive clinique jusqu'en février 2014. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats a été évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : Nous nous attendons à ce que la présente directive clinique facilite l'offre de soins optimaux et uniformes dans les cas de grossesse compliquée par un traumatisme. Déclaration sommaireLésions traumatiques particulières Pour l'instant, nous ne disposons pas de données probantes suffisantes pour soutenir la désactivation des coussins gonflables dans le cas des femmes enceintes. (III) RecommandationsExamen primaire 1. La présence d'une grossesse devrait être présumée chez toutes les femmes en âge de procréer ayant subi des blessures considérables, jusqu'à ce que le contraire ait été prouvé au moyen d'une échographie ou d'un test de grossesse définitif. (III-C) 2. Chez les femmes enceintes blessées inconscientes ou à demi conscientes, une sonde nasogastrique devrait être insérée afin de prévenir l'aspiration de contenu gastrique acide. (III-C) 3. Une oxygénothérapie devrait être mise en œuvre pour garantir le maintien d'une saturation maternelle en oxygène > 95 %, de façon à assurer une oxygénation fœtale adéquate. (II-1B) 4. Chez les femmes enceintes blessées, l'insertion d'une sonde de thoracostomie (à un endroit se situant à un ou deux espaces intercostaux de plus que d'habitude) pourrait être envisagée, au besoin. (III-C) 5. Chez les femmes enceintes gravement blessées, deux lignes intraveineuses de gros calibre (14-16) devraient être mises en place. (III-C) 6. En raison des effets indésirables qu'ils exercent sur la perfusion utéroplacentaire chez les femmes enceintes, les vasopresseurs ne devraient être utilisés qu'en présence d'une hypotension réfractaire qui ne réagit pas à la réanimation liquidienne. (II-3B) 7. Chez les femmes enceintes gravement blessées qui ont passé le cap de la mi-grossesse, l'utérus gravide devrait être repositionné de façon à ce qu'il ne comprime plus la veine cave inférieure, et ce, dans le but d'accroître le retour veineux et le débit cardiaque. Ce repositionnement peut être obtenu en déplaçant l'utérus manuellement ou en plaçant la patiente en position latérale gauche (en s'assurant alors d'immobiliser la moelle épinière de la patiente au préalable). (II-1B) 8. Pour prévenir l'allo-immunisation rhésus D chez les femmes Rh négatives, du sang O négatif devrait être transfusé, au besoin, jusqu'à ce que du sang provenant d'un donneur compatible soit obtenu. (I-A) 9. La partie abdominale du pantalon pneumatique hypotenseur ne devrait pas être gonflée en présence d'une grossesse, car cela pourrait atténuer la perfusion placentaire. (II-3B) Transfert vers un établissement de santé 10. Le transfert vers un service de maternité (service de triage d'une unité de travail et d'accouchement) est recommandé lorsque la patiente en question ne présente pas de blessures potentiellement mortelles ou pouvant mener à la perte d'un membre et lorsque le fœtus est viable (≥ 23 semaines); le transfert vers une salle des urgences est recommandé lorsque le fœtus n'a pas encore atteint l'âge gestationnel de 23 semaines ou lorsqu'il n'est pas considéré comme étant viable. En présence d'un traumatisme majeur, la patiente devrait être transférée ou transportée vers une unité de traumatologie ou une salle des urgences, sans égard à l'âge gestationnel. (III-B) 11. Lorsque la gravité du traumatisme est indéterminée ou lorsque l'âge gestationnel est incertain, la patiente devrait faire l'objet d'une évaluation menée dans une unité de traumatologie ou une salle des urgences en vue d'écarter la présence de blessures majeures. (III-C) Évaluation, au sein d'une salle des urgences, d'une patiente enceinte ayant subi un traumatisme 12. En présence d'un traumatisme majeur, la priorité doit être accordée à l'évaluation, à la stabilisation et à la prise en charge de la femme enceinte; par la suite, lorsque le fœtus est viable (≥ 23 semaines), l'auscultation de la fréquence cardiaque fœtale et un monitorage fœtal peuvent être mis en œuvre. De plus, une consultation en obstétrique devrait être obtenue dès que possible. (II-3B) 13. La tenue d'une consultation d'urgence en obstétrique est recommandée en ce qui concerne les femmes enceintes dont le fœtus est viable (≥ 23 semaines) et chez qui l'on soupçonne la présence de contractions utérines, d'un décollement placentaire ou d'une rupture utérine traumatique. (II-3B) 14. En présence de saignements vaginaux à 23 semaines ou par la suite, la tenue d'un examen vaginal au moyen d'un spéculum ou des doigts devrait être reportée jusqu'à ce que la présence d'un placenta praevia ait été écartée par échographie (préalable ou actuelle). (III-C) Tests d'appoint dans le cadre de l'évaluation maternelle 15. Les études de radiographie nécessaires aux fins de l'évaluation maternelle (dont la tomodensitométrie abdominale) ne devraient pas être retardées ni reportées en raison de préoccupations à l'égard de l'exposition du fœtus à des rayonnements. (II-2B) 16. L'utilisation de produits de contraste à base de gadolinium peut être envisagée lorsque les avantages maternels l'emportent sur les risques fœtaux potentiels. (III-C) 17. En plus des tests sanguins qui sont régulièrement menés dans le cadre de l'évaluation des patientes enceintes ayant subi un traumatisme, un profil de coagulation (comprenant la mesure du taux de fibrinogène) devrait être obtenu. (III-C) 18. Chez les patientes enceintes ayant subi un traumatisme, la tenue d'une échographie abdominale ciblée pour l'identification de traumatismes devrait être envisagée aux fins de la détection des saignements intrapéritonéaux. (II-3B) 19. Lorsque la présence de saignements intra-abdominaux est soupçonnée, la tomodensitométrie abdominale pourrait constituer une solution de rechange au lavage péritonéal diagnostique ou au lavage ouvert. (III-C) Évaluation fœtale 20. Toutes les patientes enceintes ayant subi un traumatisme qui présentent une grossesse viable (≥ 23 semaines) devraient faire l'objet d'un monitorage fœtal électronique pendant au moins 4 heures. (II-3B) 21. Les patientes enceintes ayant subi un traumatisme (≥ 23 semaines) qui présentent des facteurs indésirables (dont la sensibilité utérine, des douleurs abdominales considérables, des saignements vaginaux, des contractions soutenues [> 1/10 min], la rupture des membranes, un profil de fréquence cardiaque fœtale atypique ou anormal, un mécanisme de blessure à risque élevé ou un taux sérique de fibrinogène < 200 mg/dl) devraient être hospitalisées pour une période d'observation de 24 heures. (III-B) 22. De l'immunoglobuline anti-D devrait être administrée à toutes les patientes enceintes Rh négatives ayant subi un traumatisme. (III-B) 23. Chez les patientes enceintes Rh négatives ayant subi un traumatisme, l'hémorragie fœtomaternelle devrait être quantifiée au moyen de mesures telles que le test de Kleihauer-Betke, et ce, dans le but de déterminer la nécessité de procéder à l'administration de doses additionnelles d'immunoglobuline anti-D. (III-B) 24. Une échographie obstétricale devrait être menée d'urgence lorsque l'âge gestationnel est indéterminé et que la nécessité de procéder à l'accouchement est anticipée. (III-C) 25. Toutes les patientes enceintes ayant subi un traumatisme qui présentent une grossesse viable et qui sont hospitalisées aux fins de la tenue d'un monitorage fœtal pendant plus de 4 heures devraient faire l'objet d'une échographie obstétricale avant d'obtenir leur congé de l'hôpital. (III-C) 26. Il est important de disposer, particulièrement à des fins juridiques, d'une documentation rigoureuse du bien-être fœtal dans les cas mettant en cause de la violence. (III-C) Complications obstétricales du traumatisme 27. La prise en charge de la présence soupçonnée d'un décollement placentaire ne devrait pas être différée jusqu'à l'obtention d'une confirmation par échographie; l'échographie ne dispose pas de la sensibilité requise pour l'établissement d'undiagnostic de décollement placentaire. (II-3D) Lésions traumatiques particulières 28. La vaccination antitétanique est sûre pendant la grossesse et devrait être administrée, au besoin. (II-3B) 29. Toutes les femmes qui subissent un traumatisme devraient faire l'objet de questions visant particulièrement la violence familiale ou conjugale. (II-3B) 30. Dans le cadre des consultations prénatales, le fournisseur de soins devrait souligner l'importance du port de la ceinture de sécurité de façon adéquate, en tout temps. (II-2B) Césarienne péri-mortem 31. En présence d'une grossesse viable (≥ 23 semaines), la tenue d'une césarienne est recommandée au plus tard 4 minutes (dans la mesure du possible) à la suite de l'arrêt cardiaque chez la mère, et ce, en vue de faciliter la réanimation maternelle et le sauvetage du fœtus. (III-B).

A rare case of antepartum spontaneous septostomy in a monochorionic diamniotic twin pregnancy.

Spontaneous septostomy in a monochorionic diamniotic twin pregnancy is a rare phenomenon. We present a case of monochorionic diamniotic twin pregnancy with an intact dividing membrane seen in the 1st half of the pregnancy. At 26 weeks, when she was assessed for preterm contractions, the dividing membrane was not documented, which suggested spontaneous septostomy. There had been no invasive procedures during the pregnancy. She subsequently delivered at 29 weeks, secondary to preterm labor. No dividing membrane was noticed at the time of caesarian section. Spontaneous septostomy can complicate the management of monochorionic diamniotic twins by creating a pseudomonoamniotic environment resulting in cord entanglement, and difficulty in the diagnosis and management of twin-twin transfusion syndrome. We believe that such a case should be managed as monochorionic monoamniotic twin gestation.

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

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

SOGC CLINICAL PRACTICE GUIDELINE: guidelines for the management of vasa previa.

OBJECTIVES: To describe the etiology of vasa previa and the risk factors and associated condition, to identify the various clinical presentations of vasa previa, to describe the ultrasound tools used in its diagnosis, and to describe the management of vasa previa. OUTCOMES: Reduction of perinatal mortality, short-term neonatal morbidity, long-term infant morbidity, and short-term and long-term maternal morbidity and mortality. EVIDENCE: Published literature on randomized trials prospective cohort studies, and selected retrospective cohort studies was retrieved through searches of PubMed or Medline, CINAHL, and the Cochrane Library, using appropriate controlled vocabulary (e.g., selected epidemiological studies comparing delivery by Caesarean section with vaginal delivery studies comparing outcomes when vasa previa is diagnosed antenatally vs.intrapartum) and key words (e.g. vasa previa). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies. Searches were updated on a regular basis and incorporated into the guideline to October 1, 2008. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology assessment-related agencies,clinical practice guideline collections, clinical trial registries, and from national and international medical specialty societies. VALUES: The evidence collected was reviewed by the Diagnostic Imaging Committee and the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS: The benefit expected from this guideline is facilitation of optimal and uniform care for pregnancies complicated by vasa previa. SPONSORS: The Society of Obstetricians and Gynaecologists of Canada.

SOGC clinical practice guideline: Vaginal delivery of breech presentation: no. 226, June 2009.

OBJECTIVES: To review the physiology of breech birth; to discern the risks and benefits of a trial of labour versus planned Caesarean section; and to recommend to obstetricians, family physicians, midwives, obstetrical nurses, anaesthesiologists, pediatricians, and other health care providers selection criteria, intrapartum management parameters, and delivery techniques for a trial of vaginal breech birth. OPTIONS: Trial of labour in an appropriate setting or delivery by pre-emptive Caesarean section for women with a singleton breech fetus at term. OUTCOMES: Reduced perinatal mortality, short-term neonatal morbidity, longterm infant morbidity, and short- and long-term maternal morbidity and mortality. EVIDENCE: Medline was searched for randomized trials, prospective cohort studies, and selected retrospective cohort studies comparing planned Caesarean section with a planned trial of labour; selected epidemiological studies comparing delivery by Caesarean section with vaginal breech delivery; and studies comparing long-term outcomes in breech infants born vaginally or by Caesarean section. Additional articles were identified through bibliography tracing up to June 1, 2008. VALUES: The evidence collected was reviewed by the Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the criteria and classifications of the Canadian Task Force on Preventive Health Care. VALIDATION: This guideline was compared with the 2006 American College of Obstetrician's Committee Opinion on the mode of term singleton breech delivery and with the 2006 Royal College of Obstetrician and Gynaecologists Green Top Guideline: The Management of Breech Presentation. The document was reviewed by Canadian and International clinicians with particular expertise in breech vaginal delivery.

Management of meconium at birth.

OBJECTIVE: To provide clinician direction that is based on the best evidence available on suctioning at the perineum for infants born with meconium stained amniotic fluid. EVIDENCE: The Medline database was searched for articles published in English from 2000 to 2008 on the topic of management of meconium at birth. VALUES: The recommendation was made according to guidelines developed by the Canadian Task Force on Preventive Health Care. RECOMMENDATION: It is recommended that institutions adopt a policy indicating that non-suctioning is as safe as routine suctioning at the perineum for infants born with meconium-stained amniotic fluid. (IA).

The predictive value of 18 and 22 week uterine artery Doppler in patients with low first trimester maternal serum PAPP-A.

OBJECTIVE: To determine if the addition of uterine artery (UA) Doppler pulsatility index (PI) at 18 and 22 weeks of gestation improves the predictive accuracy of low first trimester pregnancy associated plasma protein A (PAPP-A) in the detection of adverse obstetrical outcomes. METHODS: This was a prospective interventional study. All women undergoing first trimester combined screening (FTS) at a single center, with a low maternal serum PAPP-A level (<0.4 MoM), were included. Patients underwent bilateral UA Doppler assessments at 18 and 22 weeks of gestation. A positive test was defined as a mean PI > 1.45. Primary outcomes were obtained from chart review, and logistic regression analysis was used to compare outcomes with positive and negative tests. Positive and negative predictive value, specificity and sensitivity were calculated. RESULTS: Between January and October 2007, 5359 women completed FTS. Among the low PAPP-A group (n = 289), 18 week UA Doppler was a significant predictor of low birth weight (OR = 2.28, p = 0.04) while 22 week UA Doppler significantly predicted preterm birth (OR = 12.6, p = 0.001), small for gestational age (OR = 8.24, p = 0.001) and low birth weight (OR = 2.28, p = 0.04). Test characteristics suggested improved positive and negative predictive value for Doppler at 22 versus 18 weeks for these outcomes. CONCLUSIONS: UA Doppler at 22 weeks is a useful adjunct in patients with low PAPP-A. However, a negative Doppler does not rule out all adverse outcomes and clinical judgment is advised in the management of these patients.

Guidelines for the management of pregnancy at 41+0 to 42+0 weeks.

OBJECTIVE: To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks. OUTCOMES: Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy. EVIDENCE: The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care. Recommendations 1. First trimester ultrasound should be offered, ideally between 11 and 14 weeks, to all women, as it is a more accurate assessment of gestational age than last menstrual period with fewer pregnancies prolonged past 41+0 weeks. (I-A) 2. If there is a difference of greater than 5 days between gestational age dated using the last menstrual period and first trimester ultrasound, the estimated date of delivery should be adjusted as per the first trimester ultrasound. (I-A) 3. If there is a difference of greater than 10 days between gestational age dated using the last menstrual period and second trimester ultrasound, the estimated date of delivery should be adjusted as per the second trimester ultrasound. (I-A) 4. When there has been both a first and second trimester ultrasound, gestational age should be determined by the earliest ultrasound. (I-A) 5. Women should be offered the option of membrane sweeping commencing at 38 to 41 weeks, following a discussion of risks and benefits. (I-A) 6. Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean section. (I-A) 7. Antenatal testing used in the monitoring of the 41- to 42-week pregnancy should include at least a non-stress test and an assessment of amniotic fluid volume. (I-A) 8. Each obstetrical department should establish guidelines dependent on local resources for scheduling of labour induction. (I-A).

Exercise in pregnancy and the postpartum period.

OBJECTIVE: To design Canadian guidelines advising obstetric care providers of the maternal, fetal, and neonatal implications of aerobic and strength-conditioning exercises in pregnancy. OUTCOMES: Knowledge of the impact of exercise on maternal, fetal, and neonatal morbidity, and of the maternal measures of fitness. EVIDENCE: MEDLINE search from 1966 to 2002 for English-language articles related to studies of maternal aerobic and strength conditioning in a previously sedentary population, maternal aerobic and strength conditioning in a previously active population, impact of aerobic and strength conditioning on early and late pregnancy outcomes, and impact of aerobic and strength conditioning on neonatal outcomes, as well as for review articles and meta-analyses related to exercise in pregnancy. VALUES: The evidence collected was reviewed by the Society of Obstetricians and Gynaecologists of Canada (SOGC Clinical Practice Obstetrics Committee) with representation from the Canadian Society for Exercise Physiology, and quantified using the evaluation of evidence guidelines developed by the Canadian Task Force on the Periodic Health Exam. RECOMMENDATIONS: 1. All women without contraindications should be encouraged to participate in aerobic and strength-conditioning exercises as part of a healthy lifestyle during their pregnancy. (II-1,2B) 2. Reasonable goals of aerobic conditioning in pregnancy should be to maintain a good fitness level throughout pregnancy without trying to reach peak fitness or train for an athletic competition. (II-1,2C) 3. Women should choose activities that will minimize the risk of loss of balance and fetal trauma. (III-C) 4. Women should be advised that adverse pregnancy or neonatal outcomes are not increased for exercising women. (II-1,2B) 5. Initiation of pelvic floor exercises in the immediate postpartum period may reduce the risk of future urinary incontinence. (II-1C) 6. Women should be advised that moderate exercise during lactation does not affect the quantity or composition of breast milk or impact infant growth. (I-A) VALIDATION: This guideline has been approved by the SOGC Clinical Practice Obstetrics Committee, the Executive and Council of SOGC, and the Board of Directors of the Canadian Society for Exercise Physiology. SPONSORS: This guideline has been jointly sponsored by the Society of Obstetricians and Gynaecologists of Canada and the Canadian Society for Exercise Physiology.